PacifiCare Asia Pacific http:// www. pacificare. com 2002
A Health Maintenance Organization
Serving: The Island of Guam , the Commonwealth of the Northern Mariana Islands, and the Republic of Belau (Palau)
Enrollment in this Plan is limited; you must live or work in our geographic service area to enroll. see page 6 for requirements.

Enrollment codes for this Plan:
High Option JK1 Self only JK2 Self and Family

Standard Option JK4 Self Only JK5 Self and Family
Authorized for distribution by the:
United States Office of Personnel Management
Retirement and Insurance Service http:// www. opm. gov/ insure

RI 73-776

Artwork:
For changes in benefits,
see page xx.

OPM Logo 1
1 Page 2 3
2002 PacifiCare Asia Pacific 2 Table of Contents
Table of Contents
Introduction .............................................................................................................................................................. 4
Plain Language .......................................................................................................................................................... 4
Inspector General Advisory ....................................................................................................................................... 5

Section 1. Facts about this HMO plan ...................................................................................................................... 6
How we pay providers ............................................................................................................................. 6
Your Rights.............................................................................................................................................. 6
Service Area............................................................................................................................................. 6
Section 2. How we change for 2002 ......................................................................................................................... 7
Program-wide changes............................................................................................................................. 7
Changes to this Plan................................................................................................................................. 7
Section 3. How you get care ..................................................................................................................................... 9
Identification cards................................................................................................................................... 9
Where you get covered care..................................................................................................................... 9
Plan providers.................................................................................................................................... 9
Plan facilities ..................................................................................................................................... 9
What you must do to get covered care ..................................................................................................... 9
Primary care....................................................................................................................................... 9
Specialty care..................................................................................................................................... 9
Hospital care .................................................................................................................................... 10
Circumstances beyond our control......................................................................................................... 11
Services requiring our prior approval .................................................................................................... 11
Section 4. Your costs for covered services ............................................................................................................. 12
Copayments ..................................................................................................................................... 12
Deductible........................................................................................................................................ 12
Coinsurance ..................................................................................................................................... 12
Your out-of-pocket maximum................................................................................................................ 12
Section 5. Benefits .................................................................................................................................................. 13
Overview................................................................................................................................................ 13
(a) Medical services and supplies provided by physicians and other health care professionals ....... 14
(b) Surgical and anesthesia services provided by physicians and other health care professionals.... 25
(c) Services provided by a hospital or other facility, and ambulance services.................................. 29
(d) Emergency services/ accidents ..................................................................................................... 33
(e) Mental health and substance abuse benefits ................................................................................ 35
(f) Prescription drug benefits............................................................................................................ 38
(g) Special features ........................................................................................................................... 41
(h) Dental benefits............................................................................................................................. 42 2
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2002 PacifiCare Asia Pacific 3 Table of Contents
(i) Non-FEHB benefits available to Plan members .......................................................................... 43
Section 6. General exclusions --things we don't cover.......................................................................................... 44
Section 7. Filing a claim for covered services......................................................................................................... 45
Section 8. The disputed claims process................................................................................................................... 46
Section 9. Coordinating benefits with other coverage............................................................................................. 48
When you have…................................................................................................................................... 48
Other health coverage................................................................................................................ 48
Original Medicare...................................................................................................................... 48
Medicare managed care plan ..................................................................................................... 50
TRICARE/ Workers' Compensation/ Medicaid ....................................................................................... 50
Other Government agencies ................................................................................................................... 51
When others are responsible for injuries................................................................................................ 51
Section 10. Definitions of terms we use in this brochure........................................................................................ 52
Section 11. FEHB facts........................................................................................................................................... 53

Coverage information
No pre-existing condition limitation.......................................................................................... 53
Where you get information about enrolling in the FEHB Program........................................... 53
Types of coverage available for you and your family................................................................ 53
When benefits and premiums start............................................................................................. 53
Your medical and claims records are confidential..................................................................... 53
When you retire ......................................................................................................................... 54
When you lose benefits
When FEHB coverage ends....................................................................................................... 54
Spouse equity coverage ............................................................................................................. 54
Temporary Continuation of Coverage (TCC)............................................................................ 54
Enrolling in TCC ....................................................................................................................... 54
Converting to individual coverage............................................................................................. 54
Getting a Certificate of Group Health Plan Coverage ............................................................... 55
Long term care insurance is coming later in 2000 ................................................................................................... 56 Index ........................................................................................................................................................................ 57

Summary of benefits ................................................................................................................................................ 59 3
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2002 PacifiCare Asia Pacific 4 Introduction/ Plain Language
Introduction
PacifiCare Health Insurance Company Micronesia DBA PacifiCare Asia Pacific owned by PacifiCare Health Plans
P. O. Box 6578 Tamuning, Guam 96931

This brochure describes the benefits of PacifiCare Health Plans under our contract (CS 2825) with the Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. This brochure is the
official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations, and exclusions of this brochure.

If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled for Self and Family coverage, each eligible family member is also entitled to these benefits. You do not have a right to
benefits that were available before January 1, 2002, unless those benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2002, and changes are summarized on page 5. Rates are shown at the end of this brochure.

Plain Language
Teams of Government and health plan's 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 PacifiCare Asia Pacific.
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 this brochure, let us know. Visit OPM's "Rate Us" feedback area at www. opm. gov/ insure or e-mail us at fehbwebcomments@ opm. gov or write to OPM at Insurance
Planning and Evaluation Division, 1900 E Street NW, Washington, DC 20415-3650. 4
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2002 PacifiCare Asia Pacific 5 Introduction/ Plain Language
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 202/ 418-3300 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. 5
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2002 PacifiCare Asia Pacific 6 Section 1
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and other providers that contract with us. These Plan providers coordinate your health care services.

HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in addition to treatment for illness and injury. Our providers follow generally accepted medical practice when
prescribing any course of treatment.
When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You only pay the copayments, coinsurance, and deductibles described in this brochure. When you receive emergency services from
non-Plan providers, you may have to submit claim forms.
You should join an HMO because you prefer the plan's benefits, not because a particular provider is available. You cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician,
hospital, or other provider will be available and/ or remain under contract with us.
How we pay providers
We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure. These Plan providers accept a negotiated payment from us, and you will only be responsible for your copayments or
coinsurance.
PacifiCare Health Insurance Company of Micronesia, Inc. is a Mixed Model Plan. This means the doctors provide care in contracted medical centers or in their own offices.

Your Rights
OPM requires that all FEHB Plans provide certain information to their FEHB members You may get information about us, our networks, providers, and facilities. OPM's FEHB website (www. opm. gov/ insure) lists the specific
types of information that we must make available to you. Some of the required information is listed below.
PHICM, dba PacifiCare Asia Pacific, has met all the licensing requirements needed on Guam, in the Commonwealth of the Northern Mariana Islands and the Republic of Belau (Palau) to conduct business as an
insurance company PacifiCare has been operating on Guam for 28 years
We are a for-profit organization
If you want more information about us, call 1/ 671-647-3526 or write to PacifiCare at P. O. Box 6578, Tamuning, Guam 96931. You may also contact us by fax at 1/ 671-646-6923 or visit our website at www. pacificare. com.

Service Area
To enroll in this Plan, you must live in or work in our Service Area. This is where our providers practice. Our service area is: The Island of Guam, the Commonwealth of the Northern Mariana Islands and the Republic of
Belau (Palau).
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 health care services for members outside of our
service area unless the services have prior plan approval. Medicare beneficiaries may only receive services at a plan participating Medicare contracted facility.

If you or a covered family member move outside of our service area, you should enroll in another plan. If your dependents live out of the area (for example, if your child goes to college in the United States), you should consider enrolling in a fee-for-
service plan or an HMO that has agreements with affiliates in other areas. If you or a family member move, you do not have to wait until Open Season to change plans. Contact your employing or retirement office. 6
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2002 PacifiCare Asia Pacific 7 Section 2
Section 2. How we change for 2002
Program-wide changes
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.
We increased speech therapy benefits by removing the requirement that services must be required to restore functional speech. (Section 5( a))

Changes to this Plan Your share of the High Option non-Postal premium will increase by 34. 8% for Self only or 43. 5% for Self and
Family.
Your share of the Standard Option non-Postal premium will increase by 53.8% for Self only or 53.8% for Self and Family.

We now cover certain intestinal transplants. (Section 5 (b) )
We no longer limit total blood cholesterol tests to certain age groups.
Out of area primary care – We no longer cover out of area primary care. We do cover emergency care and off island referrals for specialty care.

Lab, X-ray and other diagnostic tests – In addition to your office visit copayment, you now pay a $10 copayment for each radiological service under the High Option and a $15 copayment under the Standard Option.
These services include X-rays, non-routine mammograms, CT Scans, MRIs, and ultrasound.
Maternity Care -You now pay a $10 copayment under High Option and a $15 copayment under Standard Option for all maternity visits (pre and post natal)

Family Planning -You now pay a $15 copayment for injectable contraceptives in addition to your office visit copayment under standard and high Option.
Physical and Occupational Therapies -We now cover physical and occupational therapy for up to two (2) consecutive months per condition.
Orthopedic and prosthetic devices – We now cover externally worn breast prostheses, surgical bras and necessary replacements following a mastectomy at 80% under the Standard Option and 100% under the High
Option.

Orthopedic and prosthetic devices -We no longer cover these devices under the Standard Option.
Orthopedic and prosthetic devices -We no longer cover foot orthotics under the High Option.
Emergency Services (High Option) -You now pay a $50 copayment and all charges over $500 for in area emergency care (outpatient hospital services)

Emergency Services (Standard Option) -You now pay a $75 copayment and all charges over $500 for in area emergency care (outpatient hospital services)
Emergency Services (High Option) -You now pay a $50 copayment and all charges over $500 for out of area emergency care (outpatient hospital services) 7
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2002 PacifiCare Asia Pacific 8 Section 2
Emergency Services (Standard Option) -You now pay 20% of the first $500 of charges and all charges over $500 for out of area emergency care (outpatient hospital services)
Out of pocket maximum -The Standard Option out of pocket maximum is now $3000 per person and $6000 per family.
Dental Services – We now limit dental coverage to $1500 per member per year for both options.
Vision Services -We pay a maximum of $30 towards a basic vision exam and a maximum of $50 towards a comprehensive vision exam. You pay a $15 office visit copay under the standard Option and $10 copayment
under the high Option 8
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2002 PacifiCare Asia Pacific 9 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you
receive services from a Plan provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the Health
Benefits Election Form, SF-2809, your health benefits enrollment confirmation (for annuitants), or your Employee Express confirmation letter.

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at
671-647-3526.
Where you get covered care You get care from "Plan providers" and "Plan facilities." You will only pay copayments, and/ or deductibles, and you will not have to file claims.
Medicare beneficiaries may only receive services at a plan participating Medicare contracted facility.

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

What you must do It depends on the type of care you need. First, you and each family to get covered care member must choose a primary care physician. This decision is important
since your primary care physician provides or arranges for most of your health care. In selecting a primary care physician, call the PacifiCare Asia
Pacific Customer Service Department at 1-671-647-3526. You may have a different primary care physician for each family member.

Primary care Your primary care physician can be a family practitioner, internist , or pediatrician for children under 18 years of age . 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.
You may change your primary care physician as often as once a month. Your change to the new primary care physician will be effective on the
first of the following month
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 a specialist for return visits
unless your primary care physician gives you a referral.
However, for well-woman care, you may see an OB/ GYN within your provider group without a referral. 9
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2002 PacifiCare Asia Pacific 10 Section 3
You may access mental health care and behavioral health care through your primary care physician for an initial consultation. You must return
to your primary care physician after your consultation with the specialist. If your specialist recommends additional visits or services, your primary
care physician will review the recommendation and authorize the visits or services as appropriate. You should not continue seeing the specialist
after the initial consultation unless your primary care physician and the Plan's Medical Management Department has authorized the 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 develop
a treatment plan that allows you to see your specialist for a certain number of visits without additional referrals. Your primary care
physician will use our criteria when creating your treatment plan (the physician may have to get an authorization or approval beforehand).

If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician. Your primary care physician will decide
what treatment you need. If he or she decides to refer you to a specialist, ask if you can see your current specialist. If your current
specialist does not participate with us, you must receive treatment from a specialist who does. Generally, we will not pay for you to see
a specialist who does not participate with our Plan.
If you are seeing a specialist and your specialist leaves the Plan, call your primary care physician, who will arrange for you to see another
specialist. You may receive services from your current specialist until we can make arrangements for you to see someone else.

If you have a chronic or disabling condition and lose access to your specialist because we:
-terminate our contract with your specialist for other than cause; or
-drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB Plan; or

-reduce our service area and you enroll in another FEHB Plan,
you may be able to continue seeing your specialist for up to 90 days after you receive notice of the change. Contact us at 1-671-647-3526
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 1-671-647-3526. If you are
new to the FEHB Program, we will arrange for you to receive care. 10
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2002 PacifiCare Asia Pacific 11 Section 3
If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:
You are discharged, not merely moved to an alternative care center; or
The day your benefits from your former plan run out; or
The 92 nd day after you become a member of this Plan, whichever happens first.

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

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

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

We call this review and approval process preauthorization. Your physician must obtain preauthorization for the following services such as,
but not limited to:
All surgical procedures Audiological exams
Bone density studies CT scans
Growth Hormone Therapy (GHT) Hospitalization
MRIs Off-island referrals, consultations and procedures
Out-of-area hospitalization Plastic/ reconstructive consultation and procedures
Podiatry consultations and procedures Sleep studies
Specialty care Specialty care follow up (testing and procedures)
Other procedures including colonoscopy and endoscopy
Emergency services do not require preauthorization. However, you or your family member must notify the Plan within 48 hours, or as soon as
is reasonably possible, in order for the services to be covered. 11
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2002 PacifiCare Asia Pacific 12 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc. when you receive services.

Example: When you see your primary care physician you pay a copayment of $10 per office visit for High Option and $15 per office visit for Standard
Option and when you go in the hospital, you pay nothing per admission (High Option) or $150 per admission (Standard Option).

Deductible We do not have a deductible.
Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care.

Example: When you need emergency care outside our service area, under the Standard Option, you pay 20% of the first $500, then you are
responsible for all charges thereafter.

Your out-of-pocket After your copayments total $3000 per person and $6000 per family maximum enrollment (Standard Option) and $1,000 per person or $3,000 per family
enrollment (High Option) 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 Contraceptive Devices
Dental Services Vision Hardware
Chiropractic Services

Be sure to keep accurate records of your copayments since you are responsible for informing us when you reach the maximum. 12
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2002 PacifiCare Asia Pacific 13 Section 5
Section 5. Benefits – OVERVIEW (See page 5 for how our benefits changed this year and page 47 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. To obtain claims forms, claims filing advice, or more information about our benefits,
contact us at 1/ 671-647-3526 or at our website at www. pacificare. com/ asia pacific.

(a) Medical services and supplies provided by physicians and other health care professionals.................................. 14-24

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

Speech Therapy Hearing services (testing and treatment)
Vision services (testing, treatment and supplies) Foot care
Orthopedic and prosthetic devices Durable medical equipment (DME)
Home health services Chiropractic
Alternative treatments Educational classes and programs

(b) Surgical and anesthesia services provided by physicians and other health care professionals ............................. 25-28
Surgical procedures Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services ........................................................... 29-32
Inpatient hospital Outpatient hospital or ambulatory surgical center Extended care benefits/ skilled nursing care facility benefits Hospice care
Ambulance
(d) Emergency services/ accidents............................................................................................................................... 33-34 Medical emergency Ambulance

(e) Mental health and substance abuse benefits ......................................................................................................... 35-37
(f) Prescription drug benefits ..................................................................................................................................... 29-30
(g) Special features ..................................................................................................................................................... 41 PacifiCare Health Centers( PHC) Urgent Care Center

Health Improvement Programs
(h) Dental benefits ...................................................................................................................................................... 42
(i) Non-FEHB benefits available to Plan members ................................................................................................... 43

Summary of benefits .................................................................................................................................................... 59 13
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2002 PacifiCare Asia Pacific 14 Section 5( a)
Section 5 (a) Medical services and supplies provided by physicians and other health care professionals
I M
P O
R T
A N
T

Here are some important things 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.
Referrals to doctors or facilities not on Guam can only be made to those under contract to provide service off-island. A written referral must be made by a Plan provider and

approved by the PacifiCare Medical Management Department.

I M
P O
R T
A N
T

Benefit Description You pay
Diagnostic and treatment services You pay – Standard Option You pay -High Option
Professional services of physicians
In physician's office
In an urgent care center
Office medical consultations
Second surgical opinion

$15 per office visit $10 per office visit

Physicians' house calls or visits by nurses and health aides Nothing Nothing
Professional services of physicians
During a hospital stay
In a skilled nursing facility

Nothing Nothing

Not covered:
Off-island care without prior authorization, except in the case of emergency All charges All charges 14
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2002 PacifiCare Asia Pacific 15 Section 5( a)
Lab, X-ray and other diagnostic tests You pay – Standard Option You pay -High Option
Tests such as:

Blood tests
Urinalysis
Non-routine pap-tests
Pathology
Electrocardiogram and EEG

Nothing Nothing

X-rays
Non routine mammograms
Ultrasound
CT scans/ MRI (prior authorization required)

$15 per office visit in addition to regular office
visit copay
$10 per office visit in addition to regular
office visit copay

Preventive care, adult (Continued) You pay – Standard Option You pay – High Option
Routine screenings, such as, but not limited to:

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

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

Nothing
$15 copayment in addition to your regular office visit
copay

Nothing
$10 copayment in addition to your
regular office visit copay

Not covered:
Physical exams required for obtaining or continuing employment or insurance,
attending schools or camp, or travel and immunizations for them

All charges. All charges. 15
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2002 PacifiCare Asia Pacific 16 Section 5( a)
Routine immunizations, limited to:
Tetanus-diphtheria (Td) booster – once every 10 years, ages19 and over (except as provided for

under Childhood immunizations)
Influenza/ Pneumococcal vaccines, annually, age 65 and over

Nothing Nothing

Preventive care, children
Childhood immunizations recommended by the American Academy of Pediatrics Nothing if included as part of office visit Nothing if included as part of office visit

Well-child care charges for routine examinations and care up to 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 ( up to age 22)

$15 per office visit $10 per office visit

Not covered:
Physical exams required for obtaining or continuing employment or insurance,
attending schools or camp, or travel and immunizations for them.

All charges. All charges. 16
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2002 PacifiCare Asia Pacific 17 Section 5( a)
Maternity care You pay – Standard Option You pay -High Option
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Note: Here are some things to keep in mind:
You do not need to precertify your normal delivery; see page 22 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. The newborn
must be enrolled within 60 days of birth.
We pay hospitalization and surgeon services (delivery) the same as for illness and injury.

See Hospital benefits (Section 5c) and Surgery benefits (Section 5b)

Note: We will cover labor and delivery at the Sagua Managu Birthing Center at 100% for both
Standard Option and High Option. See "Special Features", page 41.

$15 per office visit; $150 copay per admission for
inpatient services

Note: Delivery is covered under inpatient services see section
5( c)

$10 per office visit; Nothing for inpatient services

Not covered:
Routine sonograms (ultrasound) to determine sex
All charges All charges.

Family planning
A broad range of voluntary family planning services,
Voluntary sterilization
Injectable contraceptive drugs ( such as Depo-Provera)

Intrauterine devices (IUDs)
Surgically implanted contraceptives (such as Norplant

NOTE: We cover oral contraceptives and diaphragms under the prescription drug benefit.

$15 per office visit
Note: Injectable contraceptive drugs
require an additional copay of $15.

$10 per office visit
Note: Injectable contraceptive drugs
require an additional copay of $15. 17
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2002 PacifiCare Asia Pacific 18 Section 5( a)
Not covered:
Reversal of voluntary surgical sterilization
Genetic counseling,

All charges. All charges.

Infertility services You pay -Standard Option You pay – High Option
Diagnosis and treatment of infertility, such as:
Artificial insemination: -intravaginal insemination (IVI)

-intracervical insemination (ICI)
Injectable Fertility drugs
Note: We cover oral fertility drugs under the prescription drug benefit.

50% of charges $10 per office visit

Not covered:
Assisted reproductive technology (ART) procedures, such as:

-in vitro fertilization
-embryo transfer, gamete GIFT, and zygote ZIFT

-Zygote transfer
intrauterine insemination (IUI)

Services and supplies related to excluded ART procedures

Cost of donor sperm
Cost of donor egg

All charges. All charges.

Allergy care
Testing and treatment
Allergy injection
$15 per office visit. $10 per office visit

Allergy serum Nothing Nothing
Not covered:
Provocative food testing
Sublingual allergy desensitization 18
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2002 PacifiCare Asia Pacific 19 Section 5( a)
Treatment therapies You pay–StandardOption You pay –High Option
Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone marrow transplants are

limited to those listed under Organ/ Tissue Transplants on page 28.

Respiratory and inhalation therapy
Intravenous (IV)/ Infusion Therapy
Growth hormone therapy (GHT)
Note: – We will only cover GHT when we preauthorize the treatment. Call 1/ 671-646-6956

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

Note: We cover GHT drugs under the Prescription Drug benefit

$15 per office visit; $150 copay per admission for
inpatient services
$10 per office visit; Nothing for inpatient
services

Dialysis Applies to hospital admission only $10 per office visit , nothing for inpatient 19
19 Page 20 21
2002 PacifiCare Asia Pacific 20 Section 5( a)
Physical and Occupational Therapies You pay – Standard Option You pay – High Option
Up to two (2) consecutive months per condition for the services of each of the
following:
-qualified physical therapists;
-occupational therapists.
Note: We only cover therapy to restore bodily function when there has been a total or partial

loss of bodily function due to illness or injury

$15 per office visit, nothing for home visits,
nothing per visit during covered inpatient
admission.

$10 per office visit, nothing for home visits,
nothing per visit during covered inpatient
admission.

Not covered:
long-term rehabilitative therapy
exercise programs, lifestyle modification programs

equipment, supplies or customized devices related to rehabilitative therapies, except
those provided under Section 5( a) Durable Medical Equipment

services provided by schools or government programs

All charges. All charges.

Speech Therapy You Pay You Pay
Unlimited services for the services of:
Qualified Speech Therapists

Note: All therapies are subject to medical necessity

$15 copayment per office visit;
Nothing per visit during covered inpatient admission.
$10 copayment per office visit;
Nothing per visit during covered inpatient admission.

Hearing services (testing and treatment)
Hearing testing and treatment for adults when medically indicated for other than
hearing aids
Hearing testing for children through age 17 (see Preventive care, children)

$15 per office visit $10 per office visit

Not covered: All other hearing testing
Hearing aids, testing and examinations for them
All charges. All charges. 20
20 Page 21 22
2002 PacifiCare Asia Pacific 21 Section 5( a)
Vi si on services (testing, treatment, and supplies) You pay -Standard Option You pay – High Option
Medical and surgical benefits for the diagnosis and treatment of diseases of the eye $15 per office visit $10 per office visit

Prescription Eyeglasses or prescription contact lenses All charges after $100 at participating providers All charges after $100 at participating providers

Eye exam to determine the need for vision correction for children through age 17 (see
preventive care)
Annual eye refractions
Plan pays $30 maximum benefit towards basic vision exams

Plan pays $50 maximum benefit towards comprehensive exam

$15 per office visit $10 per office visit

Not covered:
Eye exercises and orthoptics (vision therapy)
Radial keratotomy and other refractive surgery such as LASIK surgery

All charges. All charges.

Foot care
Routine foot care when you are under active treatment for a metabolic disease or peripheral

vascular disease such as diabetes.
$15 per office visit $10 per office visit.

Not covered:
Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and

similar routine treatment of conditions of the foot, except as stated above

Treatment of weak, strained or flat feet or bunions or spurs; and of any instability,
imbalance or subluxation of the foot (unless the treatment is by open cutting surgery).

All charges. All charges. 21
21 Page 22 23
2002 PacifiCare Asia Pacific 22 Section 5( a)
Orthopedic and prosthetic devices You pay -Standard Option You pay – High Option
Externally worn breast prostheses and surgical bras, including necessary

replacements, following a mastectomy (up to two surgical bras per benefit year)

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

Corrective appliances for treatment of non-dental
TMJ.

$15 per office visit plus an additional 20% of the
cost

$15 per office visit

$10 per office visit
$10 per office visit

Orthopedic Devices, such as braces Benefits are not available under Standard option $10 copayment per visit
Not covered:
Arch supports
Artificial eyes
Artificial joints and limbs
Braces and splints
Corsets, trusses, elastic stockings, support hose, stump hose and other supportive

devices
Foot orthotics
Heel pads and heel cups
Lumbosacral supports
Orthopedic and corrective shoes
Over-the-counter (OTC) items Prosthetic replacements provided less than 3

years after the last one we covered Other internal prosthetics such as heart
valves, automatic implantable cardioverter defibrillator (AICD) and other implantable
devices not specified above

All charges. All charges. 22
22 Page 23 24
2002 PacifiCare Asia Pacific 23 Section 5( a)
Durable medical equipment (DME) You pay -Standard Option You pay – High Option
Rental or purchase, at our option, including repair and adjustment, of durable medical

equipment prescribed by your Plan physician. Under this benefit, we cover:

Manual hospital beds;
Standard manual wheelchairs;
Crutches/ walk aids;

Note: Call us at 1/ 671-647-3526 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.

Benefits are not available under Standard option Member is responsible for any deposit required.

Not covered:
Motorized wheel chairs
Glucose monitors

Insulin pumps

All charges. All charges.

Home health services You pay -Standard Option You pay -High Option
Home health care ordered by a Plan physician and provided by a registered nurse (R. N.),

licensed practical nurse (L. P. N.), licensed vocational nurse (L. V. N.), or home health aide.

Services include oxygen therapy, intravenous therapy and medications.
Services ordered by a physician to homebound members:
Nursing
Physical therapy, speech therapy, occupational therapy, and respiratory therapy

Medical supplies included in the home health plan of care

Nothing. Nothing. 23
23 Page 24 25
2002 PacifiCare Asia Pacific 24 Section 5( a)
Not covered:
Nursing care requested by, or for the convenience of, the patient or the patient's

family; Services primarily for personal assistance that
does not include a medical component and is not diagnostic, therapeutic or rehabilitative.

Chiropractic

Chiropractic services --You may self refer to a participating chiropractor for up to 10
visits per calendar year.
Manipulation of the spine and extremities

All charges.
All charges above $25
All charges.
All charges above $25
Alternative treatments
No benefits All charges All charges
Educational classes and programs You pay -Standard Option You pay – High Option
Coverage is limited to programs administered through the PacifiCare Health Center only:

Smoking Cessation
Diabetes management classes
Taking Charge of your Heart Health
Note: Please call the PacifiCare Customer Service Department at 1-671-647-3526 to find
out if your class or program has a nominal charge.

Some programs may have a nominal charge.
Note: Nicotine replacement prescription
is available at a $20 copayment

Some programs may have a nominal
charge.

Note: Nicotine replacement
prescription is available at a $20
copayment 24
24 Page 25 26
2002 PacifiCare Asia Pacific 25 Section 5( c)
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
I M
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T

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

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

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

center, etc.
YOUR PHYSICIAN MUST GET PREAUTHORIZATION OF ALL SURGICAL PROCEDURES. Please refer to the prior authorization information shown in Section 3 to be sure

which services require prior authorization and identify which surgeries require preauthorization
Referrals to doctors or facilities not on Guam can only be made to t hose under contract to provide service off-island. A written referral must be made by a Plan provider and approved by the PacifiCare

Medical Management Department

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Benefit Description You pay
Surgical procedures You pay – Standard Option You pay -High Option

A comprehensive range of services such as:
Operative procedures
Treatment of fractures, including casting
Normal pre-and post-operative care by the surgeon
Correction of amblyopia and strabismus
Endoscopy procedures
Biopsy procedures
Removal of tumors and cysts
Correction of congenital anomalies (see reconstructive surgery

Surgical treatment of morbid obesity
Insertion of internal prosthetic devices. See 5( a) – Orthopedic braces and prosthetic

devices for device coverage information.
Cardiac surgery for the implantation of stents, leads and pacemakers

Cardiac surgery for the implantation of valves
Voluntary sterilization
Treatment of burns
Note: Plan pays for the cost of the insertion only. See Section 5( a) –Orthopedic and

prosthetic devices for device coverage information.

$15 per office visit; $150 copay per admission for
inpatient services.
$10 per office visit; Nothing for inpatient
services 25
25 Page 26 27
2002 PacifiCare Asia Pacific 26 Section 5( c)
Surgical procedures -Continued on next page. You pay–StandardOption You pay -HighOption
Not covered:
Reversal of voluntary sterilization
Routine treatment of conditions of the foot.

All charges. All charges.

Reconstructive surgery You pay-StandardOption You pay -HighOption
Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if:

-the condition produced a major effect on the member's appearance and
-the condition can reasonably be expected to be corrected by such surgery
Surgery to correct a condition that existed at or from birth and is a significant deviation from
the common form or norm. Examples of congenital anomalies are: protruding ear
deformities; cleft lip; cleft palate; birth marks; webbed fingers; and webbed toe

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

$15 per office visit; $150 copay per admission for
inpatient services
$10 per office visit; Nothing for inpatient
services

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

Surgeries related to sex transformation.

All charges All charges 26
26 Page 27 28
2002 PacifiCare Asia Pacific 27 Section 5( c)
Oral and maxillofacial surgery You pay -Standard Option You pay -High Option
Oral surgical procedures, limited to:
Reduction of fractures of the jaws or facial bones;

Surgical correction of cleft lip, cleft palate or severe functional malocclusion;
Removal of stones from salivary ducts;
Excision of leukoplakia or malignancies;
Excision of cysts and incision of abscesses when done as independent procedures; and

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

TMJ surgery and other related non-dental treatment

$15 per office visit; $150 copay per admission for
inpatient services
$10 per office visit; Nothing for inpatient
services

Not covered:
Oral implants and transplants
Procedures that involve the teeth or their supporting structures (such as the periodontal

membrane, gingiva, and alveolar bone)
Other dental related services for treatment of TMJ

All charges. All charges. 27
27 Page 28 29
2002 PacifiCare Asia Pacific 28 Section 5( c)
Organ/ tissue transplants You pay -Standard Option You pay – High Option
Limited to:
Cornea
Heart
Kidney
Liver
Allogeneic (donor) bone marrow transplants

Autologous bone marrow transplants (autologous stem cell and peripheral stem cell

support) for the following conditions: acute lymphocytic or non-lymphocytic leukemia;
advanced Hodgkin's lymphoma; advanced non-Hodgkin's lymphoma; advanced
neuroblastoma; breast cancer; multiple myeloma; epithelial ovarian cancer; and
testicular, mediastinal, retroperitoneal and ovarian germ cell tumors

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

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

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

$15 per office visit; $150.00 copay per
admission for inpatient services
$10 per office visit; Nothing for inpatient
services

Not covered: Donor screening tests and donor search
expenses, except those performed for the actual donor
Implants of non-human or artificial organs
Transplants not listed as covered

Transportation, lodging and living expenses

All charges All charges

Anesthesia
Professional services provided in – Hospital (inpatient)

Skilled nursing facility Hospital outpatient department
Ambulatory surgical center Office

Nothing Nothing 28
28 Page 29 30
2002 PacifiCare Asia Pacific 29 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
I M
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A N
T

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

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

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
The amounts listed below are for the charges billed by the facility (i. e., hospital or surgical center) or ambulance service for your surgery or care. Any costs

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

Referrals to doctors or facilities not on Guam can only be made to those under contract to provide service off-island. A written referral must be made by a Plan
provider and approved by the PacifiCare Medical Management Department.
YOUR PHYSICIAN MUST GET PREAUTHORIZATION OF HOSPITAL STAYS.

I M
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T

Benefit Description You pay
Inpatient hospital You pay – Standard Option You pay -High Option
Room and board, such as 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.

$150 copay per admission Nothing

Inpatient hospital continued on next page. 29
29 Page 30 31
2002 PacifiCare Asia Pacific 30 Section 5( c)
Inpatient hospital (Continued) You pay – Standard Option You pay -High Option
Other hospital services and supplies, such as:
Operating, recovery, labor and delivery and other treatment rooms

Prescribed drugs and medicines
Diagnostic laboratory tests, x-rays and pathology tests

Administration of blood and blood products
Facility fees, including, but not limited to dressings, splints, casts, and sterile tray services

Medical supplies and equipment, including oxygen
Anesthetics, including nurse anesthetist services
Rehabilitative therapies – See 5( a) for benefit limitations.

Nothing Nothing

Not covered:
Any inpatient dental procedure
Blood and blood products, whether synthetic or natural

Custodial care
Internal prosthetics except for those covered under Section 5( a) Prosthetic and Orthopedic

Devices.
Medical supplies, appliances, medical equipment, and any covered items billed by a

hospital for use at home
Non-covered facilities, such as nursing homes, schools

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

Take-home items

All charges. All charges. 30
30 Page 31 32
2002 PacifiCare Asia Pacific 31 Section 5( c)
Outpatient hospital or ambulatory surgical center You pay -Standard Option You pay -High Option
Operating, recovery, and other treatment rooms
Diagnostic laboratory tests, and pathology services
Administration of blood, blood plasma, and other biologicals
Pre-surgical testing
Anesthetics and anesthesia service
Facility fees, including but not limited to, dressings, splints, casts, sterile tray services

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

Diagnostic mammograms
Ultrasound
CT scans/ MRI (prior authorization required)
X-rays

$15 per office visit if done as an inpatient $150
copay per admission

$15 per office visit in addition to regular office
visit copay

$10 per office visit. If done as an inpatient,
nothing

$10 per office visit in addition to regular
office visit copay

Not covered:
blood and blood products, whether synthetic or natural
All charges All charges

Skilled nursing care facility benefits The Plan provides a comprehensive range of
benefits when full-time skilled nursing care and confinement in a skilled nursing facility is
medically appropriate as determined by a Plan doctor and approved by the Plan.

Standard Option – 60 days per calendar year
High Option -100 days per calendar year
All necessary services are covered, including:
Bed, board and general nursing care
Drugs, biologicals, supplies, and equipment ordinarily provided or arranged by the skilled

nursing facility when prescribed by a Plan doctor.

Nothing Nothing 31
31 Page 32 33
2002 PacifiCare Asia Pacific 32 Section 5( c)
Not covered:
blood and blood products, whether synthetic or natural

custodial care

All charges All charges

Hospice care Supportive and palliative care for a terminally ill
member is covered in the home or hospice facility when approved by the Plan's Medical
Management Department. Services are provided under the direction of a Plan doctor who certifies
that the patient is in the terminal stages of illness, with a life expectancy of approximately six
months or less.
Services include
inpatient and outpatient care
family counseling
Note: This benefit is limited to a maximum of up to 180 days per lifetime.

Nothing Nothing

Not covered:
Independent nursing
Homemaker services

All charges All charges

Ambulance
Local ground ambulance service when medically appropriate.

Not covered:
Transports that we determine are not medically necessary.

Air ambulance services

Nothing
All charges.
Nothing
All charges. 32
32 Page 33 34
2002 PacifiCare Asia Pacific 33 Section 5( d)
Section 5 (d). Emergency services/ accidents
I M
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A N
T

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

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

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

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

What to do in case of emergency?
In a life or limb threatening emergency, call 911 or go to the nearest hospital emergency room or other facility for treatment. You do not need authorization from your primary care physician before you go. True emergency is

covered no matter where you are.
Emergencies within our service area: If you are in our service area and receive emergency care that results in your hospitalization, notify your PCP on the first business day following your admission, so that he or she can coordinate

any follow-up treatment.
When you need urgent care while you are in our service area, call your primary care physician. Your physician can assess the situation and decide what type of care you need. Ask your PCP about after-hours and "on-call"

procedures now, before you need these services. If your PCP's office is closed, you may access the PHC Urgent Care Center.

Emergencies outside the service area: If you receive emergency or urgent care outside our service area, you must contact the PacifiCare Customer Service Department on 1 671-647-3526 within 48 hours, unless it was not reasonably possible to do so, to let us
know what has happened and where you went for care; otherwise, your care will not be covered We may arrange for your transfer to a Plan facility as soon as it is medically appropriate to do so.

When you have to file a claim: Please refer to Section 7 for information on how to file a claim, or contact our Customer Service Department at 1-671-647-3526.

Note: We do not coordinate benefits for outpatient prescription drugs. 33
33 Page 34 35
2002 PacifiCare Asia Pacific 34 Section 5( d)
Benefit Description You pay
Emergency within our service area You pay-StandardOption You pay -HighOption

Emergency care at a doctor's office
Urgent care at the PacifiCare Health Center (PHC)
$15 per office visit $10 per office visit

Emergency care in the hospital's emergency room $75 copay per emergency room visit
and all charges after $500

Note: We will waive the $75 copay if you are
admitted in the hospital.

$50 copay per emergency room visit
and all charges after $500

Note: We will waive the $50 copay if you
are admitted in the hospital

Emergency outside our service area
Emergency care at a doctor's office Emergency care at an urgent care center

Emergency care as an outpatient or inpatient at a hospital, including doctors' services
20% of the first $500 of charges and all
charges after $500

Note: If emergency results in admission to
the hospital, only the $150 copay applies.

$50 copay per visit and all charges after
$500

Note: If emergency results in admission to
the hospital, the $50 copay is waived.

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

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

the service area

All charges. All charges.

Ambulance
Ground ambulance service when medically necessary.

See 5( c) for non-emergency service.
According to service area benefit According to service area benefit

Not covered:
air ambulance services
transport that we determine is not medically necessary

All charges. All charges. 34
34 Page 35 36
2002 PacifiCare Asia Pacific 35 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
Network Benefit
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. Access to services must be through our behavioral health network managers.

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

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

I M
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T

Description You pay
Mental health and substance abuse benefits You pay – Standard Option You pay -High Option

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

Your cost sharing responsibilities are no
greater than for other illness or conditions.
Your cost sharing responsibilities are
no greater than for other illness or
conditions. 35
35 Page 36 37
2002 PacifiCare Asia Pacific 36 Section 5( e)
Professional services, including individual or group
therapy by providers such as psychiatrists, psychologists, or clinical social workers

Medication management
Diagnosis and treatment of psychiatric conditions,
mental illness or disorders of children, adolescents, and adults: Outpatient services include:

Diagnostic tests crisis intervention and stabilization for acute episodes
Psychological testing necessary to determine appropriate psychiatric treatment
Psychiatric treatment (including individual and group therapy visits)
Medication evaluation and management
Diagnosis and treatment of alcoholism and drug abuse. Outpatient services include:

Detoxification (the withdrawal process from physically-addictive drugs and/ or alcohol when
withdrawal is likely to cause medical or life-threatening complications)

Treatment and counseling (including individual and group therapy visits)

$15 per office visit $10 per office visit

Services provided by a hospital or other facility
Services in approved alternative care settings such as
partial hospitalization, half-way house, residential treatment, full-day hospitalization, facility based

intensive outpatient treatment
Day treatment programs for substance abuse

$150 copayment per admission Nothing

Not covered: Services we have not approved
Evaluation or therapy on court order or as a condition of parole or probation, or otherwise
required by the criminal justice system, unless determined by a Plan physician to be medically
necessary and appropriate

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. All charges

Network mental health and substance abuse benefits --Continued on next page. 36
36 Page 37 38
2002 PacifiCare Asia Pacific 37 Section 5( f)
Network Benefit – CONTINUED
Preauthorization To be eligible to receive these enhanced mental health and substance abuse benefits you must follow your treatment plan and all of our
network authorization processes. Please call 1/ 671-647-3526 for more information.

Special transitional benefit If a mental health or substance abuse professional provider is treating you under our plan as of January 1, 2002, you will be eligible for continued
coverage with your provider for up to 90 days under the following conditions:

If your mental health or substance abuse professional provider with
whom you are currently in treatment leaves the plan at our request for other than cause.

If this condition applies to you, we will allow you reasonable time to transfer your care to a Plan mental health or substance abuse professional
provider. During the transitional period, you may continue to see your treating provider. This transitional period will begin with our notice to you
of the change in coverage and will end 90 days after you receive our notice. If we write to you before October 1, 2002, the 90-day period ends before
January 1 and this transitional benefit does not apply.

Network limitation We may limit your benefits if you do not obtain a treatment plan.
How to submit network claims If you have out-of-pocket expenses for covered services, PacifiCare will reimburse you for those allowable charges, minus any applicable co-payments.
You should contact the PacifiCare Customer Service Department at 1/ 671-647-3526 and provide PacifiCare with a copy of your
bill, your proof of payment and a brief description of what happened. 37
37 Page 38 39
2002 PacifiCare Asia Pacific 38 Section 5( f)
Section 5 (f). Prescription drug benefits
I M
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A N
T

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

All benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with
other coverage, including with Medicare.

I M
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There are important features you should be aware of. These include:
Who can write your prescription. A licensed physician must write the prescription
Where you can obtain them. You must fill the prescription at a plan pharmacy or through the Plan's mail-order program

We use a formulary. The PacifiCare Formulary is a list of over 1600 prescription drugs that Physicians use as a guide when prescribing medications for patients. The Formulary plays an
important role in providing safe, effective and affordable prescription drugs to PacifiCare members. It also allows us to work together with physicians and pharmacies to ensure that our members are
getting the drug therapy they need. A Pharmacy and Therapeutics Committee consisting of physicians and pharmacists evaluate prescription drugs based on safety, effectiveness, quality
treatment and overall value. The committee considers first and foremost the safety and effectiveness of a medication before reviewing the cost. PacifiCare physicians will request prior
authorization for some non-formulary drugs. A participating physician may initiate the prior authorization request simply by phoning or faxing in the request. Requests are generally processed
within ten minutes although a few require up to 2 working days when additional information is needed from the doctor.

These are the dispensing limitations. Prescription drugs will be dispensed for up to a 30-day supply or one commercially prepared unit per copay (i. e., one inhaler, one vial of ophthalmic
medication, one tube of ointment, one vial of insulin). For drugs that could be habit forming, the prescription unit is set at a smaller quantity for the protection and safety of our members.

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 non-formulary copay.

Prescription drugs can also be obtained through the mail order program for up to a 90 day supply of oral
medication; 6 vials of insulin; or 3 commercially prepared units (i. e., inhaler, vials ophthalmic medication or topical ointments or creams). Call 1( 800) 531-3341 for mail order customer service.

Why use generic drugs? To reduce your out-of-pocket expenses! A generic drug is the chemical equivalent of a corresponding brand name drug. Generic drugs are less expensive than brand name
drugs; therefore, you may reduce your out-of-pocket costs by choosing to use a generic drug.
When you have to file a claim: Please refer to Section 7 for information on how to file a pharmacy claim, or contact our Customer Service Department at 1-671-647-3526.

Prescription drug benefits begin on the next page. 38
38 Page 39 40
2002 PacifiCare Asia Pacific 39 Section 5( f)
Benefit Description You pay
Covered medications and supplies You pay -Standard Option You pay -High Option
We cover the following medications and supplies prescribed by a Plan physician and obtained from a Plan
pharmacy or through our mail order program: Drugs and medicines that by Federal law of the
United States require a physician's prescription for their purchase, except those listed as not covered.
Insulin, copay charged to each vial Disposable needles and syringes for the
administration of covered medications; lancets
Oral contraceptive drugs (Injectable and implantable contraceptive drugs are covered under

Section 5( a) Family Planning)
Contraceptive diaphragms

Growth hormone

Drugs for sexual dysfunction are covered when Plan criteria is met. Contact Plan for dose limits.

Fertility drugs

$ 5 for each generic or brand formulary
prescription unit or refill

$20 for each non-formulary prescription
unit or refill

$5 each
50% per prescription unit or refill up to the dosage limits
and all charges above that limit

50% per prescription unit or refill up to the dosage limits
and all charges above that limit

$ 5 for each generic or brand formulary
prescription unit or refill

$20 for each non-formulary prescription
unit or refill

$5 each
50% per prescription unit or refill up to the dosage limits
and all charges above that limit

Nothing
Covered medications and supplies -Continued on next page 39
39 Page 40 41
2002 PacifiCare Asia Pacific 40 Section 5( f)
Covered medications and supplies (continued) You pay – Standard Option You pay -High Option
Not covered:
Drugs and supplies for cosmetic purposes
Vitamins, nutrients and food supplements even if a physician prescribes or administers

them unless listed in the Formulary
Non-prescription medicines

Drugs obtained at a non-Plan pharmacy
Drugs to enhance athletic performance
Medical supplies (such as dressing and antiseptics)

Hospital take-home drugs
Appetite suppressants

All charges. All charges. 40
40 Page 41 42
2002 PacifiCare Asia Pacific 41 Section 5( h)
Section 5 (g). Special Features
Feature Description

PacifiCare Health Center -Urgent Care
Center

Extended care hours are available to Plan members. If your Primary Care Doctor's clinic is closed, you may avail of the PHC's Urgent
Care services.

Health Improvement Programs The following programs are available to members at the PacifiCare Health Center only:
Taking Charge of Diabetes: a self-directed intervention program that addresses both self-care and lifestyle areas. The major

components are interactive member materials, telephonic support, and provider reporting.

Taking Charge of Your Heart Health: a self directed lifestyle management program focusing on behavior modification with diet,
exercise, stress, tobacco use and self-care.
Stop Smoking Program: highly effective self-paced smoking cessation program designed to meet individual needs. The major

components are counselor support and interactive member materials. This program requires a $20 copayment for materials and a$ 20
copayment for a nicotine replacement prescription.
Senior Member Health Questionnaire: a program designed to identify patient health needs and positively affect their overall health.

Sagua Managu Birthing Center Labor and delivery is covered at 100%. 41
41 Page 42 43
2002 PacifiCare Asia Pacific 42 Section 5( h)
Section 5 (h). Dental benefits
I M
P O
R T
A N
T

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

Plan dentists must provide or arrange your care.
We cover hospitalization for dental procedures only when a non-dental physical impairment exists which makes hospitalization necessary to safeguard the health of the patient; we do not cover the

dental procedure unless it is described below.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with

Medicare.
Dental services are limited to $1500 plan maximum per member per benefit year (High Option and Standard Option).

I M
P O
R T
A N
T

Emergency Care for Accidental Dental Injury You Pay (High Option and Standard Option)
We cover restorative services and supplies necessary to promptly repair (but not replace) sound natural teeth. The need for these services must result from an accidental injury. You pay nothing. If you are outside the service area
and receive services from a non-plan dentist, we will reimburse you up to $100. 00
Dental Benefits

Service You pay (Standard Option) You pay (High Option)

OFFICE VISIT
X-rays, including bitewings (once a year) and panoramic (once every three years) oral examination and treatment

plan; vitality test; and oral cancer exam

PREVENTIVE SERVICES
Prophylaxis (once every 6 month); sealants (up to age 12); annual topical application of fluoride (up to age 12);

RESTORATIVE DENTISTRY
Amalgam -one, two or three surfaces; composite--one or two surfaces— anterior only

ORAL SURGERY
Simple extraction for fully erupted teeth only
PROSTHETICS
Full and partial dentures; crowns and bridges; repair; relining and/ or reconstruction of dentures

Nothing
Nothing
All changes
All charges
All charges

Nothing
Nothing
20% of covered charges
20% of covered charges
75% of covered charges 42
42 Page 43 44
2002 PacifiCare Asia Pacific 43 Section 5( j)
Section 5 (j). Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed claim about them. Fees you pay for these services do not count toward FEHB deductibles or out-of-pocket
maximums.
Supplemental Dental Coverage
PacifiCare Asia Pacific offers a dental plan to supplement the dental coverage provided in the PacifiCare FEHBP plan option you have selected. Enrollment in the supplemental dental coverage will supersede your FEHB dental coverage.
The supplemental dental plan covers services provided by participating dental providers and provides coverage as follows:

YOU PAY
Diagnostic Services Nothing Routine x-rays, clinical examination and other diagnostic
dental services.
Preventive Services Nothing Routine teeth cleaning (prophylaxis), application of fluoride
to the teeth, sealants (up to age 12)
Restorative Services Nothing Routine fillings (silver amalgam and composite-anterior
only)
Oral Surgery Nothing Simple extractions, extractions of impacted teeth and other
necessary oral surgery
Endodontics 50% of covered charges Root canal fillings, pulpal therapy.

Periodontics 50% of covered charges Consultation, evaluation, and treatment of soft tissue and
bones supporting teeth, supragingival and subgingival gross scaling, subgingival curettage, root planing and periodontal
surgery.
Prosthodontics 50% of covered charges Full and partial dentures; repairs, relining and/ or
reconstruction of dentures.
Dental Plan Maximum The supplemental dental plan will pay a maximum of $1500 per member per calendar year.

For more details on the coverage and cost of the supplemental dental plan and how to enroll, call 1/ 671-647-3526. 43
43 Page 44 45
2002 PacifiCare Asia Pacific Section 6 44
Section 6. General exclusions --things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not cover it unless your Plan doctor determines it is medically necessary to prevent, diagnose, or
treat your illness, disease, injury or condition and we agree, as discussed under What Services Require Our Prior Approval on page 11. We do not cover the following:

Care by non-Plan providers except for authorized referrals or emergencies (see Emergency Benefits)
Services, drugs, or supplies you receive while you are not enrolled in this Plan;
Services, drugs, or supplies that are not medically necessary;
Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice;

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

incest;
Services, drugs, or supplies related to sex transformations; or
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program.

Dental services not listed as a benefit. 44
44 Page 45 46
2002 PacifiCare Asia Pacific 45 Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at Plan pharmacies, you will not have to file claims. Just present your identification card and pay your copayment,
coinsurance, or deductible.
You will only need to file a claim when you receive emergency services from non-plan providers. Sometimes these providers bill us directly. Check with the provider. If you need to file the claim, here is the process:

Medical, hospital and drug In most cases, providers and facilities file claims for you. Physicians benefits must file on the form HCFA-1500, Health Insurance Claim Form.
Facilities will file on the UB-92 form. For claims questions and assistance, call us at 1/ 671-647-3526.

When you must file a claim --such as for out-of-area care --submit it on the HCFA-1500 or a claim form that includes the information shown
below. Bills and receipts should be itemized and show:
Covered member's name and ID number;
Name and address of the physician or facility that provided the service or supply;

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

Receipts, if you paid for your services.
Submit your claims to: P. O. Box 6578 Tamuning, Guam 96931

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

When we need more information Please reply promptly when we ask for additional information. We may delay processing or deny your claim if you do not respond. 45
45 Page 46 47
2002 PacifiCare Asia Pacific 46 Section 8
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your claim or request for services, drugs, or supplies – including a request for prior authorization:

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: P. O. Box 6578, Tamuning, Guam 96931; 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, DC 20415-3630. 46
46 Page 47 48
2002 PacifiCare Asia Pacific 47 Section 8
The Disputed Claim Process (Continued)
Send OPM the following information:
A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;

Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms;
Copies of all letters you sent to us about the claim;
Copies of all letters we sent to you about the claim; and
Your daytime phone number and the best time to call.

Note: If you want OPM to review different claims, you must clearly identify which documents apply to which claim.

Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representative, such as medical providers, must include a copy of your specific written consent with the
review request.
Note: The above deadlines may be extended if you show that you were unable to meet the deadline because of reasons beyond your control.

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

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

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

NOTE: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and
(a) We haven't responded yet to your initial request for care or prior authorization/ prior approval, then call us at 1/ 671-647-3526 and we will expedite our review; or
(b) We denied your initial request for care or prior authorization/ 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. 47
47 Page 48 49
2002 PacifiCare Asia Pacific 48 Section 9
Section 9. Coordinating benefits with other coverage
When you have other health coverage You must tell us if you are covered or a family member is covered under another group health plan or have automobile insurance that pays health
care expenses without regard to fault. This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in full as the primary payer and the other plan pays a reduced benefit as the
secondary payer. We, like other insurers, determine which coverage is primary according to the National Association of Insurance
Commissioners' guidelines.
When we are the primary payer, we will pay the benefits described in this brochure.

When we are the secondary payer, we will determine our allowance. After the primary plan pays, we will pay what is left of our allowance, up
to our regular benefit. We will not pay more than our allowance.
What is Medicare? Medicare is a Health Insurance Program for: People 65 years of age and older.

Some people with disabilities, under 65 years of age.
People with End-State Renal Disease (permanent kidney failure requiring dialysis or a transplant).

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

employment, you should be able to qualify for premium-free Part A insurance. (Someone who was a Federal employee on January 1,
1983 or since automatically qualifies.) Otherwise, if you are age 65 or older, you may be able to buy it. Contact 1-800-MEDICARE for
more information.
Part B (Medical Insurance). Most people pay monthly for Part B. Generally, Part B premiums are withheld from your monthly Social Security check or

your retirement check.
If you are eligible for Medicare, you may have choices in how you get your health care. Medicare + Choice is the term used to describe the various health plan
choices available to Medicare beneficiaries. The information in the next few pages shows how we coordinate benefits with Medicare, depending on the type of
Medicare managed care plan you have.
The Original Medicare Plan (Part A or Part B) The Original Medicare Plan (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 in enrolled Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care.
Your care must continue to be authorized by your Plan PCP, or preauthorized as required.

We will not waive any of our copayments and coinsurance.
(Primary payer chart begins on next page.) 48
48 Page 49 50
2002 PacifiCare Asia Pacific 49 Section 9
The following chart illustrates whether the Original Medicare Plan or this Plan should be the primary payer for you according to your employment status and other factors determined by Medicare. It is critical that you tell us if you or
a covered family member has Medicare coverage so we can administer these requirements correctly.
Primary Payer Chart
Then the primary payer is… A. When either you --or your covered spouse --are age 65 or over and …

Original Medicare This Plan
1) 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,

a) Are a reemployed annuitant with the Federal government when
b) The position is excluded from FEHB, or

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

3) 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),

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

(for other services)

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

(except for claims related to Workers'

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

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

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

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

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

b) Are an active employee, or

c) Are a former spouse of an annuitant

d) Are a former spouse of an active employee

If your Plan physician does not participate in Medicare, you will have to file a claim with Medicare 49
49 Page 50 51

2002 PacifiCare Asia Pacific 50 Section 9
Claims process – When you You probably will never have to file a claim form when you have both have the Original Medicare Plan 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 1/ 671-647-3526 or visit our web
site at www. pacificare. com
We do not waive any out of pocket costs when you have the
Original Medicare

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

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

TRICARE TRICARE is the health care program for members, 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. 50
50 Page 51 52
2002 PacifiCare Asia Pacific 51 Section 9
Workers' Compensation We do not cover services that:
you need because of a workplace-related illness or injury that the Office of Workers' Compensation Programs (OWCP) or a similar
Federal or State agency determines they must provide; or
OWCP or a similar agency pays for through a third party injury settlement or other similar proceeding that is based on a claim you
filed under OWCP or similar laws.
Once OWCP or similar agency pays its maximum benefits for your treatment, we will cover your care. You must use our providers.

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

When others are responsible When you receive money to compensate you for medical or hospital care for injuries 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. 51
51 Page 52 53
2002 PacifiCare Asia Pacific 52 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 12

Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 12
Covered services Care we provide benefits for, as described in this brochure.
Custodial Care Day to day care that can be provided by a non-medical individual.
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 xx.

Experimental or Our National and Regional Medical Committees determine whether or Investigational services not treatments, procedures and drugs are no longer considered
experimental or investigational. Our determinations are based on the safety and efficacy of new medical procedures, technologies, devices and
drugs.

Medical necessity Medical necessity refers to medical services or hospital services which are determined by us to be:

Rendered for the treatment or diagnosis of an injury or illness; and Appropriate for the symptoms, consistent with diagnosis, and
otherwise in accordance with sufficient scientific evidence and professionally recognized standards; and
Not furnished primarily for the convenience of the Member, the attending physician, or other provider of service; and
Furnished in the most economically efficient manner which may be provided safely and effectively to the Member.

Plan allowance Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. Plans determine their allowances in
different ways. We determine our allowance by our contracted rate with the participating provider. If the charges exceed our contracted rate, you
will be responsible for the excess over the allowance in addition to your coinsurance

Us/ We Us and we refer to PacifiCare Asia Pacific
You You refers to the enrollee and each covered family member. 52
52 Page 53 54
2002 PacifiCare Asia Pacific 53 Section 11
Section 11. FEHB facts
No pre-existing condition We will not refuse to cover the treatment of a condition that you had limitation before you enrolled in this Plan solely because you had the condition before you enrolled.

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

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

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

Types of coverage available Self Only coverage is for you alone. Self and Family coverage is for for you and your family you, your spouse, and your unmarried dependent children under age 22, including any
foster children or stepchildren your employing or retirement office authorizes coverage for. Under certain circumstances, you may also continue coverage for a disabled child 22
years of age or older who is incapable of self-support.
If you have a Self Only enrollment, you may change to a Self and Family enrollment if you marry, give birth, or add a child to your family. You may change your enrollment 31
days before to 60 days after that event. The Self and Family enrollment begins on the first day of the pay period in which the child is born or becomes an eligible family
member. When you change to Self and Family because you marry, the change is effective on the first day of the pay period that begins after your employing office receives your
enrollment form; benefits will not be available to your spouse until you marry.
Your employing or retirement office will not notify you when a family member is no longer eligible to receive health benefits, nor will we. Please tell us immediately when
you add or remove family members from your coverage for any reason, including divorce, or when your child under age 22 marries or turns 22.

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

When benefits and The benefits in this brochure are effective on January 1. If you joined this Plan during premuim start Open Season, your coverage and premiums begin 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.

Your medical and claims We will keep your medical and claims information confidential. Only records are confidential the following will have access to it:

OPM, this Plan, and subcontractors when they administer this contract; 53
53 Page 54 55
2002 PacifiCare Asia Pacific 54 Section 11
This Plan and appropriate third parties, such as other insurance plans and the Office of Workers' Compensation Programs (OWCP), when coordinating benefit payments and
subrogating claims;
Law enforcement officials when investigating and/ or prosecuting alleged civil or criminal actions;

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

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

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

for your own FEHB coverage under the spouse equity law. If you are recently divorced or are anticipating a divorce, contact your ex-spouse's employing or retirement office to
get RI 70-5, the Guide to Federal Employees Health Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees, or other information about your
coverage choices.
Temporary Continuation If you leave Federal service, or if you lose coverage because you no longer qualify as a of Coverage 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.

Converting to individual Coverage You may convert to a non-FEHB individual policy if:
Your coverage under TCC or the spouse equity law ends. If you 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. 54
54 Page 55 56

2002 PacifiCare Asia Pacific 55 Section 11
Your benefits and rates will differ from those under the FEHB Program; however, you will not have to answer questions about your health, and we will not impose a waiting
period or limit your coverage due to pre-existing conditions.

Getting a Certificate of Group The Health Insurance Portability and Accountability Act of 1996 (HIPAA). Is a Federal Health Plan Coverage 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.

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 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.
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. 55
55 Page 56 57

2002 PacifiCare Asia Pacific 56 Long Term Care Insurance
Long Term Care Insurance Is Coming Later in 2002!
The Office of Personnel Management (OPM) will sponsor a high-quality long term care insurance program effective in October 2002. As part of its educational effort, OPM asks you to consider these questions:
What is long term care (LTC) insurance? It's insurance to help pay for long term care services you may need if you can't take care of yourself because of an extended
illness or injury, or an age-related disease such as Alzheimer's. LTC insurance can provide broad, flexible benefits for nursing home care, care in an assisted living facility, care in your home,
adult day care, hospice care, and more. It can supplement care provided by family members, reducing the burden you place on them.

I'm healthy. I won't need long term care. Or, will I? Welcome to the club!
76% of Americans believe they will never need long term care, but the facts are that about half them will. And it's not just the old folks. About 40% of people needing long term care are under age 65. They may need chronic care due to a serious accident,
a stroke, or developing multiple sclerosis, etc. We hope you will never need long term care, but everyone should have a plan just in case. Many people now consider long term
care insurance to be vital to their financial and retirement planing.
Is long term care expensive? Yes, it can be very expensive. A year in a nursing home can exceed $50,000. Home care for only three 8-hour shifts a week can
exceed $20,000 a year. And that's before inflation! Long term care can easily exhaust your savings. Long term care insurance can protect your savings.

But won't my FEHB plan, Medicare or Medicaid cover my long term care? Not FEHB. Look at the "Not covered" blocks in sections 5( a) and 5( c) of your FEHB brochure. Health plans don't cover
custodial care or a stay in an assisted living facility or a continuing need for a home health aide to help you get in and out of bed and with other activities of daily living. Limited stays in skilled nursing facilities can be covered in some circumstances.
Medicare only covers skilled nursing home care (the highest level of nursing care) after a hospitalization for those who are blind, age 65 or older or fully disabled. It also has a 100 day limit.
Medicaid covers long term care for those who meet 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.

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

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

Many FEHB enrollees think that their health plan and/ or Medicare will cover their long-term care needs. Unfortunately, they are WRONG!
How are YOU planning to pay for the future custodial or chronic care you may need? You should consider buying long-term care insurance. 56
56 Page 57 58
2002 PacifiCare Asia Pacific 57 Index
Index Do not rely on this page; it is for your convenience and may not show all pages where the terms appear.
Accidental injury 26, 42 Allergy Test 18
Alternative treatment 24 Ambulance 29, 32, 34
Anesthesia 25, 28, 31 Allogeneic (donor) bone marrow
transplants 28 Autologous bone marrow
transplant 19, 28 Biopsies 25
Birthing centers 17, 41 Blood and blood plasma 31
Breast cancer screening 28 Casts 30, 31
Catastrophic protection 60 Changes for 2002 7
Chemotherapy 19 Childbirth 41
Chiropractic 24 Cholesterol tests 7, 15
Claims 45, 46, 53 Coinsurance 12, 52
Colorectal cancer screening 14 Congenital anomalies 25, 26
Contraceptive devices & drugs 17, 39 Coordination of benefits 48
Covered charges 49, 50, 56 Covered providers 9
Crutches 23 Deductible 12, 52
Definitions 52 Dental care 42
Diagnostic services 7, 14, 41 Disputed claims review 46
Donor expenses (transplants) 28 Dressings 30
Durable medical equipment (DME) 23
Educational classes and programs 24 Effective date of enrollment 53
Emergency 33 Experimental or investigational
44, 52

Eyeglasses 21 Family planning 17
Fecal occult blood test 15 General Exclusions 44
Hearing services 20 Home health services 23
Hospice care 32 Hospital 10, 29
Immunizations 16 Infertility 18
Inhospital physician care 10, 29 Inpatient Hospital Benefits 29
Insulin 38, 39 Laboratory and pathological
services 15 Machine diagnostic tests 7,15
Magnetic Resonance Imagings (MRIs) 15, 31
Mail Order Prescription Drugs 38 Mammograms 15, 31
Maternity Benefits 17 Medicaid 57
Medically necessary 53 Medicare 51, 56
Mental Conditions/ Substance Abuse Benefits 35
Newborn care 17 Non-FEHB Benefits 44
Nurse Licensed Practical Nurse 23
Nurse Anesthetist 30 Registered Nurse 23
Obstetrical care 17 Occupational therapy 20
Office visits 7, 12, 42 Oral and maxillofacial surgery 27
Orthopedic devices 22 Out-of-pocket expenses 37, 38
Outpatient facility care 31 Oxygen 23, 30
Pap test 15 Physical examination 15, 16
Physical therapy 20

Preauthorization 37 Precertification 47
Preventive care, adult 15 Preventive care, children 16
Prescription drugs 38 Preventive services 42, 43
Prior approval 11 Prostate cancer screening 15
Prosthetic devices 7, 22, 25, 42
Psychologist 36 Psychotherapy 36
Radiation therapy 19 Renal dialysis 48
Room and board 29 Second surgical opinion 14
Skilled nursing facility care 31 Smoking cessation 24, 41
Speech therapy 20, 23 Splints 30, 31
Sterilization procedures 17, 25
Subrogation 51 Substance abuse 35
Surgery 25 Anesthesia 25, 28, 31

Oral 27, 42, 43 Outpatient 31
Reconstructive 26 Syringes 39
Temporary continuation of coverage 54
Transplants 28 Treatment Therapies 19
Vision services 8, 21 Well child care 16
Wheelchairs 23 Workers' compensation 51
X-rays 7, 15, 42 57
57 Page 58 59
2002 PacifiCare Asia Pacific 58
NOTES: 58
58 Page 59 60
2002 PacifiCare Asia Pacific 59 Summary
Summary of benefits for the PacifiCare Asia Pacific – 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 copayment: $10 primary care; $10 specialist for
High Option
Office visit copayment: $15 primary care; $15 specialist for

Standard Option

14

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

Outpatient .........................................................................................

Nothing per admission for high Option
$150 copayment per admission for Standard Option

Outpatient services are covered at your office visit copayment

29
31
Emergency benefits:
In-area.............................................................................................

Out-of-area .....................................................................................

$50 copayment for High Option $75 copayment for Standard
Option per emergency visit and all charges over $500

$50 copayment per emergency room visit High Option and 20%
of 1 st $500 for Standard Option and all charges after $500

32
32

Mental health and substance abuse treatment ...................................... Regular cost sharing 35
Prescription drugs ................................................................................ $5 copayment for formulary prescriptions $20 for non-formulary
prescriptions
38

Dental Care ....................................................................................... Nothing for preventive services 42
Vision Care ....................................................................................... Office visit copayment: $10 for High Option; $15 for Standard
Option
21 59
59 Page 60
2002 PacifiCare Asia Pacific 60 Summary
Special features: 43
Protection against catastrophic costs (your out-of-pocket maximum)......................................................... Nothing after $1,000/ Self Only or $3,000/ Family enrollment per year
for High Option
Nothing after $3,000/ Self Only or $6,000/ Family enrollment per year

for Standard Option
Some costs do not count toward this protection

12 60

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