Pages 1--60 from Universal Care

Serving: Southern California
Enrollment in this Plan is limited. You must live in or work in our
Geographic service area to enroll. See page 6 for requirements.

Enrollment codes for this Plan:
6Q1 Self Only
6Q2 Self and Family

RI 73-796

For changes
in benefits
see page 7.

This Plan has a three ( 3) year commendable
accreditation from the NCQA. See the 2002
Guide for more information on NCQA 1
1 Page 2 3
Table of Contents
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Plain Language . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Inspector General Advisory. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Section 1. Facts about this HMO plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
How we pay providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Who provides my health care? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Your Rights. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Service Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Section 2. How we change for 2002 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Program-wide changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Changes to this Plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Section 3. How you get care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Identification cards. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Where you get covered care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Plan providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Plan facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
What you must do to get covered care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Primary care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Specialty care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Hospital care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Circumstances beyond our control. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Services
requiring our prior approval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Section
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 . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
( c) Services provided by a hospital or other facility, and ambulance services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30(
d) Emergency services/ accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
( e) Mental health and substance abuse benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
( f) Prescription drug benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

2 2002 Universal Care Table of Contents 2
2 Page 3 4
( g) Special features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
( h) Dental benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40(
i) Non-FEHB benefits available to Plan members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Section 6. General exclusions things we don t cover . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Section 7. Filing a claim for covered services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Section 8. The disputed claims process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Section 9. Coordinating benefits with other coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
When you have. . .
Other health coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Original Medicare. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Medicare managed care plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
TRICARE/ Workers Compensation/ Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Other Government agencies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
When others are responsible for injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Section 10. Definitions of terms we use in this brochure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50Section
11. FEHB facts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Coverage information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
No pre-existing condition limitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Where you get information about enrolling in the FEHB Program. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Types of coverage available for you and your family. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
When benefits and premiums start . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Your medical and claims records are confidential . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
When you retire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
When you lose benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
When FEHB coverage ends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Spouse equity coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Temporary Continuation of Coverage ( TCC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Converting to individual coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Getting a Certificate of Group Health Plan Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Long term care insurance is coming later in 2002. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Summary of benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Back cover

3 2002 Universal Care Table of Contents 3
3 Page 4 5
Introduction
Universal Care
1600 East Hill Street
Signal Hill, California 90806-3682
800-635-6668

This brochure describes the benefits of Universal Care under our contract ( CS 2855) with the Office of Personnel Management
( OPM) , as authorized by the Federal Employees Health Benefits law. This brochure is the official statement of benefits. No
oral statement can modify or otherwise affect the benefits, limitations, and exclusions of this brochure.

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

OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2002, and changes are
summarized on page 7. Rates are shown at the end of this brochure.

Plain Language
Teams of Government and health plans staff worked on all FEHB brochures to make them responsive, accessible, and
understandable to the public. For instance,

Except for necessary technical terms, we use common words. For instance, you means the enrollee or family member; we means Universal Care.

W limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the Office of Personnel Management. If we use others, we tell you what they mean first.
Our brochure and other FEHB plans brochures have the same format and similar descriptions to help you compare plans.
If you have comments or suggestions about how to improve the structure of this brochure, let OPM know. Visit OPM s Rate
Us feedback area at www. opm. gov/ insure or e-mail OPM at fehbwebcomments@ opm. gov. You may also write to OPM at the
Office of Personnel Management, Office of Insurance Planning and Evaluation Division, 1900 E Street, NW Washington, DC
20415-3650.

Inspector General Advisory
Stop health care fraud. Fraud increases the cost of health care for everyone. If you suspect that a physician, pharmacy, or
hospital has charged you for services you did not receive, billed you twice for the same service, or misrepresented any
information, do the following:

Call the provider and ask for an explanation. There may be an error. If the provider does not resolve the matter, call us at 800-635-6668 and explain the situation.
If we do not resolve the issue, call THE HEALTH CARE FRAUD HOTLINE 202/ 418-3300 or write to: The United States Office of Personnel Management, Office of the Inspector General Fraud Hotline, 1900 E Street, NW, Room 6400,
Washington, DC 20415.
Penalties for Fraud. Anyone who falsifies a claim to obtain FEHB Program benefits can be prosecuted for fraud. Also, the
Inspector General may investigate anyone who uses an ID card if the person tries to obtain services for someone who is not an
eligible family member, or is no longer enrolled in the Plan and tries to obtain benefits. Your agency may also take
administrative action against you.

4 2002 Universal Care Introduction/ Plain Language 4
4 Page 5 6
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization ( HMO) . We require you to see specific physicians, hospitals, and other providers
that contract with us. These Plan providers coordinate your health care services.

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

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

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

How we pay providers
Universal Care contracts with individual physicians, medical groups, and hospitals to provide the FEHBP benefits. These Plan
providers accept a negotiated payment from us, and you will only be responsible for your copayments or coinsurance.
Universal Care provides covered services through the Universal Care Contracted Participating Medical Groups and Primary
Care Physicians. The location, telephone number and hours of service of the Contracted Participating Medical Groups and
Primary Care Physicians are listed in the Universal Care Provider Directory accompanying this Brochure. Emergency Services
are available on a 24-hour basis, seven ( 7) days a week.

Who provides my health care?
Universal Care provides covered services through the Universal Care Contracted Medical Groups and Primary Care Physicians.
The location, telephone number and hours of service of the Contracted Medical Groups and Primary Care Physicians are listed
in the Universal Care Provider Directory. Emergency Services are available on a 24-hour basis, seven ( 7) days a week.

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

Universal Care began its operations in 1983 and has been providing quality health care services for 17 years to Southern California residents.
Universal Care is a privately held, family-owned health plan. Universal Care currently has approximately 315,000 commercial ( group, individual) , and government program ( Medicaid,
Access for Infants and Mothers, Healthy Families, CalPERS, and FEHBP) enrollees.
Universal Care s focus is on quality and patient satisfaction, as reflected in routinely high scores in annual state medical audits.

Universal Care complies with State, Federal, and private accreditation standards that assure confidentiality of medical records and orderly transfer of medical records to caregivers. Universal Care has received 3-year commendable
accreditation from NCQA.
Universal Care encourages all of its members to fully participate in all decisions related to their health care.

If you want specific information about us, call 800-635-6668 or write to 1600 E. Hill St. , Signal Hill, CA 90806. You may also
contact us by fax at 562-490-9419 or visit our website at www. universalcare. com.

5 2002 Universal Care Section 1 5
5 Page 6 7
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:
Los Angeles, Orange, Riverside, San Bernardino, San Diego, Kern, and Ventura counties.

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

If you or a covered family member move outside of our service area, you can enroll in another plan. If your dependents live out
of the area ( for example, if your child goes to college in another state) , you should consider enrolling in a fee-for-service plan or
an HMO that has agreements with affiliates in other areas. If you or a family member moves, you do not have to wait until
Open Season to change plans. Contact your employing or retirement office.

.

6 2002 Universal Care Section 1 6
6 Page 7 8
Section 2. How we change for 2002
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5 Benefits.
Also, we edited and clarified language throughout the brochure; any language change not shown here is a clarification that does
not change benefits.

Program-wide changes
W no longer limit total blood cholesterol tests to certain age groups. ( Section 5( a) )

Changes to this Plan
Your share of the non-Postal premium will increase by 9.8% for Self Only and by 9.9% for Self and Family
You pay a $ 10 copay for name brand drugs on our formulary, a $ 30 copay for non-formulary drugs, or a $ 15 copay for name brand drugs obtained through our mail order program.

W increased speech therapy benefits by removing the requirement that services must be required to restore functional speech. ( Section 5( a) )
W now cover certain intestinal transplants. ( Section 5( b) )

7 2002 Universal Care Section 2 7
7 Page 8 9
Section 3. How you get care
Identification cards W will send you an identification ( ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive
services from a Plan provider, or fill a prescription at a Plan pharmacy. Until you
receive your ID card, use your copy of the Health Benefits Election Form, SF-2809,
your health benefits enrollment confirmation ( for annuitants) , or your Employee
Express confirmation letter.

If you do not receive your ID card within 30 days after the effective date of your
enrollment, or if you need replacement cards, call us at 800-635-6668.

Where you get covered care You get care from Plan providers and Plan facilities. Universal Care provides covered services through the Universal Care Contracted Medical Groups and
Primary Care Physicians ( PCP) . The location, telephone number and hours of
service of the Contracted Medical Groups and Primary Care Physicians are listed in
the Universal Care Provider Directory accompanying this Brochure. Emergency
Services are available on a 24-hour basis, seven ( 7) days a week. You will only pay
copayments and deductibles and you will not have to file claims.

Plan providers Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our members. We credential
Plan providers according to national standards. Universal Care s Plan providers
include Primary Care Physicians, specialty physicians, physician assistants and
nurse practitioners.

W list Plan providers in the provider directory, which we update periodically. The
list is also available on our website ( www. universalcare. com) .

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

What must you do to get It depends on the type of care you need. First, you and each family member must covered care choose a primary care physician. This decision is important since your primary
care physician provides or arranges for most of your health care. To select your
Primary Care Physician, call our Member Services Department at 800-635-6668.

Primary care Your Primary Care Physician can be a family practitioner, general practitioner, internist or pediatrician. Your Primary Care Physician will provide most of your
health care, or give you a referral to see a specialist. Your Primary Care Physician
is responsible for directing and coordinating all of your health care needs for
Covered Services. Your Primary Care Physician will arrange for laboratory tests, x-
rays, referrals to specialists, hospitalization, and any other Medically Necessary
Covered Services. In order to be covered under this health plan, all referrals to
specialists must be coordinated by your Primary Care Physician.

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

Specialty care Your Primary Care Physician will refer you to a specialist for needed care. However, you may see an OB/ GYN or an Internist without a referral. Generally,
your Primary Care Physician will refer you to a specialist within your Contracted
Medical Group. If you require services that are not available within your

8 2002 Universal Care Section 3 8
8 Page 9 10
Contracted Medical Group, the Primary Care Physician will arrange for a referral to
a Contracted Provider within Universal Care s network. To order certain services,
the Primary Care Physician will give you a written referral authorizing such
services. For certain specialty services, the referral is submitted by the Primary
Care Physician for review for Prior Authorization to Universal Care or to the
Contracted Medical Group s Utilization Review Committee.

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

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

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

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

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

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

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

Hospital care Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled nursing
or other type of facility.
If you are in the hospital when your enrollment in our Plan begins, call our
customer service department immediately at 800-635-6668. If you are new to the
FEHB Program, we will arrange for you to receive care.

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

9 2002 Universal Care Section 3 9
9 Page 10 11
You are discharged, not merely moved to an alternative care center; or
The day your benefits from your former plan run out; or
The 92nd day after you become a member of this Plan, whichever happens first
These provisions apply only to the benefits of the hospitalized person.
Circumstances beyond Under certain extraordinary circumstances, such as natural disasters, we may have our control 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. For prior approval 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.

W call this review and approval process Prior Authorization. Your physician must
obtain prior authorization for all authorization requests, which may include, but not
be limited to the following:

Referral to specialists
Laboratory services
Radiology
Elective procedures -inpatient or outpatient
Home health care
Durable Medical Equipment
Transportation.
Your physician must get our approval before sending you to a hospital, referring
you to a specialist, or recommending follow-up care. Prior Authorization means
that your Primary Care Physician must contact Universal Care ( or in some cases,
the Contracted Medical Group with which your Primary Care Physician is
affiliated) to request that the service be approved for coverage before services are
rendered. Requests for Prior Authorization will be denied if the requested services
are determined to be not Medically Necessary. Requests for Prior Authorization of
coverage for services by non-Contracted Providers will also be denied if Universal
Care determines that comparable or more appropriate services are available through
Universal Care s Contracted Providers.

The majority of requests for Prior Authorization of coverage are responded to
within 72 hours of their receipt, and urgent matters are expedited. Those requests
which require investigation and/ or physician review sometimes take longer as there
may be need for additional information and communication with the requesting
Primary Care Physician or specialist. Requests for coverage that are approved by
Universal Care are communicated directly to you and your Primary Care Physician
and the referral specialist along with an authorization number. Requests for Prior
Authorization of coverage that are denied by Universal Care are communicated in
writing to your Primary Care Physician and you.

10 2002 Universal Care Section 3 10
10 Page 11 12
In the event that Prior Authorization of coverage has been denied by Universal Care
( or in some cases, the Utilization Review Committee of your Contracted Medical
Group) , you, or your Primary Care Physician on your behalf may appeal the denial
by following the appeals process outlined on page 44 of this brochure. If you
would like a more detailed description of Universal Care s Criteria for Authorizing
or Denying Health Care Services, you may contact Universal Care s Member
Services Department at 800-635-6668.

11 2002 Universal Care Section 3 11
11 Page 12 13
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 $ 10per
office visit and when you go in the hospital, you pay nothing for admission.

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

Prescription drugs Durable Medical Equipment
Diagnosis and treatment of infertility
Be sure to keep accurate records of your copayments since you are responsible for
informing us when you reach the maximum.

12 2002 Universal Care Section 4

Your catastrophic protection out-of-pocket maximum for
deductibles, coinsurance, and copayments 12
12 Page 13 14
Section 5. Benefits OVERVIEW ( See page 7 for how our benefits changed this year and page 56 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 800-635-6668 or visit us at our website at www. universalcare. com.

( a) Medical services and supplies provided by physicians and other health care professionals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14-25
Diagnostic and treatment services Speech therapy Lab, X-ray, and other diagnostic tests Hearing services ( testing, treatment, and supplies)
Preventive care, adult Vision services ( testing, treatment, and supplies) Preventive care, children Foot care
Maternity care Orthopedic and prosthetic devices Family planning Durable medical equipment ( DME)
Infertility services Home health services Allergy care Chiropractic
Treatment therapies Alternative treatments Physical and occupational therapies Educational classes and programs

( b) Surgical and anesthesia services provided by physicians and other health care professionals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26-29
Surgical procedures Oral and maxillofacial surgery Reconstructive surgery Organ/ tissue transplants
Anesthesia
( c) Services provided by a hospital or other facility, and ambulance services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30-32
Inpatient hospital Hospice care Outpatient hospital or ambulatory surgical center Ambulance
Extended care benefits/ skilled nursing care facility benefits
( d) Emergency services/ accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33-34
Medical emergency Ambulance

( e) Mental health and substance abuse benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35-36
( f) Prescription drug benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37-38
( g) Special features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
24-hour nurse line

Services for deaf and hearing impaired
High risk pregnancies
Centers of Excellence for heart transplants/ heart surgeries
Travel benefits/ services overseas
( h) Dental benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40(
i) Non-FEHB benefits available to Plan members. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Summary of benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
13 2002 Universal Care Section 5 13
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14 2002 Universal Care Section 5( a)
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Section 5 ( a) . Medical services and supplies provided by physicians
and other health care professionals

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

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

including with Medicare.

Benefit Description You pay
Diagnostic and treatment services

Professional services of physicians $ 10 per office visit
In physician s office

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

At home visits by physician, nurse or health aide Nothing

Lab, X-ray and other diagnostic tests You Pay
Tests, such as: Nothing if you receive these services
Blood tests during your office visit; otherwise,
Urinalysis $ 10 per office visit
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG 14
14 Page 15 16
Preventive care, adult You Pay
Annual Physical Examination $ 10 per office visit

Routine screenings, such as: $ 10 per office visit
Blood Lead Level -One annually
Blood Cholesterol -once every three years
Colorectal Cancer Screening, including
Fecal occult blood test
Sigmoidoscopy, screening -every five years starting at age 50
Venereal Disease testing, including screening for chlamydial infection
Breast Cancer Screening

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

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

Preventive Care -Adult continued on next page

15 2002 Universal Care Section 5( a) 15
15 Page 16 17
Preventive care, adult ( continued) You pay
Routine mammogram -covered for women age 35 and older, as follows: $ 10 per office visit
From age 35 through 39, one during this five year period

From age 40 through 64, one every calendar year
At age 65 and older, one every two consecutive calendar years

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

Routine immunizations, limited to: $ 10 per office visit
Tetanus-diphtheria ( Td) booster -once every 10 years, ages 19 and over ( except as provided for under Childhood immunizations)

Influenza/ Pneumococcal vaccines, annually, age 65 and over
Travel immunizations not covered unless they are required by the country of entry

Preventive care, children You Pay
Childhood immunizations recommended by the American Academy $ 10 per office visit of Pediatrics

Well-child care charges for routine examinations, immunizations and No charge care ( up to age 2)
Well-child care charges for routine examinations, immunizations and $ 10 per office visit care ( from age 2-22)
Examinations, such as: $ 10 per office visit
Eye exams through age 19 to determine the need for vision
correction.

Ear exams through age 19 to determine the need for hearing
correction

Examinations done on the day of immunizations ( through age 22)

16 2002 Universal Care Section 5( a) 16
16 Page 17 18
17 2002 Universal Care Section 5( a)
Maternity care You pay
Complete maternity ( obstetrical) care, such as: No charge
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 30 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.
W 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.

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

Not covered: Routine sonograms to determine fetal age, size or sex All charges.
Family planning You Pay
A broad range of voluntary family planning services, limited to:
Voluntary sterilization

Vasectomy $ 100 copay
Tubal Ligation $ 100 copay
Injectable contraceptive drugs ( such as Depo Provera) $ 30 copay
Surgically implanted contraceptives ( such as Norplant) $ 10 per visit
Intrauterine devices ( IUDs) $ 10 per visit
Diaphragms $ 10 per visit
Abortion only when the life of the mother would be endangered if $ 150 copay fetus is carried to term or if the pregnancy is a result of an act of rape

or incest.
NOTE: We cover oral contraceptives under the prescription drug benefit.

Not covered: All charges.
Reversal of voluntary surgical sterilization, genetic counseling,
Any procedures, services, drugs and supplies related to Induced interruption of pregnancy ( abortion) unless under

the circumstances stated above. 17
17 Page 18 19
Infertility services You pay
Diagnosis and treatment of infertility, such as:
Artificial insemination: 50% of charges
Intravaginal insemination ( IVI)
Intracervical insemination ( ICI)
Intrauterine insemination ( IUI)
Fertility drugs 50% of charges
Note: W cover injectable fertility drugs under medical benefits and oral
fertility drugs under the prescription drug benefit.

Not covered: Assisted reproductive technology ( ART) procedures, All charges. such as:
In vitro fertilization
Embryo transfer, gamete GIFT and zygote ZIFT
Zygote transfer
Services and supplies related to excluded ART procedures
Cost of donor sperm
Cost of donor egg

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

Allergy serum Nothing
Not covered: provocative food testing and sublingual allergy All charges.
desensitization

18 2002 Universal Care Section 5( a) 18
18 Page 19 20
Treatment therapies You pay
Chemotherapy and radiation therapy $ 10 per office visit
Note: High dose chemotherapy in association with autologous bone
marrow transplants is limited to those transplants listed under
Organ/ Tissue Transplants on page 29.

Respiratory and inhalation therapy
Dialysis -Hemodialysis and peritoneal dialysis
Intravenous ( IV) / Infusion Therapy -Home IV and antibiotic therapy
Growth hormone therapy ( GHT)
Note: Growth hormone is covered under the prescription drug benefit.
Note: -W will only cover GHT when we preauthorize the treatment.
GHT is covered under the Plan s medical benefit. Call your Primary
Care Physician for preauthorization. We will ask you to submit
information that establishes that the GHT is medically necessary. Ask
us to authorize GHT before you begin treatment; otherwise, we will
only cover GHT services from the date you submit the information. If
you do not ask or if we determine GHT is not medically necessary, we
will not cover the GHT or related services and supplies. See Services
requiring our prior approval in Section 3.

19 2002 Universal Care Section 5( a) 19
19 Page 20 21
20 2002 Universal Care Section 5( a)
Physical and occupational therapies You Pay
60 visits per condition for the services of each of the following: $ 10 per outpatient visit
Qualified physical therapists and
Occupational therapists. Nothing per visit during covered inpatient
admission

Note: We only cover therapy to restore bodily function when there has
been a total or partial loss of bodily function due to illness or injury.
Occupational therapy is limited to services that assist the member to
achieve and maintain self-care and improved functioning in other
activities of daily living.

Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction, is provided for up to 60 sessions

Not covered: All charges.
Long-term rehabilitative therapy
Exercise programs

Speech therapy You Pay
60 visits per condition $ 10 per outpatient visit 20
20 Page 21 22
Hearing services ( testing, treatment, and supplies) You pay
Hearing aid and testing only when necessitated by accidental injury, $ 10 per office visit or hearing loss.

Hearing testing for children through age 19 ( see Preventive care, children)

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

Vision services ( testing, treatment, and supplies) You Pay
One pair of eyeglasses or contact lenses to correct an impairment $ 10 per office visit directly caused by accidental ocular injury or intraocular surgery
( such as for cataracts)
Diagnosis and treatment of diseases of the eye.
If you require an eye examination to determine the need for vision correction, the Plan provides for one ( 1) eye refraction a year.

Note: See Preventive care, children for eye exams for children
Not covered: All charges.
Eyeglasses or contact lenses and, after age 19, examinations for them
Eye exercises and orthoptics
Radial keratotomy and other refractive surgery

21 2002 Universal Care Section 5( a) 21
21 Page 22 23
Foot care You pay
Routine foot care when you are under active treatment for a metabolic $ 10 per office visit
or peripheral vascular disease, such as diabetes.

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

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

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

treatment is by open cutting surgery)

Orthopedic and prosthetic devices You Pay
Artificial limbs and eyes; stump hose $ 10 per office visit
Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy

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

Orthopedic devices, such as braces
Corrective orthopedic appliances for non-dental treatment of temporomandibular joint ( TMJ) pain dysfunction syndrome.

Orthopedic and prosthetic devices-Continued on next page

22 2002 Universal Care Section 5( a) 22
22 Page 23 24
Orthopedic and prosthetic devices ( Continued) You pay
Not covered: All charges.
Orthopedic and corrective shoes
Arch supports
Foot orthotics
Heel pads and heel cups
Lumbosacral supports
Corsets, trusses, elastic stockings, support hose, and other supportive devices

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

Durable medical equipment ( DME) You Pay
Rental or purchase, at our option, including repair and adjustment, of $ 10 per office visit
durable medical equipment prescribed by your Plan physician, such as
oxygen and dialysis equipment. Under this benefit, we also cover:

Hospital beds;
Wheelchairs;
Crutches;
Walkers;
Wigs are covered only for members undergoing chemotherapy or radiation treatment.

Blood glucose monitors; and
Insulin pumps.
Note: Call us at 800-635-6668 as soon as your Plan physician prescribes
this equipment. We will arrange with a health care provider to rent or
sell you durable medical equipment at discounted rates and will tell you
more about this service when you call.

Not covered: All charges.
Motorized wheel chairs

23 2002 Universal Care Section 5( a) 23
23 Page 24 25
Home health services You pay
Home health care ordered by a Plan physician and provided by a $ 10 per office visit registered nurse ( R. N. ) , licensed practical nurse ( L. P. N. ) , licensed
vocational nurse ( L. V. N. ) , or home health aide.
Services include oxygen therapy, intravenous therapy and medications.

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

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

Chiropractic You Pay
No benefit. All charges

24 2002 Universal Care Section 5( a) 24
24 Page 25 26
Alternative treatments You pay
No benefit All charges.

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

Diabetes self-management
Weight Loss
Cholesterol control
Exercise
Parenting
Healthy kids
Breast feeding
Healthy Living: Fast foods/ Dining out
Hypertension management
Stress Management
Healthy Living Back
Asthma control: Children ( ages 4-8)
Teens ( ages 9-14)
Adults ( ages 15+ )

25 2002 Universal Care Section 5( a) 25
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26 2002 Universal Care Section 5( b)

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

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

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

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

( i. e. hospital, surgical center, etc. ) .
YOU MUST GET PRIOR AUTHORIZATION FOR ALL SURGICAL PROCEDURES.

Benefit Description You pay
Surgical procedures
A comprehensive range of services, such as: $ 10 per office visit
Operative procedures
Treatment of fractures, including casting
Normal pre-and post-operative care by the surgeon
Correction of amblyopia and strabismus
Endoscopy procedures
Biopsy procedures
Removal of tumors and cysts
Correction of congenital anomalies ( see reconstructive surgery)
Surgical treatment of morbid obesity. A condition in which an individual weighs 100 pounds or 100% over his or her normal weight

according to current underwriting standards; eligible members must be
age 18 or over. Surgery for morbid obesity will be performed only as a
last resort, when the member s health is endangered and more
conservative medical measures, including prescription drugs such as
appetite suppressants, have not been successful.

Insertion of internal prosthetic devices. See 5( a) -Orthopedic and prosthetic devices for device coverage information.

Surgical procedures continued on next page. 26
26 Page 27 28
Surgical procedures ( continued) You pay
Voluntary sterilization $ 10 per office visit
Treatment of burns
Note: Generally, we pay for internal prostheses ( devices) according to
where the procedure is done. For example, we pay Hospital benefits for a
pacemaker and Surgery benefits for insertion of the pacemaker.

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

Reconstructive surgery You Pay
Surgery to correct a functional defect $ 10 per office visit
Surgery to correct a condition caused by injury or illness if:
The condition produced a major effect on the member s
appearance and

The condition can reasonably be expected to be corrected by
such surgery

Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of

congenital anomalies are: protruding ear deformities; cleft lip; cleft
palate; birth marks; webbed fingers; and webbed toes.

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

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

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

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

27 2002 Universal Care Section 5( b) 27
27 Page 28 29
Oral and maxillofacial surgery You Pay
Oral surgical procedures, limited to: $ 10 per office visit
Reduction of fractures of the jaws or facial bones;
Surgical correction of cleft lip, cleft palate or severe functional malocclusion;

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

Other surgical procedures that do not involve the teeth or their supporting structures.
Treatment of TMJ, including surgical and non-surgical intervention
Not covered: All charges.
Oral implants and transplants
Procedures that involve the teeth or their supporting structures ( such as the periodontal membrane, gingiva, and alveolar bone)

Orthopedic appliances

28 2002 Universal Care Section 5( b) 28
28 Page 29 30
Organ/ tissue transplants You pay
Limited to: Nothing
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single -Double
Pancreas
Allogeneic ( donor) bone marrow transplants
Autologous bone marrow transplants ( autologous stem cell and peripheral stem cell support) for the following conditions: acute

lymphocytic or non-lymphocytic leukemia; advanced 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: W cover related medical and hospital expenses of the donor when
we cover the recipient.

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

Implants of artificial organs
Transplants not listed as covered

Anesthesia You pay
Professional services provided in -Nothing
Hospital ( inpatient)

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

29 2002 Universal Care Section 5( b) 29
29 Page 30 31
30 2002 Universal Care Section 5( c)
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Section 5 ( c) . Services provided by a hospital or other facility,
and ambulance services

Here are some important things to 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.
W have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services , for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage,

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

charge ( i. e. , physicians, etc. ) are covered in Sections 5( a) or ( b) .
YOU MUST GET PRIOR AUTHORIZATION FOR ALL HOSPITAL STAYS.

Benefit Description You pay

Inpatient Hospital
Room and board, such as Nothing
Ward, semiprivate, or intensive care accommodations;
Private rooms,
Special duty nursing,
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.

Inpatient hospital continued on next page. 30
30 Page 31 32
Inpatient hospital ( continued) You pay
Other hospital services and supplies, such as: Nothing
Operating, recovery, maternity, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays
Administration of blood and blood products
Blood or blood plasma, if not donated or replaced
Dressings, splints, casts, and sterile tray services
Medical supplies and equipment, including oxygen
Anesthetics, including nurse anesthetist services
Take-home items
Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home

Hospitalization for certain dental procedures is covered when a Plan physician determines there is a need for hospitalization for reasons
totally unrelated to the dental procedure.

Not covered: All charges.
Custodial care
Non-covered facilities, such as nursing homes, schools
Blood and blood derivatives not replaced by the member.
Personal comfort items, such as telephone, television, barber services, guest meals and beds

Private nursing care
Outpatient hospital or ambulatory surgical center You Pay
Operating, recovery, and other treatment rooms Nothing
Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology services
Administration of blood, blood plasma, and other biologicals
Blood and blood plasma, if not donated or replaced
Pre-surgical testing
Dressings, casts, and sterile tray services
Medical supplies, including oxygen
Anesthetics and anesthesia service
NOTE: -W cover hospital services and supplies related to dental
procedures when necessitated by a non-dental physical impairment. W
do not cover the dental procedures.

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

31 2002 Universal Care Section 5( c) 31
31 Page 32 33
Extended care benefits/ skilled nursing care facility benefits You pay
Extended care benefit: Nothing
Subacute care is provided in either a designated area of an acute care
hospital, in a comprehensive freestanding rehabilitation facility, or in a
specially designed unit within a skilled nursing facility. Subacute care is
considered a lower level of care in terms of nursing and physician
contact time with the patient, and yet is still a comprehensive level of
care for patients whose condition is likely to continue to improve and
who:

Have had an acute illness of injury for which acute care is no longer medically necessary.

Have experienced a recurrence of a chronic disease process for which acute care is no longer necessary.
Though stable, may still require some diagnostic and/ or invasive procedures and nursing care and/ or monitoring.

Skilled nursing facility ( SNF) : Nothing
The Plan provides a comprehensive range of benefits with no dollar
limit, for up to 100 days per calendar year, when full-time skilled
nursing care is necessary and confinement in a skilled nursing facility is
medically appropriate as determined by a Plan doctor and approved by
the Plan. 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.

Not covered: custodial care All charges.
Hospice care You Pay
Supportive and palliative care for a terminally ill member is covered in Nothing
the home or a hospice facility. Services include inpatient and outpatient
care, and family counseling; these services are provided under the
direction of a Plan doctor who certifies that the patient is in the terminal
stages of illness, with a life expectancy of approximately six months or
less. Services must be authorized by a Plan doctor and approved by the
Plan.

Not covered: Independent nursing, homemaker services All charges.
Ambulance You Pay
Local professional ambulance service when medically appropriate Nothing

32 2002 Universal Care Section 5( c) 32
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Section 5 ( d) . Emergency services/ accidents
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure.

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

including with Medicare.

33 2002 Universal Care Section 5( d)
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:
If you are in an emergency situation, immediately call 911 or go directly to the nearest emergency room for treatment. B
sure to tell the emergency room personnel that you are a Universal Care member so they can notify the Plan.

Emergencies within our service area: You or a family member must telephone your Universal Care medical group within 24 hours ( unless it was not reasonably possible to do so) . It is your responsibility to ensure that the Plan has been timely
notified. Continuing treatment shall be covered for only so long as the Medical Director of the Plan, after reviewing any
medical records or other relevant information and conferring with the physician in charge of the patient care, determined that the
member cannot be transferred to the care of a Universal Care Medical Group or contracting provider.

Emergencies outside our service area: You or a family member must telephone your Universal Care medical group within 24 hours ( unless it was not reasonably possible to do so) . It is your responsibility to ensure that the Plan has been timely
notified. Continuing treatment shall be covered for only so long as the Medical Director of the Plan, after reviewing any
medical records or other relevant information and conferring with the physician in charge of the patient care, determined that the
member cannot be transferred to the care of a Universal Care Medical Group or contracting provider.

If you need to be hospitalized in a non-Plan facility, the Plan must be notified within 48 hours or on the first working day
following your admission, unless it was not reasonably possible to notify the Plan within that time. If you are hospitalized in a
non-Plan facility and a Plan doctor believes care can be better provided in a Plan hospital, you will be transferred when
medically feasible with any ambulance charges covered in full. 33
33 Page 34 35
Benefit Description You pay
Emergency within our service area
Emergency care at a doctor s office $ 10 per visit
Emergency care at an urgent care center $ 25 per visit
Emergency care as an outpatient or inpatient at a hospital, including $ 25 per visit doctors services If the emergency results in admission to a

hospital, the copay is waived.

Not covered: Elective care or non-emergency care All charges.
Emergency outside our service area You Pay
Emergency care at a doctor s office $ 10 per visit
Emergency care at an urgent care center $ 25 per visit
Emergency care as an outpatient or inpatient at a hospital, including $ 25 per visit doctors services If the emergency results in admission to a

hospital, the copay is waived.

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

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

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

Not covered: air ambulance All charges.

34 2002 Universal Care Section 5( d) 34
34 Page 35 36
35 2002 Universal Care Section 5( e)
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Section 5 ( e) . Mental health and substance abuse benefits
When you get our approval for services and follow a treatment plan we approve, cost-sharing and
limitations for Plan mental health and substance abuse benefits will be no greater than for similar
benefits for other illnesses and conditions.

Here are some important things to keep in mind about these benefits:
All benefits are subject to the definitions, limitations, and exclusions in this brochure.
Be sure to read Section 4, Your costs for covered services , for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage,

including with Medicare.
YOU MUST GET PRIOR AUTHORIZATION OF THESE SERVICES. See the instructions after the benefits description below.

Benefit Description You pay
Mental health and substance abuse benefits
All diagnostic and treatment services recommended by a Plan provider Your cost sharing responsibilities are no
and contained in a treatment plan that we approve. The treatment plan greater than for other illness or conditions.
may include services, drugs, and supplies described elsewhere in this
brochure.

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

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

Mental health and substance abuse benefits -continued on next page 35
35 Page 36 37
Mental health and substance abuse benefits ( continued) You pay
Diagnostic tests $ 10 for each covered visit or test

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

hospitalization, facility based intensive outpatient treatment

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

Preauthorization To be eligible to receive these benefits you must obtain a treatment plan and follow all the following authorization processes:

To get a referral, contact your Primary Care Physician. If you have an emergency and are unable to contact your PCP, call the Triage service at 800-
377-7012. In order to obtain a provider directory, call our Member Services
Department at 800-635-6668.

Limitation W may limit your benefits if you do not follow your treatment plan.

36 2002 Universal Care Section 5( e) 36
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Section 5 ( f) . Prescription drug benefits
Here are some important things to keep in mind about these benefits:
W 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.

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

including with Medicare.

There are important features you should be aware of. These include:
Who can write your prescription. A licensed Plan or referral physician must write the prescription.
Where you can obtain them. You must fill the prescription at a Plan pharmacy. Universal Care approved maintenance drugs for chronic conditions can be ordered through the mail.

We use a formulary. Universal Care uses a comprehensive formulary as a method of evaluating various drug products available to treat illnesses. The formulary is a preferred list of generic & name brand drugs that we
have selected to meet patient needs at a lower cost and are:
FDA approved for specified indications; Reviewed by Universal Care with participation by practicing physicians;

Safe and effective as well as being medically necessary for the treatment of maintenance of a medical condition; and
Cost effective for the treatment of the medical condition.
Your physician may prescribe a name brand drug or a generic drug from a formulary list. A generic equivalent will
be dispensed if it is available, unless your physician specifically requires a name brand. If your physician
prescribes a drug that is not on our formulary, you pay the non-formulary copay. Non-formulary drugs that are
prior approved by us will be subject to the applicable formulary copay.

To order a prescription drug formulary, call 800-635-6668.

These are the dispensing limitations. Up to a one-month supply of a prescription drug will be dispensed. Certain
drugs such as vitamins with fluoride for infants may be limited for up to one year. A 90-day supply of a
prescription drug for chronic conditions ordered through the mail. If a member sends in an order too soon after the
last one was filled, the new order will not go through. Only maintenance medications for conditions such as
hypertension, diabetes, etc. are available through mail order.

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

When you have to file a claim. Submit all claims to: Universal Care P. O. Box 16420Signal

Hill, CA 90806
Covered medications and supplies continued on next page

37 2002 Universal Care Section 5( f) 37
37 Page 38 39
Covered medications and supplies You pay
W 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.
Oral contraceptive drugs
Insulin; a copay charge applies to each vial
Disposable needles and syringes needed to inject covered prescribed medication

Insulin syringes, needles and blood glucose monitoring strips
Prenatal Vitamins
Vitamins with fluoride for infants up to one year of age
Intravenous fluids and medication for home use.
Off-label medication will be covered only if the Prescribing Plan Physician provides pre-reviewed medical literature or if the off-label

medication has become a community standard.
Oral fertility drugs
Drugs for sexual dysfunction
Note: Implantable drugs, such as Norplant, and some injectable drugs,
such as Depo Provera, are covered under Medical and Surgical Benefits

Not covered: All charges.
Drugs and supplies for cosmetic purposes
Drugs to enhance athletic performance
Drugs obtained at a non-Plan pharmacy; except for out-of-area emergencies

Vitamins, nutrients and food supplements even if a physician prescribes or administers them, except for prenatal vitamins and vitamins with
fluoride for infants up to one year of age
Medical supplies such as dressings and antiseptics
Diabetic supplies, except for insulin syringes, needles and blood glucose monitoring strips

Smoking cessation drugs and medication
Over the counter medications prescribed by a physician

38 2002 Universal Care Section 5( f)

$ 5 for generic drugs listed on our
formulary

$ 10 for brand name drugs with no generic
equivalent listed on our formulary

$ 30 for generic or brand name drugs not
listed on our formulary

Mail Order: 90-day supply of prescribed
maintenance drugs obtained through our
mail order program:
$ 7.50 for generic drugs
$ 15 for brand name drugs

Note: If there is no generic equivalent
available, you will still have to pay the
brand name copay. 38
38 Page 39 40
Section 5 ( g) . Special features
Feature Description
24 hour nurse line For any of your health concerns, 24 hours a day, 7 days a week, you may call 800-hearing impaired 377-7012 and talk with a registered nurse who will discuss treatment options and
answer your health questions.
Services for deaf and The hearing and speech impaired may use Universal Care s toll-free telephone hearing impaired number ( 866) -321-5955 ( TTY) )

High risk pregnancies Universal Care has a Women s Health Department that monitors and manages high-risk pregnancies.
Centers of excellence for Universal Care has contracts with centers of excellence including UCLA Medical transplants/ heart surgery/ etc Center, Loma Linda University Medical Center, and Cedars Sinai Medical Center.
Travel benefit/ services Universal Care covers all travel immunizations required for travel by the country of overseas destination

39 2002 Universal Care Section 5( g) 39
39 Page 40 41
IM
P
O
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T
A
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T

IM
P
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A
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40 2002 Universal Care Section 5( h)

Section 5 ( h) . Dental benefits
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

Plan dentists must provide or arrange your care.
W have no calendar year deductible
W cover hospitalization for dental procedures only when a nondental physical impairment exists which makes hospitalization necessary to safeguard the health of the patient; we do not cover the

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

including with Medicare.

Accidental injury benefit You pay
W cover restorative services and supplies necessary to promptly repair $ 35 for initial stabilization services
( but not replace) sound natural teeth. The need for these services must
result from an accidental injury. $ 10 for follow-up visits

Dental benefits
W have no other dental benefits. 40
40 Page 41 42
Section 5 ( i) . Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed
claim about them. Fees you pay for these services do not count toward FEHB deductibles or out-of-pocket
maximums.

Dental Benefits:
You and your family can receive Dental benefits for an annual fee payable to Universal Care.
Subscriber $ 42.00 per year Subscriber and Dependent $ 84.00 per year
Subscriber and Family $ 134.40 per year
You and each covered member of your family are entitled to enrollment in our Dental Plan. You must enroll in
Universal Care s Dental plan to receive these benefits. The following sample copayments apply.

Adult Oral Examination No charge Child Oral Examination No charge
Adult Cleaning $ 20.00 Child Cleaning $ 15.00

The Dental Plan is currently available to all members. To receive further information and enroll in Universal
Care s Dental 700 Plan, please call ( 800) 635-6668

41 2002 Universal Care Section 5( i) 41
41 Page 42 43
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.

W 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.

42 2002 Universal Care Section 6 42
42 Page 43 44
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at Plan
pharmacies, you will not have to file claims. Just present your identification card and pay your copayment.

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

Medical and hospital & drug In most cases, providers and facilities file claims for you. Physicians must file on benefits the form HCFA-1500, Health Insurance Claim Form. Facilities will file on the
UB-92 form. For claims questions and assistance, call us at 800-635-6668.
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: Universal Care
PO Box 16420Signal
Hill, CA 90806

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. W may delay processing or deny your claim if you do not respond.

43 2002 Universal Care Section 7 43
43 Page 44 45
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your
claim or request for services, drugs, or supplies -including a request for preauthorization:

Step Description
1 Ask us in writing to reconsider our initial decision. You must:
( a) Write to us within 6 months from the date of our decision; and
Send your request to us at: Universal Care
Attn: Grievance Unit
1600 E. Hill Street
Signal Hill, CA 90806

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

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

2 W 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.
W will base our decision on the information we already have.

W 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.

44 2002 Universal Care Section 8 44
44 Page 45 46
The Disputed Claims 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) W haven t responded yet to your initial request for care or preauthorization/ prior approval, then call us at
800-635-6668 and we will expedite our review; or

( b) W denied your initial request for care or preauthorization/ prior approval, then:
If we expedite our review and maintain our denial, we will inform OPM so that they can give your claim expedited treatment too, or

You can call OPM s Health Benefits Contracts Division 3 at 202-606-0737 between 8 a. m. and 5 p. m. eastern time.

45 2002 Universal Care Section 8 45
45 Page 46 47
Section 9. Coordinating benefits with other coverage
When you have other health You must tell us if you are covered or a family member is covered under another coverage group health plan or have automobile insurance that pays health care expenses
without regard to fault. This is called double coverage.
When you have double coverage, one plan normally pays its benefits in full as the
primary payer and the other plan pays a reduced benefit as the secondary payer.
We, like other insurers, determine which coverage is primary according to the
National Association of Insurance Commissioners guidelines.

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

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

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

Part B ( Medical Insurance) . Most people pay monthly for Part B. Generally, Part B premiums are withheld from your monthly Social Security check or
your retirement check.
If you are eligible for Medicare, you may have choices in how you get your health
care. Medicare + Choice is the term used to describe the various health plan
choices available to Medicare beneficiaries. The information in the next few pages
shows how we coordinate benefits with Medicare, depending on the type of
Medicare managed care plan you have.

The Original Medicare Plan The Original Medicare Plan ( Original Medicare) is available everywhere in the ( Part A or Part B) United States. It is the way everyone used to get Medicare benefits and is the way
most people get their Medicare Part A and Part B benefits now. You may go to any
doctor, specialist, or hospital that accepts Medicare. The Original Medicare Plan
pays its share and you pay your share. Some things are not covered under Original
Medicare, like prescription drugs.

When you are enrolled in Original Medicare along with this Plan, you still need to
follow the rules in this brochure for us to cover your care. When Medicare is the
primary payer, we waive all out-of-pocket costs.

( Primary payer chart begins on next page. )
46 2002 Universal Care Section 9 46
46 Page 47 48
The following chart illustrates whether the Original Medicare Plan or this Plan should be the primary payer for you according to
your employment status and other factors determined by Medicare. It is critical that you tell us if you or a covered family
member has Medicare coverage so we can administer these requirements correctly.

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

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

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

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

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

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

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

1) Are within the first 30 months of eligibility to receive Part A benefits solely
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, or
d) Are a former spouse of an active employee
47 2002 Universal Care Section 9 47
47 Page 48 49
Claims process when you have the Original Medicare Plan You probably will
never have to file a claim form when you have both our Plan and the Original
Medicare Plan.

When we are the primary payer, we process the claim first.
When Original Medicare is the primary payer, Medicare processes your claim first. In most cases, your claims will be coordinated automatically and we will
pay the balance of covered charges. You will not need to do anything. To find
out if you need to do something about filing your claims, call us at
800-635-6668.

We waive all costs when you have the Original Medicare Plan When Original
Medicare is the primary payer, we will waive all out-of-pocket costs

Medicare managed care plan If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from another type of Medicare+ Choice plan a Medicare managed care
plan. These are health care choices ( like HMOs) in some areas of the country. In
most Medicare managed care plans, you can only go to doctors, specialists, or
hospitals that are part of the plan. Medicare managed care plans provide all the
benefits that Original Medicare covers. Some cover extras, like prescription drugs.
To learn more about enrolling in a Medicare managed care plan, contact Medicare
at 1-800-MEDICARE ( 1-800-633-4227) or at www. medicare. gov.

If you enroll in a Medicare managed care plan, the following options are available
to you:

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

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

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

48 2002 Universal Care Section 9 48
48 Page 49 50
Workers Compensation W 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 W 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 for injuries 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.

If you have a malpractice claim If you have a malpractice claim because of services you did or did not receive from a plan provider, it must go to binding arbitration. Contact Universal Care at 800-
635-6668 about how to begin the binding arbitration process.

49 2002 Universal Care Section 9 49
49 Page 50 51
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 Personal services required to assist a Member in meeting the requirements of daily living. Such services include, without limitation, assistance in walking, getting in
or out of bed, bathing, dressing, feeding, or using the lavatory, preparation of
special diets and supervision of medication schedules. Custodial Care does not
require the continuing attention of trained medical or paramedical personnel.

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 12.
Experimental and For Universal Care to determine if a service or supply is experimental or Investigational Services investigational, we refer to evidence from the national medical community, which
may include one or more of the following sources:
National Centers for Health Services Research; Peer-reviewed medical and
scientific literature; Publications from organizations such as the American Medical
Association; Professionals, specialists and experts; and written protocols and
consent forms used by the proposed treating facility or other facility administering
substantially the same drug, device or medical treatment.

In addition, the service or supply must meet all of the following criteria:
If it is a drug or device, which cannot be lawfully marketed without the approval of
the United States Food and Drug Administration ( FDA ) , final approval must have
been obtained at the time the drug or device is furnished. Interim FDA approvals
for a Phase I, II or III trial, pre-market approval applications and investigational
exemptions are not sufficient.

The evidence must show conclusively that the service or supply is safe, effective
and medically appropriate for use in the treatment of the illness, injury or condition
at issue as compared to the conventional means of treatment or diagnosis.

The service or supply must be recognized or approved in accordance with generally
accepted professional medical standards. Any required approval of any federal
government or agency, or any state government or agency, must have been obtained
prior to the time of use.

To obtain additional information concerning how we determine whether a particular
service or treatment is experimental or investigational or to obtain information on
how to appeal our decision to deny a service or treatment as Experimental or
Investigational, please call our Member Services Department at 800-635-6668.

50 2002 Universal Care Section 10 50
50 Page 51 52
Group health coverage Health benefit coverage for a group that has met the program required eligibility requirements for participation and has health care provided by Universal Care.
Medical necessity The medical treatment or services are required and are necessary to maintain the health of an Enrollee consistent with professionally recognized standards of care in
the judgment of the physician in charge of the Enrollee s care. However, in the
event the medical director must determine whether or not medical treatment or
services are, or were, a Medical Necessity, ( 1) he shall confer with the physician in
charge of such patient s care, and ( 2) he shall base his decision upon the standards
of the medical community as they would apply to the specific situation.

Us/ We Us and we refer to Universal Care , a California Corporation that operates a health care service plan licensed by the State of California under the Knox-Keene Health
Care Service Plan Act of 1975.
You You refers to the enrollee and each covered family member.

51 2002 Universal Care Section 10 51
51 Page 52 53
Section 11. FEHB facts
No pre-existing condition W 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 can answer about enrolling in the your questions, and give you a Guide to Federal Employees Health Benefits Plans,
FEHB Program 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.
W 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 you, your for you and your family spouse, and your unmarried dependent children under age 22, including any foster
children or stepchildren your employing or retirement office authorizes coverage
for. Under certain circumstances, you may also continue coverage for a disabled
child 22 years of age or older who is incapable of self-support.

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

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

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

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

52 2002 Universal Care Section 11 52
52 Page 53 54
Your medical and claims W will keep your medical and claims information confidential. Only the following records are confidential will have access to it:
OPM, this Plan, and subcontractors when they administer this contract; This Plan and appropriate third parties such as other insurance plans and the
Office of Workers Compensation Programs ( OWCP) when coordinating
benefit payments and subrogating claims;

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

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

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

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

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

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

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

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

Converting to You may convert to a non-FEHB individual policy if: individual coverage

53 2002 Universal Care Section 11 53
53 Page 54 55
Your coverage under TCC or the spouse equity law ends ( If you canceled your coverage or did not pay your premium, you cannot convert) ;
You decided not to receive coverage under TCC or the spouse equity law; or
You are not eligible for coverage under TCC or the spouse equity law.
If you leave Federal service, your employing office will notify you of your right to
convert. You must apply in writing to us within 31 days after you receive this
notice. However, if you are a family member who is losing coverage, the
employing or retirement office will not notify you. You must apply in writing to us
within 31 days after you are no longer eligible for coverage.

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

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

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

54 2002 Universal Care Section 11 54
54 Page 55 56
Long Term Care Insurance Is Coming Later in 2002!
Many FEHB enrollees think that their health plan and/ or Medicare wilil cover their long-term care needs. Unfortunately, they are WRONG!
How are YOU planning to pay for the future custodial or chronic care you may need?
You should consider buying long-term care insurance.

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

What is long-term care It s insurance to help pay for long term care services you may need if you
( LTC) insurance? can t take care of yourself because of an extended illness or injury, or an age-
related disease such as Alzheimer s.
LTC insurance can provide broad, flexible benefits for nursing home care, care
in an assisted living facility, care in your home, adult day care, hospice care,
and more. LTC insurance can supplement care provided by family members,
reducing the burden you place on them.

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

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

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

Long-term care can easily exhaust your savings. Long-term care insurance can protect your savings.

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

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

Medicaid covers long term care for those who meet their state s poverty guidelines, but has restrictions on covered services and where they can be
received. Long-term care insurance can provide choices of care and preserve
your independence.

55 2002 Universal Care Section 11 55
55 Page 56 57
When will I get more information Employees will get more information from their agencies during the LTC open
on how to apply for this new enrollment period in the late summer/ early fall of 2002.
insurance coverage?
Retirees will receive information at home.

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

56 2002 Universal Care Section 11 56
56 Page 57 58
Index
Do not rely on this page; it is for your convenience and may not show all pages where the terms appear.

57 2002 Universal Care Index
Accidental injury 20, 27, 42
Allergy tests 18
Alternative treatment 25
Allogenetic ( donor) bone marrow
transplant 29
Ambulance 32, 34
Anesthesia 29
Autologous bone marrow transplant
19, 29
Biopsies 26
Blood and blood plasma 31
Breast cancer screening 15
Casts 31
Catastrophic protection 12
Changes for 2002 7
Chemotherapy 19, 23
Childbirth 17
Chiropractic 13, 24
Cholesterol tests 7, 15
Claims 37, 43, 45
Coinsurance 12, 50Colorectal
cancer screening 15
Congenital anomalies 26, 27
Contraceptive devices and drugs 17,
38
Coordination of benefits 46
Covered charges 12
Covered providers 6
Crutches 23
Deductible 12, 50Definitions
50Dental
care 40Diagnostic
services 14
Disputed claims review 44
Donor expenses ( transplants) 29
Dressings 31, 38
Durable medical equipment ( DME)
23
Educational classes and programs 25
Effective date of enrollment 52
Emergency 33
Experimental or investigational 50Eyeglasses
16, 21
Family planning 17

Fecal occult blood test 15
General Exclusions 42
Hearing services 21
Home health services 24
Hospice care 32
Home nursing care 32
Hospital 30Immunizations
16
Infertility 18
In-hospital physician care 14
Inpatient Hospital Benefits 30Insulin
38
Laboratory and pathological services
14
Machine diagnostic tests 14
Magnetic Resonance Imagings
( MRIs) 14
Mail Order Prescription Drugs 38
Mammograms 14
Maternity Benefits 17
Medicaid 49
Medically necessary 51
Medicare 46
Members 4, 6, 23, 25, 41, 52
Mental Conditions/ Substance Abuse
Benefits 35
Neurological testing 14
Newborn care 17
Non-FEHB Benefits 41
Nurse
Licensed Practical Nurse 24
Nurse Anesthetist 31
Nurse Practitioner 8
Registered Nurse 24, 39
Nursery charges 17
Obstetrical care 17
Occupational therapy 20Ocular
injury 21
Office visits 5, 14
Oral and maxillofacial surgery 28
Orthopedic devices 22
Out-of-pocket expenses 7, 12
Outpatient facility care 31
Oxygen 24,31

Pap test 15
Physical examination 15
Physical therapy 20Physician
14
Precertification 17
Preventive care, adult 15
Preventive care, children 16
Prescription drugs 37
Preventive services 15
Prior approval 10Prostate
cancer screening 15
Prosthetic devices 22
Psychologist 35
Psychotherapy 35
Radiation therapy 19
Renal dialysis 19
Room and board 30Second
surgical opinion 14
Skilled nursing facility care 32
Smoking cessation 25, 38
Speech therapy 20Splints
31
Sterilization procedures 17
Subrogation 49
Substance abuse 35
Surgery 26
Anesthesia 29
Oral 28
Outpatient 31
Reconstructive 27
Syringes 38
Temporary continuation of coverage
53
Transplants 29
Treatment therapies 19
Vision services 21
Well child care 16
Wheelchairs 23
Workers compensation 49
X-rays 14 57
57 Page 58 59
Summary of benefits for Universal Care -2002
Do not rely on this chart alone. All benefits are provided in full unless indicated and are subject to the definitions, limitations, and exclusions in this brochure. On this page we summarize specific expenses we
cover; for more detail, look inside.
If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on your enrollment form.

W only cover services provided or arranged by Plan physicians, except in emergencies.
Benefits You Pay Page
Medical services provided by physicians:
Diagnostic and treatment services provided in the office . . . . . . . . . . . . . . . . . . . . . . . . Office visit copay: $ 10 primary care; . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 10 specialist 14

Services provided by a hospital:
Inpatient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nothing 30
Outpatient. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nothing 31

Emergency benefits:
In-area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 25 per emergency room visit 33
Out-of-area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 25 per emergency room visit 33

Mental health and substance abuse treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Regular cost sharing. 35
Prescription drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Generic drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 5
Brand name drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 10Non-
formulary drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 30Mail
order drugs -generic. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 7.50Mail
order drugs -brand name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 15

Dental Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No benefit. 40Vision
Care -Annual refraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 10 copay 21
Special features: 24-hour nurse line, services for the deaf, high risk pregnancies, centers of excellence, travel benefit 39
Protection against catastrophic costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nothing after $ 1,000/ Self Only or 12
( your out-of-pocket maximum) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 3,000/ Family enrollment per year

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Some costs do not count toward this
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . protection

58 2002 Universal Care Summary 58
58 Page 59 60
NOTES 59
59 Page 60
2002 Rate Information for
Universal Care

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

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

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

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

Self Only 6Q1 $ 63.00 $ 21.00 $ 136.50 $ 45.50 $ 74.55 $ 9.45
Self & Family 6Q2 $ 166.37 $ 55.46 $ 360.47 $ 120.16 $ 196.87 $ 24.96

2002 Universal Care 60

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