Pages 1--59 from HealthSpring

Serving: Serving the Nashville metroplex and 27 counties of Middle Tennessee.
Enrollment in this Plan is limited: You must live or work in our Geographic service area to enroll. See page 7 for requirements.

Enrollment codes for this Plan:
6K1 Self Only 6K2 Self and Family

Special notice: This Plan is offered for the first time under the Federal Employees Health Benefits Program during the 2001 Open Season.

RI 73-812

This Plan has URAC accreditation from the American Accreditation Healthcare Commission/ URAC.
See the 2002 Guide for more information on accreditation. 1
1 Page 2 3
2002 HealthSpring 2 Table of Contents
Table of Contents
Introduction…………………………………………………………………. ........................................................................................ 4
Plain Language ....................................................................................................................................................................................... 4
Inspector General Advisory .................................................................................................................................................................... 4
Section 1. Facts about this HMO plan ................................................................................................................................................... 6
How we pay providers .......................................................................................................................................................... 6
Your rights ............................................................................................................................................................................ 6
Service area........................................................................................................................................................................... 7
Section 2. We are a new plan................................................................................................................................................................. 8
Section 3. How you get care ................................................................................................................................................................. 9
Identification cards................................................................................................................................................................ 9
Where you get covered care.................................................................................................................................................. 9

Plan providers ................................................................................................................................................................. 9

Plan facilities .................................................................................................................................................................. 9

What you must do to get covered care .................................................................................................................................. 9

Primary care.................................................................................................................................................................... 9

Specialty care................................................................................................................................................................ 10

Hospital care ................................................................................................................................................................. 11

Circumstances beyond our control...................................................................................................................................... 11
Services requiring our prior approval.................................................................................................................................. 11
Section 4. Your costs for covered services .......................................................................................................................................... 13

Copayments .................................................................................................................................................................. 13

Coinsurance .................................................................................................................................................................. 13

Your catastrophic protection out-of-pocket maximum....................................................................................................... 13
Section 5. Benefits ............................................................................................................................................................................... 14
Overview............................................................................................................................................................................. 14
(a) Medical services and supplies provided by physicians and other health care professionals .................................... 15
(b) Surgical and anesthesia services provided by physicians and other health care professionals................................. 25
(c) Services provided by a hospital or other facility, and ambulance services............................................................... 30
(d) Emergency services/ accidents .................................................................................................................................. 33
(e) Mental health and substance abuse benefits ............................................................................................................. 35
(f) Prescription drug benefits......................................................................................................................................... 37 2
2 Page 3 4
2002 HealthSpring 3 Table of Contents
(g) Special features ....................................................................................................................................................... 40

 HealthSpring Disease Management Program

 Quarterly newsletters

 Centers of excellence for transplant/ heart surgery

 Hospitals program

(h) Dental benefits.......................................................................................................................................................... 41
(i) Non-FEHB benefits available to Members………………………………………………………………………… 42
Section 6. General exclusions --things we don't cover........................................................................................................................ 43
Section 7. Filing a claim for covered services ..................................................................................................................................... 44
Section 8. The disputed claims process................................................................................................................................................ 45
Section 9. Coordinating benefits with other coverage ........................................................................................................................ 47
When you have…

Other health coverage ................................................................................................................................................... 47

Original Medicare......................................................................................................................................................... 48

Medicare managed care plan ....................................................................................................................................... 49

TRICARE/ Workers' Compensation/ Medicaid ................................................................................................................... 50
Other Government agencies................................................................................................................................................ 50
When others are responsible for injuries............................................................................................................................. 50
Section 10. Definitions of terms we use in this brochure...................................................................................................................... 51
Section 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 ............................................................................................................................ 53

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 ........................................................................................................................... 54

Getting a Certificate of Group Health Plan Coverage.............................................................................................. 54

Long term care insurance is coming later in 2002 ................................................................................................................................ 55
Index……….. ....................................................................................................................................................................................... 56
Summary of benefits ............................................................................................................................................................................. 57
Rates ....................................................................................................................................................................................... Back cover 3
3 Page 4 5
2002 HealthSpring 4 Introduction/ Plain Language
Introduction
HealthSpring, Inc. 44 Vantage Way, Suite 300
Nashville, TN 37228
This brochure describes the benefits of HealthSpring under our contract (CS 2865) 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.

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 HealthSpring.

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

 Our brochure and other FEHB plans' brochures have the same format and similar descriptions to help you compare plans.

If you have comments or suggestions about how to improve the structure of this brochure, let OPM know. Visit OPM's "Rate Us" feedback area at www. opm. gov/ insure or e-mail OPM at fehbwebcomments@ opm. gov. You may also write to OPM at the Office of
Personnel Management, Office of Insurance Planning and Evaluation Division, 1900 E. Street, NW Washington, DC 20415-3650.

Inspector General Advisory
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 (615) 291-5030 and explain the

situation.
 If we do not resolve the issue, call or write

THE HEALTH CARE FRAUD HOTLINE 202/ 418-3300
The United States Office of Personnel Management Office of the Inspector General Fraud Hotline
1900 E Street, NW, Room 6400 Washington, DC 20415

Stop health care fraud! 4
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2002 HealthSpring 5 Introduction/ Plain Language
Penalties for Fraud Anyone who falsifies a claim to obtain FEHB Program benefits can be prosecuted for fraud. Also, the Inspector General may investigate anyone who uses an ID card if the
person tries to obtain services for someone who is not an eligible family member, or is no longer enrolled in the Plan and tries to obtain benefits. Your agency may also take
administrative action against you. 5
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2002 HealthSpring 6 Section 1
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and other providers that contract with us. These Plan providers coordinate your health care services.

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

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.
As a member of HealthSpring, you have rights:

 Confidentiality – Your medical information is confidential. HealthSpring is subject to applicable state and federal laws
governing the release of your medical information.

 Consent – Your consent is required for treatment, unless you have an emergency, your life and health are in serious danger or
you are unable to provide affirmative verbal or written consent. If your written consent is required for special procedures such as surgery, be sure you understand the procedure and why it is advised. Should you decide you do not want a particular

treatment, discuss your concerns with your Primary Care Physician.

 Medical Records – You have the right to access your personal medical records maintained at your physician's office as
provided by state and federal laws.

 Advance Directives – Legal provisions allow your wishes to be carried out when you are incapable of making health care
decisions. Your health care professional or legal advisor can assist you with making a living will, a durable power of attorney for health care, or a mental health advance declaration a part of your medical records.

 Voice Grievances – You have the right to voice grievances about HealthSpring or the medical care you receive.

 Information – You have the right to be provided with information about HealthSpring, their participating providers, and your
rights and responsibilities.

If you want more information about us, call (615) 291-5030 in Nashville or 1-800-917-3888 from outside Nashville, or write us at P. O. Box 20000, Nashville, TN 37202-9613. You may also contact us by visiting our website at http:// www. myhealthspring. com. 6
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2002 HealthSpring 7 Section 1
Service Area
To enroll in this Plan, you must live in or work in our service area. This is where our providers practice. Our service area is the following Middle Tennessee counties:

MIDDLE TENNESSEE :
Bedford Humphreys Rutherford Cannon Lawrence Smith
Cheatham Lewis Stewart Coffee Macon Sumner
Davidson Marshall Trousdale
DeKalb Maury Warren Dickson Montgomery Wayne

Franklin Moore Williamson Hickman Robertson Wilson

Ordinarily, you must get your care from providers who contract with us. If you receive care outside our service area, we will pay only for emergency care benefits. We will not pay for any other health care services out of our service area unless the services have prior
Plan approval.
If you or a covered family member move outside of our service area, you can enroll in another plan. If your dependents live out of the area (for example, if your child goes to college in another state), you should consider enrolling in a fee-for-service plan or an HMO
that has agreements with affiliates in other areas. If you or a family member move, you do not have to wait until Open Season to change plans. Contact your employment or retirement office. 7
7 Page 8 9
2002 HealthSpring 8 Section 2
Section 2. We are a new plan
This Plan is new to the FEHB Program. We are being offered for the first time during the 2001 open season. 8
8 Page 9 10
2002 HealthSpring 9 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services from a Plan
provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits
enrollment confirmation (for annuitants), or your Employee Express confirmation letter.
If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at (615) 291-5030 in Nashville or
from outside Nashville 1-800-917-3888.

Where you get covered care You get care from "Plan Providers" and "Plan Facilities." You pay only copayments, 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. Our staff of medical professionals continually

credentials and monitors participating doctors and hospitals to assure the network meets strict industry standards of care.

Some Primary Care Physicians belong to independent physician associations (IPAs). IPAs are groups of physicians who contract with managed care organizations to provide
health care services. IPA networks may include general physicians or specialists like cardiologists and orthopedists. Note: Physicians in an IPA may refer only to other
physicians and hospitals affiliated with the same IPA. Members should look to their HealthSpring Provider Directory or call HealthSpring's Customer Service line,
(615) 291-5030 to find if a PCP has an IPA relationship.
We list Plan providers in the provider directory, which we update periodically. The provider list is also on our website. The directory lists IPA primary care and specialty
providers and independently contracted primary care providers and specialists. The provider list includes physician office addresses and phone numbers.

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

It depends on the type of care you need. First, you and each family member must choose a Primary Care Physician (PCP). This decision is important since your Primary
Care Physician provides or arranges most of your health care. Selection must be made from the HealthSpring network of Primary Care Physicians. Some Primary Care
Physicians belong to IPAs that refer patients only to other Providers in the same IPA. Members should look to their HealthSpring Provider Directory or call
HealthSpring's Customer Service line, (615) 291-5030 to find if a PCP has an IPA relationship. Once a PCP has been selected, you should schedule an initial appointment
with him/ her to establish a physician/ patient relationship.

Primary care Your Primary Care Physician can be a family practitioner, general practitioner, internist,
or pediatrician. Your Primary Care Physician cannot be an OB/ GYN. Your Primary Care Physician will provide most of your health care, or give you a referral to see a

specialist.

What you must do to get covered care 9
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2002 HealthSpring 10 Section 3
If you want to change Primary Care Physicians or if your Primary Care Physician leaves the Plan, call us. We will help you select a new one.

Specialty care Your Primary Care Physician will refer you to a specialist for needed care. When you
receive a referral from your Primary Care Physician, you must return to the Primary Care Physician after consultation, unless your Primary Care Physician authorized a certain

number of visits without additional referrals. The Primary Care Physician must provide or authorize all follow-up care. Do not go to the specialist for return visits unless your
Primary Care Physician gives you a referral. However, you may see a network gynecologist for a routine examination once each calendar year without a referral. You
do not need a referral for this annual exam. If you require additional care following your exam, you will need a referral from your Primary Care Physician. A complete list of
HealthSpring gynecologists follows the Primary Care Physician listing in the provider directory.

Remember: Some physician groups in the directory refer to a limited number of OB/ GYNs. If your Primary Care Physician belongs to an IPA, you must choose an
obstetrician/ gynecologist who belongs to the same IPA.
Here are other things you should know about specialty care:

If you need to see a specialist frequently because of a chronic, complex, or serious
medical condition, your Primary Care Physician will work with the specialists and the Plan to develop a treatment plan that allows you to see your specialist for a certain

number of visits without additional referrals. Your Primary Care Physician will use our criteria when creating your treatment plan (the physician may have to get an
authorization or approval beforehand).

If you are seeing a specialist when you enroll in our Plan, talk to your Primary Care
Physician before seeing your specialist. 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. 10
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2002 HealthSpring 11 Section 3

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 (615) 291-5030 in Nashville or 1-800-917-3888. If
you are new to the FEHB Program, we will arrange for you to receive care.
If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:

 You are discharged, not merely moved to an alternative care center; or

 The day your benefits from your former plan run out; or

 The 92 nd day after you become a member of this Plan, whichever happens first.

These provisions apply only to the benefits of the hospitalized person.
Circumstances beyond our control Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In that case, we will make all
reasonable efforts to provide you with the necessary care.
Your Primary Care Physician has authority to refer you for most services. For certain services, however, your physician must obtain approval from us. Before giving approval,
we consider if the service is covered, medically necessary, and follows generally accepted medical practice.

We call this review and approval process precertification. There are two review processes associated with review and approval of services. Precertification involves
review of elective services 5-7 days before the service occurs. Authorization involves urgent/ emergent services and usually occurs within one business day of the service. This
review may be before or after the service occurs. Your Plan physician is responsible for obtaining approval for services. Below are some of the services requiring prior approval.

 All inpatient hospital care

 Extended care/ skilled nursing facilities

 Mental Health or substance abuse services( through MHNet)

 Inpatient rehab services

 Cardiac and Pulmonary Rehab

 Organ and tissue transplants

 Infertility procedures

 Specialty referrals

 Home Health Care

 Durable Medical Equipment

 Orthopedic and prosthetic devices

 Growth Hormone Therapy

 Certain outpatient oral or injectable drugs

 Hospice

 Outpatient surgery

 Surgical treatment of morbid obesity

 Any request for non-par provider

Your Primary Care Physician must obtain a referral for specialty care physician services. If you receive services without obtaining a referral you may be obligated to pay for
unauthorized services.

Services requiring our prior approval 11
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2002 HealthSpring 12 Section 3
Your Primary Care Physician or Specialty Care Physician is responsible for calling the Health Services Department to obtain precertification or authorization. Failure to obtain
authorization or precertification may result in payment denial. You, or a provider on your behalf, may appeal any decision as outlined in the appeal and grievance process.

If your coverage is terminated prior to the date of service, the service will not be covered, regardless of a precertification or authorization given by us or your Primary or Specialty
Care Physician. 12
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2002 HealthSpring 13 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:

Copayments A copayment is a fixed amount of money you pay to the provider, facility, pharmacy,
etc., when you receive services.

Example: When you see your Primary Care Physician you pay a copayment of $10 per office visit and when you go in the hospital, you pay nothing per admission.

Coinsurance Coinsurance is the percentage of our negotiated fee that you must pay for your care.
Example: In our Plan, you pay 20% of the charges for the treatment of infertility.

Your catastrophic protection out-of-pocket maximum We do not have an out-of-pocket maximum. 13
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2002 HealthSpring 14 Section 5
Section 5. Benefits – OVERVIEW
(See page 57 for a benefits summary.)

NOTE: This benefits section is divided into subsections. Please read the important things at the beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the following subsections. To obtain claim forms, claim filing
advise, or more information about your benefits, contact us at (615) 291-5030 in Nashville or 1-800-917-3888 from outside Nashville or at our website at www. myhealthspring. com.

(a) Medical services and supplies provided by physicians and other health care professionals............................................................. 15

Diagnostic and treatment services

Lab, X-ray, and other diagnostic tests

Preventive care, adult

Preventive care, children

Maternity care

Family planning

Infertility services

Allergy care

Treatment therapies

Physical and occupational therapies

Speech therapy

Hearing services (testing, treatment, and supplies)

Vision services (testing, treatment, and supplies)

Foot care

Orthopedic and prosthetic devices

Durable medical equipment (DME)

Home health services

Chiropractic

Alternative treatments

Educational classes

(b) Surgical and anesthesia services provided by physicians and other health care professionals ...................................................... 25

Surgical procedures

Reconstructive surgery

Oral and maxillofacial surgery

Organ/ tissue transplants

Anesthesia

(c) Services provided by a hospital or other facility, and ambulance services .................................................................................... 30

Inpatient hospital

Outpatient hospital or ambulatory surgical center

Extended care benefits/ skilled nursing care facility

benefits
Hospice care

Ambulance

(d) Emergency services/ accidents ....................................................................................................................................................... 33
Medical emergency
Ambulance

(e) Mental health and substance abuse benefits .................................................................................................................................. 35
(f) Prescription drug benefits .............................................................................................................................................................. 37
(g) Special features ............................................................................................................................................................................. 40
HealthSpring Disease Management Program

Quarterly Newsletters

Centers of excellence for transplants/ heart surgery

Hospitalist Program

(h) Dental benefits ............................................................................................................................................................................... 41
(i) Non-FEHB benefits available to Plan Members............................................................................................................................ 42
Summary of benefits ............................................................................................................................................................................. 57 14
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2002 HealthSpring 15 Section 5( a)
Section 5 (a). Medical services and supplies provided by physicians and other health care professionals
I M
P O
R T
A N
T

Here are some important things to keep in mind about these benefits:

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

 Plan physicians must provide or arrange your care.

 We 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.

I M
P O
R T
A N
T

Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians

In physician's office

Office medical consultation

Second surgical opinion

During a hospital stay

In a skilled nursing facility

At home

$10 per office visit

Not covered:

 Services, drugs, or supplies you receive while you are not
enrolled in this Plan;

 Services or supplies related to self-treatment; or services or supplies
provided by any person related to you by blood or marriage or any person who resides in your immediate household;

 Services and supplies related to routine care, elective surgery or
mental health received by a student member while out of the service area;

All charges

Diagnostic and treatment services-Continued on next page 15
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2002 HealthSpring 16 Section 5( a)
Diagnostic and treatment services (continued) You pay

 Charges for telephone calls between a provider's office and the
member for consultations or medical management;

 Benefits for services otherwise covered when you have refused to
comply with or have terminated scheduled services or treatment against the advice of a participating physician or behavioral

health provider; or

 Charges incurred due to your failure to keep a scheduled
appointment or charges to complete a claim form or to provide medical records.

All charges

Lab, X-ray and other diagnostic tests
Tests, such as:

 Blood tests

 Urinalysis

 Non-routine pap tests

 Pathology

 X-rays

 Non-routine Mammograms

 Cat Scans/ MRI

 Ultrasound

 Electrocardiogram and EEG

$10 per visit

Preventive care, adult
Routine screening, such as:

 Total Blood Cholesterol – once every three years

 Colorectal Cancer Screening, including

-Fecal occult blood test
-Sigmoidoscoy, screening --every five years starting at age 50
Prostate Specific Antigen (PSA test) – one annually for men age 40 and older

$10 per office visit

Routine pap test
Note: The pap test is covered at no additional charge when provided in conjunction with an office visit. See Diagnosis and Treatment, above.
$10 per office visit

Preventive care, adult – Continued on next page 16
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2002 HealthSpring 17 Section 5( a)
Preventive care, adult (continued) You pay
Routine mammogram – covered for women age 35 and older, as follows:

 From age 35 through 39, one during this five year period

 Over age 40, one every calendar year

$10 per office visit

Routine immunizations, limited to:

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

 Influenza/ Pneumococcal vaccines, annually, age 65 and over

$10 per office visit

Not covered:

 Services related to obtaining or continuing employment or medical
research.; or

 Physical exams and immunizations required for obtaining or
continuing employment or insurance, attending schools or camp, or travel.

All charges

Preventive care, children

 Childhood immunizations recommended by the American Academy of
Pediatrics $10 per office visit

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

 Examinations, such as:

 Eye exams through age 18 to determine the need for vision correction.

 Ear exams through age 18 to determine the need for hearing correction.

$10 per office visit

Maternity care
Complete maternity (obstetrical) care, such as:

 Prenatal care

 Delivery

 Postnatal care

Note: Here are some things to keep in mind:

 You do not need to precertify your normal delivery. See page 11 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.

$10 for initial office visit to confirm pregnancy. All additional care related to
the pregnancy is covered for no additional copays.

Maternity care – Continued on next page 17
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2002 HealthSpring 18 Section 5( a)
Maternity care (continued) You pay

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

under a Self and Family enrollment.

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

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

 Voluntary sterilization

 Surgically implanted contraceptives (such as Norplant)

 Injectable contraceptive drugs (such as Depo-Provera)

 Intrauterine devices (IUDs)

 Diaphragms

Note: We cover oral contraceptives under the Prescription Drug benefit.

$10 per office visit
20% coinsurance
$35 copay
$35 copay
$20 copay

Not covered: Reversal of voluntary surgical sterilization; genetic counseling All charges
Infertility services
Diagnosis and treatment of infertility, such as:

Artificial insemination

 Intravaginal insemination (IVI)

 Intracervical insemination (ICI)

 Intrauterine insemination (IUI)

$10 per office visit & 20% coinsurance for treatment

Not covered:

 Assisted reproductive technology (ART) procedures, such as:

 in vitro fertilization

 embryo transfer, gamete GIFT and zygote ZIFT

 Zygote transfer

All charges

Infertility services – Continued on next page 18
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2002 HealthSpring 19 Section 5( a)
Infertility services (continued) You pay

 Services and supplies related to excluded ART procedures;

 Treatment of infertility when the cause for the infertility was a previous
sterilization;

 Cost of donor sperm;

 Services and supplies related to sperm preservation;

 Fertility drugs;

 Cost of donor egg

All charges

Allergy care
Testing and treatment

Allergy injections
$10 per office visit
$10 per office visit
Allergy serum Nothing
Not covered: provocative food testing and sublingual allergy desensitization. All charges

Treatment therapies

 Chemotherapy and radiation therapy

Note: High dose chemotherapy in association with autologous bone marrow transplants are limited to those transplants listed under

Organ/ Tissue Transplants on page 28.

 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. We will only cover GHT when we preauthorize the treatment. Your physician

will be given a prior authorization form and asked to submit information that establishes that GHT is medically necessary. This process must occur
before you begin treatment or this treatment may not be covered. If you do not obtain precertification or if we determine that GHT is not medically
necessary, we will not cover the GHT.

$10 per office visit

Treatment therapies – Continued on next page 19
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2002 HealthSpring 20 Section 5( a)
Treatment therapies (continued) You pay
Not covered:

 Non-medical ancillary services, testing and treatment which include,
but are not limited to, such services as: vocational rehabilitation, cognitive behavioral training/ therapy, sleep therapy, recreational

therapy, employment counseling, educational testing or therapy for learning disabilities or mental retardation, hypnotherapy,
assertiveness training, stress management, biofeedback and marital sex or family therapy; or

 Recreational Therapy.

All charges

Physical and occupational therapies

 60 visits per calendar year for the services of each of the following
(including respiratory therapy) combined therapies

 qualified physical therapists; and

 occupational therapists.

Note: We cover therapy only 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.

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

Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction, is provided for up six (6) weeks of treatment, if
begun within 90 days following discharge from the initial hospital.
$10 per outpatient visit

Not covered: exercise programs. All charges
Speech therapy

 30 visits per calendar year $10 per office visit

Hearing services (testing, treatment, and supplies)

 Hearing screening

 Hearing testing for children through age 18 (see Preventive care,
children)

$10 per office visit

Hearing services – Continued on next page 20
20 Page 21 22
2002 HealthSpring 21 Section 5( a)
Hearing services (testing, treatment, and supplies) (continued) You pay
Not covered:

 All other hearing testing;

 Hearing aids, testing and examinations for hearing aids;

 Charges and supplies related to hearing aids;

 Cochlear implants; or other hearing devices

All charges

Vision services (testing, treatment, and supplies)

 Treatment of eye disease or injury

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

 Eye exam, including refraction, by a participating provider, once every 12
months

 Eye exam to determine the need for vision correction for children through
age 18 (see Preventive care, children)

$10 per office visit

 Contact lenses used to treat Kerotoconus Nothing
Not covered:

 Eyeglasses (lenses and frames, contact lenses);

 Eyeglasses for glaucoma patients;

 Eye exercises and orthoptics; or

 Radial keratotomy and other refractive surgery.

All charges

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

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

Not covered:

 Routine foot care or the treatment of flat feet, corns, calluses, toe nails,
fallen arches, weak feet, chronic foot strain, or symptomatic complaints relating to the feet, unless determined by the Plan Medical

Director to be Medically Necessary in the preventive treatment of Diabetics;

All charges

Foot care – Continued on next page 21
21 Page 22 23
2002 HealthSpring 22 Section 5( a)
Foot care (continued) You pay

 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 surgery); or

 Foot orthotics.

Orthopedic and prosthetic devices
Note: The maximum plan allowance for external orthopedic and prosthetic devices and DME is limited to a combined benefit of $1,500.

 Artificial limbs and eyes;

 Externally worn breast prostheses and surgical bras, including
necessary replacements, following a mastectomy;

 Corrective orthopedic appliances for non-dental treatment of
temporomandibular joint (TMJ) pain dysfunction syndrome;

 Internal prosthetic devices, such as artificial joints, pacemakers,
surgically implanted breast implants following mastectomy, and lenses following cataract removal.

Note: We pay for internal prosthetic devices as hospital benefits; see Section 5( c) for payment information. See 5( b) for coverage of the surgery
to insert the device.

Nothing

Not covered:

 Orthopedic and corrective shoes, arch supports, foot orthotics, heel
pads and heel cups;

 Lumbosacral supports;

 Corsets, trusses, elastic stockings, support hose, and other supportive
devices;

 Penile prostheses or erection devices whether implantable or external;

 Replacement of external prosthetics or orthotics due to wear and tear,
loss, theft, destruction or improved available technology of the device. Repair of external prosthetics or orthotics or payment of warranties

related to the prosthetic or orthotic device. Replacement of prosthetics and orthotics is covered only when due to the member's physical
development or growth; or

 Supportive devices, including repairs (example: arch supports),
orthotics for the feet or orthopedic shoes, except when necessary as a component of an authorized brace.

All charges 22
22 Page 23 24
2002 HealthSpring 23 Section 5( a)
Durable medical equipment (DME) You pay
Note: The maximum plan allowance for external orthopedic and prosthetic devices and DME is limited to a combined benefit of $1,500.

Rental or purchase, at our option, including repair and adjustment, of durable medical equipment prescribed by your Plan physician, such as oxygen and
dialysis equipment. Under this benefit, we also cover:

 oxygen delivery systems;

 nebulizers;

 hospital beds;

 wheelchairs;

 crutches;

 walkers;

 blood glucose monitors; and

 insulin pumps ( with approval of Medical Director)

Note: Your Plan physician prescribes this equipment. The Plan physician will call the Plan when equipment is prescribed. We will arrange with a health care
provider to rent or buy you durable medical equipment.

Nothing

Not covered:

 Rentals of equipment that extend beyond the original prescription and
authorization if recertification has not been obtained;

 Braces and splints that are used primarily to assist a member during
athletic activities;

 Repairs of DME except for repairs necessary due to reasonable wear and
tear. Replacement of DME equipment is covered only if due to the member's physical development or growth;

 Air conditioners, air filters, heaters, humidifiers, and other equipment that
adjusts or regulates the interior environment, even if ordered by a participating provider;

 Physical fitness equipment, saunas, whirlpools, water purifiers, swimming
pools, tanning beds or recreational equipment even if ordered by a participating provider; or

 Self-help or hygenic products including, but not limited to, bathtub and
shower chairs, safety-grab bars, stair gliders or elevators, over-the-bed tables, or motorized vehicles.

All charges 23
23 Page 24 25
2002 HealthSpring 24 Section 5( a)
Home health services You pay

 Home health care ordered by a Plan physician and provided by a registered
nurse (R. N.), licensed practical nurse (L. P. N.), licensed vocational nurse (L. V. N.), or home health aide.

Services include oxygen therapy, intravenous therapy and medications.
Note: Oxygen covered as a DME benefit (see benefit coverage above).

$10 per visit

Not covered:

 Nursing care requested by, or for the convenience of, the patient or the
patient's family;

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

 Rest, custodial, domiciliary, convalescent care; personal comfort or
convenience items, sitter services, Private Duty Nursing, homemaker services, (including home-delivered means) or transportation services.

All charges

Chiropractic
Limited to members 18 years of age and older. Maximum of 20 visits per calendar year per member.

 Manipulation of the spine and extremities

 Adjunctive procedures such as ultrasound, electrical muscle stimulation,
vibratory therapy, and cold pack application

Note: All diagnostic and lab procedures must be coordinated by Member's Primary Care Physician. We will not cover these services if not arranged by

the PCP.
Note: Plan benefits are payable only when care is clinically appropriate to treat your condition and provided by providers contracted by the Plan.

$10 per office visit

 Not covered: Services or supplies related to the use of acupuncture or
acupressure.
All charges

Alternative treatments
No benefit All charges

Educational classes and programs
Coverage is limited to:
Diabetes self-management
$10 per office visit 24
24 Page 25 26
2002 HealthSpring 25 Section 5( b)
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
I M
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T

Here are some important things to keep in mind about these benefits:

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

 Plan physicians must provide or arrange your care.

 We 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.).

 YOUR PHYSICIAN MUST GET PRECERTIFICATION OF SOME SURGICAL PROCEDURES. Please
refer to the precertification information shown in Section 3 to be sure which services require precertification and identify which surgeries require precertification.

I M
P O
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T

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

 Operative procedures

 Treatment of fractures, including casting

 Normal pre-and post-operative care by the surgeon

 Correction of amblyopia and strabismus

 Endoscopy procedures

 Biopsy procedures

 Removal of tumors and cysts

 Correction of congenital anomalies (see reconstructive surgery)

 Surgical treatment of morbid obesity – is covered when the following
criteria are met:

 Eligible members must be 18 years or older, AND

 Documented history of repeated failure of physicians supervised
medical dietary therapies, AND

 A body mass index (BMI) exceeding 40 or greater than 35 in
conjunction with severe co-morbidity such as cardiopulmonary complications or severe diabetes.

$10 per visit

Surgical procedures-Continued on next page 25
25 Page 26 27
2002 HealthSpring 26 Section 5( b)
Surgical procedures (continued) You pay

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

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.

 Voluntary sterilization

 Treatment of burns
$10 per visit

Not covered:

 Reversal of voluntary sterilization;

 Routine treatment of conditions of the foot; see Foot care;

 Refractive eye surgery, such as radial keratotomy; or

 Consultations that are required to comply with hospital rules.

All charges

Reconstructive surgery
 Surgery to correct a functional defect

 Surgery to correct a condition caused by injury or illness if:
-the condition produced a major effect on the member's appearance and

-the condition can reasonably be expected to be corrected by such surgery

 Surgery to correct a condition that existed at or from birth and is a
significant deviation from the common form or norm. Examples of congenital anomalies are: protruding ear deformities; cleft lip; cleft

palate; birth marks; webbed fingers; and webbed toes.

$10 per visit

Reconstructive surgery -Continued on next page 26
26 Page 27 28
2002 HealthSpring 27 Section 5( b)
Reconstructive surgery (continued) You pay

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

 surgery to produce a symmetrical appearance on the other breast;

 treatment of any physical complications, such as lymphedemas;

 breast prostheses and surgical bras and replacements (see Prosthetic
devices)

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

Not covered:

 Cosmetic surgery – any surgical procedure (or any portion of a
procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury; or

 Surgeries related to sex transformation.

All charges

Oral and maxillofacial surgery
Oral surgical procedures, limited to:

 Reduction of fractures of the jaws or facial bones;

 Surgical correction of cleft lip, cleft palate or severe functional
malocclusion;

 Removal of stones from salivary ducts;

 Excision of leukoplakia or malignancies;

 Treatment for TMJ;

 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.

$10 per visit

Not covered:

 Oral implants and transplants;

 Dental care involved with the treatment of temporomadibular joint
dysfunction;

 Procedures that involve the teeth or their supporting structures (such as
the periodontal membrane, gingiva, and alveolar bone).

All charges 27
27 Page 28 29
2002 HealthSpring 28 Section 5( b)
Organ/ tissue transplants You pay
Limited to:

 Cornea

 Heart

 Heart/ lung

 Kidney

 Kidney/ Pancreas

 Liver

 Lung: Single – Double

 Pancreas

 Small Bowel

 Small Bowel/ Liver

 Allogeneic (donor) bone marrow transplants

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

lymphoma; advanced neuroblastoma; breast cancer; multiple myeloma; epithelial ovarian cancer; and testicular, mediastinal,
retroperitoneal and ovarian germ cell tumors

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

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

Note: We cover related medical and hospital expenses of the donor when we cover the recipient. Covered services are limited to those services and supplies
directly related to the transplant procedure itself.

Nothing

Transportation services, lodging and meals for the member, and one companion.
Our maximum Plan allowance for this benefit is $5,000 per person, with prior approval and coordination by HealthSpring Case Management
Department.

Nothing

Organ/ tissue transplants – Continued on next page 28
28 Page 29 30
2002 HealthSpring 29 Section 5( b)
Organ/ tissue transplants (continued) You pay
Not covered:

 Donor screening tests and donor search expenses, except those performed
for the actual donor;

 Artificial, mechanical or animal heart, or any other artificial organ or
associated expenses;

 Furnishing an organ or tissue;

 Transportation and living costs associated with transplant services for the
donor; or

 Transplants not listed as covered.

All charges

Anesthesia
Professional services provided in –

 Hospital (inpatient)
Nothing

Professional services provided in –

 Hospital outpatient department

 Skilled nursing facility

 Ambulatory surgical center

 Office

Nothing 29
29 Page 30 31
2002 HealthSpring 30 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
I M
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T

Here are some important things to remember about these benefits:

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

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

 We 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 5( a) or (b).

 YOUR PHYSICIAN MUST GET PRECERTIFICATION OF HOSPITAL STAYS. Please
refer to Section 3 to be sure which services require precertification.

I M
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T

Benefit Description You pay
Inpatient hospital
Room and board, such as

 ward, semiprivate, or intensive care accommodations;

 general nursing care; and

 meals and special diets.

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

Nothing

Other hospital services and supplies, such as:

 Operating, recovery, maternity, and other treatment rooms

 Prescribed drugs and medicines

 Diagnostic laboratory tests and X-rays

 Administration of blood and blood products

 Blood or blood plasma, if 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.

Nothing

Inpatient hospital -Continued on next page 30
30 Page 31 32
2002 HealthSpring 31 Section 5( c)
Inpatient hospital (continued) You pay
Not covered:

 Custodial care;

 Non-covered facilities, such as nursing homes;

 Personal comfort items, such as telephone, television, barber services,
guest meals and beds;

 Private nursing care; or

 Storage of autologous blood.

All charges

Outpatient hospital or ambulatory surgical center

 Operating, recovery, and other treatment rooms

 Prescribed drugs and medicines

 Diagnostic laboratory tests, X-rays, and pathology services

 Administration of blood, blood plasma, and other biologicals

 Blood and blood plasma, if donated or replaced

 Pre-surgical testing

 Dressings, casts, and sterile tray services

 Medical supplies, including oxygen

 Anesthetics and anesthesia service

Note: We cover hospital services and supplies related to dental procedures when necessitated by non-dental procedures by a non-dental physical

impairment. We do not cover the dental procedure.

Nothing

Not covered: blood and blood derivatives not replaced by the member All charges
Extended carebenefits/ skilled nursing carefacility benefits
Skilled nursing facility (SNF): Limited 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.
Nothing

Not covered: custodial care. All charges
Hospice care
Hospice Services

 We cover a maximum plan benefit of $10,000 per calendar year

.

Nothing

Not covered: Independent nursing, homemaker services All charges 31
31 Page 32 33
2002 HealthSpring 32 Section 5( c)
Ambulance You Pay

 Non-Emergency local professional ambulance service when medically
appropriate. $10 per trip 32
32 Page 33 34
2002 HealthSpring 33 Section 5( d)
Section 5 (d). Emergency services/ accidents
I M
P O
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A N
T

Here are some important things to keep in mind about these benefits:

Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure.

We 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 Medicare.

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

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

What to do in case of emergency:
Emergencies within our service area: In an emergency, go to the nearest medical facility for treatment. Notify your Primary Care Physician and HealthSpring within 24 hours of receiving emergency services unless it is not reasonably

possible to do so. Your Primary Care Physician must coordinate all follow-up care including suture removal. Emergency treatment does not require a written referral. You will have coverage for emergency room charges only when the presenting
symptoms to the emergency room meet the definition of an emergency. Emergency service copayment will be waived if admitted to the hospital from the emergency room.

Emergencies outside our service area: If an emergency occurs outside the service area, and you could not reasonably return to the service area, you should contact your Primary Care Physician the next business day after receiving
treatment to coordinate follow-up care or arrange for a transfer back into the service area. Emergency Service copayment will be waived if admitted as an inpatient from the emergency room.

Benefit Description You pay
Emergency within our service area

 Emergency care at a doctor's office

 Emergency care at an urgent care center

 Emergency care as an outpatient or inpatient at a hospital, including
doctors' services

Note: Hospital emergency room copayment is waived if member is admitted to the hospital.

$10 per office visit
$25 per visit

$50 per visit

Not covered: Elective care or non-emergency care. All charges 33
33 Page 34 35
2002 HealthSpring 34 Section 5( d)
Emergency outside our service area

 Emergency care at a doctor's office

 Emergency care at an urgent care center

 Emergency care as an outpatient or inpatient at a hospital, including
doctors' services

Note: Hospital emergency room copayment is waived if member is admitted to hospital.

$10 per office visit
$25 per visit
$50 per visit

Not covered:

 Elective care or non-emergency care;

 Emergency care provided outside the service area if the need for care
could have been foreseen before leaving the service area; or

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

All charges

Ambulance

 Professional ambulance service when medically appropriate.

See 5( c) for non-emergency service.

 Air ambulance service when medically appropriate and pre-approved
by Plan.

Nothing 34
34 Page 35 36
2002 HealthSpring 35 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
I M
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T

When you get our approval for services and follow a treatment plan we approve, cost-sharing and limitations for Plan mental health and substance 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.

 We 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.

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

I M
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A N
T

Benefit Description You pay
Mental health and substance abuse benefits

 All diagnostic and treatment services must be recommended by a Plan
provider and contained in a treatment plan we approve. The treatment plan may include services, drugs, and supplies described elsewhere in this

brochure.
Note: Plan benefits are payable only when we determine the care is clinically appropriate to treat your condition and only when you receive the care as part

of a treatment plan that we approve.

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

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

 Diagnostic tests $10 per visit

 Services provided by a hospital or other facility

 Services in approved alternative care settings such as partial
hospitalization, half-way house, residential treatment, full-day hospitalization, facility based intensive outpatient treatment

Nothing

Mental health and substance abuse benefits-Continued on next page 35
35 Page 36 37
2002 HealthSpring 36 Section 5( e)
Mental health and substance abuse benefits (continued) You pay
Not covered: Services we have not approved.
Note: OPM will base its review of disputes about treatment plans on the treatment plan's clinical appropriateness. OPM will generally not order us to

pay or provide one clinically appropriate treatment plan in favor of another.

All charges

Preauthorization To be eligible to receive these benefits you must obtain a treatment plan and follow all the following authorization processes:
All mental health and substance abuse care must be coordinated by a Participating Provider and prior authorization received from the Mental Health Organization
contracted by HealthSpring. Your Participating provider is responsible for obtaining prior approval for services. Before giving approval, we consider benefit design,
medical necessity, and generally accepted practices.

Limitation We may limit your benefits if you do not obtain a treatment plan. 36
36 Page 37 38
2002 HealthSpring 37 Section 5( f)
Section 5 (f). Prescription drug benefits
I M
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T

Here are some important things to keep in mind about these benefits:

 We cover prescribed drugs and medications, as described in the chart beginning on the next page.

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

 We 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.

I M
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There are important features you should be aware of. These include:

 Who can write your prescription. A plan physician or referral physician must write the prescription

 Where you can obtain them. You may fill the prescription at a participating pharmacy or by mail for maintenance
medications. You must use a network pharmacy. Walgreen's is not a participating pharmacy. For a complete list of participating pharmacies, please check our web page at www. myhealthspring. com.

 We use a formulary. The formulary is a list of prescription drugs that physicians use in prescribing medications. A
Pharmacy and Therapeutics Committee evaluates prescription drugs for safety, effectiveness, quality, and overall value and schedules the medications as preferred or non preferred brand after they have been on the market for at least 6 months. The

formulary is subject to change. For a current list of covered medications included in the formulary, as well as their classifications as generic, preferred brand, or non preferred brand, please check our web page at www. myhealthspring. com
or you may request a list of covered products by calling Customer Service at (615) 291-5030 in Nashville or 1-800-917-3888. All therapeutic classes are covered. Your physician may request a non-formulary drug by submitting to us medical
record information regarding treatment failure with formulary alternatives, but such requests may require up to 5 working days for approval. All injectable medication with a cost of $500 per course of treatment requires prior approval. Your
physician must send a request, with medical records, to our Medical Management/ Pharmacy authorization desk at:
HealthSpring
Medical Management/ Pharmacy Authorization
Phone: 615-291-7024
Fax: 615-291-7025
and such drugs are listed on the web site www. myhealthspring. com.

 These are the dispensing limitations. When the prescription is filled at participating pharmacy, the pharmacy may
dispense up to a 30 day supply for each oral drug or refill, or 1 vial of insulin, or one commercially prepared unit (one inhaler, one bottle of ophthalmic medication, one tube of topical ointment, etc.) A prescription may not be refilled before

75% of it has been used. You pay $10 per generic prescription, $20 per preferred brand, or $35 per non-preferred brand.

 Mail Order --Maintenance medication prescribed by participating doctors for long term use may be obtained
through our mail order program for up to a 90-day supply for two copays. Certain classes of drugs are not available for mail order. For the list, please check the web site. Mail order forms are available from Customer Service at (615)

291-5030 in Nashville or 1-800-917-3888. 37
37 Page 38 39
2002 HealthSpring 38 Section 5( f)

 Certain limitations apply:

 Covered drugs are limited to the formulary;

 In no event will the copayment exceed the cost of the drug;

 Certain injectables require prior authorization (when course of treatment exceeds $500);

 Viagra, or similar drugs for sexual dysfunction, is limited to 8 tablets per month;

 Some medications have quantity dispensing limits per month, in accordance with FDA guidelines and to promote
patient safety. (See our web site, www. myhealthspring. com, for monthly quantity limits).

 Why use generic drugs? Generic drugs are lower-priced drugs that are the therapeutic equivalent to more expensive brand-name
drugs. They must contain the same active ingredients and must be equivalent in strength and dosage to the original brand-name product. Generics cost less than the equivalent brand-name product. The U. S. Food and Drug Administration sets quality

standards for generic drugs to ensure that these drugs meet the same standards of quality and strength as brand-name drugs.
You can save money by using generic drugs, which have the lowest copayment. However, you and your physician have the option to request a name-brand drug. When a FDA approved generic is available and you or your physician requests the
brand name drug, you must pay the difference in cost between the generic and the brand name drug, plus the brand copayment. Certain drugs are exempt from the mandatory generic program and such drugs are listed on the web site
www. myhealthspring. com.

 When you have to file a claim. In most cases, you do not have to file a claim when purchasing drugs at a participating
pharmacy. However you must pay for the drug when dispensed, and file a claim for reimbursement when the following occurs:

 Your plan ID is not available, eligibility cannot be determined, or when the prescription is filled for a medical
emergency outside the service area.

For assistance in filing a claim for direct member reimbursement, call Customer Service at (615) 291-5030 in Nashville or 1-800-917-3888.

Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan physician and obtained from a Plan pharmacy or through our mail order

program:

 Drugs and medicines that by Federal law of the United States require a
physician's prescription for their purchase, except as listed as Not covered.

 Insulin

 Diabetic supplies and meters (preferred product only)

Retail Pharmacy – per 30 day supply
$10 Generic
$20 Brand Name – Preferred
$35 Brand Name – Non-Preferred

Covered medications and supplies – Continued on next page 38
38 Page 39 40
2002 HealthSpring 39 Section 5( f)
Covered medications and supplies (continued) You Pay

 Disposable needles and syringes for the administration of covered
medications

 Drugs for sexual dysfunction (see limitations on page 38)

 Self administered injectables, subject to prior approval

 Oral contraceptive and diaphragms (for implant or injected contraceptives
and IUDs, see section 5( a).

 Intravenous and provider administered medications are covered under
medical, surgical, or home health benefits see section 5( a).

 Growth hormone

Mail Order (Maintenance medications only) – per 90 day supply
$20 Generic
$40 Brand Name – Preferred
$70 Brand Name – Non Preferred

Not covered:

 Drugs and supplies for cosmetic purposes;

 Drugs to enhance athletic performance;

 Fertility drugs;

 Drugs obtained at a non-Plan pharmacy; except for out-of-area
emergencies;

 Smoking cessation drugs and medications;

 Drugs used for purpose of weight reduction or appetite suppression
(unless approved as part of a treatment plan for morbid obesity);

 Medical supplies such as dressings and antiseptic;

 Drugs for orthodonic care, dental implants, and periodontal
disease;

 Replacement of drugs due to loss, theft, or destruction;

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

 Nonprescription medicines or over the counter medications.

All charges 39
39 Page 40 41
2002 HealthSpring 40 Section 5( g)
Section 5 (g). Special features
Feature Description

HealthSpring Disease Management Program Disease Management Programs are designed to assist you and your family in managing chronic disease states. This management is done through educational assistance, dedicated telephonic nurse coordinator, integrated
member care and case management.

Quarterly Newsletters You receive Healthful News, a quarterly newsletter. The newsletter provides updates, changes and/ or important news about your Health Plan and promotes health and wellness.

Centers of excellence for transplants/ heart
surgery/ etc

Patients requiring transplant services have access to nationally recognized transplant centers. HealthSpring has dedicated Case Managers who follow
the transplant candidate from initial referral, facility selection, initial evaluation, pre-transplant services, transplant and post-transplant care.

Hospitalist Program Hospitalists are highly skilled hospital-based physicians who work with your Primary Care Physician in coordinating and managing your overall medical care during inpatient admissions. The hospitalists are readily available to
monitor your daily progress and improve the physician/ patient communication. 40
40 Page 41 42
2002 HealthSpring 41 Section 5( h)
Section 5 (h). Dental benefits
I M
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A N
T

Here are some important things to keep in mind about these benefits:

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

 Plan dentists must provide or arrange your care.

 We have no calendar year deductible.

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

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

I M
P O
R T
A N
T
Accidental injury benefit You pay

We cover treatment of accidental injury to sound natural teeth to relieve pain and stop bleeding when service occurs within 24-hours of the injury.

The need for these services must result from an accidental injury.
$10 per office visit

Dental benefits
We have no other dental benefits. 41
41 Page 42 43
2002 HealthSpring 42 Section 5( i)
Section 5 (i). Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed claim about them. Fees you pay for these services do not count toward FEHB deductible or out-of-pocket
maximums.
This Plan offers Medicare recipients the opportunity to enroll in the Plan through Medicare. As indicated on page 47, annuitants and former spouses with FEHB coverage and Medicare Part B may elect to drop their FEHB
coverage and enroll in a Medicare managed care plan when one is available in their area. They may then later reenroll in the FEHB Program. Most Federal annuitants have Medicare Part A. Those without Medicare Part A
may join this Medicare prepaid plan but will probably have to pay for hospital coverage in addition to the Part B premium. Before you join the plan, ask whether it covers hospital benefits and, if so, what you will have to pay.
Contact your retirement system for information on dropping your FEHB enrollment and changing to a Medicare managed plan. Contact us at 1-800-618-4294 for information on the Medicare managed plan and the cost of that
enrollment. If you are Medicare eligible and are interested in enrolling in a Medicare HMO sponsored by this Plan without dropping your enrollment in this Plan's FEHB plan, call 1-800-618-4294 for information on the
benefits available under the Medicare HMO. 42
42 Page 43 44
2002 HealthSpring 43 Section 6
Section 6. General exclusions --things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not cover it unless your Plan doctor determines it is medically necessary to prevent, diagnose, or treat your illness, disease, injury,
or condition, and we agree, as discussed under What Services Require Our Prior Approval on page 11.
We do not cover the following:

 Care by non-Plan providers except for authorized referrals or emergencies (See Emergency Benefits);

 Services, drugs, or supplies you receive while you are not enrolled in this Plan;

 Services, drugs, or supplies that are not medically necessary;

 Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice;

 Experimental or investigational procedures, treatments, drugs or devices;

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

 Services, drugs, or supplies related to sex transformations; or

 Services , drugs, or supplies you receive from a provider or facility barred from the FEHB Program. 43
43 Page 44 45
2002 HealthSpring 44 Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at Plan participating pharmacies, you will not have to file claims. Present your identification card and pay your copayment or coinsurance.

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

Medical, hospital and drug benefits In most cases, providers and facilities file claims for you. Physicians must file on the
form HCFA-1500, Health Insurance Claim Form. Facilities will file on the UB-92 form. For claims questions and assistance, call us at (615) 291-5030 in Nashville or 1-800-917-
3888 from outside Nashville.
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: HealthSpring
P. O. Box 20000
Nashville, TN 37202-9613

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

When we need more information Please reply promptly when we ask for additional information. We may delay processing or deny your claim if you do not respond. 44
44 Page 45 46
2002 HealthSpring 45 Section 8
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your claim or request for services, drugs, or supplies – including a request for preauthorization:

Step Description
1 Ask us in writing to reconsider our initial decision. You must: (a) Write to us within 6 months from the date of our decision; and
(b) Send your request to us at: HealthSpring, P. O. Box 20000, Nashville, TN 37202-9613; and
(c) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure; and

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

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

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

4 If you do not agree with our decision, you may ask OPM to review it. You must write to OPM within:

 90 days after the date of our letter upholding our initial decision; or

 120 days after you first wrote to us --if we did not answer that request in some way within 30 days; or

 120 days after we asked for additional information.

Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Contracts Division 3, 1900 E Street, NW, Washington, DC 20415-3630. 45
45 Page 46 47
2002 HealthSpring 46 Section 8
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) We haven't responded yet to your initial request for care or preauthorization/ prior approval, then call us at (615) 291-5030 and we will expedite our review; or
(b) We denied your initial request for care or preauthorization/ prior approval, then:

 If we expedite our review and maintain our denial, we will inform OPM so that they can give your claim expedited
treatment too, or

 You can call OPM's Health Benefits Contracts Division at 202/ 606-0737 between 8 a. m. and 5 p. m. eastern time. 46
46 Page 47 48
2002 HealthSpring 47 Section 9
Section 9. Coordinating benefits with other coverage
When you have other health coverage You must tell us if you are covered or a family member is covered under another group health plan or have automobile insurance that pays health care expenses without regard to
fault. This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in full as the primary payer and the other plan pays a reduced benefit as the secondary payer. We, like
other insurers, determine which coverage is primary according to the National Association of Insurance Commissioners' guidelines.

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

What is Medicare? Medicare is a Health Insurance Program for:

 People 65 years of age and older.

 Some people with disabilities, under 65 years of age.

 People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or
a transplant).

Medicare has two parts:

 Part A (Hospital Insurance). Most people do not have to pay for Part A. If you or
your spouse worked for at least 10 years in Medicare-covered employment, you should be able to qualify for premium-free Part A insurance. (Someone who was a

Federal employee on January 1, 1983 or since automatically qualifies.) Otherwise, if you are age 65 or older, you may be able to buy it. Contact 1-800-MEDICARE for
more information.

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

If you are eligible for Medicare, you may have choices in how you get your health care. Medicare + Choice is the term used to describe the various health plan choices available
to Medicare beneficiaries. The information in the next few pages shows how we coordinate benefits with Medicare, depending on the type of Medicare managed care plan
you have.
The Original Medicare Plan (Original Medicare) is available everywhere in the United States. It is the way everyone used to get Medicare benefits and is the way most people
get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist, or hospital that accepts Medicare. The Original Medicare Plan pays its share and you pay
your share. Some things are not covered under Original Medicare, like prescription drugs.

When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care. Your care must be coordinated by
your Primary Care Physician (PCP) and provided by participating plan providers unless approved in advance by the Plan, except in an emergency. We will not waive any of our
copayment or coinsurance.

The Original Medicare Plan
(Part A or Part B) 47
47 Page 48 49
2002 HealthSpring 48 Section 9
The following chart illustrates whether the Original Medicare Plan or this Plan should be the primary payer for you according to your employment status and other factors determined by Medicare. It is critical that you tell us if you or a covered family member
has Medicare coverage so we can administer these requirements correctly.
Primary Payer Chart
Then the primary payer is… A. When either you --or your covered spouse --are age 65 or over and …

Original Medicare This Plan
1) Are anactiveemployeewith theFederalgovernment(including whenyouora familymemberare eligibleforMedicaresolely becauseofadisability), 

2) Are an annuitant, 

3) Are a reemployed annuitant with the Federal government when…

a) The position is excluded from FEHB, or

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

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

covered spouse is this type of judge), 
5) Are enrolled in Part B only, regardless of your employment status,  (for Part B services)  (for other services)
6) Are a former Federal employee receiving Workers' Compensation and the Office of Workers' Compensation Programs has determined that
you are unable to return to duty,


(except for claims related to Workers'

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

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

b) Are an active employee, or 
c) Are a former spouse of an annuitant, or 
d) Are a former spouse of an active employee 

Please note, if your Plan physician does not participate in Medicare, you will have to file a claim with Medicare. 48
48 Page 49 50
2002 HealthSpring 49 Section 9
Claims process when you have the Original Medicare Plan --You probably will never have to file a claim form when you have both our Plan and the Original Medicare Plan.

 When we are the primary payer, we process the claim first.

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

something about filing your claims, call us at (615) 291-5030 or contact us through our web site at www. myhealthspring. com.

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

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

If you do not have one or both Parts of Medicare, you can still be covered under the FEHB Program. We will not require you to enroll in Medicare Part B and, if you can't
get premium-free Part A, we will not ask you to enroll in it.

If you do not enroll in
Medicare Part A or Part B 49
49 Page 50 51
2002 HealthSpring 50 Section 9
TRICARE TRICARE is the health care program for eligible dependents of military persons and retirees of the military. TRICARE includes the CHAMPUS program. If both TRICARE
and this Plan cover you, we pay first. See your TRICARE Health Benefits Advisor if you have questions about TRICARE coverage.

Workers' Compensation We do not cover services that:

you need because of a workplace-related illness or injury that the Office of Workers' Compensation Programs (OWCP) or a similar Federal or State agency determines

they must provide; or

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

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

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

When others are responsible When you receive money to compensate you for for injuries medical or hospital care for injuries or illness caused by another person, you must reimburse us for any expenses we
paid. However, we will cover the cost of treatment that exceeds the amount you received in the settlement.

If you do not seek damages you must agree to let us try. This is called subrogation. If you need more information, contact us for our subrogation procedures. 50
50 Page 51 52
2002 HealthSpring 51 Section 10
Section 10. Definitions of terms we use in this brochure
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on December 31 of the same
year.

Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. See page 13.

Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 13.
Covered services Care we provide benefits for, as described in this brochure.
Custodial care Care that is provided primarily for maintenance of your condition. Custodial care is designed to assist in activities of daily living (walking, bathing, dressing, feeding,
housekeeping) and includes self-administration of medications not requiring constant attention of medical personnel.

Service not already in general use or not recognized by the United States Pharmacopeail Convention, the American Medial Association, or the American society of Pharmacists
Compendia.

Medical necessity Treatment that is non-experimental or investigational, consistent with the symptoms or diagnosis of the condition, appropriate in regards to standards of good medical practice,
not primarily for the convenience of the patient, physician, hospital or other provider, and the most appropriate supply or level of service which can safely be provided.

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

Experimental or investigational services 51
51 Page 52 53
2002 HealthSpring 52 Section 11
Section 11. FEHB facts
No pre-existing condition We will not refuse to cover the treatment of a condition that you had limitation before you enrolled in this Plan solely because you had the condition before you enrolled.

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

When you may change your enrollment;

How you can cover your family members;

What happens when you transfer to another Federal agency, go on leave without pay,
enter military service, or retire;

When your enrollment ends; and

When the next open season for enrollment begins.

We don't determine who is eligible for coverage and, in most cases, cannot change your enrollment status without information from your employing or retirement office.

Types of coverage available Self Only coverage is for you alone. Self and Family coverage is for you, your spouse, and your unmarried dependent children under age 22, including any foster children or
stepchildren your employing or retirement office authorizes coverage for. Under certain circumstances, you may also continue coverage for a disabled child 22 years of age or
older who is incapable of self-support.
If you have a Self Only enrollment, you may change to a Self and Family enrollment if you marry, give birth, or add a child to your family. You may change your enrollment
31 days before to 60 days after that event. The Self and Family enrollment begins on the first day of the pay period in which the child is born or becomes an eligible family
member. When you change to Self and Family because you marry, the change is effective on the first day of the pay period that begins after your employing office receives your
enrollment form; benefits will not be available to your spouse until you marry.
Your employment 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. 52
52 Page 53 54
2002 HealthSpring 53 Section 11
When benefits and The benefits in this brochure are effective on January 1. If you joined this Plan premiums start during Open Season, your coverage begins on the first day of your first pay period that
starts on or after January 1. Annuitants' coverage and premiums begin on January 1. If you joined at any other time during the year, your employing office will tell you the
effective date of coverage.

Your medical and claims We 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 If you are divorced from a Federal employee or annuitant, you may not
coverage continue to get benefits under your former spouse's enrollment. But, you may be eligible for your own FEHB coverage under the spouse equity law. If you are recently divorced

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

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

For example, you can receive TCC if you are not able to continue your FEHB enrollment after you retire, if you lose your job, if you are a covered dependent child and you turn 22
or marry, etc.
You may not elect TCC if you are fired from your Federal job due to gross misconduct.
Enrolling in TCC. Get the RI 79-27, which describes TCC, and the RI 70-5, the Guide to Federal Employees Health Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees, 53
53 Page 54 55
2002 HealthSpring 54 Section 11
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
 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 Health Plan Coverage The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a Federal
law that offers limited Federal protections for health coverage availability and continuity to people who lose employer group coverage. If you leave the FEHB Program, we will
give you a Certificate of Group Health Plan Coverage that indicates how long you have been enrolled with us. You can use this certificate when getting health insurance or other
health care coverage. Your new plan must reduce or eliminate waiting periods, limitations, or exclusions for health related conditions based on the information in the
certificate, as long as you enroll within 63 days of losing coverage under this Plan. If you have been enrolled with us for less than 12 months, but were previously enrolled in other
FEHB plans, you may also request a certificate from those plans.
For more information, get OPM pamphlet RI 79-27, Temporary Continuation of Coverage (TCC) under the FEHB Program. See also the FEHB web site
(www. opm. gov/ insure/ health); refer to the "TCC and HIPAA" frequently asked questions. These HIPAA rules, such as the requirement that Federal employees must
exhaust any TCC eligibility as one condition for guaranteed access to individual health coverage under HIPAA, and have information about Federal and State agencies you can
contact for more information. 54
54 Page 55 56
2002 HealthSpring 55 Long Term Care Insurance
Long Term Care Insurance Is Coming Later in 2002!
The Office of Personnel Management (OPM) will sponsor a high-quality long term care insurance program effective in October 2002. As part of its educational effort, OPM asks you to consider these questions:
What is long term care (LTC) insurance?
 It's insurance to help pay for long term care services you may need if you can't take care of yourself because of an extended
illness or injury, or an age-related disease such as Alzheimer's.
 LTC insurance can provide broad, flexible benefits for nursing home care, care in an assisted living facility, care in your home,
adult day care, hospice care, and more. LTC insurance can supplement care provided by family members, reducing the burden you place on them.

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

 We hope you will never need long term care, but everyone should have a plan just in case. LTC insurance may be vital to your
financial and retirement planning.

Is long term care expensive?
 Yes. A year in a nursing home can exceed $50,000 and only three 8-hour shifts a week can exceed $20,000 a year, that's before
inflation!
 Long term care can easily exhaust your savings. But LTC insurance can protect it.

But won't my FEHB plan, Medicare or Medicaid cover my long term care?
 Not FEHB. Look at the "Not covered" blocks in sections 5( a) and 5( c) of your FEHB brochure. Custodial care, assisted living,
continuing home health care for activities of daily living are not covered. Limited stays in skilled nursing facilities can be covered in some circumstances.

 Medicare only covers skilled nursing home care after a hospitalization with a 100 day limit.

 Medicaid covers LTC for those who meet their state's guidelines, but restricts covered services and where they can be received.

LTC insurance can provide choices of care and preserve your independence.

When will I get more information?
 Employees will get more information from their agencies during the late summer/ early fall of 2002.

 Retirees will receive information at home.

How can I find out more about the program NOW?
 A toll-free telephone number will begin in mid-2002. You can learn more about the program now at www. opm. gov/ insure/ ltc.

 Many FEHB enrollees think their health plan and/ or Medicare will cover their long-term care needs. Unfortunately,
they are WRONG!

How are YOU planning to pay for the future custodial or chronic care you may need? Consider buying long term care insurance. 55
55 Page 56 57
2002 HealthSpring 56 Index
Index
Do not rely on this page; it is for your convenience and may not show all pages where the terms appear.
Accidental injury 41 Allergy tests 19
Ambulance 32, 34 Anesthesia 29
Blood and blood plasma 31 Chemotherapy 19
Chiropractic 24 Contraceptive devices and drugs 18
Diagnostic services 31 Durable medical equipment (DME) 23
Emergency 33 Family planning 18
General Exclusions 43 Home health services 24
Hospice care 31 Hospital 30
Immunizations 17 Infertility 18
Inpatient Hospital Benefits 30

Laboratory and pathological services 31
Mail Order Prescription Drugs 37 Mammograms 16
Maternity Benefits 17 Medicare 47
Mental Conditions/ Substance Abuse Benefits 35
Occupational therapy 20 Orthopedic devices 22
Oxygen 23 Pap test 16
Physical therapy 20 Precertification 30
Preventive care, adult 16 Preventive care, children 17
Prescription drugs 37 Prior approval 11
Prosthetic devices 22

Skilled nursing facility care 31 Speech therapy 20
Surgery 25 Transplants 28
Vision services 21 56
56 Page 57 58
2002 HealthSpring 57 Summary
Summary of benefits for HealthSpring -2002

 Do not rely on this chart alone. All benefits are provided in full unless indicated and are subject to the definitions,
limitations, and exclusions in this brochure. On this page we summarize specific expenses we cover; for more detail, look inside.

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

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

Benefits You Pay Page
Medical services provided by physicians:

 Diagnostic and treatment services provided in the office................. Office visit copay: $10 primary care; $10 specialist 31

Services provided by a hospital:

 Inpatient............................................................................................

 Outpatient .........................................................................................
Nothing

Nothing
30
31

Emergency benefits:

 In-area..............................................................................................

 Out-of-area ......................................................................................
$25 per urgent care center visit; 50 per emergency care visit 33

Mental health and substance abuse treatment...................................... Regular cost sharing. 35
Prescription drugs ................................................................................. Retail Pharmacy: $10 generic / $20 brand preferred/ $35 brand non-preferred

Mail Order Maintenance Drugs: $20 generic / $40 brand preferred / $70 brand non-preferred 37
Dental Care (Accidental Injury Only).............................................. $10 per office visit 41
Vision Care (Eye exam, including annual refraction)...................... $10 per office visit 21
Special features: HealthSpring Disease Management Program; Quarterly Newsletters, Centers of Excellence for transplants/ heart surgery, etc; Hospitalists Program 40

Protection against catastrophic costs (your out-of-pocket maximum)......................................................... We do not have an out of pocket maximum. 13 57
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2002 Rate Information for HealthSpring
Non-Postal rates apply to most non-Postal enrollees. If you are in a special enrollment category, refer to the FEHB Guide for that category or contact the agency that maintains your
health benefits enrollment.
Postal rates apply to career Postal Service employees. Most employees should refer to the FEHB Guide for United States Postal Service Employees, RI 70-2. Different postal rates apply
and special FEHB guides are published for Postal Service Nurses, RI 70-2B; and for Postal Service Inspectors and Office of Inspector General (OIG) employees (see RI 70-2IN).

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

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

Nashville-Middle Tennessee Areas

Self Only 6K1 $87.29 $29.09 $189.12 $63.04 $103.29 $13.09

Self and Family 6K2 $223.41 $100.89 $484.06 $218.59 $263.75 $60.55 59

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