Document Body Page Navigation Panel Document Outline

Blue Cross and Blue Shield Service Benefit Plan

Federal Employees Health Benefits Program
2003 Plan Brochure
Accessible Version

Document Outline

Introduction
Plain Language
Stop Health Care Fraud!
Section 1. Facts about this fee-for-service Plan
Section 2. How we change for 2003
Section 3. How you receive benefits
Section 4. Your costs for covered services
Section 5. Benefits
Section 6. General exclusions things we don't cover
Section 7. Filing a claim for covered services
Section 8. The disputed claims process
Section 9. Coordinating benefits with other coverage
Section 10. Definitions of terms we use in this brochure
Section 11. FEHB facts
Long Term Care Insurance Is Still Available
Index
Summary of Standard Option benefits
Summary of Basic Option benefits
2003 Rate Information

Pages 1--124

Page 1


Dear Federal Employees Health Benefits Program Participant: I am pleased to present this Federal Employees Health Benefits (FEHB) Program plan brochure for 2003. The brochure explains all the benefits this health plan offers to its enrollees. Since benefits can vary from year to year, you should review your plan's brochure every Open Season. Fundamentally, I believe that FEHB participants are wise enough to determine the care options best suited for themselves and their families. In keeping with the President's health care agenda, we remain committed to providing FEHB members with affordable, quality health care choices. Our strategy to maintain quality and cost this year rested on four initiatives. First, I met with FEHB carriers and challenged them to contain costs, maintain quality, and keep the FEHB Program a model of consumer choice and on the cutting edge of employer-provided health benefits. I asked the plans for their best ideas to help hold down premiums and promote quality. And, I encouraged them to explore all reasonable options to constrain premium increases while maintaining a benefits program that is highly valued by our employees and retirees, as well as attractive to prospective Federal employees. Second, I met with our own FEHB negotiating team here at OPM and I challenged them to conduct tough negotiations on your behalf. Third, OPM initiated a comprehensive outside audit to review the potential costs of federal and state mandates over the past decade, so that this agency is better prepared to tell you, the Congress and others the true cost of mandated services. Fourth, we have maintained a respectful and full engagement with the OPM Inspector General (IG) and have supported all of his efforts to investigate fraud and waste within the FEHB and other programs. Positive relations with the IG are essential and I am proud of our strong relationship. The FEHB Program is market-driven. The health care marketplace has experienced significant increases in health care cost trends in recent years. Despite its size, the FEHB Program is not immune to such market forces. We have worked with this plan and all the other plans in the Program to provide health plan choices that maintain competitive benefit packages and yet keep health care affordable. Now, it is your turn. We believe if you review this health plan brochure and the FEHB Guide you will have what you need to make an informed decision on health care for you and your family. We suggest you also visit our web site at www.opm.gov/insure.
		Sincerely, Kay Coles James Director

Blue Cross and Blue Shield Service Benefit Plan
http:// www. fepblue. org
2003

A fee-for-service plan
with a preferred provider organization

Sponsored and administered by: The Blue Cross and Blue Shield Association and participating
Blue Cross and Blue Shield Plans

Who may enroll in this Plan: All Federal employees and annuitants who are eligible to enroll in the
FEHB

Enrollment codes for this Plan:
104 Standard Option -Self Only 105 Standard Option -Self and Family
111 Basic Option -Self Only 112 Basic Option -Self and Family
This Plan has Case Management
accreditation from URAC (also
known as the American Accreditation
HealthCare Commission).

RI 71-005

For changes
in benefits
see page 8. 1.
1 Page 2 3
2.
2 Page 3 4
Notice of the Office of Personnel Management's
Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW
IT CAREFULLY.

By law, the Office of Personnel Management (OPM), which administers the Federal Employees Health Benefits (FEHB) Program, is
required to protect the privacy of your personal medical information. OPM is also required to give you this notice to tell you how
OPM may use and give out (" disclose") your personal medical information held by OPM.

OPM will use and give out your personal medical information:

To you or someone who has the legal right to act for you (your personal representative), To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is protected,
To law enforcement officials when investigating and/ or prosecuting alleged or civil or criminal actions, and Where required by law.

OPM has the right to use and give out your personal medical information to administer the FEHB Program. For example:
To communicate with your FEHB health plan when you or someone you have authorized to act on your behalf asks for our assistance regarding a benefit or customer service issue.
To review, make a decision, or litigate your disputed claim. For OPM and the General Accounting Office when conducting audits.

OPM may use or give out your personal medical information for the following purposes under limited circumstances:
For Government healthcare oversight activities (such as fraud and abuse investigations), For research studies that meet all privacy law requirements (such as for medical research or education), and
To avoid a serious and imminent threat to health or safety.
By law, OPM must have your written permission (an "authorization") to use or give out your personal medical information for any
purpose that is not set out in this notice. You may take back (" revoke") your written permission at any time, except if OPM has
already acted based on your permission.

By law, you have the right to:

See and get a copy of your personal medical information held by OPM. Amend any of your personal medical information created by OPM if you believe that it is wrong or if information is
missing, and OPM agrees. If OPM disagrees, you may have a statement of your disagreement added to your personal
medical information.

Get a listing of those getting your personal medical information from OPM in the past 6 years. The listing will not cover your personal medical information that was given to you or your personal representative, any information that you

authorized OPM to release, or that was given out for law enforcement purposes or to pay for your health care or a disputed
claim. 3.
3 Page 4 5

Ask OPM to communicate with you in a different manner or at a different place (for example, by sending materials to a P. O. Box instead of your home address).
Ask OPM to limit how your personal medical information is used or given out. However, OPM may not be able to agree to your request if the information is used to conduct operations in the manner described above.
Get a separate paper copy of this notice.
For more information on exercising your rights set out in this notice, look at www. opm. gov/ insure on the web. You may also call
202-606-0191 and ask for OPM's FEHB Program privacy official for this purpose.

If you believe OPM has violated your privacy rights set out in this notice, you may file a complaint with OPM at the following
address:

Privacy Complaints
Office of Personnel Management
P. O. Box 707
Washington, DC 20004-0707

Filing a complaint will not affect your benefits under the FEHB Program. You also may file a complaint with the Secretary of the
Department of Health and Human Services.

By law, OPM is required to follow the terms in this privacy notice. OPM has the right to change the way your personal medical
information is used and given out. If OPM makes any changes, you will get a new notice by mail within 60 days of the change. The
privacy practices listed in this notice will be effective April 14, 2003. 4.
4 Page 5 6

2003 Blue Cross and Blue Shield
Service Benefit Plan 2 Table of Contents

2003 Blue Cross and Blue Shield
Service Benefit Plan 3 Table of Contents

2003 Blue Cross and Blue Shield
Service Benefit Plan 4 Introduction/ Plain Language/ Advisory

Introduction
This brochure describes the benefits of the Blue Cross and Blue Shield Service Benefit Plan under our contract (CS 1039) with the
Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. This Plan is underwritten by
participating Blue Cross and Blue Shield Plans (Local Plans) that administer this Plan on behalf of the Blue Cross and Blue Shield
Association (the Carrier). The address for the Blue Cross and Blue Shield Service Benefit Plan administrative offices is:

Blue Cross and Blue Shield Service Benefit Plan 1310 G Street, NW, Suite 900
Washington, DC 20005
This brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations, and
exclusions of this brochure. It is your responsibility to be informed about your health care benefits.

If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in 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, 2003, unless those benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2003, and changes are
summarized on page 8. Rates are shown at the end of this brochure.

Plain Language
All FEHB brochures are written in plain language 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 the Blue Cross and Blue Shield Service Benefit Plan.

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. 7.
7 Page 8 9
2003 Blue Cross and Blue Shield
Service Benefit Plan 5 Introduction/ Plain Language/ Advisory

Stop Health Care Fraud!
Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits (FEHB) Program premium.
OPM's Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program regardless of the
agency that employs you or from which you retired.

Protect Yourself From Fraud Here are some things you can do to prevent fraud:

Be wary of giving your plan identification (ID) number over the telephone or to people you do not know, except to your doctor, other provider, or authorized plan or OPM representative.
Let only the appropriate medical professionals review your medical record or recommend services. Avoid using health care providers who say that an item or service is not usually covered, but they know how to bill us to get it
paid.
Carefully review explanations of benefits (EOBs) that you receive from us. Do not ask your doctor to make false entries on certificates, bills or records in order to get us to pay for an item or service.

If you suspect that a provider 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 1-800-FEP-8440 and explain the situation.
If we do not resolve the issue:

Do not maintain as a family member on your policy: your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise); or
your child over age 22 (unless he/ she is disabled and incapable of self support). If you have any questions about the eligibility of a dependent, check with your personnel office if you are employed or with
OPM if you are retired.
You can be prosecuted for fraud and your agency may take action against you if you falsify a claim to obtain FEHB benefits or try to obtain services for someone who is not an eligible family member or who is no longer enrolled in the Plan.

CALL THE HEALTH CARE FRAUD HOTLINE
202-418-3300

OR WRITE TO:
The United States Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street, NW, Room 6400
Washington, DC 20415 8.
8 Page 9 10

2003 Blue Cross and Blue Shield
Service Benefit Plan 6 Section 1

Section 1. Facts about this fee-for-service Plan
This Plan is a fee-for-service (FFS) plan. You can choose your own physicians, hospitals, and other health care providers.
We reimburse you or your provider for your covered services, usually based on a percentage of the amount we allow. The type and
extent of covered services, and the amount we allow, may be different from other plans. Read brochures carefully.

We also have a Preferred Provider Organization (PPO):
Our fee-for-service plan offers services through a PPO. When you use our PPO (Preferred) providers, you will receive covered
services at a reduced cost. Your Local Plan (or, for retail pharmacies, AdvancePCS) is solely responsible for the selection of PPO
providers in your area. Contact your Local Plan for the names of PPO (Preferred) providers and to verify their continued
participation. You can also go to our web page, which you can reach through the FEHB website, www. opm. gov/ insure. Contact
your Local Plan to request a PPO directory.

Under Standard Option, non-PPO (Non-preferred) benefits are the standard benefits available to you. PPO (Preferred) benefits
apply only when you use a PPO (Preferred) provider. PPO networks may be more extensive in some areas than in others. We
cannot guarantee the availability of every specialty in all areas. If no PPO (Preferred) provider is available, or you do not use a PPO
(Preferred) provider, the standard non-PPO (Non-preferred) benefits apply.

Under Basic Option, you must use Preferred providers in order to receive benefits. See page 11 for the exceptions to this
requirement.

How we pay professional and facility providers:
We pay benefits when we receive a claim for covered services. Each Local Plan contracts with hospitals and other health care
facilities, physicians, and other health care professionals in its service area, and is responsible for processing and paying claims for
services you receive within that area. Many, but not all, of these contracted providers are in our PPO (Preferred) network.

PPO providers. PPO (Preferred) providers have agreed to accept a specific negotiated amount as payment in full for covered services provided to you. We refer to PPO facility and professional providers as "Preferred." They will generally bill the
Local Plan directly, who will then pay them directly. You do not file a claim. Your out-of-pocket costs are generally less when
you receive covered services from Preferred providers, and are limited to your coinsurance or copayments (and, under Standard
Option only, the applicable deductible).

Participating providers. Some Local Plans also contract with other providers that are not in our Preferred network. If they are professionals, we refer to them as "Participating" providers. If they are facilities, we refer to them as "Member" facilities.
They have agreed to accept a different negotiated amount than our Preferred providers as payment in full. They will also
generally file your claims for you. They have agreed not to bill you for more than your applicable deductible, and coinsurance or
copayments, for covered services. We pay them directly, but at our Non-preferred benefit levels. Your out-of-pocket costs will be
greater than if you use Preferred providers.

Note: Not all areas have Participating providers and/ or Member facilities. To verify the status of a provider, please contact the
Local Plan where the services will be performed. 9.
9 Page 10 11

2003 Blue Cross and Blue Shield
Service Benefit Plan 7 Section 1

Non-participating providers. Providers who are not Preferred or Participating providers do not have contracts with us, and may or may not accept our allowance. We refer to them as "Non-participating providers" generally, although if they are facilities
we refer to them as "Non-member facilities." When you use Non-participating providers, you may have to file your claim with
us. We will then pay our benefits to you, and you must pay the provider.

You must pay any difference between the amount Non-participating providers charge and our allowance, in addition to any
applicable coinsurance amounts, copayment amounts, amounts applied to your calendar year deductible, and amounts for
noncovered services. Important: Under Standard Option, your out-of-pocket costs may be substantially higher when you
use Non-participating providers than when you use Preferred or Participating providers. Under Basic Option, you must use
Preferred providers to receive benefits. See page 11 for the exceptions to this requirement.

Note: In Local Plan areas, Preferred providers and Participating providers who contract with us will accept 100% of the Plan
allowance as payment in full for covered services. As a result, you are only responsible for applicable coinsurance or copayments
(and, under Standard Option only, the applicable deductible), for covered services, and any charges for noncovered services.

Your Rights
OPM requires that all FEHB Plans provide certain information to their FEHB members. You may get information about us, our
networks, and providers. 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.

Care management, including medical practice guidelines;
Disease management programs; and
How we determine if procedures are experimental or investigational.
If you want more information about us, call or write to us. Our telephone number and address are shown on the back of your
Service Benefit Plan ID card. You may also visit our website at www. fepblue. org. 10.
10 Page 11 12

2003 Blue Cross and Blue Shield
Service Benefit Plan 8 Section 2

Section 2. How we change for 2003
Do not rely only on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5 (Benefits).
Also, we edited and clarified language throughout the brochure; any language change not shown here is a clarification that does not
change benefits.

Program-wide changes
A Notice of the Office of Personnel Management's Privacy Practices is included.
A section on the Children's Equity Act describes when an employee is required to maintain Self and Family coverage.
Program information on TRICARE and CHAMPVA explains how annuitants or former spouses may suspend their FEHB Program enrollment.

Program information on Medicare is revised.
The Medically Underserved section is revised.
By law, the DoD/ FEHB Demonstration project ends on December 31, 2002.

Changes to this Plan

Under Standard Option, your share of the non-Postal premium will increase by 11. 0% for Self Only or 11. 0% for Self and Family.

Under Basic Option, your share of the non-Postal premium will increase by 10.7% for Self Only or 8.6% for Self and Family.
We no longer require prior approval for cardiac rehabilitation services.
We now provide benefits for certain organ/ tissue transplants provided at Blue Quality Centers for Transplant (BQCT). [See Sections 3 and 5( b).]

We now provide benefits for colonoscopies when performed for screening purposes. [See Section 5( b).]
We now provide preventive benefits for double contrast barium enemas as part of our colorectal cancer screening benefit. [See Section 5( a).]

We now provide preventive benefits for fasting lipoprotein profiles (total cholesterol, LDL, HDL, and triglycerides) when performed by a Preferred provider, or by any independent laboratory, as part of a routine physical examination. [See Section
5( a).]
We changed the address for filing claims for drugs purchased on and after January 1, 2003 from pharmacies outside the United States and Puerto Rico. [See Section 5( i).]

Under Standard Option, we now provide benefits for facility care you receive outside the United States and Puerto Rico at the Preferred benefit level. This means you pay the cost-sharing amounts listed in Section 5( c) wherever your facility care is
provided. Previously, we provided benefits in full for facility services received overseas. [See Sections 5( c) and 5( i).]
In all Local Plan areas, Preferred providers and Participating providers who contract with us will accept 100% of the Plan allowance as payment in full for covered services. This applies even when you have other coverage. Previously, Preferred and

Participating providers in certain Local Plan areas could bill the patient for the difference between our allowance and the billed
amount when the member had other coverage. (See Section 1.)

Merck-Medco Rx Services, the administrator of our Mail Service Prescription Drug Program, has changed its name to Medco Health Solutions, Inc.

We now have Case Management accreditation from URAC (also known as the American Accreditation HealthCare Commission). 11.
11 Page 12 13

2003 Blue Cross and Blue Shield
Service Benefit Plan 9 Section 3

Section 3. How you receive benefits
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 will need it whenever you receive services from a
covered provider, or fill a prescription through a Preferred retail or internet pharmacy.
Until you receive your ID card, use your copy of the Health Benefits Election Form,
SF-2809, your health benefits enrollment confirmation letter (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 the Local Plan serving the area
where you reside and ask them to assist you, or write to us directly at: FEP Enrollment
Services, 550 12 th Street, SW, Washington, DC 20065-1463. You may also request
replacement cards through our website, www. fepblue. org.

Where you get covered care Under Standard Option, you can get care from any "covered professional provider" or "covered facility provider." How much we pay and you pay depends on the type
of covered provider you use. If you use our Preferred, Participating, or Member
providers, you will pay less.

Under Basic Option, you must use those "covered professional providers" or
"covered facility providers" that are Preferred providers for Basic Option in order to
receive benefits. Please refer to page 11 for the exceptions to this requirement. Refer
to page 6 for more information about Preferred providers.

Covered professional providers We consider the following to be covered professionals when they perform services within the scope of their license or certification:

Physicians Doctors of medicine (M. D.); osteopathy (D. O.); dental surgery (D. D. S.);
medical dentistry (D. M. D.); podiatric medicine (D. P. M.); and optometry (O. D.). For
Basic Option, the term "primary care provider" includes family practitioners, general
practitioners, medical internists, pediatricians, and obstetricians/ gynecologists.

Other Covered Health Care Professionals Professionals who provide additional
covered services and meet the state's applicable licensing or certification requirements
and the requirements of the Local Plan. Other covered health care professionals
include:

Audiologist A professional who, if the state requires it, is licensed, certified, or registered as an audiologist where the services are performed.

Clinical Psychologist A psychologist who (1) is licensed or certified in the state where the services are performed; (2) has a doctoral degree in psychology (or an
allied degree if, in the individual state, the academic licensing/ certification
requirement for clinical psychologist is met by an allied degree) or is approved by
the Local Plan; and (3) has met the clinical psychological experience requirements
of the individual State Licensing Board.

Clinical Social Worker A social worker who (1) has a master's or doctoral degree in social work; (2) has at least two years of clinical social work practice; and

(3) if the state requires it, is licensed, certified, or registered as a social worker
where the services are performed.

Diabetic educator A professional who, if the state requires it, is licensed, certified, or registered as a diabetic educator where the services are performed.

Dietician A professional who, if the state requires it, is licensed, certified, or registered as a dietician where the services are performed.
Independent Laboratory A laboratory that is licensed under state law or, where no licensing requirement exists, that is approved by the Local Plan.
Nurse Midwife A person who is certified by the American College of Nurse Midwives or, if the state requires it, is licensed or certified as a nurse midwife. 12.
12 Page 13 14

2003 Blue Cross and Blue Shield
Service Benefit Plan 10 Section 3

Nurse Practitioner/ Clinical Specialist A person who (1) has an active R. N. license in the United States; (2) has a baccalaureate or higher degree in nursing; and
(3) if the state requires it, is licensed or certified as a nurse practitioner or clinical
nurse specialist.

Nursing School Administered Clinic A clinic that (1) is licensed or certified in the state where services are performed; and (2) provides ambulatory care in an

outpatient setting primarily in rural or inner-city areas where there is a shortage of
physicians. Services billed for by these clinics are considered outpatient "office"
services rather than facility charges.

Nutritionist A professional who, if the state requires it, is licensed, certified, or registered as a nutritionist where the services are performed.

Physical, Speech, and Occupational Therapist A professional who is licensed where the services are performed or meets the requirements of the Local Plan to
provide physical, speech, or occupational therapy services.
Other professional providers specifically shown in the benefit descriptions in Section 5.

Medically underserved areas. In states that OPM determines are "medically
underserved":

Under Standard Option, we cover any licensed medical practitioner for any covered service performed within the scope of that license.

Under Basic Option, we cover any licensed medical practitioner who is Preferred
for any covered service performed within the scope of that license.

For 2003, the states are: Alabama, Idaho, Kentucky, Louisiana, Maine, Mississippi,
Missouri, Montana, New Mexico, North Dakota, South Carolina, South Dakota, Texas,
Utah, West Virginia, and Wyoming.

Covered facility providers Covered facilities include those listed below, when they meet the state's applicable licensing or certification requirements.

Hospital An institution, or a distinct portion of an institution, that:
(1) Primarily provides diagnostic and therapeutic facilities for surgical and medical
diagnoses, treatment, and care of injured and sick persons provided or supervised
by a staff of licensed doctors of medicine (M. D.) or licensed doctors of osteopathy
(D. O.), for compensation from its patients, on an inpatient or outpatient basis;
(2) Continuously provides 24-hour-a-day professional registered nursing (R. N.)
services; and
(3) Is not, other than incidentally, an extended care facility; a nursing home; a place
for rest; an institution for exceptional children, the aged, drug addicts, or
alcoholics; or a custodial or domiciliary institution having as its primary purpose
the furnishing of food, shelter, training, or non-medical personal services.

Note: We consider college infirmaries to be Non-member hospitals. In addition, we
may, at our discretion, recognize any institution located outside the 50 states and the
District of Columbia as a Non-member hospital.

Freestanding Ambulatory Facility A freestanding facility, such as an ambulatory surgical center, freestanding surgi-center, freestanding dialysis center,

or freestanding ambulatory medical facility, that:
(1) Provides services in an outpatient setting;
(2) Contains permanent amenities and equipment primarily for the purpose of
performing medical, surgical, and/ or renal dialysis procedures;
(3) Provides treatment performed or supervised by doctors and/ or nurses, and may
include other professional services performed at the facility; and
(4) Is not, other than incidentally, an office or clinic for the private practice of a
doctor or other professional. 13.
13 Page 14 15

2003 Blue Cross and Blue Shield
Service Benefit Plan 11 Section 3

Note: We may, at our discretion, recognize any other similar facilities, such as birthing
centers, as freestanding ambulatory facilities.

Blue Quality Centers for Transplant (BQCT)
In addition to Preferred transplant facilities, you have access to the Blue Quality
Centers for Transplant (BQCT), a centers of excellence program. BQCT institutions
are selected based on their ability to meet defined clinical quality criteria that are
unique for each type of transplant. BQCT negotiates a payment for transplant services
performed during the transplant period (see page 113 for the definition of "transplant
period").

Members who choose to use a BQCT facility for a covered transplant only pay the
$100 per admission copayment under Standard Option, or the $100 per day copayment
($ 500 maximum) under Basic Option for the transplant period. Members are not
responsible for additional costs for included professional services. Regular Preferred
benefits (subject to the regular cost-sharing levels for facility and professional services)
are paid for pre-and post-transplant services performed in BQCT facilities before and
after the transplant period.

BQCT institutions are available for seven types of transplants: heart; heart-lung; single
or bilateral lung; liver; pancreas; simultaneous pancreas-kidney; and autologous or
allogeneic bone marrow (see pages 52 and 53 for limitations).

Contact us at the customer service number listed on the back of your ID card before
obtaining services. We will give you information about BQCT, a list of approved
facilities, and access to a Transplant Coordinator who will help your doctor arrange
your transplant at a BQCT facility.

Cancer Research Facility A facility that is:
(1) A National Cooperative Cancer Study Group institution that is funded by the
National Cancer Institute (NCI) and has been approved by a Cooperative Group as
a bone marrow transplant center;
(2) An NCI-designated Cancer Center; or
(3) An institution that has an NCI-funded, peer-reviewed grant to study allogeneic or
autologous bone marrow transplants and blood stem cell transplant support.

Other facilities specifically listed in the benefits descriptions in Section 5( c).
What you must do to get covered care Under Standard Option, you can go to any covered provider you want, but in some circumstances, we must approve your care in advance.

Under Basic Option, you must use Preferred providers in order to receive benefits,
except under the special situations listed below. In addition, we must approve certain
types of care in advance. Please refer to Section 4, Your costs for covered services, for
related benefits information.

(1) Medical emergency or accidental injury care in a hospital emergency room and
related ambulance transport as described in Section 5( d), Emergency
services/ accidents;
(2) Professional care provided at Preferred facilities by Non-preferred radiologists,
anesthesiologists, certified registered nurse anesthetists (CRNAs), pathologists,
emergency room physicians, and assistant surgeons;
(3) Laboratory and pathology services, X-rays, and diagnostic tests billed by Non-preferred
laboratories, radiologists, and outpatient facilities;
(4) Services of assistant surgeons;
(5) Special provider access situations (contact your Local Plan for more information);
or
(6) Care received outside the United States and Puerto Rico. 14.
14 Page 15 16

2003 Blue Cross and Blue Shield
Service Benefit Plan 12 Section 3

Unless otherwise noted in Section 5, when services of Non-preferred providers are
covered in a special exception, benefits will be provided based on the Plan allowance.
You are responsible for the applicable coinsurance or copayment, and may also be
responsible for any difference between our allowance and the billed amount.

Transitional care: Specialty care: If you have a chronic or disabling condition and
lose access to your specialist because we drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB plan, or

lose access to your Preferred specialist because we terminate our contract with your specialist for other than cause,
you may be able to continue seeing your specialist and receiving any Preferred benefits
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
and any Preferred benefits will continue until the end of your postpartum care, even if
it is beyond the 90 days.

Hospital care: We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our Plan begins, call us immediately.
If you have not yet received your Service Benefit Plan ID card, you can contact your
Local Plan at the telephone number listed in your local telephone directory. If you
already have your new Service Benefit Plan ID card, call us at the number on the back
of the card. If you are new to the FEHB Program, we will reimburse you for your
covered expenses while in the hospital.

However, 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.

How to get approval for . . .

Your hospital stay Precertification is the process by which prior to your inpatient hospital admission we evaluate the medical necessity of your proposed stay and the number of days
required to treat your condition. Unless we are misled by the information given to us,
we will not change our decision on medical necessity.

In most cases, your physician or hospital will take care of precertification. Because
you are still responsible for ensuring that we are asked to precertify your care, you
should always ask your physician or hospital whether they have contacted us.

Warning: We will reduce our benefits for the inpatient hospital stay by $500 if no one contacts us for precertification. If the stay is not medically necessary, we will not pay any benefits.

How to precertify an admission: You, your representative, your doctor, or your hospital must call us at the telephone
number listed on the back of your Service Benefit Plan ID card any time prior to
admission.

If you have an emergency admission due to a condition that you reasonably believe puts your life in danger or could cause serious damage to bodily function,

you, your representative, your doctor, or your hospital must telephone us within two
business days following the day of the emergency admission, even if you have been
discharged from the hospital. 15.
15 Page 16 17

2003 Blue Cross and Blue Shield
Service Benefit Plan 13 Section 3

Provide the following information:
Enrollee's name and Plan identification number;
Patient's name, birth date, and phone number;
Reason for hospitalization, proposed treatment, or surgery;
Name and phone number of admitting doctor;
Name of hospital or facility; and
Number of planned days of confinement.
We will then tell the doctor and/ or hospital the number of approved inpatient days and we will send written confirmation of our decision to you, your doctor, and the

hospital.
Maternity care You do not need to precertify a maternity admission for a routine delivery. However, if your medical condition requires you to stay more than 48 hours after a vaginal delivery

or 96 hours after a cesarean section, then your physician or the hospital must contact us
for precertification of additional days. Further, if your baby stays after you are
discharged, then your physician or the hospital must contact us for precertification of
additional days for your baby.

If your hospital stay
needs to be extended:
If your hospital stay including for maternity care needs to be extended, you, your
representative, your doctor, or the hospital must ask us to approve the additional days.

What happens when you
do not follow the
precertification rules

If no one contacted us, we will decide whether the hospital stay was medically necessary.

If we determine that the stay was medically necessary, we will pay the inpatient charges, less the $500 penalty. [See Section 5( c) for payment information.]
If we determine that it was not medically necessary for you to be an inpatient, we will not pay inpatient hospital benefits. We will only pay for any covered
medical supplies and services that are otherwise payable on an outpatient basis.
If we denied the precertification request, we will not pay inpatient hospital benefits or inpatient physician care benefits. We will only pay for any covered medical

supplies and services that are otherwise payable on an outpatient basis.
When we precertified the admission but you remained in the hospital beyond the number of days we approved and you did not get the additional days precertified,

then:
for the part of the admission that was medically necessary, we will pay inpatient benefits, but

for the part of the admission that was not medically necessary, we will pay only medical services and supplies otherwise payable on an outpatient basis and we
will not pay inpatient benefits.
Exceptions: You do not need precertification in these cases:
You are admitted to a hospital outside the United States.
You have another group health insurance policy that is the primary payer for the hospital stay.

Your Medicare Part A is the primary payer for the hospital stay.
Note: If you exhaust your Medicare hospital benefits and do not want to use your
Medicare lifetime reserve days, then we will become the primary payer and you do
need precertification. 16.
16 Page 17 18

2003 Blue Cross and Blue Shield
Service Benefit Plan 14 Section 3

Other services These services require prior approval under both Standard and Basic Option:
Home hospice care Contact us at the customer service number listed on the back of your ID card before obtaining services. We will request the medical evidence we

need to make our coverage determination and advise you which home hospice care
agencies we have approved.

Partial hospitalization or intensive outpatient treatment for mental health/ substance abuse Contact us at the mental health and substance abuse

number listed on the back of your ID card before obtaining services for intensive
outpatient treatment or partial hospitalization. We will request the medical evidence
we need to make our coverage determination. We will also consider the necessary
duration of either of these services.

Organ/ tissue transplants Contact us at the customer service number listed on the back of your ID card before obtaining services. We will request the medical

evidence we need to make our coverage determination. We will consider whether
the facility is approved for the procedure and whether you meet the facility's criteria.

Clinical trials for certain organ/ tissue transplants Contact our Clinical Trials Information Unit at 1-800-225-2268 for information or to request prior approval

before obtaining services. We will request the medical evidence we need to make
our coverage determination. Use this number only for prior approval of clinical
trials for bone marrow and peripheral blood stem cell transplant support procedures
for those conditions shown on page 53 as covered only in clinical trials.

Prescription drugs Certain prescription drugs require prior approval. Contact our Retail Pharmacy Program at 1-800-624-5060 (TDD: 1-800-624-5077 for the hearing

impaired) to request prior approval, or to obtain an updated list of prescription drugs
that require prior approval. We will request the information we need to make our
coverage determination. You must periodically renew prior approval for certain
drugs. See page 84 for more about our prescription drug prior approval program,
which is part of our Patient Safety and Quality Monitoring (PSQM) program.

Note: Benefits for drugs to aid smoking cessation that require a prescription by Federal
law are limited to one course of treatment per calendar year. Prior approval is required
before benefits will be provided for additional medication. To obtain approval, the
physician must certify the patient is participating in a smoking cessation program that
provides clinical treatment, including counseling and behavioral therapies.

Note: Until we approve them, you must pay for these drugs in full when you
purchase them even if you purchase them at a Preferred retail pharmacy or through
an internet pharmacy and submit the expense( s) to us on a claim form. Preferred
pharmacies will not file these claims for you.

Under Standard Option, members may use our Mail Service Prescription Drug
Program to fill their prescriptions. However, the Mail Service Prescription Drug
Program also will not fill your prescription until you have obtained prior approval.
Medco Health Solutions, Inc., the administrator of the Mail Service Prescription
Drug Program, will hold your prescription for you up to thirty days. If prior approval
is not obtained within 30 days, your prescription will be returned to you along with a
Prior Approval Request Form and a letter explaining the prior approval procedures.

The Mail Service Prescription Drug Program is not available under Basic Option.
In addition to the types of care listed above, these services also require prior
approval under Basic Option:

Outpatient mental health and substance abuse treatment You must call us at the number listed on the back of your ID card for mental health and substance abuse

before receiving any outpatient professional or facility care. We will then
provide you with the names and phone numbers of several Preferred providers to
choose from and tell you how many visits we are initially approving. 17.
17 Page 18 19
2003 Blue Cross and Blue Shield
Service Benefit Plan 15 Section 4

Section 4. Your costs for covered services
This is what you will pay out-of-pocket for your covered care:
Copayments A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive certain services.

Example: If you have Standard Option when you see your Preferred physician, you pay
a copayment of $15 for the office visit and we then pay the remainder of the amount
billed for the office visit. (You may have to pay separately for other services you
receive while in the physician's office.) When you go into a Preferred hospital, you pay
a copayment of $100 per admission. We then pay the remainder of the hospital bill for
the covered services you receive.

Copayments do not apply to services and supplies that are subject to a deductible and/ or
coinsurance amount.

Note: If the billed amount (or the Plan allowance that providers we contract with have
agreed to accept as payment in full) is less than your copayment, you pay the lower
amount.

Deductible A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for them. Copayments and

coinsurance amounts do not count toward your deductible. When a covered service or
supply is subject to a deductible, only the Plan allowance for the service or supply that
you then pay counts toward meeting your deductible.

Under Standard Option, the calendar year deductible is $250 per person. Under a family enrollment, the calendar year deductible for each family member is satisfied and

benefits are payable for all family members when the combined covered expenses of the
family reach $500.

Note: If the billed amount (or the Plan allowance that providers we contract with have
agreed to accept as payment in full) is less than the remaining portion of your
deductible, you pay the lower amount.

Example: If the billed amount is $100, the provider has an agreement with us to accept
$80, and you have not paid any amount toward meeting your Standard Option calendar
year deductible, you must pay $80. We will apply $80 to your deductible. We will
begin paying benefits once the remaining portion of your Standard Option calendar year
deductible ($ 170) has been satisfied.

Note: If you change plans during Open Season and the effective date of your new plan
is after January 1 of the next year, you do not have to start a new deductible under your
old plan between January 1 and the effective date of your new plan. If you change
plans at another time during the year, you must begin a new deductible under your new
plan.

Under Basic Option, there is no calendar year deductible.

Coinsurance Coinsurance is the percentage of the Plan allowance that you must pay for your care. Your coinsurance is based on the Plan allowance, or billed amount, whichever is less.

Under Standard Option only, coinsurance does not begin until you meet your deductible.

Example: You pay 10% of the Plan allowance under Standard Option for durable
medical equipment obtained from a Preferred provider, after meeting your $250
calendar year deductible.

Note: If your provider routinely waives (does not require you to pay) your applicable
deductible (under Standard Option only), coinsurance, or copayments, the provider is
misstating the fee and may be violating the law. In this case, when we calculate our
share, we will reduce the provider's fee by the amount waived. 18.
18 Page 19 20

2003 Blue Cross and Blue Shield
Service Benefit Plan 16 Section 4

Example: If your physician ordinarily charges $100 for a service but routinely waives
your 25% Standard Option coinsurance, the actual charge is $75. We will pay $56.25
(75% of the actual charge of $75).

Waivers In some instances, a Preferred, Participating, or Member provider may ask you to sign a "waiver" prior to receiving care. This waiver may state that you accept responsibility
for the total charge for any care that is not covered by your health plan. If you sign
such a waiver, whether you are responsible for the total charge depends on the content
of the contracts that the Local Plan has with its providers. If you are asked to sign this
type of waiver, please be aware that, if benefits are denied for the services, you could be
legally liable for the related expenses. If you would like more information about
waivers, please contact us at the customer service number on the back of your ID card.

Differences between our allowance and the bill Our "Plan allowance" is the amount we use to calculate our payment for certain types of covered services. Fee-for-service plans arrive at their allowances in different ways,

so allowances vary. For information about how we determine our Plan allowance, see
the definition of Plan allowance in Section 10.

Often, the provider's bill is more than a fee-for-service plan's allowance. Whether or
not you have to pay the difference between our allowance and the bill will depend on
the type of provider you use. In this Plan, we have the following types of providers:

Preferred providers. These types of providers have agreements with the Local Plan to limit what they bill our members. Because of that, when you use a Preferred

provider, your share of the provider's bill for covered care is limited.
Under Standard Option, your share consists only of your deductible and coinsurance or copayment. Here is an example about coinsurance: You see a

Preferred physician who charges $150, but our allowance is $100. If you have met
your deductible, you are only responsible for your coinsurance. That is, under
Standard Option, you pay just 10% of our $100 allowance ($ 10). Because of the
agreement, your Preferred physician will not bill you for the $50 difference between
our allowance and his/ her bill.

Under Basic Option, your share consists only of your copayment or coinsurance
amount, since there is no calendar year deductible. Here is an example involving a
copayment: You see a Preferred physician who charges $150 for covered services
subject to a $20 copayment. Even though our allowance may be $100, you still pay
just the $20 copayment. Because of the agreement, your Preferred physician will not
bill you for the $130 difference between your copayment and his/ her bill.

Remember, under Basic Option, you must use Preferred providers in order to receive benefits. See page 11 for the exceptions to this requirement.

Participating providers. These types of Non-preferred providers have agreements with the Local Plan to limit what they bill our Standard Option members.
Under Standard Option, when you use a Participating provider, your share of covered charges consists only of your deductible and coinsurance or copayment.
Here is an example: You see a Participating physician who charges $150, but the
Plan allowance is $100. If you have met your deductible, you are only responsible
for your coinsurance. That is, under Standard Option, you pay just 25% of our $100
allowance ($ 25). Because of the agreement, your Participating physician will not bill
you for the $50 difference between our allowance and his/ her bill.

Under Basic Option, there are no benefits for care performed by Participating providers; you pay all charges. See page 11 for the exceptions to this requirement.

Non-participating providers. These Non-preferred providers have no agreement to limit what they will bill you. 19.
19 Page 20 21

2003 Blue Cross and Blue Shield
Service Benefit Plan 17 Section 4

Under Standard Option, when you use a Non-participating provider, you will pay
your deductible and coinsurance plus any difference between our allowance and the
charges on the bill. For example, you see a Non-participating physician who charges
$150. The Plan allowance is again $100, and you have met your deductible. You are
responsible for your coinsurance, so you pay 25% of the $100 Plan allowance or $25.
Plus, because there is no agreement between the Non-participating physician and us,
the physician can bill you for the $50 difference between our allowance and his/ her
bill.

Under Basic Option, there are no benefits for care performed by Non-participating providers; you pay all charges. See page 11 for the exceptions to

this requirement.

The following table illustrates examples of how much you have to pay out-of-pocket for
services from a Preferred physician, a Participating physician, and a Non-participating
physician. The table uses our example of a service for which the physician charges
$150 and the Plan allowance is $100. For Standard Option, the table shows the amount
you pay if you have met your calendar year deductible.

EXAMPLE
Preferred
physician
Standard Option

Preferred
physician
Basic Option

Participating
physician (Standard Option*)
Non-participating
physician (Standard Option*)

Physician's charge $150 $150 $150 $150
Our allowance We set it at: 100 We set it at: 100 We set it at: 100 We set it at: 100

We pay 90% of our allowance: 90 Our allowance less copay: 80 75% of our allowance: 75 75% of our allowance: 75
You owe:
Coinsurance
10% of our
allowance: 10 Not applicable
25% of our
allowance: 25
25% of our
allowance: 25

You owe:
Copayment Not applicable 20 Not applicable Not applicable

+Difference up to
charge? No: 0 No: 0 No: 0 Yes: 50

TOTAL YOU PAY $10 $20 $25 $75

*Under Basic Option, there are no benefits for care performed by Participating and Non-participating physicians. You must use Preferred providers in order to
receive benefits. See page 11 for the exceptions to this requirement.
Note: Under Standard Option, had you not met any of your deductible in the above
examples, only our allowance ($ 100), which you would pay in full, would count toward
your deductible.

Overseas providers. We pay overseas claims at Preferred benefit levels, using an Overseas Fee Schedule as our Plan allowance. Most overseas professional providers

are under no obligation to accept our allowance, and you must pay any difference
between our payment and the provider's bill. For facility care you receive overseas,
we provide benefits in full after you pay the applicable copayment or coinsurance
(and, under Standard Option, any deductible amount that may apply). See Section
5( i) for more information about our overseas benefits.

Dental care. Under Standard Option, we pay scheduled amounts for routine dental services and you pay any balance. Under Basic Option, you pay $20 for any

covered evaluation and we pay the balance for covered services. See Section 5( h) for
a listing of covered dental services and additional payment information. 20.
20 Page 21 22

2003 Blue Cross and Blue Shield
Service Benefit Plan 18 Section 4

Hospital care. You pay the coinsurance or copayment amounts listed in Section 5( c). Under Standard Option, you must meet your deductible before we begin
providing benefits for certain hospital-billed services. Under Basic Option, you
must use Preferred facilities in order to receive benefits. See page 11 for the
exceptions to this requirement.

Your catastrophic protection out-of-pocket maximum for

deductibles, coinsurance, and copayments

If the total amount of out-of-pocket expenses in a calendar year for you and your
covered family members for deductibles (Standard Option only), coinsurance, and
copayments (other than those listed below) exceeds $6,000 under Standard Option, or
$5, 000 under Basic Option, then you and any covered family members will not have to
continue paying them for the remainder of the calendar year.

Standard Option Preferred maximum: If the total amount of these out-of-pocket
expenses from using Preferred providers for you and your covered family members
exceeds $4,000 in a calendar year under Standard Option, then you and any covered
family members will not have to pay these expenses for the remainder of the calendar
year when you continue to use Preferred providers. You will, however, have to pay
them when you use Non-preferred providers, until your out-of-pocket expenses (for the
services of both Preferred and Non-preferred providers) reach $6,000 under Standard
Option, as shown above.

Basic Option maximum: If the total amount of these out-of-pocket expenses from
using Preferred providers for you and your covered family members exceeds $5,000 in
a calendar year under Basic Option, then you and any covered family members will not
have to pay these expenses for the remainder of the calendar year.

The following expenses are not included under this feature. These expenses do not
count toward your catastrophic protection out-of-pocket maximum, and you must
continue to pay them even after your expenses exceed the limits described above.

The difference between the Plan allowance and the billed amount. See pages 16-18; Expenses for services, drugs, and supplies in excess of our maximum benefit

limitations;
Under Standard Option, your 30% coinsurance for inpatient care in a Non-member hospital;

Under Standard Option, your 25% coinsurance for outpatient care by a Non-member facility;
Your expenses for mental conditions and substance abuse care by a Non-preferred professional or facility provider;
Your expenses for dental services in excess of our fee schedule payments under Standard Option. See Section 5( h);
The $500 penalty for failing to obtain precertification, and any other amounts you pay because we reduce benefits for not complying with our cost containment
requirements;
Under Basic Option, coinsurance you pay for non-formulary brand-name drugs; and Under Basic Option, your expenses for care received from Participating/ Non-participating

professional providers or Member/ Non-member facilities, except for
coinsurance and copayments you pay in those special situations where we do pay for
care provided by Non-preferred providers. Please see page 11 for the exceptions to
the requirement to use Preferred providers.

Note: If you change to another plan during Open Season, we will continue to provide
benefits between January 1 and the effective date of your new plan.

If you had already paid the out-of-pocket maximum, we will continue to provide benefits as described on this page until the effective date of your new plan.

If you had not yet paid the out-of-pocket maximum, we will apply any expenses you incur in January (before the effective date of your new plan) to our prior year's out-of-
pocket maximum. Once you reach the maximum, you don't need to pay our
deductibles, copayments or coinsurance amounts (except as shown on this page) from
that point until the effective date of your new plan. 21.
21 Page 22 23
2003 Blue Cross and Blue Shield
Service Benefit Plan 19 Section 4

Note: Because benefit changes are effective January 1, we will apply our next year's
benefits to any expenses you incur in January.

Note: If you change options in this Plan during the year, we will credit the amounts
already accumulated toward the catastrophic protection out-of-pocket limit of your old
option to the catastrophic protection out-of-pocket limit of your new option. If you
change from Self Only to Self and Family, or vice versa, during the calendar year,
please call us about your out-of-pocket accumulations and how they carry over.

When government facilities bill us Facilities of the Department of Veterans Affairs, the Department of Defense, and the Indian Health Service are entitled to seek reimbursement from us for certain services
and supplies they provide to you or a family member. They may not seek more than
their governing laws allow.

If we overpay you We will make diligent efforts to recover benefit payments we made in error but in good faith. We may reduce subsequent benefit payments to offset overpayments.

Note: We will generally first seek recovery from the provider if we paid the provider
directly, or from the person (covered family member, guardian, custodial parent, etc.) to
whom we sent our payment. 22.
22 Page 23 24
2003 Blue Cross and Blue Shield
Service Benefit Plan 20 Section 4

When you are age 65 or over and you do not have Medicare
Under the FEHB law, we must limit our payments for those benefits you would be entitled to if you had Medicare. And, your
physician and hospital must follow Medicare rules and cannot bill you for more than they could bill you if you had Medicare. The
following chart has more information about the limits.

If you
are age 65 or over; and
do not have Medicare Part A, Part B, or both; and
have this Plan as an annuitant, as a former spouse, or as a family member of an annuitant or former spouse; and
are not employed in a position that gives FEHB coverage. (Your employing office can tell you if this applies.)

Then, for your inpatient hospital care,
the law requires us to base our payment on an amount the "equivalent Medicare amount" set by Medicare's rules for what Medicare would pay and not on the actual charge;

you are responsible for your deductible (Standard Option only), coinsurance, or copayments you owe under this Plan;
you are not responsible for any charges greater than the equivalent Medicare amount; we will show that amount on the explanation of benefits (EOB) form that we send you; and

the law prohibits a hospital from collecting more than the equivalent Medicare amount.
And, for your physician care, the law requires us to base our payment and your applicable coinsurance or copayment on
an amount set by Medicare and called the "Medicare approved amount," or
the actual charge if it is lower than the Medicare approved amount.

If your physician Then you are responsible for

Standard Option: your deductibles, coinsurance, and copayments Participates with Medicare or accepts Medicare assignment for the claim and is in our Preferred
network Basic Option: your copayments and coinsurance

Standard Option: your deductibles, coinsurance, and copayments, and any balance up to the Medicare approved amount Participates with Medicare or accepts Medicare
assignment and is not in our Preferred network Basic Option: all charges

Standard Option: your deductibles, coinsurance, and copayments, and any balance up to 115% of the Medicare approved amount
Basic Option: your copayments and coinsurance Does not participate with Medicare, and is in
our Preferred network Note: In many cases, your payment will be less because
of our Preferred agreements. Contact your Local Plan
for information about what your specific Preferred
provider can collect from you.

Standard Option: your deductibles, coinsurance, copayments, and any balance up to 115% of the Medicare approved amount Does not participate with Medicare and is not in
our Preferred network Basic Option: all charges

It is generally to your financial advantage to use a physician who participates with Medicare. Such physicians are permitted to collect
only up to the Medicare approved amount.

Our explanation of benefits (EOB) form will tell you how much the physician or hospital can collect from you. If your physician or
hospital tries to collect more than allowed by law, ask the physician or hospital to reduce the charges. If you have paid more than
allowed, ask for a refund. If you need further assistance, call us. 23.
23 Page 24 25

2003 Blue Cross and Blue Shield
Service Benefit Plan 21 Section 4

When you have the Original Medicare Plan
(Part A, Part B, or both)

We limit our payment to an amount that supplements the benefits that Medicare would
pay under Medicare Part A (Hospital Insurance) and Medicare Part B (Medical
Insurance), regardless of whether Medicare pays.

Note: We pay our regular benefits for emergency services to a facility provider, such as
a hospital, that does not participate with Medicare and is not reimbursed by Medicare.

If you are covered by Medicare Part B and it is primary, your out-of-pocket costs for
services that both Medicare Part B and we cover depend on whether your physician
accepts Medicare assignment for the claim.

If your physician accepts Medicare assignment, then you pay nothing for covered charges.

If your physician does not accept Medicare assignment, then you pay the difference between our payment combined with Medicare's payment, and the charge.
Note: Under Basic Option, you must see Preferred providers in order to receive
benefits. See page 11 for the exceptions to this requirement.

Note: The physician who does not accept Medicare assignment may not bill you for
more than 115% of the amount Medicare bases its payment on, called the "limiting
charge." The Medicare Summary Notice (MSN) form that you receive from Medicare
will have more information about the limiting charge. If your physician tries to collect
more than allowed by law, ask the physician to reduce the charges. If the physician
does not, report the physician to your Medicare carrier who sent you the MSN form.
Call us if you need further assistance.

Please see Section 9, Coordinating benefits with other coverage, for more
information about how we coordinate benefits with Medicare. 24.
24 Page 25 26

2003 Blue Cross and Blue Shield
Service Benefit Plan 22 Section 5

Section 5. Benefits OVERVIEW
(See page 8 for how our benefits changed this year and pages 119-120 for a benefits summary.)

NOTE: This benefits section is divided into subsections. Please read the important things you should keep in mind at the
beginning of each subsection. Also read the General exclusions in Section 6; they apply to the benefits in the following
subsections. To obtain claim forms, claims filing advice, or more information about our benefits, contact us at the customer
service telephone number on the back of your Service Benefit Plan ID card or at our website at www. fepblue. org.

(a) Medical services and supplies provided by physicians and other health care professionals..................................................... 23-43
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 therapy
Occupational and speech therapies

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

(b) Surgical and anesthesia services provided by physicians and other health care professionals................................................. 44-55
Surgical procedures
Reconstructive surgery
Oral and maxillofacial surgery

Organ/ tissue transplants
Anesthesia

(c) Services provided by a hospital or other facility, and ambulance services............................................................................... 56-65
Inpatient hospital
Outpatient hospital or ambulatory surgical center
Extended care benefits/ Skilled nursing care
facility benefits

Hospice care
Ambulance

(d) Emergency services/ Accidents ................................................................................................................................................. 66-70
Accidental injury
Medical emergency
Ambulance

(e) Mental health and substance abuse benefits ............................................................................................................................. 71-77
(f) Prescription drug benefits ......................................................................................................................................................... 78-85
(g) Special features.............................................................................................................................................................................. 86

2003 Blue Cross and Blue Shield
Service Benefit Plan 23 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 you should 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.

Under Standard Option, the calendar year deductible is $250 per person ($ 500 per family). The calendar year deductible applies to almost all benefits in this Section. We added "( No deductible)" to
show when the calendar year deductible does not apply.
Under Basic Option, there is no calendar year deductible.
Under Basic Option, you must use Preferred providers in order to receive benefits. See page 11 for the exceptions to this requirement.

Please refer to Section 3, How you receive benefits, for a list of providers we consider to be primary care providers (under Basic Option) and other health care professionals.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works, with special sections for members who are age 65 or over. Also read Section 9 about
coordinating benefits with other coverage, including Medicare.
We base payment on whether a facility or a health care professional bills for the services or supplies. You will find that some benefits are listed in more than one section of the brochure. This is because

how they are paid depends on what type of provider bills for the service. For example, physical
therapy is paid differently depending on whether it is billed by an inpatient facility, a doctor, a
physical therapist, or an outpatient facility.

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

outpatient facility, etc.).
The non-PPO benefits are the standard benefits for Standard Option. PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non-PPO benefits apply.

I M
P O
R T
A N
T

Diagnostic and treatment services You Pay Standard Option You Pay Basic Option

Professional services of physicians and other
health care professionals:

Outpatient consultations
Outpatient second surgical opinions
Office visits
Home visits
Initial examination of a newborn needing definitive treatment when covered under a

family enrollment

Preferred: $15 copayment for
the office visit charge (No
deductible)

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Preferred primary care
provider or other health care
professional: $20 copayment
per visit

Preferred specialist: $30
copayment per visit

Note: You pay 30% of the
Plan allowance for drugs and
supplies.

Participating/ Non-participating:
You pay all
charges

Diagnostic and treatment services continued on next page 26.
26 Page 27 28

2003 Blue Cross and Blue Shield
Service Benefit Plan 24 Section 5( a)

NOTE: The calendar year deductible applies to almost all Standard Option benefits in this Section.
We say "( No deductible)" when the Standard Option deductible does not apply.
There is no calendar year deductible under Basic Option.

Diagnostic and treatment services (continued) You Pay Standard Option You Pay Basic Option

Outpatient professional services:
Pharmacotherapy [see Section 5( f) for prescription drug coverage]

Neurological testing

Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Preferred primary care
provider or other health care
professional: $20 copayment
per visit

Preferred specialist: $30
copayment per visit

Note: You pay 30% of the
Plan allowance for drugs and
supplies.

Participating/ Non-participating:
You pay all
charges

Inpatient professional services:
During a hospital stay
Services for nonsurgical procedures when ordered, provided, and billed by a physician

during a covered inpatient hospital admission
Medical care by the attending physician (the physician who is primarily responsible for

your care when you are hospitalized) on days
we pay inpatient hospital benefits

Note: A consulting physician employed by
the hospital is not the attending physician.

Consultations when requested by the attending physician

Concurrent care hospital inpatient care by a physician other than the attending physician
for a condition not related to your primary
diagnosis, or because the medical complexity
of your condition requires this additional
medical care

Physical therapy by a physician other than the attending physician

Initial examination of a newborn needing definitive treatment when covered under a
family enrollment
Pharmacotherapy [see Section 5( c) for prescription drug coverage]

Neurological testing
Second surgical opinion

Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Note: We provide benefits at
90% of the Plan allowance
for services provided in
Preferred facilities by Non-preferred
radiologists,
anesthesiologists, certified
registered nurse anesthetists
(CRNAs), pathologists, and
emergency room physicians.
You are responsible for any
difference between our
allowance and the billed
amount.

Preferred: Nothing
Participating/ Non-participating:
You pay all
charges

Note: We provide benefits at
100% of the Plan allowance
for services provided in
Preferred facilities by Non-preferred
radiologists,
anesthesiologists, certified
registered nurse anesthetists
(CRNAs), pathologists,
emergency room physicians,
and assistant surgeons. You
are responsible for any
difference between our
allowance and the billed
amount.

Diagnostic and treatment services continued on next page 27.
27 Page 28 29

2003 Blue Cross and Blue Shield
Service Benefit Plan 25 Section 5( a)

Diagnostic and treatment services (continued) You Pay Standard Option You Pay Basic Option

Not covered:
Routine services except for those Preventive care services described on pages 27-30

Inpatient private duty nursing
Standby physicians
Routine radiological and staff consultations required by hospital rules and regulations

Inpatient physician care when your hospital admission or portion of an admission is not
covered [see Section 5( c)]
Note: If we determine that a hospital admission
is not covered, we will not provide benefits for
inpatient room and board or inpatient
physician care. However, we will provide
benefits for covered services or supplies other
than room and board and inpatient physician
care at the level that we would have paid if they
had been provided in some other setting.

All charges All charges 28.
28 Page 29 30

2003 Blue Cross and Blue Shield
Service Benefit Plan 26 Section 5( a)

Lab, X-ray, and other diagnostic tests You Pay Standard Option You Pay Basic Option

Diagnostic tests provided, or ordered and billed
by a physician, such as:

Blood tests
CT scans/ MRIs
EKGs and EEGs
Laboratory tests
Pathology services
Ultrasounds
Urinalysis
X-rays
Laboratory and pathology services billed by an
independent laboratory

Note: See Section 5( c) for services billed for by
a facility, such as the outpatient department of a
hospital.

Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Note: If your Preferred
provider uses a Non-preferred
laboratory or
radiologist, we will pay Non-preferred
benefits for any
laboratory and X-ray charges.

Preferred primary care
provider or other health care
professional: $20 copayment
per visit

Preferred specialist: $30
copayment per visit

Note: You pay 30% of the
Plan allowance for drugs and
supplies.

Participating/ Non-participating:
You pay all
charges

Note: For services billed by
Participating and Non-participating
laboratories or
radiologists, you pay a
separate $20 copayment, plus
any difference between our
allowance and the billed
amount.

Other diagnostic tests provided, or ordered and
billed by a physician, such as:

Fecal occult blood tests
Non-routine mammograms
Non-routine Pap tests
Prostate Specific Antigen (PSA) tests
Sigmoidoscopies
Note: See Section 5( c) for services billed for by
a facility, such as the outpatient department of a
hospital.

Preferred: $15 copayment for
associated office visits (No
deductible); nothing for
services or tests

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Note: If your Preferred
provider uses a Non-preferred
laboratory or
radiologist, we will pay Non-preferred
benefits for any
laboratory and X-ray charges.

Preferred primary care
provider or other health care
professional: $20 copayment
per visit

Preferred specialist: $30
copayment per visit

Note: You pay 30% of the
Plan allowance for drugs and
supplies.

Participating/ Non-participating:
You pay all
charges

Note: For services billed by
Participating and Non-participating
laboratories or
radiologists, you pay a
separate $20 copayment, plus
any difference between our
allowance and the billed
amount. 29.
29 Page 30 31

2003 Blue Cross and Blue Shield
Service Benefit Plan 27 Section 5( a)

Preventive care, adult You Pay Standard Option You Pay Basic Option

Home and office visits for routine (screening)
physical examinations

Under Standard Option, benefits are limited
to the following services when performed as
part of a routine physical examination:

History and risk assessment
Chest X-ray
EKG
Urinalysis
Basic or comprehensive metabolic panel test
CBC
Fasting lipoprotein profile (total cholesterol, LDL, HDL, and triglycerides) when

performed by a Preferred provider or any
independent laboratory

Note: The benefits listed above do not apply to
children up to age 22. (See benefits under
Preventive care, children, this section.)

Chlamydial infection test
Under Basic Option, benefits are provided for
all of the services listed above and for other
appropriate screening tests and services.

Preferred: $15 copayment for
the examination (No
deductible); nothing for
services or tests

Note: We cover one routine
physical examination every
three calendar years for
members under age 65 and
one each calendar year for
members age 65 and older.

Note: We provide benefits
for adult routine physical
examinations only when you
receive these services from a
Preferred provider.

Participating:
You pay all charges

Non-participating:
You pay all charges

Note: When billed by a
facility, such as the
outpatient department of a
hospital, we provide benefits
as shown here, according to
the contracting status of the
facility.

Preferred primary care
provider or other health care
professional: $20 copayment
per visit

Preferred specialist: $30
copayment per visit

Note: You pay 30% of the
Plan allowance for drugs and
supplies.

Participating/ Non-participating:
You pay all
charges

Note: For services billed by
Participating and Non-participating
laboratories or
radiologists, you pay a
separate $20 copayment, plus
any difference between our
allowance and the billed
amount.

Note: See Section 5( c) for
our payment levels for these
services when billed for by a
facility, such as the
outpatient department of a
hospital.

Preventive care, adult continued on next page 30.
30 Page 31 32

2003 Blue Cross and Blue Shield
Service Benefit Plan 28 Section 5( a)

Preventive care, adult (continued) You Pay Standard Option You Pay Basic Option

Cancer screening
Colorectal cancer screening, including:
Fecal occult blood test
Sigmoidoscopy
Double contrast barium enema
Prostate cancer screening Prostate Specific Antigen (PSA) test

Cervical cancer screening
Breast cancer screening (routine mammograms)

Preferred: $15 copayment for
associated office visits (No
deductible); nothing for
services or tests

Note: We provide benefits in
full for preventive
(screening) tests and
immunizations only when
you receive these services
from a Preferred provider
on an outpatient basis. If
these services are billed
separately from the routine
physical examination, you
may be responsible for
paying an additional
copayment for each office
visit billed.

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Note: When billed by a
facility, such as the
outpatient department of a
hospital, we provide benefits
as shown here, according to
the contracting status of the
facility.

Preferred primary care
provider or other health care
professional: $20 copayment
per visit

Preferred specialist: $30
copayment per visit

Note: You pay 30% of the
Plan allowance for drugs and
supplies.

Participating/ Non-participating:
You pay all
charges

Note: For services billed by
Participating and Non-participating
laboratories or
radiologists, you pay a
separate $20 copayment, plus
any difference between our
allowance and the billed
amount.

Note: See Section 5( c) for
our payment levels for these
services when billed for by a
facility, such as the
outpatient department of a
hospital.

Preventive care, adult continued on next page 31.
31 Page 32 33

2003 Blue Cross and Blue Shield
Service Benefit Plan 29 Section 5( a)

Preventive care, adult (continued) You Pay Standard Option You Pay Basic Option

Cancer screening (continued) Note: If you go to a
Participating or Non-participating
provider for
these services, the following
limits apply:

Fecal occult blood test one annually starting at age

40
Sigmoidoscopy one every five years starting at age 50

Double contrast barium enema one every five
years starting at age 50
Prostate Specific Antigen (PSA) test one annually

for males age 40 and older
Cervical cancer screening one routine Pap test

annually for females of any
age

Breast cancer screening routine mammograms for

females age 35 and older,
as follows

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

period
From age 40 through 64, one annually

At age 65 and older, one every two consecutive
calendar years
Note: When billed by a
facility, such as the
outpatient department of a
hospital, we provide benefits
as shown here, according to
the contracting status of the
facility.

See page 28

Preventive care, adult continued on next page 32.
32 Page 33 34

2003 Blue Cross and Blue Shield
Service Benefit Plan 30 Section 5( a)

Preventive care, adult (continued) You Pay Standard Option You Pay Basic Option

Routine immunizations without regard to age,
limited to:

Hepatitis immunizations (Types A and B) for patients with increased risk or family history

Influenza and pneumococcal vaccines, annually
Lyme disease vaccine
Tetanus-diphtheria (Td) booster once every 10 years

Preferred: $15 copayment for
associated office visits (No
deductible); nothing for
immunizations

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Preferred primary care
provider or other health care
professional: $20 copayment
for associated office visits;
nothing for immunizations

Preferred specialist: $30
copayment for associated
office visits; nothing for
immunizations

Participating/ Non-participating:
You pay all
charges

Not covered: Office visit charges associated
with preventive services and routine
immunizations performed by Participating and
Non-participating providers

All charges All charges

Preventive care, children
We provide benefits for the following services:
All healthy newborn visits including routine screening (inpatient or outpatient)

The following routine services as recommended by the American Academy of
Pediatrics for children up to the age of 22,
including children living, traveling, or
adopted from outside the United States:

Routine physical examinations
Routine hearing tests
Laboratory tests
Immunizations
Related office visits

Preferred: Nothing (No
deductible)

Participating: Nothing (No
deductible)

Non-participating: Nothing
(No deductible) up to the
Plan allowance. You are
responsible only for any
difference between our
allowance and the billed
amount.

Note: When billed by a
facility, such as the
outpatient department of a
hospital, we provide benefits
as shown here, according to
the contracting status of the
facility.

Preferred primary care
provider or other health care
professional: $20 copayment
per visit; you pay nothing for
inpatient visits

Preferred specialist: $30
copayment per visit; you pay
nothing for inpatient visits

Participating/ Non-participating:
You pay all
charges

Note: For services billed by
Participating and Non-participating
laboratories or
radiologists, you pay a
separate $20 copayment, plus
any difference between our
allowance and the billed
amount.

Note: See Section 5( c) for
our payment levels for these
services when billed for by a
facility, such as the
outpatient department of a
hospital. 33.
33 Page 34 35

2003 Blue Cross and Blue Shield
Service Benefit Plan 31 Section 5( a)

Maternity care You Pay Standard Option You Pay Basic Option
Complete maternity (obstetrical) care including
related conditions resulting in childbirth or
miscarriage when provided, or ordered and
billed by a physician or nurse midwife, such as:

Prenatal care (including laboratory and diagnostic tests)

Delivery
Postpartum care
Note: Here are some things to keep in mind:

You do not need to precertify your normal delivery; see page 13 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 cover an
extended stay, if medically necessary, but
you, your representative, your doctor, or your
hospital must precertify the extended stay.
See Section 3 for information on requesting
additional days.

We cover routine nursery care of the newborn child during the covered portion of the mother's

maternity stay, or if the child is covered under
the father's Self and Family enrollment.

Preferred: Nothing (No
deductible)

Note: For facility care related
to maternity, including care
at birthing facilities, we
waive the per admission
copayment and pay for
covered services in full when
you use Preferred providers.

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Preferred: $100 copayment
for the delivery; nothing for
prenatal and postpartum care

Note: For facility care related
to maternity, including care
at birthing facilities, see
Section 5( c).

Participating/ Non-participating:
You pay all
charges

Note: For services billed by
Participating and Non-participating
laboratories and
radiologists, you are
responsible only for any
difference between our
allowance and the billed
amount.

Note: When a newborn requires definitive
treatment including incubation charges by
reason of prematurity or evaluation for medical
or surgical reasons during or after the mother's
confinement, the newborn is considered a patient
in his or her own right.

Note: Expenses of the newborn are eligible for
benefits only if the child is covered by a Self and
Family enrollment. For services such as
circumcision, regular medical or surgical
benefits apply rather than maternity benefits.

Note: See page 45 for our payment levels for
circumcision.

Note: We pay assistant surgeon services
(delivery) and anesthesia the same as for illness
or injury. See Surgical and anesthesia benefits
in Section 5( b).

Not covered: Procedures, services, drugs, and
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

All charges All charges 34.
34 Page 35 36

2003 Blue Cross and Blue Shield
Service Benefit Plan 32 Section 5( a)

Family planning You Pay Standard Option You Pay Basic Option

A range of voluntary family planning services,
limited to:

Depo-Provera
Diaphragms and contraceptive rings
Intrauterine devices (IUDs)
Implantable contraceptives
Oral and transdermal contraceptives
Voluntary sterilization [see Surgical procedures in Section 5( b)]

Note: See Section 5( f) for prescription drug
coverage.

Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Preferred primary care
provider or other health care
professional: $20 copayment
per visit

Preferred specialist: $30
copayment per visit

Note: You pay $100 for
related surgical procedures.
See Section 5( b) for our
coverage for related surgical
procedures.

Note: You pay 30% of the
Plan allowance for drugs and
supplies.

Participating/ Non-participating:
You pay all
charges

Not covered:
Reversal of voluntary surgical sterilization
Contraceptive devices not described above

All charges All charges

Infertility services
Diagnosis and treatment of infertility, except as
shown in Not Covered

Note: See Section 5( f) for prescription drug
coverage.

Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Preferred primary care
provider or other health care
professional: $20 copayment
per visit

Preferred specialist: $30
copayment per visit

Note: You pay 30% of the
Plan allowance for drugs and
supplies.

Participating/ Non-participating:
You pay all
charges

Note: For services billed by
Participating and Non-participating
laboratories or
radiologists, you pay a
separate $20 copayment, plus
any difference between our
allowance and the billed
amount.

Infertility services continued on next page 35.
35 Page 36 37
2003 Blue Cross and Blue Shield
Service Benefit Plan 33 Section 5( a)

Infertility services (continued) You Pay Standard Option You Pay Basic Option

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

artificial insemination (AI)
in vitro fertilization (IVF)
embryo transfer and Gamete Intrafallopian Transfer (GIFT)

intravaginal insemination (IVI)
intracervical insemination (ICI)
intrauterine insemination (IUI)
Services and supplies related to ART procedures, such as sperm banking

All charges All charges

Allergy care
Testing and treatment, including materials (such as allergy serum)

Allergy injections

Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Preferred primary care
provider or other health care
professional: $20 copayment
per visit; nothing for
injections

Preferred specialist: $30
copayment per visit; nothing
for injections

Participating/ Non-participating:
You pay all
charges

Note: For services billed by
Participating and Non-participating
laboratories or
radiologists, you pay a
separate $20 copayment, plus
any difference between our
allowance and the billed
amount.

Not covered: Provocative food testing and
sublingual allergy desensitization
All charges All charges 36.
36 Page 37 38

2003 Blue Cross and Blue Shield
Service Benefit Plan 34 Section 5( a)

Treatment therapies You Pay Standard Option You Pay Basic Option

Outpatient treatment therapies:
Chemotherapy and radiation therapy
Note: We cover high dose chemotherapy
and/ or radiation therapy in connection with
bone marrow transplants, and drugs or
medications to stimulate or mobilize stem cells
for transplant procedures, only for those
conditions listed as covered under Organ/ tissue
transplants in Section 5( b). See also, Services
requiring our prior approval, in Section 3.

Renal dialysis Hemodialysis and peritoneal dialysis

Intravenous (IV)/ infusion therapy Home IV or infusion therapy
Note: Home nursing visits associated with
Home IV/ infusion therapy are covered as
shown under Home health services on page 41.

Pharmacotherapy [see Section 5( f) for prescription drug coverage]

Outpatient cardiac rehabilitation
Note: See Section 5( c) for our payment levels
for treatment therapies billed for by the
outpatient department of a hospital.

Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Preferred primary care
provider or other health care
professional: $20 copayment
per visit

Preferred specialist: $30
copayment per visit

Note: You pay 30% of the
Plan allowance for drugs and
supplies.

Participating/ Non-participating:
You pay all
charges

Inpatient treatment therapies:
Chemotherapy and radiation therapy
Note: We cover high dose chemotherapy
and/ or radiation therapy in connection with
bone marrow transplants, and drugs or
medications to stimulate or mobilize stem
cells for transplant procedures, only for those
conditions listed as covered under
Organ/ tissue transplants in Section 5( b). See
also, Services requiring our prior approval, in
Section 3.

Renal dialysis Hemodialysis and peritoneal dialysis

Pharmacotherapy [see Section 5( f) for prescription drug coverage]

Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of the
Plan allowance, plus any
difference between our
allowance and the billed
amount

Note: We provide benefits at
90% of the Plan allowance for
services provided in Preferred
facilities by Non-preferred
radiologists, anesthesiologists,
certified registered nurse
anesthetists (CRNAs),
pathologists, and emergency
room physicians. You are
responsible for any difference
between our allowance and
the billed amount.

Preferred: Nothing
Participating/ Non-participating:
You pay all
charges

2003 Blue Cross and Blue Shield
Service Benefit Plan 35 Section 5( a)

Physical therapy You Pay Standard Option You Pay Basic Option

When performed by a physical therapist or
physician:

Physical therapy
Acupuncture as a physical therapy modality and for pain management

Note: See Section 5( c) for our payment levels
for physical therapy performed in and billed by
the outpatient department of a hospital.

Note: When billed by a skilled nursing facility,
nursing home, or extended care facility, we pay
benefits as shown here for professional care,
according to the contracting status of the
therapist.

Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Note: Benefits are limited to
50 visits per person, per
calendar year.

Note: Visits that you pay for
while meeting your calendar
year deductible count toward
the limit cited above.

Preferred primary care
provider or other health care
professional: $20 copayment
per visit

Preferred specialist: $30
copayment per visit

Note: You pay 30% of the
Plan allowance for drugs and
supplies.

Note: Benefits are limited to
50 visits per person, per
calendar year for physical,
occupational, or speech
therapy, or a combination of
all three.

Participating/ Non-participating:
You pay all
charges

Not covered:
Recreational or educational therapy, and any related diagnostic testing except as provided

by a hospital as part of a covered inpatient
stay

Maintenance or palliative rehabilitative therapy

Exercise programs
Hippotherapy (exercise on horseback)

All charges All charges 38.
38 Page 39 40

2003 Blue Cross and Blue Shield
Service Benefit Plan 36 Section 5( a)

Occupational and speech therapies You Pay Standard Option You Pay Basic Option

Occupational and speech therapy when
performed by an occupational therapist, speech
therapist, or physician

Note: See Section 5( c) for our payment levels
for occupational and speech therapy performed
in and billed by the outpatient department of a
hospital.

Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Note: Benefits are limited to
25 visits per person, per
calendar year for
occupational therapy or
speech therapy, or a
combination of both.

Note: Visits that you pay for
while meeting your calendar
year deductible count toward
the limit cited above.

Preferred primary care
provider or other health care
professional: $20 copayment
per visit

Preferred specialist: $30
copayment per visit

Note: You pay 30% of the
Plan allowance for drugs and
supplies.

Note: Benefits are limited to
50 visits per person, per
calendar year for physical,
occupational, or speech
therapy, or a combination of
all three.

Participating/ Non-participating:
You pay all
charges

Not covered:
Recreational or educational therapy, and any related diagnostic testing except as provided

by a hospital as part of a covered inpatient
stay

Maintenance or palliative rehabilitative therapy

Exercise programs

All charges All charges 39.
39 Page 40 41

2003 Blue Cross and Blue Shield
Service Benefit Plan 37 Section 5( a)

Hearing services (testing, treatment, and supplies) You Pay Standard Option You Pay Basic Option

Hearing tests related to illness or injury Preferred: 10% of the Plan
allowance

Participating: 25% of the Plan
allowance

Non-participating: 25% of the
Plan allowance, plus any
difference between our
allowance and the billed
amount

Preferred primary care
provider or other health care
professional: $20 copayment
per visit

Preferred specialist: $30
copayment per visit

Note: You pay 30% of the
Plan allowance for drugs and
supplies.

Participating/ Non-participating:
You pay all
charges

Not covered:
Routine hearing tests (except as indicated under Preventive care, children)

Hearing aids (including implanted bone conduction hearing aids)
Testing and examinations for the prescribing or fitting of hearing aids

All charges All charges

Vision services (testing, treatment, and supplies)
One pair of eyeglasses, replacement lenses, or contact lenses to correct an impairment
directly caused by a single instance of
accidental ocular injury or intraocular surgery

Note: This benefit may also be used to obtain
one pair of eyeglasses, replacement lenses, or
contact lenses prescribed in lieu of surgery
when the condition can be corrected by surgery,
but surgery is precluded because of age or
medical condition.

Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Preferred: 30% of the Plan
allowance

Participating/ Non-participating:
You pay all
charges

Eye examinations related to a specific medical condition
Nonsurgical treatment for amblyopia and strabismus, for children from birth through
age 12
Note: See Section 5( b), Surgical procedures,
for coverage for surgical treatment of
amblyopia and strabismus.

Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Preferred primary care
provider or other health care
professional: $20 copayment
per visit

Preferred specialist: $30
copayment per visit

Note: You pay 30% of the
Plan allowance for drugs and
supplies.

Participating/ Non-participating:
You pay all
charges

Vision services (testing, treatment, and supplies) continued on next page 40.
40 Page 41 42

2003 Blue Cross and Blue Shield
Service Benefit Plan 38 Section 5( a)

NOTE: The calendar year deductible applies to almost all Standard Option benefits in this Section.
We say "( No deductible)" when the Standard Option deductible does not apply. There is no calendar year deductible under Basic Option.

Vision services (testing, treatment, and supplies) (continued) You Pay Standard Option You Pay Basic Option

Not covered:
Eyeglasses, contact lenses, routine eye examinations, or vision testing for the

prescribing or fitting of eyeglasses or contact
lenses, except as described on page 37

Eye exercises, visual training, or orthoptics, except for nonsurgical treatment of amblyopia

and strabismus as described on page 37
LASIK, radial keratotomy, and other refractive services

All charges All charges

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

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

Note: See Section 5( b) for our coverage for
surgical procedures.

Preferred: $15 copayment for
the office visit (No
deductible); 10% of the Plan
allowance for all other
services (deductible applies)

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Preferred primary care
provider or other health care
professional: $20 copayment
per visit

Preferred specialist: $30
copayment per visit

Note: You pay 30% of the
Plan allowance for drugs and
supplies.

Participating/ Non-participating:
You pay all
charges

Not covered: Routine foot care, such as 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

All charges All charges 41.
41 Page 42 43

2003 Blue Cross and Blue Shield
Service Benefit Plan 39 Section 5( a)

Orthopedic and prosthetic devices You Pay Standard Option You Pay Basic Option

Orthopedic braces and prosthetic appliances
such as:

Artificial limbs and eyes
Functional foot orthotics when prescribed by a physician

Rigid devices attached to the foot or a brace, or placed in a shoe
Replacement, repair, and adjustment of covered devices
Following a mastectomy, breast prostheses and surgical bras, including necessary
replacements
Note: A prosthetic appliance is a device that is
surgically inserted or physically attached to the
body to restore a bodily function or replace a
physical portion of the body.

We provide hospital benefits for internal
prosthetic devices, such as artificial joints,
pacemakers, cochlear implants, and surgically
implanted breast implants following
mastectomy; see Section 5( c) for payment
information. Insertion of the device is paid as
surgery; see Section 5( b).

Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Preferred: 30% of the Plan
allowance

Participating/ Non-participating:
You pay all
charges

Not covered:
Shoes and over-the-counter orthotics
Arch supports
Heel pads and heel cups
Penile implants
Wigs
Implanted bone conduction hearing aids

All charges All charges 42.
42 Page 43 44
2003 Blue Cross and Blue Shield
Service Benefit Plan 40 Section 5( a)

Durable medical equipment (DME) You Pay Standard Option You Pay Basic Option

Durable medical equipment (DME) is equipment
and supplies that:

1. Are prescribed by your attending physician
(i. e., the physician who is treating your
illness or injury);

2. Are medically necessary;
3. Are primarily and customarily used only for
a medical purpose;

4. Are generally useful only to a person with
an illness or injury;

5. Are designed for prolonged use; and
6. Serve a specific therapeutic purpose in the
treatment of an illness or injury.

We cover rental or purchase, at our option,
including repair and adjustment, of durable
medical equipment. Under this benefit, we
cover:

Home dialysis equipment
Oxygen equipment
Hospital beds
Wheelchairs
Crutches
Walkers
Other items that we determine to be DME

Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Preferred: 30% of the Plan
allowance

Participating/ Non-participating:
You pay all
charges

Not covered:
Exercise and bathroom equipment
Lifts, such as seat, chair, or van lifts
Car seats
Air conditioners, humidifiers, dehumidifiers, and purifiers

Breast pumps
Computer "story boards" or "light talkers" for communication-impaired individuals

Equipment for cosmetic purposes

All charges All charges 43.
43 Page 44 45
2003 Blue Cross and Blue Shield
Service Benefit Plan 41 Section 5( a)

Medical supplies You Pay Standard Option You Pay Basic Option

Medical foods for children with inborn errors of amino acid metabolism

Medical foods and nutritional supplements when administered by catheter or nasogastric
tubes
Ostomy and catheter supplies
Oxygen, regardless of the provider
Blood and blood plasma except when donated or replaced, and blood plasma expanders

Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Preferred: 30% of the Plan
allowance

Participating/ Non-participating:
You pay all
charges

Home health services
Home nursing care for two (2) hours per day,
up to 25 visits per calendar year, when:

A registered nurse (R. N.) or licensed practical nurse (L. P. N.) provides the services; and

A physician orders the care

Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Note: Visits that you pay for
while meeting your calendar
year deductible count toward
the annual visit limit.

Preferred: $20 copayment per
visit

Participating/ Non-participating:
You pay all
charges

Not covered:
Nursing care requested by, or for the convenience of, the patient or the patient's

family
Services primarily for bathing, feeding, exercising, moving the patient, homemaking,

giving medication, or acting as a companion
or sitter

All charges All charges 44.
44 Page 45 46

2003 Blue Cross and Blue Shield
Service Benefit Plan 42 Section 5( a)

Chiropractic You Pay Standard Option You Pay Basic Option

Initial office visit
Spinal manipulations
Initial set of X-rays

All charges
Note: Benefits may be
available for covered services
you receive from
chiropractors in medically
underserved areas. See page
10 for additional information.

Preferred: $20 copayment per
visit, up to 20 manipulations
per calendar year

Participating/ Non-participating:
You pay all
charges

Alternative treatments
Acupuncture when performed and billed by a
physician or physical therapist, for:

pain relief, and
as a modality of physical therapy
Note: See page 35 for limitations.
Note: We may also cover services of certain
alternative treatment providers in medically
underserved areas. See page 10 for additional
information.

Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Preferred primary care
provider or other health care
professional: $20 copayment
per visit

Preferred specialist: $30
copayment per visit

Note: You pay 30% of the
Plan allowance for drugs and
supplies.

Participating/ Non-participating:
You pay all
charges

Not covered:
Services you receive from non-covered providers such as:

naturopaths
hypnotherapists
Biofeedback (or other forms of self-care or self-help training)

All charges All charges 45.
45 Page 46 47

2003 Blue Cross and Blue Shield
Service Benefit Plan 43 Section 5( a)

Educational classes and programs You Pay Standard Option You Pay Basic Option

Smoking cessation
Note: See Section 5( e) for our coverage of
individual and group psychotherapy for
smoking cessation and Section 5( f) for our
coverage of smoking cessation drugs.

Preferred: $15 copayment for
the office visit charge (No
deductible); 10% of the Plan
allowance for all other
services (deductible applies)

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Preferred primary care
provider or other health care
professional: $20 copayment
per visit

Preferred specialist: $30
copayment per visit

Participating/ Non-participating:
You pay all
charges

Diabetic education when billed by a covered provider
Note: We cover diabetic educators, dieticians,
and nutritionists who bill independently only
as part of a covered diabetic education
program.

Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Preferred primary care
provider or other health care
professional: $20 copayment
per visit

Preferred specialist: $30
copayment per visit

Participating/ Non-participating:
You pay all
charges

Not covered:
Marital, family, educational, or other counseling or training services when

performed as part of an educational class or
program

Premenstrual syndrome (PMS), lactation, headache, eating disorder, and other

educational clinics
Recreational or educational therapy, and any related diagnostic testing except as provided

by a hospital as part of a covered inpatient
stay

Services performed or billed by a school or halfway house or a member of its staff

All charges All charges 46.
46 Page 47 48

2003 Blue Cross and Blue Shield
Service Benefit Plan 44 Section 5( b)

Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
I M
P O
R T
A N
T

Under Standard Option, the calendar year deductible is $250 per person ($ 500 per family). The calendar year deductible applies to almost all Standard Option benefits in this Section. We say "( No deductible)"
to show when the calendar year deductible does not apply.
Under Basic Option, there is no calendar year deductible.
Under Basic Option, you must use Preferred providers in order to receive benefits. See page 11 for the exceptions to this requirement.

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works, with special sections for members who are age 65 or over. Also read Section 9 about coordinating
benefits with other coverage, including Medicare.
We base payment on whether a facility or a health care professional bills for the services or supplies. You will find that some benefits are listed in more than one section of the brochure. This is because how they

are paid depends on what type of provider bills for the service.
The amounts listed below are for the charges billed by a physician or other health care professional for your surgical care. Look in Section 5( c) for charges associated with the facility (i. e., hospital, surgical

center, etc.).
YOU MUST GET PRIOR APPROVAL for all organ transplant surgical procedures; and if your surgical procedure requires an inpatient admission, YOU MUST GET PRECERTIFICATION. Please

refer to the prior approval and precertification information shown in Section 3 to be sure which
services require prior approval or precertification.

The non-PPO benefits are the standard benefits for Standard Option. PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non-PPO benefits apply.

I M
P O
R T
A N
T

Surgical procedures You Pay Standard Option You Pay Basic Option
A comprehensive range of services provided, or
ordered and billed by a physician, such as:

Operative procedures
Treatment of fractures and dislocations, including casting

Normal pre-and post-operative care by the surgeon
Correction of amblyopia and strabismus
Colonoscopy screening or diagnostic
Other endoscopy procedures
Biopsy procedures
Removal of tumors and cysts

Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Preferred: $100 copayment
per performing surgeon

Note: If you receive the
services of a co-surgeon, you
pay a second $100
copayment for those services.
No additional copayment
applies to the services of
assistant surgeons.

Participating/ Non-participating:
You pay all
charges

Surgical procedures continued on next page 47.
47 Page 48 49

2003 Blue Cross and Blue Shield
Service Benefit Plan 45 Section 5( b)

Surgical procedures (continued) You Pay Standard Option You Pay Basic Option

Correction of congenital anomalies (see Reconstructive surgery on page 46)

Treatment of burns
Circumcision of newborn
Insertion of internal prosthetic devices. See Section 5( a) Orthopedic and prosthetic

devices, and Section 5( c) Other hospital
services and supplies for our coverage for
the device.

Voluntary sterilization (e. g., Tubal ligation, Vasectomy)

Assistant surgeons/ surgical assistance by a physician if required because of the
complexity of the surgical procedures
Gastric bypass surgery or gastric stapling procedures for morbid obesity a condition in

which an individual weighs 100 pounds over,
or 100% over, his or her normal weight
according to current underwriting standards;
eligible members must be age 18 or over

Note: When multiple surgical procedures that
add time or complexity to patient care are
performed during the same operative session,
the Local Plan determines our allowance for the
combination of multiple, bilateral, or incidental
surgical procedures. Generally, we will allow a
reduced amount for procedures other than the
primary procedure.

Note: We do not pay extra for "incidental"
procedures (those that do not add time or
complexity to patient care).

Note: When unusual circumstances require the
removal of casts or sutures by a physician other
than the one who applied them, the Local Plan
may determine that a separate allowance is
payable.

Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Preferred: $100 copayment
per performing surgeon

Note: If you receive the
services of a co-surgeon, you
pay a second $100
copayment for those services.
No additional copayment
applies to the services of
assistant surgeons.

Participating/ Non-participating:
You pay all
charges

Note: We provide benefits at
100% of the Plan allowance
for services provided in
Preferred facilities by Non-preferred
radiologists,
anesthesiologists, certified
registered nurse anesthetists
(CRNAs), pathologists,
emergency room physicians,
and assistant surgeons
(including assistant surgeons
in a physician's office). You
are responsible for any
difference between our
allowance and the billed
amount.

Not covered:
Reversal of voluntary sterilization
Services of a standby physician
Routine surgical treatment of conditions of the foot [see Section 5( a) Foot care]

Cosmetic surgery
LASIK, radial keratotomy, and other refractive surgery

All charges All charges 48.
48 Page 49 50

2003 Blue Cross and Blue Shield
Service Benefit Plan 46 Section 5( b)

NOTE: The calendar year deductible applies to almost all Standard Option benefits in this Section.
We say "( No deductible)" when the Standard Option deductible does not apply. There is no calendar year deductible under Basic Option.

Reconstructive surgery You Pay Standard Option You Pay Basic Option
Surgery to correct a functional defect
Surgery to correct a congenital anomaly 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; and webbed fingers and
toes.

Note: Congenital anomalies do not include
conditions related to the teeth or intra-oral
structures supporting the teeth.

Treatment to restore the mouth to a pre-cancer state

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
Note: Internal breast prostheses are paid as
Medical services and supplies [see Section
5( a)], or Other hospital services and supplies
[see Section 5( c)].

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.

Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Preferred: $100 copayment
per performing surgeon

Note: If you receive the
services of a co-surgeon, you
pay a second $100
copayment for those services.
No additional copayment
applies to the services of
assistant surgeons.

Participating/ Non-participating:
You pay all
charges

Note: We provide benefits at
100% of the Plan allowance
for services provided in
Preferred facilities by Non-preferred
radiologists,
anesthesiologists, certified
registered nurse anesthetists
(CRNAs), pathologists,
emergency room physicians,
and assistant surgeons
(including assistant surgeons
in a physician's office). You
are responsible for any
difference between our
allowance and the billed
amount.

Not covered:
Cosmetic surgery any operative procedure or any portion of a procedure performed

primarily to improve physical appearance
through change in bodily form unless
required for a congenital anomaly or to
restore or correct a part of the body that has
been altered as a result of accidental injury,
disease, or surgery (does not include
anomalies related to the teeth or structures
supporting the teeth)

Surgeries related to sex transformation, sexual dysfunction, or sexual inadequacy

All charges All charges 49.
49 Page 50 51

2003 Blue Cross and Blue Shield
Service Benefit Plan 47 Section 5( b)

Oral and maxillofacial surgery You Pay Standard Option You Pay Basic Option

Oral surgical procedures, limited to:
Excision of tumors and cysts of the jaws, cheeks, lips, tongue, roof and floor of mouth

when pathological examination is necessary
Surgery needed to correct accidental injuries (see Definitions) to jaws, cheeks, lips, tongue,

roof and floor of mouth
Excision of exostoses of jaws and hard palate
Incision and drainage of abscesses and cellulitis

Incision and surgical treatment of accessory sinuses, salivary glands, or ducts
Reduction of dislocations and excision of temporomandibular joints
Removal of impacted teeth

Preferred: 10% of the Plan
allowance

Participating: 25% of the Plan
allowance

Non-participating: 25% of the
Plan allowance, plus any
difference between our
allowance and the billed
amount

Note: We provide benefits at
90% of the Plan allowance for
services provided in Preferred
facilities by Non-preferred
radiologists, anesthesiologists,
certified registered nurse
anesthetists (CRNAs),
pathologists, and emergency
room physicians. You are
responsible for any difference
between our allowance and
the billed amount.

Preferred: $100 copayment
per performing surgeon

Note: If you receive the
services of a co-surgeon, you
pay a second $100 copayment
for those services. No
additional copayment applies
to the services of assistant
surgeons.

Participating/ Non-participating:
You pay all
charges

Note: We provide benefits at
100% of the Plan allowance
for services provided in
Preferred facilities by Non-preferred
radiologists,
anesthesiologists, certified
registered nurse anesthetists
(CRNAs), pathologists,
emergency room physicians,
and assistant surgeons
(including assistant surgeons
in a physician's office). You
are responsible for any
difference between our
allowance and the billed
amount.

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

periodontal membrane, gingiva, and alveolar
bone), except as shown above and in Section
5( h)

Surgical procedures involving orthodontic care, dental implants, or preparation of the mouth for

the fitting or the continued use of dentures,
except as specifically shown above and in
Section 5( h)

All charges All charges 50.
50 Page 51 52
2003 Blue Cross and Blue Shield
Service Benefit Plan 48 Section 5( b)

Organ/ tissue transplants You Pay Standard Option You Pay Basic Option

Cornea
Heart
Heart-lung

Kidney
Liver
Pancreas
Single or double lung: only for the following end-stage pulmonary diseases: pulmonary

fibrosis, primary pulmonary hypertension,
and emphysema

Double lung: only for patients with end-stage cystic fibrosis

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

Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Note: We provide benefits at
90% of the Plan allowance for
services provided in Preferred
facilities by Non-preferred
radiologists, anesthesiologists,
certified registered nurse
anesthetists (CRNAs),
pathologists, and emergency
room physicians. You are
responsible for any difference
between our allowance and
the billed amount.

Preferred: $100 copayment
per performing surgeon

Note: If you receive the
services of a co-surgeon, you
pay a second $100
copayment for those services.
No additional copayment
applies to the services of
assistant surgeons.

Participating/ Non-participating:
You pay all
charges

Note: We provide benefits at
100% of the Plan allowance
for services provided in
Preferred facilities by Non-preferred
radiologists,
anesthesiologists, certified
registered nurse anesthetists
(CRNAs), pathologists,
emergency room physicians,
and assistant surgeons
(including assistant surgeons
in a physician's office). You
are responsible for any
difference between our
allowance and the billed
amount.

Organ/ tissue transplants continued on next page 51.
51 Page 52 53
2003 Blue Cross and Blue Shield
Service Benefit Plan 49 Section 5( b)

Organ/ tissue transplants (continued) You Pay Standard Option You Pay Basic Option

Bone marrow and stem cell transplants, limited
to:

Allogeneic bone marrow transplants and allogeneic cord blood stem cell transplants

(from related or unrelated donors) for:
Advanced neuroblastoma
Infantile malignant osteopetrosis
Severe combined immunodeficiency
Mucopolysaccharidosis (e. g., Hunter, Hurler's, Sanfilippo, Maroteaux-Lamy

variants)
Mucolipidosis (e. g., Gaucher's disease, metachromatic leukodystrophy,

adrenoleukodystrophy)
Severe or very severe aplastic anemia
Thalassemia major (homozygous beta-thalassemia)

Sickle cell anemia
Phagocytic deficiency diseases (e. g., Wiskott-Aldrich syndrome)

Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Preferred: $100 copayment
per performing surgeon

Note: If you receive the
services of a co-surgeon, you
pay a second $100
copayment for those services.
No additional copayment
applies to the services of
assistant surgeons.

Participating/ Non-participating:
You pay all
charges

Note: We provide benefits at
100% of the Plan allowance
for services provided in
Preferred facilities by Non-preferred
radiologists,
anesthesiologists, certified
registered nurse anesthetists
(CRNAs), pathologists,
emergency room physicians,
and assistant surgeons
(including assistant surgeons
in a physician's office). You
are responsible for any
difference between our
allowance and the billed
amount.

Organ/ tissue transplants continued on next page 52.
52 Page 53 54
2003 Blue Cross and Blue Shield
Service Benefit Plan 50 Section 5( b)

Organ/ tissue transplants (continued) You Pay Standard Option You Pay Basic Option

Bone marrow and stem cell transplants, limited
to: (continued)

Allogeneic bone marrow transplants, allogeneic cord blood stem cell transplants

(from related or unrelated donors) and
allogeneic peripheral blood stem cell
transplants for:

Acute lymphocytic or non-lymphocytic (i. e., myelogenous) leukemia

Advanced Hodgkin's lymphoma
Advanced non-Hodgkin's lymphoma
Chronic myelogenous leukemia
Advanced forms of myelodysplastic syndromes

Autologous bone marrow transplants and autologous peripheral blood stem cell
transplants (collectively referred to as
autologous stem cell support) for:

Acute lymphocytic or nonlymphocytic (i. e., myelogenous) leukemia

Advanced Hodgkin's lymphoma
Advanced non-Hodgkin's lymphoma
Advanced neuroblastoma
Amyloidosis
Testicular, Mediastinal, Retroperitoneal, and Ovarian germ cell tumors

Multiple myeloma

Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Note: We provide benefits at
90% of the Plan allowance for
services provided in Preferred
facilities by Non-preferred
radiologists, anesthesiologists,
certified registered nurse
anesthetists (CRNAs),
pathologists, and emergency
room physicians. You are
responsible for any difference
between our allowance and
the billed amount.

Preferred: $100 copayment
per performing surgeon

Note: If you receive the
services of a co-surgeon, you
pay a second $100
copayment for those services.
No additional copayment
applies to the services of
assistant surgeons.

Participating/ Non-participating:
You pay all
charges

Note: We provide benefits at
100% of the Plan allowance
for services provided in
Preferred facilities by Non-preferred
radiologists,
anesthesiologists, certified
registered nurse anesthetists
(CRNAs), pathologists,
emergency room physicians,
and assistant surgeons
(including assistant surgeons
in a physician's office). You
are responsible for any
difference between our
allowance and the billed
amount.

Organ/ tissue transplants continued on next page 53.
53 Page 54 55

2003 Blue Cross and Blue Shield
Service Benefit Plan 51 Section 5( b)

Organ/ tissue transplants (continued) You Pay Standard Option You Pay Basic Option

Extraction or reinfusion of bone marrow, blood stem cells, or cord blood as a source of
stem cells as part of a covered allogeneic or
autologous bone marrow transplant or blood
stem cell transplant support procedure

Marrow harvesting in anticipation of a covered autologous bone marrow transplant,

for patients diagnosed at the time of
harvesting with one of the conditions listed on
page 49 or 50

Collection, processing, storage, and distribution of cord blood only when

performed by a cord blood bank approved by
the FDA

Storage of harvested bone marrow, blood stem cells, or cord blood as a source of stem

cells, only when a covered transplant has
already been scheduled

Related medical and hospital expenses of the donor, as part of a covered transplant

procedure
Related services or supplies provided to the recipient

Note: See Section 5( a) for coverage for related
services, such as chemotherapy and/ or radiation
therapy and drugs administered to stimulate or
mobilize stem cells for covered transplant
procedures.

Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Note: We provide benefits at
90% of the Plan allowance for
services provided in Preferred
facilities by Non-preferred
radiologists, anesthesiologists,
certified registered nurse
anesthetists (CRNAs),
pathologists, and emergency
room physicians. You are
responsible for any difference
between our allowance and
the billed amount.

Preferred: $100 copayment
per performing surgeon

Note: If you receive the
services of a co-surgeon, you
pay a second $100
copayment for those services.
No additional copayment
applies to the services of
assistant surgeons.

Participating/ Non-participating:
You pay all
charges

Note: We provide benefits at
100% of the Plan allowance
for services provided in
Preferred facilities by Non-preferred
radiologists,
anesthesiologists, certified
registered nurse anesthetists
(CRNAs), pathologists,
emergency room physicians,
and assistant surgeons
(including assistant surgeons
in a physician's office). You
are responsible for any
difference between our
allowance and the billed
amount.

Organ/ tissue transplants continued on next page 54.
54 Page 55 56

2003 Blue Cross and Blue Shield
Service Benefit Plan 52 Section 5( b)

Organ/ tissue transplants (continued)
Organ/ Tissue Transplants at Blue Quality Centers for Transplant (BQCT)
We participate in the Blue Quality Centers for Transplant (BQCT), a centers of excellence program for the organ/ tissue
transplants listed below. You will receive enhanced benefits if you use a BQCT facility.

Contact us at the customer service number listed on the back of your ID card before obtaining services. You will be given
information about BQCT and a list of approved facilities.

Heart
Heart-lung
Liver
Pancreas
Simultaneous pancreas-kidney
Single or double lung: only for the following end-stage pulmonary diseases: pulmonary fibrosis, primary pulmonary hypertension, and emphysema

Double lung: only available for patients with end-stage cystic fibrosis
Bone marrow and stem cell transplants listed on pages 49 and 50.
Related transplant services listed on page 51
Note: Benefits for cornea, kidney, and intestinal transplants are not available through BQCT. See page 48 for benefit
information for these transplants.

Note: See Section 5( c) for our benefits for facility care.
Note: Members will not be responsible for separate cost-sharing for the included professional services (see page 11).
Note: See below and page 53 for limitations to bone marrow and stem cell transplant coverage.

Organ/ tissue transplants (continued) You Pay Standard Option You Pay Basic Option
Limitations
(1) You must obtain prior approval (see page 14)
from the Local Plan, for both the procedure
and the facility, for the following transplant
procedures:

Bone marrow, cord blood stem cell, and peripheral blood stem cell transplant

support procedures
Heart
Heart-lung
Liver
Lung (single/ double)
Pancreas
Intestinal transplants (small intestine with or without other organs)

Organ/ tissue transplants continued on next page 55.
55 Page 56 57

2003 Blue Cross and Blue Shield
Service Benefit Plan 53 Section 5( b)

NOTE: The calendar year deductible applies to almost all Standard Option benefits in this Section.
We say "( No deductible)" when the Standard Option deductible does not apply. There is no calendar year deductible under Basic Option.

Organ/ tissue transplants (continued) You Pay Standard Option You Pay Basic Option
(2) For the following procedures, we provide
benefits only when conducted at a Cancer
Research Facility (see page 11) and
performed as part of a clinical trial that meets
the requirements shown below:

Allogeneic bone marrow transplants, syngeneic bone marrow transplants, and

allogeneic peripheral blood stem cell
transplants for:

Multiple myeloma
Chronic lymphocytic leukemia
Early stage (indolent or non-advanced) small cell lymphocytic

lymphoma
Nonmyeloablative allogeneic stem cell transplants for:

Chronic myelogenous leukemia
Acute lymphocytic or non-lymphocytic (i. e., myelogenous)

leukemia
Advanced Hodgkin's lymphoma
Advanced non-Hodgkin's lymphoma
Advanced forms of myelodysplastic syndromes

Multiple myeloma
Chronic lymphocytic leukemia
Early stage (indolent or non-advanced) small cell lymphocytic

lymphoma
Renal cell carcinoma
Autologous bone marrow transplants and autologous peripheral blood stem cell

transplants (collectively referred to as
autologous stem cell support) for:

Breast cancer
Epithelial ovarian cancer
Chronic myelogenous leukemia
Chronic lymphocytic leukemia
Early stage (indolent or non-advanced) small cell lymphocytic lymphoma

Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Preferred: $100 copayment
per performing surgeon

Note: If you receive the
services of a co-surgeon, you
pay a second $100
copayment for those services.
No additional copayment
applies to the services of
assistant surgeons.

Participating/ Non-participating:
You pay all
charges

Note: We provide benefits at
100% of the Plan allowance
for services provided in
Preferred facilities by Non-preferred
radiologists,
anesthesiologists, certified
registered nurse anesthetists
(CRNAs), pathologists,
emergency room physicians,
and assistant surgeons
(including assistant surgeons
in a physician's office). You
are responsible for any
difference between our
allowance and the billed
amount.

Organ/ tissue transplants continued on next page 56.
56 Page 57 58

2003 Blue Cross and Blue Shield
Service Benefit Plan 54 Section 5( b)

Organ/ tissue transplants (continued) You Pay Standard Option You Pay Basic Option

For these bone marrow transplant procedures
and related services or supplies covered only
through clinical trials:

1. You must contact our Clinical Trials
Information Unit at 1-800- 225-2268 for prior
approval (see page 14);

2. The clinical trial must be reviewed and
approved by the Institutional Review Board
of the Cancer Research Facility where the
procedure is to be delivered; and

3. The patient must be properly and lawfully
registered in the clinical trial, meeting all the
eligibility requirements of the trial.

If a non-randomized clinical trial meeting these
requirements is not available at a Cancer
Research Facility where you are eligible, we will
arrange for the transplant to be provided at
another Plan-designated transplant facility.

Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Preferred: $100 copayment
per performing surgeon

Note: If you receive the
services of a co-surgeon, you
pay a second $100
copayment for those services.
No additional copayment
applies to the services of
assistant surgeons.

Participating/ Non-participating:
You pay all
charges

Note: We provide benefits at
100% of the Plan allowance
for services provided in
Preferred facilities by Non-preferred
radiologists,
anesthesiologists, certified
registered nurse anesthetists
(CRNAs), pathologists,
emergency room physicians,
and assistant surgeons
(including assistant surgeons
in a physician's office). You
are responsible for any
difference between our
allowance and the billed
amount.

Not covered:
Transplants for any diagnosis not listed as covered

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

All charges All charges 57.
57 Page 58 59

2003 Blue Cross and Blue Shield
Service Benefit Plan 55 Section 5( b)

Anesthesia You Pay Standard Option You Pay Basic Option

Anesthesia (including acupuncture) for covered
surgical services when requested by the
attending physician and performed by:

a certified registered nurse anesthetist (CRNA), or

a physician other than the operating physician (surgeon) or the assistant
Professional services provided in:
Hospital (inpatient)
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center
Office
Anesthesia services consist of administration by
injection or inhalation of a drug or other
anesthetic agent (including acupuncture) to
obtain muscular relaxation, loss of sensation, or
loss of consciousness.

Note: See Section 5( c) for our payment levels for
anesthesia services billed by a facility.

Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Note: We provide benefits at
90% of the Plan allowance
for services provided in
Preferred facilities by Non-preferred
anesthesiologists
and certified registered nurse
anesthetists (CRNAs). You
are responsible for any
difference between our
allowance and the billed
amount.

Preferred: Nothing
Participating/ Non-participating:
You pay all
charges

Note: We provide benefits at
100% of the Plan allowance
for services provided in
Preferred facilities by Non-preferred
anesthesiologists
and certified registered nurse
anesthetists (CRNAs). You
are responsible for any
difference between our
allowance and the billed
amount. 58.
58 Page 59 60

2003 Blue Cross and Blue Shield
Service Benefit Plan 56 Section 5( c)

Section 5 (c). Services provided by a hospital or other facility, and ambulance services
I M
P O
R T
A N
T

In this section, unlike Sections 5( a) and 5( b), the Standard Option calendar year deductible applies to only a few benefits. In that case, we added "( calendar year deductible applies)" when it applies. The
calendar year deductible is $250 per person ($ 500 per family) under Standard Option.
Under Basic Option, there is no calendar year deductible.
Under Basic Option, you must use Preferred providers in order to receive benefits. See page 11 for the exceptions to this requirement.

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works, with special sections for members who are age 65 or over. Also read Section 9 about
coordinating benefits with other coverage, including Medicare.
YOU MUST GET PRECERTIFICATION OF HOSPITAL STAYS; FAILURE TO DO SO WILL RESULT IN A $500 PENALTY. Please refer to the precertification information listed in Section 3 to

be sure which services require precertification.
You should be aware that some PPO hospitals may have non-PPO professional providers on staff.
We base payment on whether a facility or a health care professional bills for the services or supplies. You will find that some benefits are listed in more than one section of the brochure. This is because

how they are paid depends on what type of provider bills for the service. For example, physical therapy
is paid differently depending on whether it is billed by an inpatient facility, a doctor, a physical
therapist, or an outpatient facility.

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

(i. e., physicians, etc.) are listed in Sections 5( a) or 5( b).
The non-PPO benefits are the standard benefits for Standard Option. PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non-PPO benefits apply.

I M
P O
R T
A N
T 59.
59 Page 60 61
2003 Blue Cross and Blue Shield
Service Benefit Plan 57 Section 5( c)

Benefit Description You Pay
NOTE: The Standard Option calendar year deductible applies ONLY when we say below: "( calendar year deductible applies) ." There is no calendar year deductible under Basic Option.

Inpatient hospital You Pay Standard Option You Pay Basic Option
Room and board, such as:
semiprivate or intensive care accommodations

general nursing care
meals and special diets
Note: We cover a private room only when you
must be isolated to prevent contagion, when
your isolation is required by law, or when a
Preferred or Member hospital only has private
rooms. Otherwise, we will pay the hospital's
average daily rate for semiprivate rooms as
determined by the Local Plan. If a Non-member
hospital only has private rooms, we
base our payment on the average daily rate as
determined by the Local Plan.

Preferred: $100 per
admission copayment for
unlimited days

Member: $300 per admission
copayment for unlimited days

Non-member: $300 per
admission copayment for
unlimited days, plus 30% of
the Plan allowance, and any
remaining balance after our
payment

Preferred: $100 per day
copayment up to $500 per
admission for unlimited days

Member/ Non-member: You
pay all charges

Inpatient hospital continued on next page 60.
60 Page 61 62

2003 Blue Cross and Blue Shield
Service Benefit Plan 58 Section 5( c)

NOTE: The Standard Option calendar year deductible applies ONLY when we say below:
"( calendar year deductible applies) ." There is no calendar year deductible under Basic Option.

Inpatient hospital (continued) You Pay Standard Option You Pay Basic Option

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

Prescribed drugs
Diagnostic laboratory tests, pathology services, MRIs, machine diagnostic tests, and

X-rays
Administration of blood or blood plasma
Dressings, splints, casts, and sterile tray services

Internal prosthetic devices
Other medical supplies and equipment, including oxygen

Anesthetics and anesthesia services
Take-home items
Pre-admission testing recognized as part of the hospital admissions process

Note: Here are some things to keep in mind:
You do not need to precertify your normal delivery; see page 13 for other circumstances,

such as extended stays for you or your baby.
If you need to stay longer in the hospital than initially planned, we will cover an extended

stay if it is medically necessary. However,
you must precertify the extended stay. See
Section 3 for information on requesting
additional days.

We pay inpatient hospital benefits for an admission in connection with dental

procedures only when a non-dental physical
impairment exists that makes hospitalization
necessary to safeguard the health of the
patient. We provide benefits for dental
procedures as shown in Section 5( h).

Note: See page 31 for covered maternity
services.

Note: See page 41 for coverage of blood and
blood products.

Preferred: $100 per
admission copayment for
unlimited days

Member: $300 per admission
copayment for unlimited
days

Non-member: $300 per
admission copayment for
unlimited days, plus 30% of
the Plan allowance, and any
remaining balance after our
payment

Preferred: $100 per day
copayment up to $500 per
admission for unlimited days

Member/ Non-member: You
pay all charges

Inpatient hospital continued on next page 61.
61 Page 62 63
2003 Blue Cross and Blue Shield
Service Benefit Plan 59 Section 5( c)

NOTE: The Standard Option calendar year deductible applies ONLY when we say below:
"( calendar year deductible applies) ." There is no calendar year deductible under Basic Option.

Inpatient hospital (continued) You Pay Standard Option You Pay Basic Option

Not covered:
Hospital room and board expenses when in our
judgement, a hospital admission or portion of
an admission is:

Custodial care
Convalescent care or a rest cure
Domiciliary care provided because care in the home is not available or unsuitable

Not medically necessary, such as when services did not require the acute/ subacute
hospital inpatient (overnight) setting but
could have been provided safely and
adequately in a physician's office, the
outpatient department of a hospital, or some
other setting, without adversely affecting your
condition or the quality of medical care you
receive. Some examples are:

Admissions for, or consisting primarily of, observation and/ or

evaluation that could have been
provided safely and adequately in
some other setting (such as a
physician's office)

Admissions primarily for diagnostic studies, laboratory and pathology services,

X-rays, MRIs, or machine diagnostic tests
that could have been provided safely and
adequately in some other setting (such as
the outpatient department of a hospital or a
physician's office)

Note: If we determine that a hospital admission
is one of the types listed above, we will not
provide benefits for inpatient room and board
or inpatient physician care. However, we will
provide benefits for covered services or
supplies other than room and board and
inpatient physician care at the level that we
would have paid if they had been provided in
some other setting.

Admission to non-covered facilities, such as nursing homes, extended care facilities,

schools, residential treatment centers
Personal comfort items, such as guest meals and beds, telephone, television, beauty and

barber services
Inpatient private duty nursing

All charges All charges 62.
62 Page 63 64

2003 Blue Cross and Blue Shield
Service Benefit Plan 60 Section 5( c)

NOTE: The Standard Option calendar year deductible applies ONLY when we say below:
"( calendar year deductible applies) ." There is no calendar year deductible under Basic Option.

Outpatient hospital or ambulatory surgical center You Pay Standard Option You Pay Basic Option

Outpatient medical services performed and
billed for by a hospital or freestanding
ambulatory facility, such as:

Use of special treatment rooms
Diagnostic tests, such as laboratory and pathology services, MRIs, machine diagnostic

tests, and X-rays
Administration of blood, blood plasma, and other biologicals

Cardiac rehabilitation
Renal dialysis
Note: See pages 27-30 for covered preventive
services for adults and children.

Preferred facilities: 10% of
the Plan allowance (calendar
year deductible applies)

Member facilities: 25% of
the Plan allowance (calendar
year deductible applies)

Non-member facilities: 25%
of the Plan allowance
(calendar year deductible
applies); plus any difference
between our allowance and
the billed amount

Preferred: $30 copayment per
day per facility

Member/ Non-member: You
pay all charges

Note: For outpatient
diagnostic tests billed for by
a Member or Non-member
facility, you pay a $30
copayment, plus any
difference between our
allowance and the billed
amount.

Outpatient hospital or ambulatory surgical center continued on next page 63.
63 Page 64 65

2003 Blue Cross and Blue Shield
Service Benefit Plan 61 Section 5( c)

NOTE: The Standard Option calendar year deductible applies ONLY when we say below:
"( calendar year deductible applies) ." There is no calendar year deductible under Basic Option.

Outpatient hospital or ambulatory surgical center (continued) You Pay Standard Option You Pay Basic Option

Outpatient surgery and related services
performed and billed for by a hospital or
freestanding ambulatory facility, such as:

Operating, recovery, and other treatment rooms

Pre-surgical testing performed within one business day of the covered surgical services
Facility supplies for hemophilia home care
Diagnostic tests, such as laboratory and pathology services, MRIs, machine diagnostic

tests, and X-rays
Administration of blood, blood plasma, and other biologicals

Note: We cover outpatient hospital services and
supplies related to dental procedures only when
a non-dental physical impairment exists that
makes the hospital setting necessary to
safeguard the health of the patient. See Section
5( h), Dental benefits, for additional benefit
information.

Note: See page 31 for covered maternity services.

Preferred facilities: 10% of
the Plan allowance

Member facilities: 25% of
the Plan allowance

Non-member facilities: 25%
of the Plan allowance, plus
any difference between our
allowance and the billed
amount

Preferred: $30 copayment per
day per facility

Member/ Non-member: You
pay all charges

Note: For outpatient
diagnostic tests billed for by
a Member or Non-member
facility, you pay a $30
copayment, plus any
difference between our
allowance and the billed
amount.

Outpatient hospital or ambulatory surgical center continued on next page 64.
64 Page 65 66
2003 Blue Cross and Blue Shield
Service Benefit Plan 62 Section 5( c)

NOTE: The Standard Option calendar year deductible applies ONLY when we say below:
"( calendar year deductible applies) ." There is no calendar year deductible under Basic Option.

Outpatient hospital or ambulatory surgical center (continued) You Pay Standard Option You Pay Basic Option

Outpatient drugs and supplies billed for by a
hospital or freestanding ambulatory facility,
such as:

Prescribed drugs
Blood and blood plasma, if not donated or replaced

Dressings, splints, casts, and sterile tray services
Other medical supplies, including oxygen

Preferred facilities: 10% of
the Plan allowance (calendar
year deductible applies)

Member facilities: 25% of
the Plan allowance (calendar
year deductible applies)

Non-member facilities: 25%
of the Plan allowance
(calendar year deductible
applies); plus any difference
between our allowance and
the billed amount

Preferred: 30% of the Plan
allowance

Note: You may also be
responsible for paying a $30
copayment per day per
facility for outpatient
services.

Member/ Non-member: You
pay all charges 65.
65 Page 66 67

2003 Blue Cross and Blue Shield
Service Benefit Plan 63 Section 5( c)

NOTE: The Standard Option calendar year deductible applies ONLY when we say below:
"( calendar year deductible applies) ." There is no calendar year deductible under Basic Option.

Extended care benefits/ Skilled nursing care facility benefits You Pay Standard Option You Pay Basic Option

Limited to the following benefits for Medicare
Part A copayments:

When Medicare Part A is the primary payer
(meaning that it pays first) and has made
payment, Standard Option provides limited
secondary benefits.

We pay the applicable Medicare Part A
copayments incurred in full during the first
through the 30 th day of confinement for each
benefit period (as defined by Medicare) in a
qualified skilled nursing facility. A qualified
skilled nursing facility is a facility that
specializes in skilled nursing care performed by
or under the supervision of licensed nurses,
skilled rehabilitation services, and other related
care, and meets Medicare's special qualifying
criteria, but is not an institution that primarily
cares for and treats mental diseases.

If Medicare pays the first 20 days in full, Plan
benefits will begin on the 21 st day (when
Medicare Part A copayments begin) and will
end on the 30 th day.

Note: See pages 35 and 36 for benefits
provided for outpatient physical, occupational,
and speech therapy when billed by a skilled
nursing facility. See Section 5( f) for benefits
for prescription drugs.

Note: If you do not have Medicare Part A,
we do not provide benefits for skilled
nursing facility care.

Preferred: Nothing
Participating/ Member:
Nothing

Non-participating/ Non-member:
Nothing

Note: You pay all charges
not paid by Medicare after
the 30 th day.

All charges 66.
66 Page 67 68

2003 Blue Cross and Blue Shield
Service Benefit Plan 64 Section 5( c)

NOTE: The Standard Option calendar year deductible applies ONLY when we say below:
"( calendar year deductible applies) ." There is no calendar year deductible under Basic Option.

Hospice care You Pay Standard Option You Pay Basic Option

Hospice care is an integrated set of services
and supplies designed to provide palliative and
supportive care to terminally ill patients in their
homes.

We provide the following home hospice care
benefits for members with a life expectancy of
six months or less when prior approval is
obtained from the Local Plan and the home
hospice agency is approved by the Local Plan:

Physician visits
Nursing care
Medical social services
Physical therapy
Services of home health aides
Durable medical equipment rental
Prescription drugs
Medical supplies

Nothing Nothing

Inpatient hospice for members receiving home
hospice care benefits:

Benefits are provided for up to five (5)
consecutive days in a hospital or a freestanding
hospice inpatient facility.

Each inpatient stay must be separated by at
least 21 days.

These covered inpatient hospice benefits are
available only when inpatient services are
necessary to:

control pain and manage the patient's symptoms; or

provide an interval of relief (respite) to the family
Note: You are responsible for making sure
that the home hospice care provider has
received prior approval from the Local Plan (see page 14 for instructions). Please check

with your Local Plan and/ or your PPO directory
for listings of approved agencies.

Preferred: $100 per
admission copayment

Member: $300 per admission
copayment

Non-member: $300 per
admission copayment plus
30% of the Plan allowance,
and any remaining balance
after our payment

Preferred: $100 per day
copayment up to $500 per
admission

Member/ Non-member: You
pay all charges

Not covered: Homemaker or bereavement
services
All charges All charges 67.
67 Page 68 69
2003 Blue Cross and Blue Shield
Service Benefit Plan 65 Section 5( c)

NOTE: The Standard Option calendar year deductible applies ONLY when we say below:
"( calendar year deductible applies) ." There is no calendar year deductible under Basic Option.

Ambulance You Pay Standard Option You Pay Basic Option

Local professional ambulance transport services
to or from the nearest hospital equipped to
adequately treat your condition, when
medically appropriate, and:

Associated with covered hospital inpatient care

Related to medical emergency
Associated with covered hospice care

Preferred: 10% of the Plan
allowance (calendar year
deductible applies)

Participating/ Member: 25%
of the Plan allowance
(calendar year deductible
applies)

Non-participating/ Non-member:
25% of the Plan
allowance (calendar year
deductible applies); plus any
difference between our
allowance and the billed
amount

Preferred: $50 copayment
per trip

Participating/ Member or
Non-participating/ Non-member:
$50 copayment
per trip

Ambulance services related to accidental injury Preferred: Nothing (No
deductible)

Participating/ Member:
Nothing (No deductible)

Non-participating/ Non-member:
Any difference
between the Plan allowance
and the billed amount (No
deductible)

Note: These benefit levels
apply only if you receive care
in connection with, and
within 72 hours after, an
accidental injury. For
services received after 72
hours, see above.

Preferred: $50 copayment
per trip

Participating/ Member or
Non-participating/ Non-member:
$50 copayment
per trip 68.
68 Page 69 70

2003 Blue Cross and Blue Shield
Service Benefit Plan 66 Section 5( d)

Section 5 (d). Emergency services/ accidents
I M
P O
R T
A N
T

Under Standard Option, the calendar year deductible is $250 per person ($ 500 per family). The calendar year deductible applies to almost all Standard Option benefits in this Section. We added
"( No deductible)" to show when the calendar year deductible does not apply.
Under Basic Option, there is no calendar year deductible.
Under Basic Option, you must use Preferred providers in order to receive benefits, except in cases of medical emergency or accidental injury. Refer to the guidelines appearing below for additional

information.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works, with special sections for members who are age 65 or over. Also read Section 9 about

coordinating benefits with other coverage, including Medicare.
The non-PPO benefits are the standard benefits for Standard Option. PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non-PPO benefits apply.

I M
P O
R T
A N
T

What is an accidental injury?
An accidental injury is an injury caused by an external force or element such as a blow or fall and which requires immediate
medical attention, including animal bites and poisonings. [See Section 5( h) for dental care for accidental injury.]

What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or
could result in serious injury or disability, and requires immediate medical or surgical care. Some problems are emergencies
because, if not treated promptly, they might become more serious; examples include deep cuts and broken bones. Others are
emergencies because they are potentially life threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or
sudden inability to breathe. There are many other acute conditions that we may determine are medical emergencies what
they all have in common is the need for quick action.

Basic Option benefits for emergency care
Under Basic Option, you are encouraged to seek care from Preferred providers in cases of accidental injury or medical
emergency. However, if you need care immediately and cannot access a Preferred provider, we will provide benefits for the
initial treatment provided in the emergency room of any hospital even if the hospital is not a Preferred facility. We will also
provide benefits if you are admitted directly to the hospital from the emergency room until your condition has been stabilized. In
addition, we will provide benefits for emergency ambulance transportation provided by Preferred or Non-preferred ambulance
providers if the transport is due to a medical emergency or accidental injury.

We provide emergency benefits when you have acute symptoms of sufficient severity including severe pain such that a
prudent layperson, who possesses average knowledge of health and medicine, could reasonably expect the absence of immediate
medical attention to result in serious jeopardy to the person's health, or with respect to a pregnant woman, the health of the
woman and her unborn child. 69.
69 Page 70 71

2003 Blue Cross and Blue Shield
Service Benefit Plan 67 Section 5( d)

Benefit Description You Pay
NOTE: The calendar year deductible applies to almost all Standard Option benefits in this Section. We say "( No deductible)" when the Standard Option deductible does not apply.
There is no calendar year deductible under Basic Option.
Accidental injury You Pay Standard Option You Pay Basic Option
Physician services in the hospital outpatient department, urgent care center, or physician's
office, including X-rays, MRIs, laboratory
and pathology services, and machine
diagnostic tests

Related outpatient hospital services and supplies, including X-rays, MRIs, laboratory

and pathology services, and machine
diagnostic tests

Note: We pay Inpatient hospital benefits if you
are admitted [see Section 5( c)].

Note: See Section 5( h) for dental benefits for
accidental injuries.

Preferred: Nothing (No
deductible)

Participating/ Member:
Nothing (No deductible)

Non-participating/ Non-member:
Any difference
between the Plan allowance
and the billed amount (No
deductible)

Note: These benefit levels
apply only if you receive care
in connection with, and
within 72 hours after, an
accidental injury. For
services received after 72
hours, regular medical and
outpatient hospital benefits
apply. See Section 5( a),
Medical services and
supplies, Section 5( b),
Surgical procedures, and
Section 5( c), Outpatient
hospital, for the benefits we
provide.

Preferred emergency room:
$50 copayment per visit

Participating/ Member
emergency room:
$50 copayment per visit

Non-participating/ Non-member
emergency room:
$50 copayment per visit

Note: You are responsible for
the applicable copayment as
shown above. If you use a
Non-preferred provider, you
may also be responsible for
any difference between our
allowance and the billed
amount.

Note: If you are admitted
directly to the hospital from
the emergency room, you do
not have to pay the $50
emergency room copayment.
However, the $100 per day
copayment for Preferred
inpatient care still applies.

Note: All follow-up care
must be performed and billed
for by Preferred providers to
be eligible for benefits.

Accidental injury continued on next page 70.
70 Page 71 72

2003 Blue Cross and Blue Shield
Service Benefit Plan 68 Section 5( d)

Accidental injury (continued) You Pay Standard Option You pay Basic Option

For the following places of
service, you must receive
care from a Preferred
provider:

Preferred urgent care center:
$30 copayment per visit

Preferred primary care
provider or other health care
professional's office:
$20 copayment per visit

Preferred specialist's office:
$30 copayment per visit

Participating/ Member (for
other than emergency room):
You pay all charges

Non-participating/ Non-member
(for other than
emergency room): You pay
all charges

Not covered:
Oral surgery except as shown in Section 5( b)
Injury to the teeth while eating

All charges All charges 71.
71 Page 72 73

2003 Blue Cross and Blue Shield
Service Benefit Plan 69 Section 5( d)

Medical emergency You Pay Standard Option You pay Basic Option

Physician services in the hospital outpatient department, urgent care center, or
physician's office, including X-rays, MRIs,
laboratory and pathology services, and
machine diagnostic tests

Related outpatient hospital services and supplies, including X-rays, MRIs, laboratory

and pathology services, and machine
diagnostic tests

Note: We pay Inpatient hospital benefits if you
are admitted as a result of a medical
emergency [see Section 5( c), Inpatient
hospital].

Note: Please refer to Section 3 for information
about precertifying emergency hospital
admissions.

Preferred: 10% of the Plan
allowance

Note: If you receive services
in a Preferred physician's
office, you pay a $15
copayment (No deductible)
for the office visit, and 10%
of the Plan allowance for all
other services (deductible
applies).

Participating/ Member: 25%
of the Plan allowance

Non-participating/ Non-member:
25% of the Plan
allowance, plus any
difference between our
allowance and the billed
amount

Note: These benefit levels do
not apply if you receive care
in connection with, and
within 72 hours after, an
accidental injury. See
Accidental Injury benefits on
pages 66-68 for the benefits
we provide.

Preferred emergency room:
$50 copayment per visit

Participating/ Member
emergency room:
$50 copayment per visit

Non-participating/ Non-member
emergency room:
$50 copayment per visit

Note: All follow-up care
must be performed and billed
for by Preferred providers to
be eligible for benefits.

For the following places of
service, you must receive
care from a Preferred
provider:

Preferred urgent care center:
$30 copayment per visit

Preferred primary care
provider or other health care
professional's office:
$20 copayment per visit

Preferred specialist's office:
$30 copayment per visit

Participating/ Member (for
other than emergency room):
You pay all charges

Non-participating/ Non-member
(for other than
emergency room): You pay
all charges 72.
72 Page 73 74

2003 Blue Cross and Blue Shield
Service Benefit Plan 70 Section 5( d)

Ambulance You Pay Standard Option You pay Basic Option

Local professional ambulance transport
services to or from the nearest hospital
equipped to adequately treat your condition,
when medically appropriate, and:

Associated with covered hospital inpatient care

Related to medical emergency
Associated with covered hospice care
Note: See Section 5( c) for non-emergency
ambulance services.

Preferred: 10% of the Plan
allowance

Participating/ Member: 25%
of the Plan allowance

Non-participating/ Non-member:
25% of the Plan
allowance, plus any
difference between our
allowance and the billed
amount

Preferred: $50 copayment
per trip

Participating/ Member or
Non-participating/ Non-member:
$50 copayment
per trip

Ambulance services related to accidental
injury
Preferred: Nothing (No
deductible)

Participating/ Member:
Nothing (No deductible)

Non-participating/ Non-member:
Any difference
between the Plan allowance
and the billed amount (No
deductible)

Note: These benefit levels
apply only if you receive care
in connection with, and
within 72 hours after, an
accidental injury. For
services received after 72
hours, see above.

Preferred: $50 copayment
per trip

Participating/ Member or
Non-participating/ Non-member:
$50 copayment
per trip 73.
73 Page 74 75

2003 Blue Cross and Blue Shield
Service Benefit Plan 71 Section 5( e)

Section 5 (e). Mental health and substance abuse benefits
I M
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Under Standard Option, the calendar year deductible or, for facility care, the inpatient per admission copay, applies to almost all benefits in this Section. We added "( No deductible)" to show when the
deductible does not apply.
Under Standard Option, there is a maximum of 25 visits per year for office visits, partial hospitalization, intensive outpatient treatment, and other hospital outpatient treatment. The first 25 visits under Standard

Option each calendar year by Preferred providers and Non-preferred providers count toward this
maximum. This maximum may be waived for services received from Preferred providers.

Under Standard Option, you may choose to get care In-Network (Preferred) or Out-of-Network (Non-preferred). When you use a Preferred provider, he or she must submit a treatment plan to us prior to your

ninth outpatient visit in order to maximize the benefits you receive. Preferred benefits are payable when the care is clinically appropriate to treat your condition and when you receive the care as part of a
treatment plan that we approve. Cost-sharing and limitations for In-Network (Preferred) mental health and
substance abuse benefits are no greater than for similar benefits for other illnesses and conditions.

Under Basic Option, you must call us for prior approval before receiving care. We will provide you with the names and phone numbers of several Preferred providers and tell you how many visits we are

initially approving. You may then choose which of those providers you would like to see. You must use
Preferred providers in order to receive Basic Option benefits.

Under Basic Option, there is no calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works, with special sections for members who are age 65 or over. Also read Section 9 about coordinating

benefits with other coverage, including Medicare.
YOU MUST GET PRECERTIFICATION OF HOSPITAL STAYS; FAILURE TO DO SO WILL RESULT IN A $500 PENALTY. Please refer to the precertification information listed in Section 3.

Some other services also require prior approval. See the instructions after the benefits descriptions below.
Standard Option and Basic Option benefits for Preferred (In-Network) mental health and substance abuse care begin below and are continued on the following pages. Standard Option benefits for Non-preferred

(Out-of-Network) care begin on page 75.
The non-PPO benefits are the standard benefits for Standard Option. PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non-PPO benefits apply.

I M
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Benefit Description You Pay
NOTE: The calendar year deductible applies to almost all Standard Option benefits in this Section. We say "( No deductible)" when the Standard Option deductible does not apply.
There is no calendar year deductible under Basic Option.
Preferred (In-Network) benefits You Pay Standard Option You Pay Basic Option
All diagnostic and treatment services contained
in a treatment plan that we approve. The
treatment plan may include services, drugs, and
supplies described elsewhere in this brochure.

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

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

Preferred (In-Network) benefits continued on next page 74.
74 Page 75 76
2003 Blue Cross and Blue Shield
Service Benefit Plan 72 Section 5( e)

NOTE: The calendar year deductible applies to almost all Standard Option benefits in this Section.
We say "( No deductible)" when the Standard Option deductible does not apply. There is no calendar year deductible under Basic Option.

Preferred (In-Network) benefits (continued) You Pay Standard Option You Pay Basic Option

Professional services, including individual or
group therapy by providers such as
psychiatrists, psychologists, clinical social
workers, or psychiatric nurses

Office and home visits
In a hospital outpatient department (except for emergency rooms)

Psychotherapy for smoking cessation
Note: Additional types of licensed providers may
be available to you for mental health and
substance abuse services. Consult your PPO
directory or contact your Local Plan at the mental
health and substance abuse phone number on the
back of your ID card.

$15 copayment for the visit,
up to two hours per visit (No
deductible)

$20 copayment per visit
Note: You pay a $30
copayment for outpatient
services billed for by a
facility.

Other services:
Pharmacotherapy (medication management)
Psychological testing
Note: Additional types of licensed providers may
be available to you for mental health and
substance abuse services. Consult your PPO
directory or contact your Local Plan at the mental
health and substance abuse phone number on the
back of your ID card.

10% of the Plan allowance
(deductible applies)

Note: Other services are not
subject to the two-hour limit.

Preferred primary care
provider or other health care
professional: $20 copayment
per visit

Preferred specialist: $30
copayment per visit

Note: You pay a $30
copayment for outpatient
services billed for by a
facility.

Note: You pay 30% of the
Plan allowance for drugs and
supplies.

Inpatient professional visits
Professional charges for facility-based intensive outpatient treatment

10% of the Plan allowance
Note: Intensive outpatient
treatment is not limited to
two hours per visit but you
must obtain prior approval.

Nothing

Professional charges for intensive outpatient treatment in a provider's office or other
professional setting

10% of the Plan allowance
Note: Intensive outpatient
treatment is not limited to
two hours per visit but you
must obtain prior approval.

Preferred: $30 copayment per
visit

Professional charges for outpatient diagnostic tests 10% of the Plan allowance $20 copayment per visit
Preferred (In-Network) benefits continued on next page 75.
75 Page 76 77
2003 Blue Cross and Blue Shield
Service Benefit Plan 73 Section 5( e)

NOTE: The calendar year deductible applies to almost all Standard Option benefits in this Section.
We say "( No deductible)" when the Standard Option deductible does not apply. There is no calendar year deductible under Basic Option.

Preferred (In-Network) benefits (continued) You Pay Standard Option You Pay Basic Option
Inpatient services provided and billed by a
hospital or other covered facility

Room and board, such as semiprivate or intensive accommodations, general nursing

care, meals and special diets, and other
hospital services

Diagnostic tests
Note: You must get precertification of inpatient
hospital stays; failure to do so will result in a
$500 penalty.

$100 per admission
copayment (No deductible)
$100 per day copayment up
to $500 per admission

Outpatient services provided and billed by a
hospital or other covered facility

Diagnostic tests
Services in the following approved treatment programs (must be prior approved):

partial hospitalization
facility-based intensive outpatient treatment

10% of the Plan allowance $30 copayment per day per
facility

Note: You pay 30% of the
Plan allowance for drugs and
supplies.

Not covered:
Services we have not approved
Educational or training services
Psychoanalysis or psychotherapy credited toward earning a degree or furtherance of

education or training regardless of diagnosis
or symptoms that may be present

All charges All charges

Preferred (In-Network) benefits continued on next page 76.
76 Page 77 78

2003 Blue Cross and Blue Shield
Service Benefit Plan 74 Section 5( e)

Preferred (In-Network) benefits (continued)
Authorization Procedures Standard Option: To be eligible to receive Preferred mental health and substance abuse benefits you must see a Preferred provider, obtain a treatment plan, and
follow the applicable authorization processes.
To locate a Preferred provider, please refer to your PPO directory, visit our website
at www. fepblue. org, or contact us at the mental health and substance abuse phone
number shown on the back of your ID card.

Basic Option: To be eligible to receive mental health and substance abuse benefits,
you must call us for prior approval at the mental health and substance abuse phone
number on the back of your ID card before you receive care. We will then provide
you with the names and phone numbers of several Preferred providers to choose
from and tell you how many visits we are initially approving.

Precertification You must get precertification of inpatient hospital stays; failure to do so will result in a $500 penalty. Please refer to the precertification information listed in Section 3

for additional information.
Prior Approval Standard Option: Prior approval is required for partial hospitalization and intensive outpatient treatment programs.

Basic Option: Prior approval is required for all mental health and substance abuse
services.

Prior to starting treatment, you, someone acting on your behalf, your physician, or your
hospital must call us at the mental health and substance abuse phone number on the
back of your ID card. We will not pay for mental health and substance abuse services
under Basic Option or for partial hospitalization or intensive outpatient treatment
programs under Standard Option, even at Preferred facilities, until you obtain prior
approval.

Treatment Plans Standard Option: We provide Preferred benefits only when you receive care as part of a treatment plan that we have approved. In order to maximize your

benefits, your provider must submit a treatment plan to us prior to your ninth
outpatient visit. When we approve the treatment plan, we will give your provider
authorization for additional visits or services. The services or number of additional
visits authorized will depend on the treatment plan. We may need to request
updated treatment plans as your treatment progresses. If a treatment plan is not
submitted or approved, we will provide only Non-preferred (out-of-network)
benefits. If you change providers, a new treatment plan must be submitted. We will
be flexible in allowing additional visits while your treatment plan is being prepared
or under review.

Basic Option: We will work directly with your provider and may request a
treatment plan from your provider.

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.

Preferred Limitation Under Standard Option, if you do not obtain an approved treatment plan, we will provide only Non-preferred (out-of-network) benefits. 77.
77 Page 78 79
2003 Blue Cross and Blue Shield
Service Benefit Plan 75 Section 5( e)

NOTE: The calendar year deductible applies to almost all Standard Option benefits in this Section.
We say "( No deductible)" when the Standard Option deductible does not apply. There is no calendar year deductible under Basic Option.

Non-preferred (Out-of-Network) benefits You Pay Standard Option You Pay Basic Option
Professional services, including individual or
group therapy, by providers such as
psychiatrists, psychologists, clinical social
workers, or psychiatric nurses, for:

Office and home visits
In a hospital outpatient department (except for emergency rooms)

Psychotherapy for smoking cessation

40% of the Plan allowance
for up to two hours per visit
and up to 25 outpatient visits
per calendar year; all charges
after 25 visits*. You may
also be responsible for any
difference between the Plan
allowance and the billed
amount.

*The 25-visit limit is a
combined maximum for all
outpatient professional care,
partial hospitalization,
intensive outpatient
treatment, and outpatient
facility care, whether
performed by Preferred or
Non-preferred providers, or
applied to your calendar year
deductible.

Participating/ Non-participating:
You pay all
charges

Other services:
Pharmacotherapy (medication management)
Psychological testing

25% of the Plan allowance.
You may also be responsible
for any difference between
the Plan allowance and the
billed amount.

Note: Other services are not
subject to the 25-visit
limitation.

Participating/ Non-participating:
You pay all
charges

Inpatient visits 40% of the Plan allowance up
to 100 days per calendar
year; all charges after 100
days. You may also be
responsible for any difference
between the Plan allowance
and the billed amount.

Participating/ Non-participating:
You pay all
charges

Non-preferred (Out-of-Network) benefits continued on next page 78.
78 Page 79 80

2003 Blue Cross and Blue Shield
Service Benefit Plan 76 Section 5( e)

Non-preferred (Out-of-Network) benefits (continued) You Pay Standard Option You Pay Basic Option

Inpatient services provided and billed by a
hospital or other covered facility

Room and board, such as semiprivate or intensive accommodations, general nursing

care, meals and special diets, and other
hospital services

You must get precertification of inpatient
hospital stays; failure to do so will result in a
$500 penalty.

$400 copayment per day (No
deductible) up to 100 days
per calendar year; all charges
after 100 days

Member/ Non-member: You
pay all charges

Outpatient services provided and billed by a
hospital or other covered facility

Psychological testing

25% of the Plan allowance,
plus any difference between
the Plan allowance and the
billed amount

Note: Psychological testing
is not subject to the visit
limitations.

Member/ Non-member: You
pay all charges

Partial hospitalization and intensive outpatient
treatment

Note: You must request and receive prior
approval for these services. See Section 3 for
more information about prior approval.

25% of the Plan allowance,
plus any difference between
the Plan allowance and the
billed amount; all charges
after 25 visits*

Note: Visits that you pay for
while meeting your
deductible count toward the
limit cited above.

Participating/ Member or
Non-participating/ Non-member:
You pay all charges

Non-preferred (Out-of-Network) benefits continued on next page 79.
79 Page 80 81

2003 Blue Cross and Blue Shield
Service Benefit Plan 77 Section 5( e)

Non-preferred (Out-of-Network) benefits (continued) You Pay Standard Option You Pay Basic Option

Inpatient care to treat substance abuse includes
room and board and ancillary charges for
confinements in a treatment facility for
rehabilitative treatment of alcoholism or
substance abuse

Non-preferred facility: $400
copayment per day (No
deductible); all charges after
28 days per lifetime

Non-preferred professional:
40% of the Plan allowance;
all charges after 28 days per
lifetime. You may also be
responsible for any difference
between the Plan allowance
and the billed amount.

Note: Non-preferred
inpatient care for the
treatment of substance abuse
is limited to one treatment
program (28-day maximum)
per lifetime.

Member/ Non-member: You
pay all charges

Participating/ Non-participating:
You pay all
charges

Not covered:
Marital, family, educational, or other counseling or training services

Services performed by a non-covered provider
Testing and treatment for learning disabilities and mental retardation
Services performed or billed by schools, residential treatment centers, halfway houses,
or members of their staffs
Psychoanalysis or psychotherapy credited toward earning a degree or furtherance of

education or training regardless of diagnosis
or symptoms that may be present

All charges All charges

Lifetime maximum Non-preferred inpatient care for the treatment of substance abuse is limited to one treatment program (28-day maximum) per lifetime under Standard Option.
Precertification You must get precertification of the medical necessity of your admission to a
hospital or other covered facility. Report emergency admissions within two
business days following the day of admission, even if you have been discharged.
Otherwise, we will reduce the benefits payable by $500. See Section 3 for more
information on precertification.

See these sections of the brochure for more valuable information about these benefits:
Section 4, Your costs for covered services, for information about catastrophic protection for mental health and substance abuse benefits.

Section 7, Filing a claim for covered services, for information about submitting Non-preferred claims. 80.
80 Page 81 82

2003 Blue Cross and Blue Shield
Service Benefit Plan 78 Section 5( f)

Section 5 (f). Prescription drug benefits
I M
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T

Here are some important things you should keep in mind about these benefits:
We cover prescription drugs and supplies, as described in the chart beginning on page 80.
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.

Under Standard Option, the calendar year deductible does not apply to prescriptions filled through the Retail Pharmacy Program or Mail Service Prescription Drug Program. We added "( calendar year
deductible applies)" when it applies.
Under Basic Option, there is no calendar year deductible.
YOU MUST GET PRIOR APPROVAL FOR CERTAIN DRUGS, and prior approval must be renewed periodically. Please refer to the prior approval information shown on page 84 of this

Section and in Section 3. Prior approval is part of our Patient Safety and Quality Monitoring (PSQM)
program. See page 84 of this Section for more information about this important program.

coordinating benefits with other coverage, including Medicare.
Under Standard Option, non-PPO benefits are the standard benefits. PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non-PPO benefits apply.

Under Basic Option, you must use Preferred providers in order to receive benefits. See page 11 for the exceptions to this requirement.
Please note that retail pharmacies and internet pharmacies that are Preferred under Standard Option are not necessarily Preferred under Basic Option. Refer to page 81 for information about locating Preferred
pharmacies.
Under Standard Option, you may use the Mail Service Prescription Drug Program to fill your prescriptions.

The Mail Service Prescription Drug Program is not available under Basic Option.

I M
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T

We will send each new enrollee a description of our prescription drug program and a combined prescription drug/ Plan
identification card. Standard Option members are eligible to use the Mail Service Prescription Drug Program and will also
receive a mail order form/ patient profile and a preaddressed reply envelope.

Who can write your prescriptions. A physician or dentist licensed in the United States or Puerto Rico, or a nurse practitioner in states that permit it, must write your prescriptions [see Section 5( i) for drugs purchased overseas].

Where you can obtain them.
Under Standard Option, you may fill prescriptions at a Preferred retail pharmacy, through a Preferred internet pharmacy,
at a Non-preferred retail pharmacy, or through our Mail Service Prescription Drug Program. Under Standard Option, we
pay a higher level of benefits when you use a Preferred retail pharmacy, a Preferred internet pharmacy, or our Mail Service
Prescription Drug Program.

Under Basic Option, you must fill prescriptions only at a Preferred retail pharmacy or through a Preferred internet pharmacy in order to receive benefits.

We use an open formulary. This is a list of preferred brand-name drugs selected to meet patient needs at a lower cost to us. If your physician believes a brand-name drug is necessary or there is no generic equivalent available, ask your
physician to prescribe a brand-name drug from our formulary list.
Under Standard Option, we may ask your doctor to substitute a formulary drug in order to help control costs. We cover drugs that require a prescription (whether or not they are on our formulary list). Your cooperation with our cost-savings

efforts helps keep your premium affordable. 81.
81 Page 82 83

2003 Blue Cross and Blue Shield
Service Benefit Plan 79 Section 5( f)

Under Basic Option, we encourage you to ask your physician to prescribe a brand-name drug from our formulary list
when your physician believes a brand-name drug is necessary or when there is no generic equivalent available. If you
purchase a drug that is not on our formulary list, your cost will be higher. (We cover drugs that require a prescription
whether or not they are on our formulary list.)

Note: Before filling your prescription, please check the formulary status of your medication. Other than changes
resulting from new drugs or safety issues, the formulary list is updated twice a year. Prescription drugs are reviewed
by the Plan for safety and clinical efficacy. Drugs determined to be of equal therapeutic value and similar safety and
efficacy are then evaluated on the basis of cost. Using lower cost formulary drugs will provide you with a high
quality, cost-effective prescription drug benefit.

You can view our formulary on our website at www. fepblue. org or request a copy by mail by calling 1-800-624-5060
(TDD: 1-800-624-5077). Any savings we receive on the cost of drugs purchased under this Plan from drug
manufacturers are credited to the reserves held for this Plan.

Generic equivalents.
Standard Option: By submitting your prescription (or those of family members covered by the Plan) to your retail pharmacy or the Mail Service Prescription Drug Program, you authorize them to substitute any available Federally

approved generic equivalent, unless you or your physician specifically request a brand-name drug.
Basic Option: By filling your prescriptions (or those of family members covered by the Plan) at a Preferred retail
pharmacy or through a Preferred internet pharmacy, you authorize the pharmacist to substitute any available Federally
approved generic equivalent, unless you or your physician specifically request a brand-name drug.

Why use generic drugs? Generic drugs are lower-priced drugs that are the therapeutic equivalent to more expensive brand-name drugs. In most cases, 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 (FDA) 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. However, you and your doctor have the option to request a brand-name
drug even if a generic option is available. Using the most cost-effective medication saves money.

Disclosure of information. As part of our administration of prescription drug benefits, we may disclose information about your prescription drug utilization, including the names of your prescribing physicians, to any treating physicians
or dispensing pharmacies.
These are the dispensing limitations.
Standard Option: You may purchase up to a 90-day supply of covered drugs and supplies through the Retail
Pharmacy Program. You may purchase a supply of more than 21 days up to 90 days through the Mail Service
Prescription Drug Program for a single copayment.

Basic Option: When you fill a prescription for the first time, you may purchase up to a 34-day supply for a single
copayment. For additional copayments, you may purchase up to a 90-day supply for continuing prescriptions and for
refills.

Note: Certain drugs such as narcotics may have additional FDA limits on the quantities that a pharmacy may dispense. In
addition, pharmacy dispensing practices are regulated by the state where they are located and may also be determined by
individual pharmacies. In most cases, refills cannot be obtained until 75% of the prescription has been used. Call us or
visit our website if you have any questions about dispensing limits. See the contact information below.

Important contact information.
Standard Option: Retail Pharmacy Program: 1-800-624-5060 (TDD: 1-800-624-5077); Mail Service Prescription Drug Program: 1-800-262-7890 (TDD: 1-800-446-7292); or www. fepblue. org.

Basic Option: Retail Pharmacy Program: 1-800-624-5060 (TDD: 1-800-624-5077) or www. fepblue. org. 82.
82 Page 83 84

2003 Blue Cross and Blue Shield
Service Benefit Plan 80 Section 5( f)

Covered medications and supplies You Pay Standard Option You Pay Basic Option
Drugs, vitamins and minerals, and nutritional supplements that by Federal law of the United
States require a prescription for their purchase
Insulin
Needles and disposable syringes for the administration of covered medications

Drugs to aid smoking cessation that require a prescription by Federal law
Note: Prior approval is required if drug treatment
extends beyond the initial course of treatment.
See Section 3 for more information.

Contraceptive drugs and devices, limited to:
Depo-Provera*
Diaphragms and contraceptive rings*
Intrauterine Devices (IUDs)
Implantable contraceptives*
Oral and transdermal contraceptives
*available only through retail and internet
pharmacies

Note: See Family planning in Section 5( a).

See following pages See following pages

Covered medications and supplies continued on next page 83.
83 Page 84 85

2003 Blue Cross and Blue Shield
Service Benefit Plan 81 Section 5( f)

Covered medications and supplies (continued) You Pay Standard Option You Pay Basic Option
Here is how to obtain your prescription drugs
and supplies:

Preferred Retail Pharmacies
Make sure you have your Plan ID card when you're ready to purchase your prescription

Go to any Preferred retail pharmacy,
or

Visit our special website, www. fepblue. org, click on "Pharmacy Programs," and follow

the FEP Retail Pharmacy Providers link to fill
your prescription and receive home delivery

For a listing of Preferred retail pharmacies, call the Retail Pharmacy Program at

1-800-624-5060 (TDD: 1-800-624-5077) or
visit our website, www. fepblue. org

Note: Please be sure to request the Preferred retail or internet pharmacy listing for your

specific option. Retail and internet pharmacies that are Preferred under Standard
Option are not necessarily Preferred under Basic Option.

Note: For prescription drugs billed for by a
skilled nursing facility, nursing home, or
extended care facility, we provide benefits as
shown on this page for retail pharmacy-obtained
drugs, as long as the pharmacy
supplying the drugs to the facility is a Preferred
pharmacy. For a list of the Preferred Network
Long Term Care pharmacies, call
1-800-624-5060 (TDD: 1-800-624-5077) or
visit our website at www. fepblue. org. For
benefit information about drugs supplied by
Non-preferred pharmacies, please refer to
the next page.

Note: For coordination of benefits purposes, if
you need a statement of Preferred retail
pharmacy benefits in order to file claims with
your other coverage when this Plan is the
primary payer, call the Retail Pharmacy
Program at 1-800-624-5060 (TDD: 1-800-624-
5077) or visit our website at www. fepblue. org.

25% of the Plan allowance First-time purchase of a new
prescription up to a 34-day
supply:

Generic drug:
$10 copayment

Formulary brand-name
drug: $25 copayment

Non-formulary
brand-name drug:
50% of Plan allowance ($ 35
minimum)

Refills or continuing prescriptions up to a 90-day

supply:
Generic drug:
$10 copayment for each
purchase of up to a 34-day
supply ($ 30 copayment for
90-day supply)

Formulary brand-name
drug: $25 copayment for
each purchase of up to a 34-
day supply ($ 75 copayment
for 90-day supply)

Non-formulary
brand-name drug:
50% of Plan allowance ($ 35
minimum for each purchase
of up to a 34-day supply, or
$105 minimum for 90-day
supply)

Note: If there is no generic
equivalent available, you
must still pay the brand-name
copayment when you receive
a brand-name drug.

Note: For generic and brand-name
drug purchases, if the
cost of your prescription is
less than your cost-sharing
amount noted above, you pay
only the cost of your
prescription.

Covered medications and supplies continued on next page 84.
84 Page 85 86

2003 Blue Cross and Blue Shield
Service Benefit Plan 82 Section 5( f)

Covered medications and supplies (continued) You Pay Standard Option You Pay Basic Option
Non-preferred Retail Pharmacies 45% of the Plan allowance (Average wholesale price
AWP), plus any difference
between our allowance and
the billed amount

Note: If you use a Non-preferred
retail pharmacy,
you must pay the full cost of
the drug or supply at the time
of purchase and file a claim
with the Retail Pharmacy
Program to be reimbursed.
Please refer to Section 7 for
instructions on how to file
prescription drug claims.

All charges

Mail Service Prescription Drug Program
Under Standard Option, if your doctor orders
more than a 21-day supply of covered drugs or
supplies, up to a 90-day supply, you can use
this service for your prescriptions and refills.

Please refer to Section 7 for instructions on
how to use the Mail Service Prescription Drug
Program.

Note: Not all drugs are available through the Mail Service Prescription Drug Program.

Mail Service Program:
$10 generic
$35 brand-name

Note: If there is no generic
equivalent available, you
must still pay the brand-name
copayment when you receive
a brand-name drug.

Note: If the cost of your
prescription is less than your
copayment, you pay only the
cost of your prescription.
The Mail Service
Prescription Drug Program
will charge you the lesser of
the prescription cost or the
copayment when you place
your order. If you have
already sent in your
copayment, they will credit
your account with any
difference.

No benefit
Note: You may request home
delivery of your internet
prescription drug purchases.
See page 81 of this Section
for our payment levels for
drugs obtained through
Preferred retail and internet
pharmacies.

Covered medications and supplies continued on next page 85.
85 Page 86 87

2003 Blue Cross and Blue Shield
Service Benefit Plan 83 Section 5( f)

Covered medications and supplies (continued) You Pay Standard Option You Pay Basic Option
Drugs from other sources
Covered prescription drugs and supplies not obtained at a retail pharmacy, through an

internet pharmacy, or, for Standard Option
only, through the Mail Service Prescription
Drug Program

Note: Drugs purchased overseas must be the
equivalent to drugs that by Federal law of the
United States require a prescription.

Note: For covered prescription drugs and
supplies purchased outside of the United States
and Puerto Rico, please submit claims on an
Overseas Claim Form. See Section 5( i) for
information on how to file claims for overseas
services.

Please refer to the Sections indicated for additional benefit information when you

purchase drugs from a:
Physician's office Section 5( a)
Home health care agency Section 5( a)
Hospital (inpatient or outpatient) Section 5( c)

Hospice agency Section 5( c)

Preferred: 10% of the Plan
allowance (calendar year
deductible applies)

Participating/ Member: 25%
of the Plan allowance
(calendar year deductible
applies)

Non-participating/ Non-member:
25% of the Plan
allowance (calendar year
deductible applies); plus any
difference between our
allowance and the billed
amount

Preferred: 30% of the Plan
allowance

Participating/ Member or
Non-participating/ Non-member:
You pay all
charges

Covered medications and supplies continued on next page 86.
86 Page 87 88

2003 Blue Cross and Blue Shield
Service Benefit Plan 84 Section 5( f)

Covered medications and supplies (continued) You Pay Standard Option You Pay Basic Option
Patient Safety and Quality Monitoring (PSQM)
We have a special program to promote patient
safety and monitor health care quality. Our
Patient Safety and Quality Monitoring (PSQM)
program features a set of closely aligned
programs that are designed to promote the safe
and appropriate use of medications. Examples
of these programs include:

Prior approval As described below, this program requires that approval be obtained for

certain prescription drugs and supplies before
we provide benefits for them.

Safety checks Before your prescription is filled, we perform quality and safety checks

for usage precautions, drug interactions, drug
duplication, excessive use, and frequency of
refills.

Quantity allowances Specific allowances for several medications are based on FDA-approved

recommendations, clinical studies,
and manufacturer guidelines.

For more information about our PSQM program,
including listings of drugs subject to prior
approval or quantity allowances, visit our
website at www. fepblue. org or call the Retail
Pharmacy Program at 1-800- 624-5060
(TDD: 1-800-624-5077).

Prior Approval
As part of our Patient Safety and Quality
Monitoring (PSQM) program (see above),
members must request and receive prior
approval for certain prescription drugs and
supplies in order to use their prescription drug
coverage. Prior approval must be renewed
periodically. To obtain a list of these drugs and
supplies and to obtain prior approval request
forms, call the Retail Pharmacy Program at
1-800-624-5060 (TDD: 1-800-624-5077). You
can also obtain the list through our website at
www. fepblue. org. Please read Section 3 for
more information about prior approval.

Note: If your prescription requires prior
approval and you have not yet obtained prior
approval, you must pay the full cost of the drug
or supply at the time of purchase and file a claim
with the Retail Pharmacy Program to be
reimbursed. Please refer to Section 7 for
instructions on how to file prescription drug
claims.

Covered medications and supplies continued on next page 87.
87 Page 88 89

2003 Blue Cross and Blue Shield
Service Benefit Plan 85 Section 5( f)

Covered medications and supplies (continued) You Pay Standard Option You Pay Basic Option
Not covered:
Medical supplies such as dressings and antiseptics

Drugs and supplies for cosmetic purposes
Drugs and supplies for weight loss
Drugs for orthodontic care, dental implants, and periodontal disease

Medication that does not require a prescription under Federal law even if your
doctor prescribes it or a prescription is
required under your State law

Drugs for which prior approval has been denied or not obtained

Infant formula other than described on page 41

All charges All charges 88.
88 Page 89 90

2003 Blue Cross and Blue Shield
Service Benefit Plan 86 Section 5( g)

Section 5 (g). Special features
Special feature Description
Flexible benefits option Under the flexible benefits option, we determine the most effective way to provide services.

We may identify medically appropriate alternatives to traditional care and/ or direct the provision of Plan benefits to a less costly alternative benefit.

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

The decision to offer an alternative benefit is solely ours, and we may withdraw it at any time and resume regular contract benefits.
Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process.
Note: Under the Blue Cross and Blue Shield Service Benefit Plan, the flexible
benefits option is also referred to as "case management."

Online customer and claims service By visiting our website, www. fepblue. org, you may check the status of your claims, change your address of record, request claim forms, request a duplicate or
replacement Service Benefit Plan ID card, and access a range of other service and
information options. It's easy! Give it a try and share any suggestions you may
have for improved service by using the site's "Contact Us" feature.

24-hour nurse line Help with health concerns is available 24 hours a day, 365 days a year, by calling a toll-free telephone number, 1-888-258-3432, or by accessing our website,
www. fepblue. org. The service, called Blue Health Connection, offers health advice
or health information and counseling by registered nurses. Also available is the
AudioHealth Library with hundreds of tapes, ranging from first aid to infectious
diseases to general health issues.

You can get information about health care resources to help you find local doctors,
hospitals, or other health care services affiliated with the Blue Cross and Blue Shield
Service Benefit Plan. Contact us at the number above or visit our website for more
information. Please keep in mind that benefits for any health care services you may
seek after using Blue Health Connection are subject to the terms of your coverage
under this Plan.

Services for the deaf and hearing impaired All Blue Cross and Blue Shield Plans provide TDD access for the hearing impaired to access information and receive answers to their questions.

Travel benefit/ services overseas Please refer to Section 5( i) for benefit and claims information for care you receive outside the United States and Puerto Rico.
Health support programs The Service Benefit Plan is developing and may offer patient education and support programs for certain diagnoses in select locations on a pilot basis. One program we
have developed is the PPO Performance Measurement Pilot Program. We will notify
you if this pilot or other programs are available in your area.

Healthy Families Program Healthy Families is a national health education prevention program that provides information to members and their families. The educational mailings assist members
to understand and adopt healthy behaviors, reduce risk of injury and disease, and
improve existing chronic conditions. 89.
89 Page 90 91

2003 Blue Cross and Blue Shield
Service Benefit Plan 87 Section 5( h)

Section 5 (h). Dental benefits
I M
P O
R T
A N
T

Under Standard Option, the calendar year deductible applies only to the accidental injury benefit below. We added "( calendar year deductible applies)" when it applies.
Under Basic Option, there is no calendar year deductible.
Under Basic Option, you must use Preferred providers in order to receive benefits, except in cases of dental care resulting from an accidental injury as described below.

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works, with special sections for members who are age 65 or over. Also read Section 9 about
coordinating benefits with other coverage, including Medicare.
Note: We cover hospitalization for dental procedures only when a non-dental physical impairment exists that makes hospitalization necessary to safeguard the health of the patient (even if the dental

procedure itself is not covered). See Section 5( c) for inpatient hospital benefits.

I M
P O
R T
A N
T

Accidental injury benefit You Pay Standard Option You Pay Basic Option
We provide benefits for services, supplies, or
appliances for dental care necessary to
promptly repair injury to sound natural teeth
required as a result of, and directly related to,
an accidental injury.

Note: An accidental injury is an injury caused
by an external force or element such as a blow
or fall and that requires immediate attention.
Injuries to the teeth while eating are not
considered accidental injuries.

Note: A sound natural tooth is a tooth that is
whole or properly restored (restoration with
amalgams only); is without impairment,
periodontal, or other conditions; and is not in
need of the treatment provided for any reason
other than an accidental injury. For purposes of
this Plan, a tooth previously restored with a
crown, inlay, onlay, or porcelain restoration, or
treated by endodontics, is not considered a
sound natural tooth.

Note: Treatment must be started promptly and
completed within 12 months of the accident.

Preferred: 10% of the Plan
allowance (calendar year
deductible applies)

Participating: 25% of the
Plan allowance (calendar
year deductible applies)

Non-participating: 25% of
the Plan allowance (calendar
year deductible applies), plus
any difference between our
allowance and the billed
amount

Note: Under Standard
Option, we first provide
benefits as shown in the
Schedule of Dental
Allowances on the following
pages. We then pay benefits
as shown here for any
balances.

$20 copayment
Note: We provide benefits
for accidental dental injury
care in cases of medical
emergency when performed
by Preferred or Non-preferred providers. See

Section 5( d) for the criteria
we use to determine if
emergency care is required.
You are responsible for the
applicable copayment as
shown above. If you use a
Non-preferred provider, you
may also be responsible for
any difference between our
allowance and the billed
amount.

Note: All follow-up care
must be performed and billed
for by Preferred providers to
be eligible for benefits.

Dental benefits continued on next page 90.
90 Page 91 92

2003 Blue Cross and Blue Shield
Service Benefit Plan 88 Section 5( h)

Dental benefits (continued)
What is Covered
Standard Option dental benefits are presented in the chart beginning below and continuing on the following pages.
Basic Option dental benefits appear on page 92.
Note: See Section 5( b) for our benefits for Oral and maxillofacial surgery, and Section 5( c) for our benefits for hospital services
(inpatient/ outpatient) in connection with dental services, available under both Standard Option and Basic Option.

Preferred Dental Network
All Local Plans contract with Preferred dentists who are available in most areas. Preferred dentists agree to accept a negotiated,
discounted amount called the Maximum Allowable Charge (MAC) as payment in full for the following services. They will also
file your dental claims for you. Under Standard Option, you are responsible, as an out-of-pocket expense, for the difference
between the amount specified in this Schedule of Dental Allowances and the MAC. To find a Preferred dentist near you, refer to
the Preferred provider directory, visit our website at www. fepblue. org, or call us at the customer service number on the back of
your ID card. You can also call us to obtain a copy of the applicable MAC listing.

Note: Dentists who are in our Preferred Dental Network are not necessarily Preferred providers for other services covered by this
Plan under other benefit provisions (such as oral and maxillofacial surgery).

Standard Option dental benefits
Under Standard Option, we pay billed charges for the following services, up to the amounts shown per service as listed in the
Schedule of Dental Allowances below and on the following pages. This is a complete list of dental services covered under this
benefit for Standard Option. There are no deductibles, copayments, or coinsurance. When you use Non-preferred dentists, you pay
all charges in excess of the listed fee schedule amounts. For Preferred dentists, you pay the difference between the fee schedule
amount and the MAC (see above).

Standard Option dental benefits Standard Option Only
Service and ADA Code We pay You pay
Clinical oral evaluations
0120 Periodic oral evaluation*
0140 Limited oral evaluation
0150 Comprehensive oral evaluation
0160 Detailed and extensive oral evaluation
*Limited to two per person per calendar year

To age 13
$12
$14
$14
$14

Age 13 and over
$8
$9
$9
$9

Radiographs
0210 Intraoral complete series
0220 Intraoral periapical first film
0230 Intraoral periapical each additional film
0240 Intraoral occlusal film
0250 Extraoral first film
0260 Extraoral each additional film
0270 Bitewing single film
0272 Bitewings two films
0274 Bitewings four films

$36
$7
$4
$12
$16
$6
$9
$14
$19

$22
$5
$3
$7
$10
$4
$6
$9
$12

All charges in excess
of the scheduled
amounts listed to the
left

Note: For services
performed by dentists
in our Preferred
Dental Network, you
pay the difference
between the amounts
listed to the left and
the Maximum
Allowable Charge
(MAC).

Dental benefits continued on next page 91.
91 Page 92 93
2003 Blue Cross and Blue Shield
Service Benefit Plan 89 Section 5( h)

Standard Option dental benefits (continued) Standard Option Only
Service and ADA Code We pay You pay
Radiographs continued
0277 Bitewings vertical
0290 Posterior-anterior or lateral skull and facial
bone survey film

0330 Panoramic film

To age 13
$12

$45
$36

Age 13 and over
$7

$28
$23

Tests and laboratory exams
0460 Pulp vitality tests $11 $7

Palliative treatment
9110 Palliative (emergency) treatment of dental
pain minor procedure

2940 Sedative filling
$24
$24
$15
$15

Preventive
1110 Prophylaxis adult*
1120 Prophylaxis child*
1201 Topical application of fluoride (including
prophylaxis) child*

1203 Topical application of fluoride (prophylaxis
not included) child

1204 Topical application of fluoride (prophylaxis
not included) adult

1205 Topical application of fluoride (including
prophylaxis) adult*

*Limited to two per person per calendar year

---$
22

$35
$13
-----
-

$16
$14

$22
$8
$8
$24

Space maintenance (passive
appliances)

1510 Space maintainer fixed unilateral
1515 Space maintainer fixed bilateral
1520 Space maintainer removable unilateral
1525 Space maintainer removable bilateral
1550 Recementation of space maintainer

$94
$139
$94
$139
$22

$59
$87
$59
$87
$14

All charges in excess
of the scheduled
amounts listed to the
left

Note: For services
performed by dentists
in our Preferred
Dental Network, you
pay the difference
between the amounts
listed to the left and
the Maximum
Allowable Charge
(MAC).

Dental benefits continued on next page 92.
92 Page 93 94
2003 Blue Cross and Blue Shield
Service Benefit Plan 90 Section 5( h)

Standard Option dental benefits (continued) Standard Option Only
Service and ADA Code We pay You pay
Amalgam restorations (including polishing)

2110 Amalgam one surface, primary
2120 Amalgam two surfaces, primary
2130 Amalgam three surfaces, primary
2131 Amalgam four or more surfaces, primary
2140 Amalgam one surface, permanent
2150 Amalgam two surfaces, permanent
2160 Amalgam three surfaces, permanent
2161 Amalgam four or more surfaces, permanent

To age 13
$22
$31
$40
$49
$25
$37
$50
$56

Age 13 and over
$14
$20
$25
$31
$16
$23
$31
$35

Filled or unfilled resin restorations
2330 Resin one surface, anterior
2331 Resin two surfaces, anterior
2332 Resin three surfaces, anterior
2335 Resin four or more surfaces or involving
incisal angle (anterior)

2380 Resin one surface, posterior-primary
2381 Resin two surfaces, posterior-primary
2382 Resin three or more surfaces, posterior-primary

2385 Resin one surface, posterior-permanent
2386 Resin two surfaces, posterior-permanent
2387 Resin three surfaces, posterior-permanent
2388 Resin four or more surfaces, posterior-permanent

$25
$37
$50

$56
$22
$31

$40
$25
$37
$50

$50

$16
$23
$31

$35
$14
$20

$25
$16
$23
$31

$31
Inlay restorations
2510 Inlay metallic one surface
2520 Inlay metallic two surfaces
2530 Inlay metallic three or more surfaces
2610 Inlay porcelain/ ceramic one surface
2620 Inlay porcelain/ ceramic two surfaces
2630 Inlay porcelain/ ceramic three or more
surfaces

$25
$37
$50
$25
$37

$50

$16
$23
$31
$16
$23

$31

All charges in excess
of the scheduled
amounts listed to the
left

Note: For services
performed by dentists
in our Preferred
Dental Network, you
pay the difference
between the amounts
listed to the left and
the Maximum
Allowable Charge
(MAC).

Dental benefits continued on next page 93.
93 Page 94 95
2003 Blue Cross and Blue Shield
Service Benefit Plan 91 Section 5( h)

Standard Option dental benefits (continued) Standard Option Only
Service and ADA Code We pay You pay
Inlay restorations continued
2650 Inlay composite/ resin one surface
2651 Inlay composite/ resin two surfaces
2652 Inlay composite/ resin three or more
surfaces

To age 13
$25
$37

$50

Age 13 and over
$16
$23

$31
Other restorative services
2951 Pin retention per tooth, in addition to
restoration $13 $8

Extractions includes local
anesthesia and routine post-operative
care

7110 Single tooth
7120 Each additional tooth
7130 Root removal exposed roots
7210 Surgical removal of erupted tooth requiring
elevation of mucoperiosteal flap and removal of
bone and/ or section of tooth

7250 Surgical removal of residual tooth roots (cutting
procedure)

9220 General anesthesia in connection with covered
extractions

$30
$27
$71

$43
$71
$43

$19
$17
$45

$27
$45
$27

All charges in excess
of the scheduled
amounts listed to the
left

Note: For services
performed by
dentists in our
Preferred Dental
Network, you pay
the difference
between the amounts
listed to the left and
the Maximum
Allowable Charge
(MAC).

Not covered: Any service not specifically listed above Nothing Nothing All charges
Dental benefits continued on next page 94.
94 Page 95 96

2003 Blue Cross and Blue Shield
Service Benefit Plan 92 Section 5( h)

Basic Option dental benefits
Under Basic Option, we provide benefits for the services listed below. You pay a $20 copayment for each evaluation, and we
pay any balances in full. This is a complete list of dental services covered under this benefit for Basic Option. You must use a
Preferred dentist in order to receive benefits. For a list of Preferred dentists, please refer to the Preferred provider directory, visit
our website at www. fepblue. org, or call us at the customer service number on the back of your ID card.

Basic Option dental benefits Basic Option Only
Service and ADA Code We pay You pay
Clinical oral evaluations
0120 Periodic oral evaluation
0140 Limited oral evaluation
0150 Comprehensive oral evaluation
Note: Benefits are limited to a combined total of 2
evaluations per person per calendar year for 0120
and 0150.

Radiographs
0210 Intraoral complete series including
bitewings (limited to 1 complete series
every 3 years)

0270 Bitewing single film
0272 Bitewings two films
0274 Bitewings four films
Note: Benefits are limited to a combined total of 4
films per person per calendar year for 0270, 0272,
and 0274.

Preventive
1110 Prophylaxis adult (up to 2 per calendar
year)

1120 Prophylaxis child (up to 2 per calendar
year)

1201 Topical application of fluoride (including
prophylaxis) child (up to 2 per calendar
year)

1203 Topical application of fluoride
(prophylaxis not included) child (up to
2 per calendar year)

1351 Sealant per tooth, first and second
molars only (once per tooth for children
up to age 16 only)

Note: Benefits are limited to a combined total of 2
visits per person per calendar year for 1120 and
1201.

Preferred: All charges in
excess of your $20
copayment

Participating/ Non-participating:

Nothing

Preferred: $20 copayment
per evaluation

Participating/ Non-participating:

You pay all charges

Not covered: Any service not specifically listed
above
Nothing All charges 95.
95 Page 96 97

2003 Blue Cross and Blue Shield
Service Benefit Plan 93 Section 5( i)

Section 5 (i). Services, drugs, and supplies provided overseas
If you travel or live outside the United States and Puerto Rico, you are still entitled to the benefits described in this brochure.
Unless otherwise noted in this section, the same definitions, limitations, and exclusions also apply.

Please note that the requirements to obtain precertification for inpatient care and prior approval for those services listed in
Section 3 do not apply when you receive care outside the United States.

Overseas claims payment For professional care you receive overseas, we provide benefits at Preferred benefit levels using an Overseas Fee Schedule as our Plan allowance. Under Standard Option, you must pay any
difference between our payment and the amount billed, in addition to any applicable deductible,
coinsurance, and/ or copayment amounts. You must also pay any charges for noncovered services.

Under Basic Option, you pay any difference between our payment and the amount billed, as well as the applicable copayment or coinsurance. You must also pay any charges for noncovered

services. The requirement to use Preferred providers in order to receive benefits under Basic
Option does not apply when you receive care outside the United States and Puerto Rico.

For facility care you receive overseas, we provide benefits at the Preferred level under both
Standard and Basic Options after you pay the applicable copayment or coinsurance. Standard Option members are also responsible for any amounts applied to the calendar year deductible for

certain outpatient facility services please see pages 60-62.
Worldwide Assistance Center We have a network of participating hospitals overseas that will file your claims for inpatient facility care for you without an advance payment for the covered services you receive. The Worldwide
Assistance Center can help you locate a hospital in our network near where you are staying. You
may also view a list of our network hospitals on our website, www. fepblue. org. Although we do
not have a network of professionals overseas, the Worldwide Assistance Center can also help you
locate a physician. You will have to file a claim to us for reimbursement for professional services.

If you are overseas and need assistance locating providers, contact the Worldwide Assistance
Center (provided by World Access Service Corporation), by calling the center collect at
1-804-673-1678. Members in the United States, Puerto Rico, or the Virgin Islands should call
1-800-699-4337. World Access Service Corporation also offers emergency evacuation services to
the nearest facility equipped to adequately treat your condition, translation services, and conversion
of foreign medical bills to U. S. currency. You may contact one of their multilingual operators 24
hours a day, 365 days a year.

Filing overseas claims
Hospital and physician care Most overseas providers are under no obligation to file claims on behalf of our members. You may need to pay for the services at the time you receive them and then submit a claim to us for
reimbursement. To file a claim for covered hospital and physician services received outside the
United States and Puerto Rico, send a completed Overseas Claim Form and itemized bills to: FEP
Overseas Claims Section, CareFirst Blue Cross and Blue Shield, 550 12 th Street, SW, Washington,
DC 20065. We will provide translation and currency conversion services for your overseas claims.
Send any written inquiries concerning the processing of your overseas claims to this address or call
us at 1-888-999-9862. You may also obtain Overseas Claim Forms from this address, from our
website (www. fepblue. org), or from your Local Plan. 96.
96 Page 97 98

2003 Blue Cross and Blue Shield
Service Benefit Plan 94 Section 5( i)

Pharmacy benefits Drugs purchased overseas must be the equivalent to drugs that by Federal law of the United States require a prescription. To file a claim for covered drugs and supplies you purchase from
pharmacies outside the United States and Puerto Rico, send a completed FEP Retail Prescription
Drug Overseas Claim Form, along with itemized pharmacy receipts or bills, to: Blue Cross and
Blue Shield Service Benefit Plan Retail Pharmacy Program, P. O. Box 52057, Phoenix, AZ 85072-
2057. We will provide translation and currency conversion services for your overseas claims. You
may obtain claim forms for your drug purchases by writing to this address, by calling 1-888-999-
9862, or by visiting our website, www. fepblue. org. Send any written inquiries concerning drugs
you purchase to this address as well.

For covered drugs and supplies you purchase prior to January 1, 2003, follow the claims filing
guidelines presented above for hospital and physician care.

Please note that under both Standard and Basic Options, you may fill your prescriptions through a
Preferred internet pharmacy only if the prescribing physician is licensed in the United States or
Puerto Rico.

Under Standard Option, you may order your prescription drugs from the Mail Service
Prescription Drug Program only if:

a) Your address includes a U. S. zip code (such as with APO and FPO addresses and in U. S.
territories) and

b) The prescribing physician is licensed in the United States or Puerto Rico.
Please see page 82 for more information about using this program.
The Mail Service Prescription Drug Program is not available under Basic Option. 97.
97 Page 98 99

2003 Blue Cross and Blue Shield
Service Benefit Plan 95 Section 5( j)

Section 5 (j). Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB dispute regarding
these benefits. Fees you pay for these services do not count toward FEHB deductibles or out-of-pocket maximums. In
addition, these services are not eligible for benefits under the FEHB program. Please do not file a claim with us for these
services.

Vision Care Program
Service Benefit Plan members may obtain eye exams and
eyewear at substantial savings from EyeMed* Vision Care
providers. EyeMed Vision Care operates a national
provider network consisting of about 6,900 providers,
including LensCrafters locations and doctors located next
to LensCrafters, independent optometrists,
ophthalmologists, and opticians. For a complete
description of the program or to find a provider near you,
visit our website at www. fepblue. org or call EyeMed at
1-800-551-3337. Provider information is available 24
hours a day; customer service is available from 8: 00 a. m. to
11: 00 p. m. eastern time, Monday through Saturday, and
from 11: 00 a. m. to 8: 00 p. m. eastern time on Sunday.

Service Benefit Plan members may also obtain contact
lenses through the Advantage Program. Contact one of the
participating optometrists next to a LensCrafters for
information on how to enroll in this program. You can also
save 15% off the retail price or 5% off promotional pricing
on LASIK or PRK vision correction procedures provided
by the U. S. Laser Network. Simply call
1-877-552-7376 for the nearest laser facility and to receive
authorization for the discount.

There are no enrollment fees and no additional paperwork
or claim forms to be filed in this program. All charges for
eye exams and eyewear are handled directly between you
and the EyeMed provider.

Complementary and Alternative Medicine
Service Benefit Plan members have access to a national
network of chiropractors, acupuncturists, and massage
therapists at discounted rates, through American Specialty
Health Networks, Inc. (ASH Networks)*. The program
is simple to use. Members may call providers directly and
schedule appointments; no physician referral is required.
There are no enrollment fees and no additional paperwork
or claim forms for this program. All charges for health
services are handled directly between you and the ASH
Networks provider.

For more information or to find a provider near you, visit
our website at www. fepblue. org or call ASH Networks
Member Services at 1-877-258-7283. This discount
provider network is available to members nationwide,
unless prohibited by state law or regulation.

Through ASH's affiliate, Healthyroads Inc., members
may purchase health and wellness products, including
vitamins, minerals, herbal supplements, homeopathic
remedies, sports nutrition products, books, videotapes, and
skin care products, at discounted prices. Standard shipping
is free to Service Benefit Plan members. To take
advantage of special member discounts, visit Healthyroads
online through www. fepblue. org or call 1-877-258-7283 to
order products or request a free catalog.

ASH Networks customer service hours are from 8: 00 a. m. to 9: 00 p. m. eastern time, Monday through Friday.

Federal DentalBlue
Federal DentalBlue is an optional dental product with an additional premium that supplements the dental benefits

included in your Service Benefit Plan coverage. To apply for Federal DentalBlue, you must be:

1. Enrolled in Standard Option and reside in one of the following Plan areas: Alabama, Oklahoma, or
Washington State (only counties served by Regence BlueShield); or

2. Enrolled in Basic Option and reside in Alabama.
To purchase this additional coverage, complete and sign the Federal DentalBlue enrollment form, which you can obtain

from your Local Plan.
Many other Blue Cross and Blue Shield Plans offer dental insurance to Service Benefit Plan members for an additional

premium. For more information, contact your Local Plan about the availability of a non-FEHB dental program in
your area.

Medicare Prepaid Plan Enrollment
Some local Blue Cross and Blue Shield Plans offer Medicare recipients the opportunity to enroll in a Medicare

prepaid plan without payment of an FEHB premium. Contact your local Blue Cross and Blue Shield Plan to find
out if a Medicare prepaid plan is available in your area and the cost, if any, of that enrollment.

*The Blue Cross and Blue Shield Association and participating Local Plans will receive remuneration from EyeMed and ASH to cover their administrative costs for offering these programs and for other purposes. 98.
98 Page 99 100

2003 Blue Cross and Blue Shield
Service Benefit Plan 96 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 we determine it is medically necessary to prevent, diagnose, or treat your illness, disease, injury, or condition.

We do not cover the following:
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 in the United States;

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, sexual dysfunction, or sexual inadequacy;
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program;
Services, drugs, or supplies you would not be charged for if you had no health insurance coverage;
Services, drugs, or supplies you receive without charge while in active military service;
Amounts charged that neither you nor we are legally obligated to pay, such as amounts over the Medicare limiting charge or equivalent Medicare amount as described in Section 4 under Your costs for covered services, or State premium taxes,

however applied;
Services, drugs, or supplies you receive from immediate relatives or household members, such as spouse, parent, child, brother, or sister, by blood, marriage, or adoption;

Services or supplies (except for medically necessary prescription drugs) that you receive from a noncovered facility, such as an extended care facility or nursing home, except as specifically described in Sections 5( a) and 5( c);
Services, drugs, or supplies you receive from noncovered providers except in medically underserved areas as specifically described on page 10;
Services, drugs, or supplies you receive for cosmetic purposes;
Services, drugs, or supplies for the treatment of obesity, weight reduction, or dietary control, except for gastric bypass surgery or gastric stapling procedures;

Any dental or oral surgical procedures or drugs involving orthodontic care, the teeth, dental implants, periodontal disease, or preparing the mouth for the fitting or continued use of dentures, except as specifically described in Section 5( h), Dental
benefits, and Section 5( b) under Oral and maxillofacial surgery;
Orthodontic care for temporomandibular joint (TMJ) syndrome;
Services of standby physicians;
Self-care or self-help training;
Custodial care;
Personal comfort items such as beauty and barber services, radio, television, or telephone;
Routine services, such as periodic physical examinations; screening examinations; immunizations; and services or tests not related to a specific diagnosis, illness, injury, set of symptoms, or maternity care, except for those preventive services

specifically covered under Preventive care, adult and child in Sections 5( a) and 5( c) and screenings specifically listed on
page 44;

Recreational or educational therapy, and any related diagnostic testing, except as provided by a hospital during a covered inpatient stay; or

Services not specifically listed as covered. 99.
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2003 Blue Cross and Blue Shield
Service Benefit Plan 97 Section 7

Section 7. Filing a claim for covered services
How to claim benefits To obtain claim forms or other claims filing advice, or answers to your questions about our benefits, contact us at the customer service number on the back of your
Service Benefit Plan ID card, or at our website at www. fepblue. org.
In most cases, physicians and facilities file claims for you. Just present your Service
Benefit Plan ID card when you receive services. Your physician must file on the
HCFA-1500, Health Insurance Claim Form. Your facility will file on the UB-92
form.

When you must file a claim such as when another group health plan is primary
submit it on the HCFA-1500 or a claim form that includes the information shown
below. Use a separate claim form for each family member. For long or continuing
hospital stays, or other long-term care, you should submit claims at least every 30
days. Bills and receipts should be itemized and show:

Name of patient and relationship to enrollee;
Plan identification number of the enrollee;
Name and address of person or firm providing the service or supply;
Dates that services or supplies were furnished;
Diagnosis;
Type of each service or supply; and
The charge for each service or supply.
Note: Canceled checks, cash register receipts, balance due statements, or bills you
prepare yourself are not acceptable substitutes for itemized bills.

In addition:

You must send a copy of the explanation of benefits (EOB) form from any primary payer [such as the Medicare Summary Notice (MSN)] with your claim.

Bills for home nursing care must show that the nurse is a registered or licensed practical nurse.
Claims for rental or purchase of durable medical equipment, private duty nursing, and physical, occupational, and speech therapy, require a written statement from
the physician specifying the medical necessity for the service or supply and the
length of time needed.

Claims for prescription drugs and supplies that are not received from the Retail Pharmacy Program, through a Preferred internet pharmacy, or through the Mail

Service Prescription Drug Program must include receipts that show the prescription
number, name of drug or supply, prescribing physician's name, date, and charge.
(See below for information on how to obtain benefits from the Retail Pharmacy
Program, a Preferred internet pharmacy, and the Mail Service Prescription Drug
Program.) 100.
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2003 Blue Cross and Blue Shield
Service Benefit Plan 98 Section 7

Prescription drug claims Preferred Retail/ Internet Pharmacies When you use Preferred retail pharmacies, show your Service Benefit Plan ID card. Preferred retail pharmacies will file your
claims for you. To use Preferred internet pharmacies, go to our special website,
www. fepblue. org, click on "Pharmacy Programs," and follow the FEP Retail
Pharmacy Providers link to fill your prescriptions and receive home delivery. Be
sure to have your Service Benefit Plan ID card ready to complete your purchase. We
reimburse the Preferred retail or internet pharmacy for your covered drugs and
supplies. You pay the applicable coinsurance or copayment.

Note: Even if you use Preferred pharmacies, you will have to file a paper claim form
to obtain reimbursement if:

You do not have a valid Service Benefit Plan ID card;
You do not use your valid Service Benefit Plan ID card at the time of purchase; or
You did not obtain prior approval when required (see page 14).
See the following paragraph for claim filing instructions.
Non-Preferred Retail/ Internet Pharmacies

Standard Option: You must file a paper claim for any covered drugs or supplies you
purchase at Non-preferred retail or internet pharmacies. Contact your Local Plan or
call 1-800-624-5060 to request a retail prescription drug claim form to claim benefits.
Hearing-impaired members with TDD equipment may call 1-800-624-5077. Follow
the instructions on the prescription drug claim form and submit the completed form
to: Blue Cross and Blue Shield Service Benefit Plan Retail Pharmacy Program, P. O.
Box 52057, Phoenix, AZ 85072-2057.

Basic Option: There are no benefits for drugs or supplies purchased at Non-preferred retail or internet pharmacies.

Mail Service Prescription Drug Program
Standard Option: We will send you information on our Mail Service Prescription
Drug Program, including an initial mail order form. To use this program:

1) Complete the initial mail order form;
2) Enclose your prescription and copayment;
3) Mail your order to Medco Health Solutions, Inc., P. O. Box 30492, Tampa, FL
33633-0144; and

4) Allow approximately two weeks for delivery.
Alternatively, your physician may call in your initial prescription at 1-800-262-7890
(TDD: 1-800-446-7292). You will be billed later for the copayment.

After that, to order refills either call the same number or access our website at
www. fepblue. org and either charge your copayment to your credit card or have it
billed to you later. Allow approximately one week for delivery on refills.

Basic Option: The Mail Service Prescription Drug Program is not available under
Basic Option. 101.
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2003 Blue Cross and Blue Shield
Service Benefit Plan 99 Section 7

Records Keep a separate record of the medical expenses of each covered family member, because deductibles (under Standard Option) and benefit maximums (such as those
for outpatient physical therapy or preventive dental care), apply separately to each
person. Save copies of all medical bills, including those you accumulate to satisfy a
deductible under Standard Option. In most instances they will serve as evidence of
your claim. We will not provide duplicate or year-end statements.

Deadline for filing your claim Send us your claim and appropriate documentation 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 you submitted the claim as soon as reasonably possible. If
we return a claim or part of a claim for additional information, you must resubmit it
within 90 days, or before the timely filing period expires, whichever is later.

Note: Once we pay benefits, there is a three-year limitation on the reissuance of
uncashed checks.

Overseas claims Please refer to the claims filing information on pages 93 and 94 of this brochure.

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. 102.
102 Page 103 104
2003 Blue Cross and Blue Shield
Service Benefit Plan 100 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 precertification or prior approval:

Step Description
. Ask us in writing to reconsider our initial decision. Write to us at the address shown on your explanation of benefits (EOB) form. You must:
(a) Write to us within 6 months from the date of our decision; and
(b) Send your request to us at the address shown on your explanation of benefits (EOB) form for the Local Plan that
processed the claim (or, for Prescription drug benefits, our Retail Pharmacy Program or Mail Service Prescription Drug
Program); 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.

. We have 30 days from the date we receive your request to:
(a) Pay the claim (or, if applicable, precertify your hospital stay or grant your request for prior approval for a service, drug,
or supply); 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.

. 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.

. 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 if we did not send you a decision within 30 days after we received the additional information.

Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Health Benefits Contracts Division I,
1900 E Street, NW, Washington, DC 20415-3610. 103.
103 Page 104 105
2003 Blue Cross and Blue Shield
Service Benefit Plan 101 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 more than one claim, 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.

. 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 determine if we correctly applied the terms of our contract when we denied your claim or
request for service. OPM will send you a final decision within 60 days. There are no other administrative appeals.

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 claims 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 have not responded yet to your initial claim or request for precertification/ prior approval, then call us at the customer
service number on the back of your Service Benefit Plan ID card and we will expedite our review; or

(b) We denied your initial claim or request for precertification/ 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 may call OPM's Health Benefits Contracts Division I at 1-202-606-0727 between 8 a. m. and 5 p. m. eastern time. 104.
104 Page 105 106

2003 Blue Cross and Blue Shield
Service Benefit Plan 102 Section 9

Section 9. Coordinating benefits with other coverage
When you have other health coverage You must tell us if you or a covered family member has coverage 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. For example:

If you are covered under our Plan as a dependent, any group health insurance you have from your employer will pay primary and we will pay secondary.

If you are an annuitant under our Plan and also are actively employed, any group health insurance you have from your employer will pay primary and we will pay
secondary.
When you are entitled to the payment of health care expenses under automobile insurance, including no-fault insurance and other insurance that pays without regard

to fault, your automobile insurance is the primary payer and we are the secondary
payer.

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. For example, we will generally only make up the
difference between the primary payer's benefits payment and 100% of the Plan
allowance, subject to our applicable deductible (under Standard Option) and
coinsurance or copayment amounts, except when Medicare is the primary payer (see
Section 4). Thus, it is possible that the combined payments from both plans may not
equal the entire amount billed by the provider.

Note: When we pay secondary to primary coverage you have from a prepaid plan
(HMO), we base our benefits on your out-of-pocket liability under the prepaid plan
(generally, the prepaid plan's copayments), subject to our deductible (under Standard
Option) and coinsurance or copayment amounts.

In certain circumstances when we are secondary and there is no adverse effect on you
(that is, you do not pay any more), we may also take advantage of any provider discount
arrangements your primary plan may have and only make up the difference between the
primary plan's payment and the amount the provider has agreed to accept as payment in
full from the primary plan.

Note: Any visit limitations that apply to your care under this Plan are still in effect when
we are the secondary payer.

Remember: Even if you do not file a claim with your other plan, you must still tell us
that you have double coverage, and you must also send us documents about your other
coverage if we ask for them.

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). 105.
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2003 Blue Cross and Blue Shield
Service Benefit Plan 103 Section 9

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+ Choice plan you
have.

The Original Medicare Plan (Part A or Part B) The Original Medicare Plan (Original Medicare) is available everywhere in the United States. It is the way everyone used to get Medicare benefits and is the way most people
get their Medicare Part A and Part B benefits now. You may go to any doctor,
specialist, or hospital that accepts Medicare. The Original Medicare Plan pays its share
and you pay your share. Some things are not covered under the Original Medicare Plan,
such as most 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. For example, you must
continue to obtain prior approval for some prescription drugs and organ/ tissue
transplants before we will pay benefits. However, you do not have to precertify
inpatient hospital stays when Medicare Part A is primary (see page 13 for exception).

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 the Original Medicare Plan is the primary payer, Medicare processes your claim first. In most cases, your claims will be coordinated automatically and we will

then provide secondary benefits for the covered charges. You will not need to do
anything. To find out if you need to do something to file your claims, call us at the
customer service number on the back of your Service Benefit Plan ID card or visit our
website at www. fepblue. org. 106.
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2003 Blue Cross and Blue Shield
Service Benefit Plan 104 Section 9

We waive some costs if the Original Medicare Plan is your primary payer We
will waive some out-of-pocket costs as follows:

When Medicare Part A is primary
Under Standard Option, we will waive our: Inpatient hospital per-admission copayments;

Inpatient Non-member hospital coinsurance; and Non-Preferred inpatient per-day copayments for mental conditions/ substance
abuse care.
Under Basic Option, we will waive our: Inpatient hospital per-day copayments.

Note: Once you have exhausted your Medicare Part A benefits, we become primary.
Under Standard Option, you must then pay any difference between our allowance and the billed amount at Non-member hospitals.

Under Basic Option, you must then pay the inpatient hospital per-day copayments.
When Medicare Part B is primary
Under Standard Option, we will waive our: Calendar year deductible;

Coinsurance for services and supplies provided by physicians and other covered health care professionals (inpatient and outpatient, including mental conditions
and substance abuse care);
Copayments for office visits to Preferred physicians and other health care professionals;

Copayments for routine physical examinations and preventive (screening) services performed by Preferred physicians, other health care professionals, and
facilities; and
Outpatient facility coinsurance for medical, surgical, preventive, and mental conditions and substance abuse care.

Under Basic Option, we will waive our: Copayments and coinsurance for care received from covered professional and
facility providers.
Note: We do not waive benefit limitations, such as the 25-visit limit for home nursing
visits. In addition, we do not waive any coinsurance or copayments for prescription
drugs.

Tell us about your Medicare coverage You must tell us if you or a covered family member has Medicare coverage, and let us obtain information about services denied or paid under Medicare if we ask. You must
also tell us about other coverage you or your covered family members may have, as this
coverage may affect the primary/ secondary status of this Plan and Medicare. 107.
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2003 Blue Cross and Blue Shield
Service Benefit Plan 105 Section 9

The following chart illustrates whether Original Medicare or this Plan should be the primary payer for you according to your
employment status and other factors determined by Medicare. It is critical that you tell us if you or a covered family member has
Medicare coverage so we can administer these requirements correctly.

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

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

2) Are an annuitant .
3) Are a re-employed 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 . 108.
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2003 Blue Cross and Blue Shield
Service Benefit Plan 106 Section 9

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

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

This Plan and 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.
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.

Under Standard Option, 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,
but we will not waive any of our copayments, coinsurance, or deductibles, if you receive
services from providers who do not participate in the Medicare managed care plan.

Under Basic Option, we provide benefits for care received from Preferred providers
when your Medicare managed care plan is primary, even out of the managed care plan's
network and/ or service area. However, we will not waive any of our copayments or
coinsurance for services you receive from Preferred providers who do not participate in
the Medicare managed care plan. Please remember that you must receive care from
Preferred providers in order to receive Basic Option benefits. See page 11 for the
exceptions to this requirement.

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

Medicare managed care plan, eliminating your FEHB 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.

Private contract with your physician A physician may ask you to sign a private contract agreeing that you can be billed directly for services ordinarily covered by the Original Medicare Plan. Should you sign
an agreement, Medicare will not pay any portion of the charges, and we will not
increase our payment. We will still limit our payment to the amount we would have
paid after the Original Medicare Plan's payment. You will be responsible for paying the
difference between the billed amount and the amount we paid.

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

get premium-free Part A, we will not ask you to enroll in it. 109.
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2003 Blue Cross and Blue Shield
Service Benefit Plan 107 Section 9

TRICARE and CHAMPVA TRICARE is the health care program for eligible dependents of military persons and retirees of the military. TRICARE includes the CHAMPUS program. CHAMPVA
provides health coverage to disabled Veterans and their eligible dependents. If
TRICARE or CHAMPVA and this Plan cover you, we pay first. See your TRICARE or
CHAMPVA Health Benefits Advisor if you have questions about these programs.

Suspended FEHB coverage to enroll in TRICARE or CHAMPVA: If you are an
annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of
these programs, eliminating your FEHB premium. (OPM does not contribute to any
applicable plan premiums.) For information on suspending your FEHB enrollment,
contact your retirement office. If you later want to reenroll in the FEHB Program,
generally you may do so only at the next Open Season unless you involuntarily lose
coverage under these programs.

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 a similar agency pays its maximum benefits for your treatment, we will
cover your care.

Medicaid When you have this Plan and Medicaid, we pay first.
Suspended FEHB coverage to enroll in Medicaid or a similar State-sponsored program of medical assistance: If you are an annuitant or former spouse, you can

suspend your FEHB coverage to enroll in one of these State programs, eliminating your
FEHB 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 under
the State program.

When other Government agencies are responsible for
your care

We do not cover services and supplies when a local, State, or Federal Government
agency directly or indirectly pays for them. 110.
110 Page 111 112
2003 Blue Cross and Blue Shield
Service Benefit Plan 108 Section 9

When others are responsible for injuries If another person or entity, through an act or omission, causes you to suffer an injury or illness, and if we pay benefits for that injury or illness, you must agree to the following:
All recoveries you obtain (whether by lawsuit, settlement, or otherwise), no matter how described or designated, must be used to reimburse us in full for benefits we paid.
Our share of any recovery extends only to the amount of benefits we have paid or will
pay to you or, if applicable, to your heirs, administrators, successors, or assignees.

We will not reduce our share of any recovery unless we agree in writing to a reduction, (1) because you do not receive the full amount of damages that you claimed

or (2) because you had to pay attorneys' fees. This is our right of recovery.
If you do not seek damages for your illness or injury, you must permit us to initiate recovery on your behalf (including the right to bring suit in your name). This is called

subrogation.
If we pursue a recovery of the benefits we have paid, you must cooperate in doing what is reasonably necessary to assist us. You must not take any action that may

prejudice our rights to recover.
You must tell us promptly if you have a claim against another party for a condition that
we have paid or may pay benefits for, and you must tell us about any recoveries you
obtain, whether in or out of court. We may seek a lien on the proceeds of your claim in
order to reimburse ourselves to the full amount of benefits we have paid or will pay.

We may request that you assign to us (1) your right to bring an action or (2) your right
to the proceeds of a claim for your illness or injury. We may delay processing of your
claims until you provide the assignment.

Note: We will pay the costs of any covered services you receive that are in excess of
any recoveries made.

The following are examples of circumstances in which we may subrogate or assert a
right of recovery:

When you or your dependent are injured on premises owned by a third party; or When you or your dependent are injured and benefits are available to you or your

dependent, under any law or under any type of insurance, including, but not limited to:
Personal injury protection benefits Uninsured and underinsured motorist coverage (does not include no-fault

automobile insurance)
Workers' compensation benefits Medical reimbursement coverage

2003 Blue Cross and Blue Shield
Service Benefit Plan 109 Section 10

Section 10. Definitions of terms we use in this brochure
Accidental injury An injury caused by an external force or element such as a blow or fall that requires immediate medical attention, including animal bites and poisonings. Note: Injuries to
the teeth while eating are not considered accidental injuries. Dental care for accidental
injury is limited to dental treatment necessary to repair sound natural teeth.

Admission The period from entry (admission) as an inpatient into a hospital (or other covered facility) until discharge. In counting days of inpatient care, the date of entry and the
date of discharge count as the same day.
Assignment An authorization by the enrollee or spouse for us to issue payment of benefits directly to the provider. We reserve the right to pay you, the enrollee, directly for all covered
services.
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.
Carrier The Blue Cross and Blue Shield Association, on behalf of the local Blue Cross and Blue Shield Plans.

Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. You may also be responsible for additional amounts. See page 15.
Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 15.
Cosmetic surgery Any surgical procedure or any portion of a procedure performed primarily to improve physical appearance through change in bodily form, except for repair of accidental
injury, or to restore or correct a part of the body that has been altered as a result of
disease or surgery or to correct a congenital anomaly.

Covered services Services we provide benefits for, as described in this brochure.

Custodial care Treatment or services, regardless of who recommends them or where they are provided, that a person not medically skilled could perform safely and reasonably, or that mainly
assist the patient with daily living activities, such as:
1. Personal care including help in walking, getting in and out of bed, bathing, eating
(by spoon, tube, or gastrostomy), exercising, or dressing;
2. Homemaking, such as preparing meals or special diets;
3. Moving the patient;
4. Acting as companion or sitter;
5. Supervising medication that can usually be self-administered; or
6. Treatment or services that any person can perform with minimal instruction, such as
recording pulse, temperature, and respiration; or administration and monitoring of
feeding systems.

Custodial care that lasts 90 days or more is sometimes known as Long Term Care. The
Carrier, its medical staff, and/ or an independent medical review determines which
services are custodial care.

Deductible A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies in a calendar year before we start paying benefits for those
services. See page 15. 112.
112 Page 113 114
2003 Blue Cross and Blue Shield
Service Benefit Plan 110 Section 10

Durable medical equipment Equipment and supplies that: 1. Are prescribed by your physician (i. e., the physician who is treating your illness or
injury);
2. Are medically necessary;
3. Are primarily and customarily used only for a medical purpose;
4. Are generally useful only to a person with an illness or injury;
5. Are designed for prolonged use; and
6. Serve a specific therapeutic purpose in the treatment of an illness or injury.

Experimental or investigational services A drug, device, or biological product is experimental or investigational if the drug, device, or biological product cannot be lawfully marketed without approval of the U. S.
Food and Drug Administration (FDA); and, approval for marketing has not been given
at the time it is furnished. Note: Approval means all forms of acceptance by the FDA.

A medical treatment or procedure, or a drug, device, or biological product, is
experimental or investigational if:

1. Reliable evidence shows that it is the subject of ongoing phase I, II, or III clinical
trials or under study to determine its maximum tolerated dose, its toxicity, its safety,
its efficacy, or its efficacy as compared with the standard means of treatment or
diagnosis; or

2. Reliable evidence shows that the consensus of opinion among experts regarding the
drug, device, or biological product or medical treatment or procedure, is that further
studies or clinical trials are necessary to determine its maximum tolerated dose, its
toxicity, its safety, its efficacy, or its efficacy as compared with the standard means
of treatment or diagnosis.

Reliable evidence shall mean only:

published reports and articles in the authoritative medical and scientific literature; the written protocol or protocols used by the treating facility or the protocol( s) of

another facility studying substantially the same drug, device, or biological product
or medical treatment or procedure; or

the written informed consent used by the treating facility or by another facility studying substantially the same drug, device, or biological product or medical

treatment or procedure.
Each Local Plan has a Medical Review department that determines whether a claimed
service is experimental or investigational after consulting with internal or external
experts or nationally recognized guidelines in a particular field or specialty.

For more detailed information, contact your Local Plan at the customer service
telephone number located on the back of your Service Benefit Plan ID card.

Group health coverage Health care coverage that you are eligible for based on your employment, or your membership in or connection with a particular organization or group, that provides
payment for medical services or supplies, or that pays a specific amount of more than
$200 per day for hospitalization (including extension of any of these benefits through
COBRA).

Intensive outpatient care A comprehensive, structured outpatient treatment program that includes extended periods of individual or group therapy sessions designed to assist members with mental
health and/ or substance abuse conditions. It is an intermediate setting between
traditional outpatient therapy and partial hospitalization, typically performed in an
outpatient facility or outpatient professional office setting. Program sessions may occur
more than one day per week. Timeframes and frequency will vary based upon
diagnosis and severity of illness. 113.
113 Page 114 115

2003 Blue Cross and Blue Shield
Service Benefit Plan 111 Section 10

Lifetime maximum The maximum amount the Plan will pay on your behalf for covered services you receive while you are enrolled in your option. Benefit amounts accrued are
accumulated in a permanent record regardless of the number of enrollment changes.
Please see page 77.

Local Plan A Blue Cross and/ or Blue Shield Plan that serves a specific geographic area.
Medical necessity We determine whether services, drugs, supplies, or equipment provided by a hospital or other covered provider are:

1. Appropriate to prevent, diagnose, or treat your condition, illness, or injury;
2. Consistent with standards of good medical practice in the United States;
3. Not primarily for the personal comfort or convenience of the patient, the family, or
the provider;
4. Not part of or associated with scholastic education or vocational training of the
patient; and
5. In the case of inpatient care, cannot be provided safely on an outpatient basis.

The fact that one of our covered providers has prescribed, recommended, or approved a
service or supply does not, in itself, make it medically necessary or covered under this
Plan.

Mental conditions/ substance abuse Conditions and diseases listed in the most recent edition of the International Classification of Diseases (ICD) as psychoses, neurotic disorders, or personality
disorders; other nonpsychotic mental disorders listed in the ICD; or disorders listed in
the ICD requiring treatment for abuse of, or dependence upon, substances such as
alcohol, narcotics, or hallucinogens.

Partial hospitalization An intensive facility-based treatment program during which an interdisciplinary team provides care related to mental health and/ or substance abuse conditions. Program
sessions may occur more than one day per week and may be full or half days, evenings,
and/ or weekends. The duration of care per session is less than 24 hours. Timeframes
and frequency will vary based upon diagnosis and severity of illness.

Plan allowance Our Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. Fee-for-service plans determine their allowances in
different ways. If the amount your provider bills for covered services is less than our
allowance, we base our payment, and your share (coinsurance, deductible, and/ or
copayments), on the billed amount. We determine our allowance as follows:

PPO providers Our allowance (which we may refer to as the "PPA" for "Preferred Provider Allowance") is the negotiated amount that most Preferred

providers (hospitals and other facilities, physicians, and other covered health care
professionals that contract with each local Blue Cross and Blue Shield Plan, and
retail and internet pharmacies that contract with AdvancePCS) have agreed to accept
as payment in full, when we pay primary benefits.

Our PPO allowance includes any known discounts that can be accurately calculated
at the time your claim is processed. For PPO facilities, we sometimes refer to our
allowance as the "Preferred rate." The Preferred rate may be subject to a periodic
adjustment after your claim is processed that may decrease or increase the amount
of our payment that is due to the facility. However, your cost sharing (if any) does
not change. If our payment amount is decreased, we credit the amount of the
decrease to the reserves of this Plan. If our payment amount is increased, we pay
that cost on your behalf. (See page 88 for special information about limits on the
amounts Preferred dentists can charge you under Standard Option.) 114.
114 Page 115 116

2003 Blue Cross and Blue Shield
Service Benefit Plan 112 Section 10

Participating providers Our allowance (which we may refer to as the "PAR" for "Participating Provider Allowance") is the negotiated amount that these providers
(hospitals and other facilities, physicians, and other covered health care
professionals that contract with some local Blue Cross and Blue Shield Plans) have
agreed to accept as payment in full, when we pay primary benefits. For facilities,
we sometimes refer to our allowance as the "Member rate." The member rate
includes any known discounts that can be accurately calculated at the time your
claim is processed, and may be subject to a periodic adjustment after your claim is
processed that may decrease or increase the amount of our payment that is due to the
facility. However, your cost sharing (if any) does not change. If our payment
amount is decreased, we credit the amount of the decrease to the reserves of this
Plan. If our payment amount is increased, we pay that cost on your behalf.

Non-participating providers We have no agreements with these providers. We determine our allowance as follows:

For inpatient services by hospitals and other facilities that do not contract with your local Blue Cross and Blue Shield Plan, our allowance is the average
semiprivate room rate charged for inpatient care by similar institutions in the
same area, as determined by your Local Plan;

For outpatient services by hospitals and other facilities that do not contract with your local Blue Cross and Blue Shield Plan, our allowance is the billed amount

(minus any amounts for non-covered services);
For physicians and other covered health care professionals that do not contract with your local Blue Cross and Blue Shield Plan, our allowance is equal to the

greater of 1) the Medicare participating fee schedule amount for the service or
supply in the geographic area in which it was performed or obtained (or 60% of
the billed charge if there is no equivalent Medicare fee schedule amount) or 2)
80% of the 2003 Usual, Customary, and Reasonable (UCR) amount for the
service or supply in the geographic area in which it was performed or obtained.
Local Plans determine the UCR amount in different ways. Contact your Local
Plan if you need more information. We may refer to our allowance for Non-participating
providers as the "NPA" (for "Non-participating Provider
Allowance");

For prescription drugs furnished by retail and internet pharmacies that do not contract with AdvancePCS, our allowance is the average wholesale price

(" AWP") of a drug on the date it is dispensed, as set forth in the most current
version of First DataBank's National Drug Data File; and

For services you receive outside of the United States and Puerto Rico from providers that do not contract with us or with World Access, Inc., our allowance is

an Overseas Fee Schedule that is based on amounts comparable to what
Participating providers in the Washington, DC, area have agreed to accept.

Non-participating providers are under no obligation to accept our allowance as payment
in full. If you use Non-participating providers, you will be responsible for any
difference between our payment and the billed amount, including any applicable
copayments, coinsurance, or deductibles.

For more information, see Differences between our allowance and the bill in Section 4.
For more information about how we pay providers overseas, see pages 17, 93, and 94. 115.
115 Page 116 117

2003 Blue Cross and Blue Shield
Service Benefit Plan 113 Section 10

Precertification The requirement to contact the local Blue Cross and Blue Shield Plan serving the area where the services will be performed before being admitted to the hospital for inpatient
care, or within two business days following an emergency admission.
Preferred provider organization (PPO) arrangement An arrangement between Local Plans and physicians, hospitals, health care institutions, and other covered health care professionals (or for retail and internet pharmacies,
between pharmacies and AdvancePCS) to provide services to you at a reduced cost.
The PPO provides you with an opportunity to reduce your out-of-pocket expenses for
care by selecting your facilities and providers from among a specific group. PPO
providers are available in most locations; using them whenever possible helps contain
health care costs and reduces your out-of-pocket costs. The selection of PPO providers
is solely the Local Plan's (or for pharmacies, AdvancePCS's) responsibility. We
cannot guarantee that any specific provider will continue to participate in these PPO
arrangements.

Prior approval Written assurance that benefits will be provided by:
1. The Local Plan where the services will be performed;
2. The Retail Pharmacy Program (for prescription drugs and supplies purchased
through Preferred retail and internet pharmacies) or the Mail Service Prescription
Drug Program; or
3. The Blue Cross and Blue Shield Association Clinical Trials Information Unit for
certain organ/ tissue transplants we cover only in clinical trials. See Section 5( b).

For more information, see the benefit descriptions in Section 5 and How to get approval
for . . . other services on pages 12 to 14. See Section 5( e) for special authorization
requirements for mental health and substance abuse benefits.

Routine services Services that are not related to a specific illness, injury, set of symptoms, or maternity care.

Sound natural tooth A tooth that is whole or properly restored (restoration with amalgams only); is without impairment, periodontal or other conditions; and is not in need of the treatment
provided for any reason other than an accidental injury. For purposes of this Plan, a
tooth previously restored with a crown, inlay, onlay, or porcelain restoration, or treated
by endodontics, is not considered a sound natural tooth.

Transplant period A defined number of consecutive days associated with a covered organ/ tissue transplant procedure.

Us/ We/ Our "Us," "we," and "our" refer to the Blue Cross and Blue Shield Service Benefit Plan, and the local Blue Cross and Blue Shield Plans that administer it.
You/ Your "You" and "your" refer to the enrollee (the contract holder eligible for enrollment and coverage under the Federal Employees Health Benefits Program and enrolled in the
Plan) and each covered family member. 116.
116 Page 117 118

2003 Blue Cross and Blue Shield
Service Benefit Plan 114 Section 11

Section 11. FEHB facts
No pre-existing condition limitation We will not refuse to cover the treatment of a condition that you had before you enrolled in this Plan solely because you had the condition before you enrolled.
Where you can get information about enrolling in the FEHB
Program

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

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 for you and your family Self Only coverage is for you alone. Self and Family coverage is for you, your spouse, and your unmarried dependent children under age 22, including any foster children or
stepchildren your employing or retirement office authorizes coverage for. Under certain
circumstances, you may also continue coverage for a disabled child 22 years of age or
older who is incapable of self-support.

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

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

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

Children's Equity Act OPM has implemented the Federal Employees Health Benefits Children's Equity Act of 2000. This law mandates that you be enrolled for Self and Family coverage in the
Federal Employees Health Benefits (FEHB) Program, if you are an employee subject to
a court or administrative order requiring you to provide health benefits for your
child( ren).

If this law applies to you, you must enroll for Self and Family coverage in a health plan
that provides full benefits in the area where your children live or provide documentation
to your employing office that you have obtained other health benefits coverage for your
children. If you do not do so, your employing office will enroll you involuntarily as
follows:

If you have no FEHB coverage, your employing office will enroll you for Self and Family coverage in the Blue Cross and Blue Shield Service Benefit Plan's Basic

Option. 117.
117 Page 118 119
2003 Blue Cross and Blue Shield
Service Benefit Plan 115 Section 11

If you have a Self Only enrollment in a fee-for-service plan or in an HMO that serves the area where your children live, your employing office will change your enrollment
to Self and Family in the same option of the same plan; or
If you are enrolled in an HMO that does not serve the area where the children live, your employing office will change your enrollment to Self and Family in the Blue

Cross and Blue Shield Service Benefit Plan's Basic Option.
As long as the court/ administrative order is in effect, and you have at least one child
identified in the order who is still eligible under the FEHB Program, you cannot cancel
your enrollment, change to Self Only, or change to a plan that doesn't serve the area in
which your children live, unless you provide documentation that you have other
coverage for the children. If the court/ administrative order is still in effect when you
retire, and you have at least one child still eligible for FEHB coverage, you must
continue your FEHB coverage into retirement (if eligible) and cannot make any changes
after retirement. Contact your employing office for further information.

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

Your medical and claims records are confidential We will keep your medical and claims information confidential. Please note that as part of our administration of this contract, we may disclose your medical and claims
information (including your prescription drug utilization) to any treating physicians or
dispensing pharmacies.

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. 118.
118 Page 119 120

2003 Blue Cross and Blue Shield
Service Benefit Plan 116 Section 11

Spouse equity coverage If you are divorced from a Federal employee or annuitant, you may not continue to get benefits under your former spouse's enrollment. This is the case even when the court
has ordered your former spouse to supply health benefits coverage to you. But, you
may be eligible for your own FEHB coverage under the spouse equity law or
Temporary Continuation of Coverage (TCC). 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. You can also download the guide from OPM's website,
www. opm. gov/ insure.

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 Federal job, if you are a covered dependent
child and you turn 22 or marry, etc.

You may not elect TCC if you are fired from your Federal job due to gross misconduct.
Enrolling in TCC. Get the RI 79-27, which describes TCC, and the RI 70-5, the Guide
to Federal Employees Health Benefits Plans for Temporary Continuation of Coverage
and Former Spouse Enrollees, from your employing or retirement office or from
www. opm. gov/ insure. It explains what you have to do to enroll.

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

Your coverage under TCC or the spouse equity law ends (if you canceled your coverage or did not pay your premium, you cannot convert);

You decided not to receive coverage under TCC or the spouse equity law; or
You are not eligible for coverage under TCC or the spouse equity law.
If you leave Federal service, your employing office will notify you of your right to
convert. You must apply in writing to us within 31 days after you receive this notice.
However, if you are a family member who is losing coverage, the employing or
retirement office will not notify you. You must apply in writing to us within 31 days
after you are no longer eligible for coverage.

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 website
(www. opm. gov/ insure/ health), and refer to the "TCC and HIPAA" frequently asked
questions. These highlight HIPAA rules, such as the requirement that Federal
employees must exhaust any TCC eligibility as one condition for guaranteed access to
individual health coverage under HIPAA, and have information about Federal and State
agencies you can contact for more information. 119.
119 Page 120 121

2003 Blue Cross and Blue Shield
Service Benefit Plan 117 Long Term Care Insurance

Long Term Care Insurance Is Still Available!
Open Season for Long Term Care Insurance
You can protect yourself against the high cost of long term care by applying for insurance in the Federal Long Term Care Insurance Program.
Open Season to apply for long term care insurance through LTC Partners ends on December 31, 2002. If you're a Federal employee, you and your spouse need only answer a few questions about your health during Open
Season.
If you apply during the Open Season, your premiums are based on your age as of July 1, 2002. After Open Season, your premiums are based on your age at the time LTC Partners receives your application.

FEHB Doesn't Cover It
Neither FEHB plans nor Medicare cover the cost of long term care. Also called "custodial care," long term care helps you perform the activities of daily living such as bathing or dressing yourself. It can also provide help you may need due to a
severe cognitive impairment such as Alzheimer's disease.
You Can Also Apply Later, But
Employees and their spouses can still apply for coverage after the Federal Long Term Care Insurance Program Open Season ends, but they will have to answer more health-related questions.
For annuitants and other qualified relatives, the number of health-related questions that you need to answer is the same during and after the Open Season.

You Must Act to Receive an Application
Unlike other benefit programs, YOU have to take action you won't receive an application automatically. You must request one through the toll-free number or website listed below.
Open Season ends December 31, 2002 act NOW so you won't miss the abbreviated underwriting available to employees and their spouses, and the July 1 "age freeze!"

Find Out More Contact LTC Partners by calling 1-800-LTC-FEDS (1-800-582-3337) (TDD for the hearing impaired: 1-800-
843-3557) or visiting www. ltcfeds. com to get more information and to request an application. 120.
120 Page 121 122

2003 Blue Cross and Blue Shield
Service Benefit Plan 118 Index

Index
Do not rely on this page; it is for your convenience and may not show all pages where the terms appear. This Index is not an official
statement of benefits.

Accidental injury 66-68, 70, 87, 109 Acupuncture 35, 42, 55

Allergy tests 33
Allogeneic (donor) bone marrow
transplant 49-54
Ambulance 65, 70
Anesthesia 55, 58
Autologous bone marrow transplant
50-54
Average wholesale price (AWP) 82,
112
Biopsies 44 Birthing centers 11, 31

Blood and blood plasma 41, 62
Blue Quality Centers for Transplant (BQCT) 11, 52

Breast cancer screening 28-29
Breast reconstruction 46
Cancer screenings 28-29 Cardiac rehabilitation 34, 60

Case management 86
Casts 44, 58, 62
Catastrophic protection 18-19
Certificate of Group Health Plan
Coverage 116
CHAMPVA 107
Chemotherapy 34
Chiropractic 42
Cholesterol tests 27
Circumcision 31, 45
Claims and claim filing 97-99
Coinsurance 15, 109
Colorectal cancer screening 28
Confidentiality 115
Congenital anomalies 46
Contraceptive devices and drugs 32, 80
Coordination of benefits 102-108
Copayments 15, 109
Cosmetic surgery 46, 109
Covered providers 9-11
Custodial care 109
Deductible 15, 109
Definitions 109-113
Dental care 47, 87-92
Diabetic education 9, 43
Diagnostic services 23-25
Disputed claims process 100-101
DoD facilities (MTFs) 19
Donor expenses (transplants) 51, 54
Durable medical equipment 40, 110
Emergency 66-70, 87
Enrollment questions 9, 114-115
Exclusions 96
Experimental or investigational 110

Eyeglasses 37-38, 95
Family planning 32
Fecal occult blood test 26, 28, 29
Foot care 38
Formulary 78-79
Freestanding ambulatory facilities 10-11,
60-62
Hearing services 37
Home nursing care 41
Hospice care 64
Hospital 10, 56-62
Immunizations 30 Independent laboratories 9, 26, 27

Infertility 32-33
Inpatient hospital benefits 56-59
Inpatient physician benefits 24-25, 44-54
Insulin 80
Internet pharmacies 78-83, 94, 98
Laboratory and pathology services 26-
30, 58-61, 67, 69
Lifetime maximum 77, 111
Machine diagnostic tests 26, 58-61, 67,
69
Magnetic Resonance Imaging (MRIs)
26, 58-61, 67, 69
Mail Service Prescription Drugs 78-79, 82,
94, 98
Mammograms 28, 29
Maternity benefits 31, 58
Medicaid 107
Medical foods 41, 85
Medically necessary 12- 13, 59, 96, 111
Medically underserved areas 10, 42
Medicare 20-21, 102-106
Member/ Non-member facilities 6, 7
Mental health 71-77, 111
Neurological testing 24
Newborn care 23, 24, 30, 31
Nurse 9-10, 41, 64, 72, 75
Nurse help line (Blue Health
Connection) 86
Obstetrical care 31
Occupational therapy 36
Office visits 23-28, 30, 38, 43, 69, 72, 75
Oral statements 4
Orthopedic devices 39
Ostomy and catheter supplies 41
Other covered health care professionals 9-10

Out-of-pocket expenses 15-19
Outpatient facility benefits 60-62
Overpayments 19
Overseas claims 17, 83, 93-94
Oxygen 40, 41, 58, 62

Pap test 26, 28, 29 Participating/ Non-participating
providers 6-7, 112
Patient Safety and Quality Monitoring
Program 84
Patients' Bill of Rights 7
Pharmacotherapy 24, 34, 72, 75
Physical examination 27, 30
Physical therapy 35
Physician 9
Plan allowance 16-17, 111-112
Pre-admission testing 58
Precertification 12-13, 113
Pre-existing conditions 114
Preferred Provider Organization (PPO)
6-7, 113
Prescription drugs 78-85
Preventive care, adult, children 27-30
Primary care providers 9
Prior approval 13-14, 113
Prostate cancer screening 28, 29
Prosthetic devices 39
Psychologist 9, 72, 75
Psychotherapy 71-77
Radiation therapy 34
Renal dialysis 34, 60
Room and board 57, 59, 73, 76, 77
Second surgical opinion 24 Skilled nursing facility care 63

Smoking cessation 14, 43, 72, 75, 80
Social Worker 9, 72, 75
Speech therapy 36
Stem cell transplant support 14, 49-53
Sterilization procedures 32, 45
Subrogation 108
Substance abuse 71-77, 111
Surgery 44-47

Assistant surgeon 45 Multiple procedures 45

Oral and maxillofacial surgery 47 Outpatient 44-46, 61
Reconstructive 46 Syringes 80
Temporary Continuation of Coverage
(TCC) 116
Transplants 48-54
TRICARE 107
VA facilities 19
Vision services 37-38
Weight control 45, 85
Wheelchairs 40
Workers' compensation 105, 107
X-rays 26, 27, 42, 58-61, 67, 69 121.
121 Page 122 123

2003 Blue Cross and Blue Shield
Service Benefit Plan 119 Standard Option Summary

Summary of benefits for the Blue Cross and Blue Shield Service Benefit Plan
Standard Option 2003

Do not rely on this chart alone. All benefits 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.
Below, an asterisk (*) means the item is subject to the $250 per person ($ 500 per family) calendar year deductible. If you use a Non-PPO physician or other health care professional, you generally pay any difference between our allowance and the billed
amount, in addition to any share of our allowance shown below.

Benefits You Pay Page
Medical services provided by physicians:
Diagnostic and treatment services provided in the office.....................................................
PPO: 10%* of our allowance; $15 per office visit

Non-PPO: 25%* of our allowance 23-24

Services provided by a hospital:
Inpatient..........................................................
PPO: $100 per admission
Non-PPO: $300 per admission 56-59

Outpatient....................................................... PPO: 10%* of our allowance (no deductible for surgery) Non-PPO: 25%* of our allowance (no deductible for surgery) 60-62

Emergency benefits:
Accidental injury............................................
PPO: Nothing for outpatient hospital and physician services within 72
hours; regular benefits thereafter

Non-PPO: Any difference between our payment and the billed amount
within 72 hours; regular benefits thereafter

66-68

Medical emergency ........................................ Regular benefits 69
Mental health and substance abuse treatment...... In-Network (PPO): Regular cost sharing, such as $15 office visit
copay; $100 per inpatient admission

Out-of-Network (Non-PPO): Benefits are limited
71-77

Prescription drugs ................................................ Retail Pharmacy Program:
PPO: 25% of our allowance; up to a 90-day supply Non-PPO: 45% of our allowance (AWP); up to a 90-day supply

Mail Service Prescription Drug Program:
$10 generic/$ 35 brand-name per prescription; up to a 90-day supply

78-85

Dental care........................................................... Scheduled allowances for diagnostic and preventive services, fillings,
extractions; regular benefits for dental services required due to
accidental injury and covered oral and maxillofacial surgery

47, 87-and
91

Special features: Flexible benefits option; online customer and claims service; 24-hour nurse line; services for deaf and
hearing impaired; travel benefit/ services overseas; health support programs; and Healthy Families program 86

Protection against catastrophic costs
(your catastrophic protection out-of-pocket
maximum)............................................................

Nothing after $4,000 (PPO) or $6, 000 (PPO/ Non-PPO) per contract
per year; some costs do not count toward this protection 18-19 122.
122 Page 123 124

2003 Blue Cross and Blue Shield
Service Benefit Plan 120 Basic Option Summary

Summary of benefits for the Blue Cross and Blue Shield Service Benefit Plan
Basic Option 2003

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.
Basic Option does not provide benefits when you use Non-preferred providers. For a list of the exceptions to this requirement, see page 11. There is no deductible for Basic Option.

Non-PPO: You pay all charges 23-24

Services provided by a hospital:
Inpatient..........................................................
PPO: $100 per day up to $500 per admission
Non-PPO: You pay all charges
55-59

Outpatient....................................................... PPO: $30 per day per facility Non-PPO: You pay all charges 60-62
Emergency benefits:
Accidental injury............................................
PPO: $50 copayment for emergency room care; $30 copayment for
urgent care

Non-PPO: $50 copayment for emergency room care

66-68

Medical emergency ........................................ Same as for accidental injury 69
Mental health and substance abuse treatment...... In-Network (PPO): Regular cost sharing, such as $20 office visit
copayment (prior approval required); $100 per day up to $500 per
inpatient admission

Out-of-Network (Non-PPO): You pay all charges

71-77

Prescription drugs ................................................ Retail Pharmacy Program:
PPO: $10 generic/$ 25 formulary brand-name per prescription/ 50% coinsurance ($ 35 minimum) for non-formulary brand-name drugs.

34-day maximum supply on initial prescription; up to 90 days for
refills with 3 copayments

Non-PPO: You pay all charges

78-85

Dental care........................................................... PPO: $20 copayment per evaluation (exam, cleaning, and x-rays);
most services limited to 2 per year; sealants for children up to age 16;
$20 copayment for dental services required due to accidental injury;
benefits for covered oral and maxillofacial surgery

Non-PPO: You pay all charges

47, 87-regular
88, 92

Protection against catastrophic costs (your catastrophic protection out-of-pocket
maximum)............................................................
Nothing after $5,000 (PPO) per contract per year; some costs do not
count toward this protection 18-19 123.
123 Page 124
2003 Rate Information for
Blue Cross and Blue Shield Service Benefit Plan

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 a special FEHB guide is published 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

Standard Option
Self Only 104 $109.30 $45.66 $236.82 $98. 93 $129.03 $25.93

Standard Option
Self and Family 105 $249.62 $105. 22 $540.84 $227. 98 $294.70 $60.14

Basic Option
Self Only 111 $104.99 $34.99 $227.47 $75. 82 $124.23 $15.75

Basic Option
Self and Family 112 $246.83 $82.27 $534.79 $178. 26 $292.08 $37.02 124.

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