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Government Employees Hospital Association, Inc. 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 get care
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
- Coverage information
- When you lose benefits
Long term care insurance is still available
Index
Summary of Standard Option benefits
Summary of High Option benefits
Rates

Pages 1--102 from The Benefit Plan

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

Government Employees Hospital Association, Inc. Benefit Plan
http:// www. geha. com
2003 A fee-for-service plan

with a preferred provider organization

Sponsored and administered by: Government Employees Hospital Association, Inc.
Who may enroll in this Plan: All Federal employees and annuitants who are eligible to enroll in the Federal Employees Health Benefits Program may become members of
GEHA. You must be, or must become a member of Government Employees Hospital Association, Inc.

To become a member: You join simply by signing a completed Standard Form 2809, Health Benefits Registration Form, evidencing your enrollment in the Plan.
Membership dues: There are no membership dues for the Year 2003.
Enrollment codes for this Plan:

311 Self Only High Option 312 Self and Family High Option

314 Self Only Standard Option 315 Self and Family Standard Option

RI 71-006

For changes in benefits,
see pages 8-9 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 3.
3 Page 4 5

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.
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.
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2003 GEHA 4 Introduction/ Plain Language/ Advisory
Introduction
This brochure describes the benefits of Government Employees Hospital Association, Inc. under our contract (CS 1063) with the Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits
law. This plan is underwritten by Government Employees Hospital Association, Inc. The address for the Government Employees Hospital Association, Inc. administrative offices is:

Government Employees Hospital Association, Inc. P. O. Box 4665
Independence, Missouri 64051-4665
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 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 pages 8 and 9. 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 Government Employees Hospital Association, Inc.
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.
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2003 GEHA 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 (800-821-6136) and explain the situation.
If we do not resolve the issue:

CALL --THE HEALTH CARE FRAUD HOTLINE (202) 418-3300

OR WRITE TO: The United States Office of Personnel Management
Office of the Inspector General Fraud Hotline 1900 E Street, NW, Room 6400
Washington, DC 20415
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. 8.
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2003 GEHA 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 providers, you will receive covered services at reduced cost. Government Employees Hospital Association, Inc. is solely responsible for the selection of
PPO providers in your area. Contact us for the names of PPO providers and to verify their continued participation. You can also go to our web page, which you can reach through the FEHB web site, www. opm. gov/ insure. Contact
Government Employees Hospital Association, Inc. to request a PPO directory.
We have entered into arrangements with Alliance PPO, Inc.; Arizona Foundation for Medical Care, FCHN; Freedom Network; HealthCare Preferred; HealthLink; MedSolutions; MultiPlan; PPO Oklahoma; PPO USA; Private
Healthcare Systems; Providence Preferred; and SouthCare, which are Preferred Providers or networks of hospitals and/ or doctors in all states. The doctors and hospitals participating in these networks have agreed to provide services
to Plan members. You always have the right to choose a PPO provider or a non-PPO provider for medical treatment.
PPO networks are now available in many metropolitan areas and additional coverage areas will be added throughout the year. Enrollees residing in a PPO network area will receive a directory of the PPO providers in their service area.
These providers are required to meet licensure and certification standards established by State and Federal authorities, however, inclusion in the network does not represent a guarantee of professional performance nor does it constitute
medical advice. To locate a participating provider in your area, call (800) 296-0776 or visit the GEHA web site at www. geha. com. When you phone for an appointment, please remember to verify that the physician is still a PPO
provider.
The non-PPO benefits are the standard benefits of this Plan. PPO benefits apply only when you use a PPO provider. Provider networks may be more extensive in some areas than others. We cannot guarantee the availability of every
specialty in all areas. If no PPO provider is available, or you do not use a PPO provider, the standard non-PPO benefits apply. However, if the services are rendered at a PPO hospital, we will pay the services of radiologists,
anesthesiologists and pathologists who are not preferred providers at the preferred provider rate. This non-standard benefit does not include the services of emergency room physicians. In addition, providers outside the United States
will be paid at the PPO level of benefits.
How we pay providers
Fee-for-service plans reimburse you or your provider for covered services. They do not typically provide or arrange for health care. Fee-for-service plans let you choose your own physicians, hospitals and other health care providers.

The FFS plan reimburses you for your health care expenses, usually on a percentage basis. These percentages, as well as deductibles, methods for applying deductibles to families, and the percentage of coinsurance you must pay vary by
plan.
We offer a preferred provider organization (PPO) arrangement. This arrangement with health care providers gives you enhanced benefits or limits your out-of-pocket expenses. 9.
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2003 GEHA 7 Section 1
Your Rights
OPM requires that all FEHB Plans provide certain information to their FEHB members. You may get information about us, our networks, providers, and facilities. OPM's FEHB website (www. opm. gov/ insure) lists the specific types
of information that we must make available to you. Some of the required information is listed below.
Government Employees Hospital Association, Inc. was founded in 1937 as the Railway Mail Hospital Association. For more than 60 years now, GEHA has provided health insurance benefits to federal employees and retirees.

GEHA is incorporated as a General Not-For-Profit Corporation pursuant to Chapter 355 of the Revised Statutes of the State of Missouri.
GEHA's Preferred Provider Organization includes more than 3,800 hospitals and more than 450,000 physician locations throughout the United States. In circumstances where there is limited access to PPO providers, GEHA may
negotiate discounts with some providers which will reduce your overall out-of-pocket expenses.
If you want more information about us, call (800) 821-6136, or write to GEHA, P. O. Box 4665, Independence, MO 64051. You may also contact us by fax at (816) 257-3233 or visit our website at www. geha. com. 10.
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2003 GEHA 8 Section 2
Section 2. How we change for 2003
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5 Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here is a
clarification that does not change benefits.
Program-wide changes
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
Your share of the non-Postal premium under the High Option will increase by 12.5% for Self Only or 12.5% for Self and Family. Under the Standard Option, your share of the premium will not increase.

We now cover medically necessary charges from Audiologists. (Section 5 (a))
We now cover Orthognathic surgery only when conservative treatment has failed for severe sleep apnea. (Section 5 (b))

Certain outpatient radiology procedures now require precertification. You or your physician must contact MedSolutions at 866-879-8317 before scheduling the following procedures: CAT Scan, Magnetic Resonance
Imaging (MRI), Magnetic Resonance Angiography (MRA), Nuclear Cardiology (NC), Positron Emission Tomography (PET). If you do not obtain precertification of these procedures, we will reduce our benefit by $100.
If the procedure is not medically necessary, we will not pay any benefits. (Section 3)
The name of our prescription drug program Merck-Medco has changed to Medco Health. (Section 5 (f))

We have changed PPO Networks in the following states: Alabama, Arkansas, Arizona, California, Connecticut, Hawaii, Massachusetts, Maine, North Carolina, New Hampshire, Rhode Island, South Carolina, Vermont, Utah.
(Section 1)
Community Care Network and United Payors and United Providers are no longer Preferred Provider Networks for GEHA. (Section 1)

We have added Arizona Foundation for Medical Care and MedSolutions to our PPO Network. (Section 1)

Changes to High Option Only
The Calendar Year Deductible has increased to $350 per person. Under a family enrollment the maximum deductible is $700 per calendar year. (Section 4)

Under the High Option we have changed the Prescription Drug Copayments. (Section 5 (f)) The copayments are now:
NonMedicare Members:
Network Retail Pharmacy (Initial prescription not to exceed 30 days supply and first refill) $5 generic/$ 20 single source brand/$ 35 multisource brand (after 1 st refill you pay 50%)

Home Delivery Pharmacy (for up to 90 day supply) $10 generic/$ 40 single source brand/$ 55 multisource brand. 11.
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2003 GEHA 9 Section 2
Medicare A & B Primary Members:
Network Retail Pharmacy (initial prescription not to exceed 30 day supply and first refill). $3 generic/$ 10 single source brand/$ 25 multisource brand (after first refill you pay 50%)

Home Delivery Pharmacy (for up to 90 day supply) $5 generic/$ 20 single source brand/$ 35 multisource brand.
Under the High Option, the copayment for office visits for Preferred Providers is now $20. (Section 4)
In-hospital expenses at PPO hospitals including in-network mental health admissions are now subject to a $100 per admission deductible, up to a maximum of 2 per person per calendar year. In-hospital expenses at Non-PPO

hospitals are now subject to a $300 per admission deductible up to a maximum of 2 per person per calendar year. (Section 5 (e) and 5 (f))

We clarified the following:
We have clarified after the deductible amount is satisfied by an individual, covered services are payable for that individual. (Section 4)

We clarified diabetic shoes are not covered. (Section 5 (a))
We clarified Cold Therapy Units are not covered. (Section 5 (a))
We clarified Body Mass Index Criteria is used to determine benefits for surgical treatment of obesity. (Section 5 (b))

We clarified Air Ambulance is not covered if requested by the patient or physician for continuity of care or other reasons if transport is beyond the nearest available suitable facility. (Section 5 (c) and 5 (d))
We clarified Psychological tests are covered both in and out of Network. (Section 5 (e))
Prescription drug clarifications: (Section 5 (f))
Any Prescription purchased twice at retail, regardless of the quantity purchased is considered maintenance medication.

Orders for ostomy and insulin pump supplies through Home Delivery should include the product number.
At Network retail pharmacies and Home Delivery service, a program is in place to promote safe and appropriate use of medications. This program includes prior approval and quantity limitations on certain

drugs. Quantity limitations are based on FDA approval and manufacturer's recommended dosage.
Compound drug pricing at Medco Health Solutions is based on the contractual Average Wholesale Price (AWP) cost of each component, the professional fee and applicable sales tax and the applicable copayment.

We clarified Telephone therapy is not covered for out-of-network mental health services. (Section 5 (e))
We clarified Travel time for providers to render therapy at patient's home is not covered for out-of-network mental health services. (Section 5 (e))

We updated the address for submitting claims for mental health services. (Section 5 (e))
We clarified when Medicare is the primary payer and does not cover a charge, we will determine our Plan allowance and pay our benefit up to this amount. (Section 9)

We clarified that if you sign a Medicare Private Contact agreement with a physician, neither you nor the physician can bill Medicare and you will be financially responsible for the entire balance after we make our
payment. (Section 9)
We have clarified Outpatient Cardiac Rehabilitation is covered. Section 5( a)) and 5( c)) 12.
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2003 GEHA 10 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you
receive services from a Plan provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the Health
Benefits Election Form, SF-2809, your health benefits enrollment confirmation (for annuitants), or your Employee Express confirmation
letter.

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at
(800) 821-6136 or write to us at GEHA, P. O. Box 4665, Independence, MO 64051. You may also request replacement cards through our website:
www. geha. com.

Where you get covered care You can get care from any "covered provider" or "covered facility." How much we pay and you pay depends on the type of covered provider or
facility you use. If you use our preferred providers, you will pay less.
Covered providers We consider the following to be covered providers when they perform services within the scope of their license or certification:

A licensed doctor of medicine (M. D.) or a licensed doctor of osteopathy (D. O.). Other covered providers include a chiropractor, nurse midwife,
nurse anesthetist, audiologist, dentist, optometrist, licensed clinical social worker, licensed clinical psychologist, podiatrist, speech, physical and
occupational therapist, nurse practitioner/ clinical specialist, nursing school administered clinic and physician assistant.

The term "doctor" includes all of these providers when the services are performed within the scope of their license or certification. The term
"primary care physician" includes family or general practitioners, pediatricians, obstetricians/ gynecologists and medical internists.

Medically underserved areas. Note: We cover any licensed medical practitioner for any covered service performed within the scope of that
license in states OPM determines are "medically underserved". 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 facilities Covered facilities include:
Freestanding ambulatory facility
A facility which is licensed by the state as an ambulatory surgery center or has Medicare certification as an ambulatory surgical center,

has permanent facilities and equipment for the primary purpose of performing surgical and/ or renal dialysis procedures on an outpatient
basis; provides treatment by or under the supervision of doctors and nursing services whenever the patient is in the facility; does not
provide inpatient accommodations; and is not, other than incidentally, a facility used as an office or clinic for the private
practice of a doctor or other professional. 13.
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2003 GEHA 11 Section 3
Hospice
A facility which meets all of the following: (1) primarily provides inpatient hospice care to terminally ill

persons; (2) is certified by Medicare as such, or is licensed or accredited as
such by the jurisdiction it is in; (3) is supervised by a staff of M. D. 's or D. O. 's, at least one of whom
must be on call at all times; (4) provides 24 hour a day nursing services under the direction of an
R. N. and has a full-time administrator; and (5) provides an ongoing quality assurance program.

Hospital
(1) An institution which is accredited as a hospital under the Hospital Accreditation Program of the Joint Commission on Accreditation

of Healthcare Organizations (JCAHO); or (2) A medical institution which is operated pursuant to law, under the
supervision of a staff of doctors, and with 24 hour a day nursing service, and which is primarily engaged in providing general
inpatient care and treatment of sick and injured persons through medical, diagnostic, and major surgical facilities, all of which
facilities must be provided on its premises or have such arrangements by contract or agreement: or
(3) An institution which is operated pursuant to law, under the supervision of a staff of doctors and with 24 hour a day nursing
service and which provides services on the premises for the diagnosis, treatment, and care of persons with mental/ substance
abuse disorders and has for each patient a written treatment plan which must include diagnostic assessment of the patient and a
description of the treatment to be rendered and provides for follow-up assessments by or under the direction of the
supervising doctor.
The term hospital does not include a convalescent home or skilled nursing facility, or any institution or part thereof which a) is used principally as a
convalescent facility, nursing facility, or facility for the aged; b) furnishes primarily domiciliary or custodial care, including training in the routines of
daily living; or c) is operating as a school or residential treatment facility.
What you must do to It depends on the kind of care you want to receive. You can go to any get covered care provider you want, but we must approve some care in advance.

Transitional care: Specialty care: If you have a chronic or disabling condition and
lose access to your PPO 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 PPO 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 PPO 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 PPO specialist based on the above circumstances, you can continue 14.
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2003 GEHA 12 Section 3
to see your specialist and any PPO benefits 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 our customer service department immediately at (800) 821-6136.

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 won't 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: For medical and surgical services, you, your representative, your
doctor, or your hospital must call Intracorp before admission. The toll-free number is (800) 747-GEHA or (800) 747-4342. (See page 55 for
mental health/ substance abuse precertification.)

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

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; 15.
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2003 GEHA 13 Section 3
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 If your hospital stay --including for maternity care --needs to be needs to be extended: extended, you, your representative, your doctor or the hospital must ask us
to approve the additional days.
What happens when you If no one contacted us, we will decide whether the hospital stay was do not follow the medically necessary.
precertification rules If we determine that the stay was medically necessary, we will pay
the inpatient charges, less the $500 penalty.
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. 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 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 will not pay inpatient benefits.
Exceptions: You do not need precertification in these cases:
You are admitted to a hospital outside the United States and Puerto Rico.

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.
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2003 GEHA 14 Section 3
Radiology/ Imaging Procedures Radiology precertification is the process by which prior to scheduling Precertification specific imaging procedures we evaluate the medical necessity of your
proposed procedure to ensure the appropriate procedure is being requested for your condition. In most cases your physician will take care of
precertification. Because you are still responsible for ensuring that we are asked to precertify your procedure, you should ask your doctor to contact
us.
The following outpatient radiology services need to be precertified:
CT -Computerized Axial Tomography MRI -Magnetic Resonance Imaging

MRA -Magnetic Resonance Angiography NC -Nuclear Cardiology
PET -Positron Emission Tomography
How to precertify a radiology/ For outpatient CT, MRI, MRA, NC and PET studies, you, your Imaging procedure: representative or your doctor must call MedSolutions before scheduling
the procedure. The toll free number is 866-879-8317. Provide the following information: patient's name, plan identification number, and
birth date, requested procedure and clinical support for request, name and telephone number of ordering provider, and name of requested imaging
facility.
Exceptions: You do not need precertification in these cases:
You have another health insurance policy that is primary payer including Medicare Part A & B or Part B only;

The procedure is performed outside the United States and Puerto Rico;
You are an inpatient in a hospital;
The procedure is performed as an emergency.

Warning: We will reduce our benefits for these procedures by $100 if no one contacts us for precertification. If the procedure is not medically
necessary, we will not pay any benefits.
Other services Some services require a referral, precertification, or prior authorization. You need to call us at (800) 821-6136 before receiving treatment care such
as:
Physical therapy Growth hormone therapy (GHT)

Surgical treatment of morbid obesity Certain prescription drugs
Organ and tissue transplant procedures Surgical correction of congenital anomalies
In-network Mental Health and Substance Abuse Benefits (See page 55) 17.
17 Page 18 19
2003 GEHA 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 services.

Example: When you see your PPO physician, under the High Option, you pay a copayment of $20 per office visit.

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 do not count toward any deductible.
The calendar year deductible is $350 per person under High Option and $450 per person under Standard Option. After the deductible amount is

satisfied for an individual, covered services are payable for that individual. Under a family enrollment, all family member's individual deductibles are
considered to be satisfied when the family member's deductibles are combined and reach $700 under High Option and $900 under Standard
Option.
We also have a separate deductible for:
A High Option per admission (including in-network mental health) deductible of $100 per person (PPO) and $300 (non-PPO) for inpatient

hospital services up to a maximum of two per person, per calendar year.
Mental health and substance abuse treatment of $350, per person, under High Option and $450, per person, under Standard Option. Under a
family enrollment, the deductible is satisfied for all family members when the combined covered expenses applied to the mental health and
substance abuse treatment deductible for family members reach $700 under High Option and $900 under Standard Option.

Mental health and substance abuse treatment of $500, per person, per calendar year, for out-of-network hospital inpatient and hospital
outpatient/ intensive day treatment
Note: If you change plans during open season, you do not have to start a new deductible under your old plan between January 1 and the effective

date of your new plan. If you change plans at another time during the year, you must begin a new deductible under your new plan.

And, if you change options in this Plan during the year, we will credit the amount of covered expenses already applied toward the deductible of your
old option to the deductible of your new option.
Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. Coinsurance doesn't begin until you meet your deductible. We will
base this percentage on either the billed charge or the Plan Allowance, whichever is less.

Example: Under the High Option, you pay 25% of our allowance for non-PPO office visits.
Note: If your provider routinely waives (does not require you to pay) your copayments, deductibles, or coinsurance, 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 GEHA 16 Section 4
For example, if your physician ordinarily charges $100 for a service but routinely waives your 25% coinsurance, the actual charge is $75. We will
pay $56.25 (75% of the actual charge of $75).

Differences between Our "Plan allowance" is the amount we use to calculate our payment our allowance and for covered services. Fee-for-service plans arrive at their allowances in
the bill different ways, so their allowances vary. For more 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 provider you use.
PPO providers agree to limit what they will bill you. Because of that,
when you use a preferred provider, your share of covered charges consists only of your deductible and coinsurance or copayment. Here is

an example about coinsurance: You see a PPO physician who charges $150, but our allowance is $100. If you have met your deductible, you
are only responsible for your coinsurance. That is, with High Option you pay just 10% of our $100 allowance ($ 10). Because of the
agreement, your PPO physician will not bill you for the $50 difference between our allowance and his bill.

Non-PPO providers, on the other hand, have no agreement to limit
what they will bill you. When you use a non-PPO provider, you will pay your deductible and coinsurance --plus any difference between

our allowance and charges on the bill. Here is an example: You see a non-PPO physician who charges $150 and our allowance is again $100.
Because you've met your deductible, you are responsible for your coinsurance, so with High Option you pay 25% of our $100 allowance
($ 25). Plus, because there is no agreement between the non-PPO physician and us, he can bill you for the $50 difference between our
allowance and his bill.
The following table illustrates the examples of how much you have to pay out-of-pocket, under the High Option, for services from a PPO physician
vs. a non-PPO physician. The table uses our example of a service for which the physician charges $150 and our allowance is $100. The table
shows the amount you pay if you have met your calendar year deductible.
EXAMPLE PPO physician Non-PPO physician Physician's charge $150 $150
Our allowance We set it at: 100 We set it at: 100 We pay 90% of our allowance: 90 75% of our allowance: 75
You owe: Coinsurance 10% of our allowance: 10 25% of our allowance: 25
+Difference up to charge? No: 0 Yes: 50
TOTAL YOU PAY $10 $75

Your catastrophic protection For those medical and surgical services with coinsurance, we pay 100% out-of-pocket maximum for of our allowable amount for the remainder of the calendar year after
deductibles, coinsurance, and out-of-pocket expenses for coinsurance exceed: copayments 19.
19 Page 20 21
2003 GEHA 17 Section 4
PPO $3,500 for Self and Family (High Option) or $4,500 (Standard Option) and $3,000 for Self Only (High Option) or $4,000 (Standard Option) if
you use PPO Providers. Out-of-pocket expenses from both PPO and non-PPO providers count toward this limit. If you reach this limit,
expenses from non-PPO providers must reach the non-PPO out-of-pocket limit before they are paid at 100% of our allowable amount.
Non-PPO $4,500 for Self and Family (High Option) or $5,500 (Standard Option) and $4,000 for Self Only (High Option) or $5,000 (Standard Option) if
you use non-PPO providers. Any of the above expenses for PPO providers also count toward this limit. Your eligible out-of-pocket
expenses will not exceed this amount whether or not you use PPO providers.

Refer to pages 56 and 59 for separate in-and out-of-network catastrophic protection out-of-pocket maximums for mental health and substance abuse.
Out-of-pocket expenses for this benefit are:
The 10% (High Option) or 15% (Standard Option) you pay for PPO charges under medical services and supplies, surgical and anesthesia
services and hospital, facility and ambulance services.
The 25% (High Option) or 35% (Standard Option) you pay for non-PPO charges under medical services and supplies, surgical and

anesthesia services and hospital, facility and ambulance services.
The following cannot be counted toward catastrophic protection out-of-pocket expenses:

The $350 (High Option) or $450 (Standard Option) calendar year deductible;
The (High Option) $100 (PPO) or $300 (non-PPO) per in-hospital admission deductible;
The $20 copayment for doctor's office visits (High Option); or the $10 copayment for primary care physician/$ 25 specialist office visits
(Standard Option);
Expenses in excess of our allowable amount or maximum benefit limitations;

Expenses for well child care and immunizations; Expenses for dental and chiropractic care;

Any amounts you pay because benefits have been reduced for non-compliance with our cost containment requirements (see pages12-13);
Expenses for prescription drugs purchased through retail or Home Delivery Pharmacy service.

When government facilities Facilities of the Department of Veterans Affairs, the Department of bill us 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. 20.
20 Page 21 22
2003 GEHA 18 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 or 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, not on the actual charge;
you are responsible for your applicable deductibles, 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 Medicare equivalent amount.
When inpatient claims are paid according to a Diagnostic Related Group (DRG) limit (for instance, for admissions of certain retirees who do not have Medicare), we will pay 30% of the total covered amount as

room and board charges and 70% as other charges and will apply your coinsurance accordingly.
And, for your physician care, the law requires us to base our payment and your coinsurance 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

Participates with Medicare or accepts Medicare assignment for the claim and
is a member of our PPO network,
your deductibles, coinsurance, and copayments;

Participates with Medicare and is not in our PPO network, your deductibles, coinsurance, copayments, and any balance up to the Medicare approved
amount;
Does not participate with Medicare, your deductibles, coinsurance, copayments, and any balance up to 115% of the Medicare

approved amount

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. 21.
21 Page 22 23
2003 GEHA 19 Section 4
When you have the We limit our payment to an amount that supplements the benefits that Original Medicare Plan Medicare would pay under Medicare Part A (Hospital insurance) and
(Part A, Part B, or both) Medicare Part B (Medical insurance), regardless of whether Medicare pays. Note: We pay our regular benefits for emergency services to an
institutional 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 we waive some of
your deductibles, copayment and coinsurance 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. Please see Section 9, Coordinating benefits

with other coverage, for more information about how we coordinate benefits with Medicare.

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) that Medicare will send you 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. 22.
22 Page 23 24

2003
GEHA

Section
5

20
Section
5.
Benefits

OVERVIEW

(See
pages

8
and

9
for

how

our
benefits

changed

this
year

and
pages

97
and

98
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
(800)

821-6136

or
at
our

website

at
www.

geha.
com.

(a)
Medical

services
and
supplies

provided

by
physicians

and
other

health

care
professionals

..................................................................................................

21-33

Diagnostic

and
treatment

services

Lab,

X-ray,

and
other

diagnostic

tests

Preventive

care,
adult

Preventive

care,
children

Maternity

care

Family

planning

Infertility

services

Allergy

care

Treatment

therapies

Physical

and
occupational

therapy

Speech

therapy

Hearing

services
(testing,
treatment,

and
supplies)

Vision

services

(testing,
treatment,

and
supplies)

Foot

care

Orthopedic

and
prosthetic

devices

Durable

medical
equipment

(DME)

Home

health
services

Chiropractic Alternative treatments Educational

classes
and
programs

(b)
Surgical

and
anesthesia

services
provided

by
physicians

and
other

health

care
professionals

...............................................................................................

34-42

Surgical

procedures

Reconstructive

surgery

Oral

and
maxillofacial

surgery

Organ/

tissue
transplants

Anesthesia

provided

by
a
hospital

or
other

facility,

and
ambulance
services.............................................................................................................................

43-49

Inpatient

hospital

Outpatient

hospital
or
ambulatory

surgical
center

Extended

care
benefits/

Skilled
nursing
care

facility
benefits

Hospice

care

Ambulance

(d)
Emergency

services/
Accidents
...............................................................................................................................................................................................

50-52

Accidental

injury

Medical

emergency

Ambulance

(e)
Mental

health
and
substance

abuse
benefits
...........................................................................................................................................................................

53-60

(f)
Prescription

drug
benefits
.......................................................................................................................................................................................................

61-67

(g)
Special
features............................................................................................................................................................................................................................

Flexible

benefits
option

Services

for
deaf

and
hearing

impaired

High

risk
pregnancies

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

69-70

(i)
Non-
FEHB

benefits

available

to
Plan

members
.....................................................................................................................................................................

71-72

SUMMARY
OF
BENEFITS
...........................................................................................................................................................................................................

97-98 23.
23 Page 24 25
2003
GEHA

21
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.

The

calendar

year
deductible

is
$350

per
person

($
700

per
family)

under
the
High

Option

and
$450

per
person

($
900

per
family)

under

the
Standard

Option.
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.

The

non-PPO

benefits
are
the
standard

benefits
of
this

Plan.

PPO
benefits

apply
only
when

you
use
a
PPO

provider.

When
no
PPO

provider
is
available,

non-PPO
benefits
apply.

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
with
Medicare.

When

you
use
a
PPO

hospital

the
professionals

who
provide

services

to
you

in
a
hospital

may
not
all
be
preferred

providers.

If
they

are

not,
they

will
be
paid

by
this

plan

as
non-PPO

providers.
However,
if
the

services

are
rendered

at
a
PPO

hospital,

we
will

pay
the

services
of
radiologists,

anesthesiologists

and
pathologists

who
are
not
preferred

providers

at
the

preferred

provider
rate.
This
non-

standard
benefit
does
not
include

the
services

of
emergency

room
physicians.

YOU

MUST

GET
PRECERTIFICATION

OF
CERTAIN

OUTPATIENT

IMAGING
PROCEDURES.

FAILURE
TO
DO
SO

WILL
RESULT

IN
A
MINIMUM

OF
$100

PENALTY.

Please
refer
to
precertification

information
in
Section

3
to

sure

which

procedures
require
precertification.

I M P O R T A N T

Benefit
Description

You
pay

After
the
calendar

year
deductible

NOTE:
The
calendar

year
deductible

applies
to
almost

all
benefits

in
this

Section.

We
say
"(
No

deductible)"

when
it
does

not
apply.

Diagnostic
and
treatment

services

Standard
Option

High
Option

Professional
services
of
physicians

In
physician's

office

Routine

physical
examinations

Office

medical

consultations

Second

surgical
opinions

Note:
The
facility

charge
for
clinic

or
office

visits
is
considered

a
part

of
the

fee
charged

by
the
physician.

PPO:
$10
copayment

for

office
visits
to
primary

care

physicians;
$25
copayment

for
office

visits
to
specialists

(No
deductible) Non-PPO: 35%

of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount.

PPO:
$20
copayment

(No

deductible) Non-PPO: 25%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

Diagnostic
and
treatment

services

continued

next
page 24.
24 Page 25 26
2003
GEHA

22
Section
5( a)

You
pay

Diagnostic
and
treatment

services
(continued)

Standard
Option

High
Option

Professional
services
of
physicians

Emergency

room
physician

care
(non-accidental

injury)

During

a
hospital

stay

At
home

PPO:
15%
of
the

Plan

allowance

Non-PPO:
35%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

PPO:
10%
of
the

Plan

allowance

Non-PPO:
25%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

Not
covered: Urgent care

facilities
except
for
services

of
covered

physicians,

xray
and
laboratory

services.

All
charges

Lab,
X-ray

and
other

diagnostic

tests

Tests,
such
as:

Blood

tests

Urinalysis Non-routine

pap
tests

Pathology X-rays Non-routine

mammograms

CAT

Scans/ MRI

(Outpatient
requires
precertification)

Ultrasound Electrocardiogram

and
EEG

PPO:
15%
of
the

Plan

allowance

Non-PPO:
35%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount Note: If your PPO

provider
uses

a
non-PPO

lab
or
radiologist,

we
will

pay
non-PPO

benefits

for
any

lab
and

X-ray

charges.

PPO:
10%
of
the

Plan

allowance

Non-PPO:
25%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount Note: If your PPO

provider
uses

a
non-PPO

lab
or
radiologist,

we
will

pay
non-PPO

benefits

for
any

lab
and

X-ray

charges. 25.
25 Page 26 27
2003
GEHA

23
Section
5( a)

You
Pay

Preventive
care,
adult

Standard
Option

High
Option

Routine
screenings,

limited
to:

Total

Blood
Cholesterol

screenings

Chlamydial

infection

Colorectal

cancer
screening,

including

Annual

coverage

of
one

fecal

occult

blood
test
for
members

age
40
and

older

Sigmoidoscopy Prostate cancer screening Annual coverage

of
one

PSA

(Prostate

Specific
Antigen)

test
for
men

age
40
and

older

Routine

pap
test

Annual

coverage

of
one

pap
smear

for
women

age
18
and

older

Routine

mammogram

PPO:
15%
of
the

Plan

allowance

Non-PPO:
35%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

PPO:
10%
of
the

Plan

allowance

Non-PPO:
25%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

Mammograms

for
diagnostic

and/
or
routine

screening

Routine

immunizations Tetanus-diphtheria

(Td)
booster

Influenza/

Pneumococcal

vaccines

Preventive
care,
children

For
dependent

children
under
age
22:

Childhood

immunizations

recommended
by
the
American

Academy
of
Pediatrics

For

well-child

care
charges

for
routine

examinations,

immunizations

and
care

Initial

examination

of
a
newborn

child
covered

under
a
family

enrollment

PPO:
Nothing

(No
deductible)

Non-PPO:
Nothing,
except
any

difference
between
our
Plan

allowance
and
the
billed

amount.
(No
deductible)

PPO:
Nothing

(No
deductible)

Non-PPO:
Nothing,
except
any

difference
between
our
Plan

allowance
and
the
billed

amount.
(No
deductible)

Vision

examinations,

limited
to:

Examinations

for
amblyopia

and
strabismus

PPO:
$10
copayment

for
office

visits
to
primary

care
physicians;

$25
copayment

for
office

visits
to

specialists
(No
deductible)

Non-PPO:
35%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

PPO:
$20
copayment

(No

deductible) Non-PPO: 25%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount 26.
26 Page 27 28
2003
GEHA

24
Section
5( a)

You
Pay

Maternity
Care

Standard
Option

High
Option

Complete
maternity
(obstetrical)

care,
such
as:

Prenatal

care

Delivery Postnatal

care

Physician

care
such

as
non-routine

sonograms.

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.

cover

routine

nursery

care
of
the

newborn

child
during

the
covered

portion
of
the

mother's
maternity

stay.

will
cover

other
care
of
an
infant

who
requires

non-routine

treatment
if
we

cover

the
infant

under
a
Self

and
Family

enrollment.

See
Hospital

benefits
(Section

5
(c))

and
Surgery

benefits
(Section

5
(b))

Circumcision

is
covered

under
Surgery

benefits.
(Section
5
(b))

PPO:
Nothing

(No
deductible)

Non-PPO:
35%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

PPO:
Nothing

(No
deductible)

Non-PPO:
25%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

Approved
fetal
monitors

are
covered

the
same

as
other

medical

benefits
for
diagnostic

and

treatment
services

PPO:
15%
of
the

Plan

allowance

Non-PPO:
35%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

PPO:
10%
of
the

Plan

allowance

Non-PPO:
25%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

Not
covered: Routine sonograms

to
determine

fetal
age,
size
or
sex.

Home

uterine

monitoring

devices,
unless
preauthorized

by
our

Medical

Director.

Charges

related
to
abortions

except
when
the
life
of
the

mother

would
be
endangered

the
fetus

were
carried

to
term

or
when

the
pregnancy

is
the

result

of
rape

or
incest.

Charges

for
services

and
supplies

incurred
after
termination

of
coverage.

All
charges

All
charges 27.
27 Page 28 29
2003
GEHA

25
Section
5( a)

You
Pay

Family
planning

Standard
Option

High
Option

A
range

of
voluntary

family
planning

services,
limited
to:

Voluntary

sterilization

(See
Surgical

procedures

Section
5
(b))

Surgically

implanted
contraceptives

Injectable

contraceptive

drugs
(such
as
Depo

provera)

Intrauterine

devices
(IUDs)

Diaphragms Note: We cover

oral
contraceptives

under
the
prescription

drug
benefit.

PPO:
15%
of
the

Plan

allowance

Non-PPO:
35%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

PPO:
10%
of
the

Plan

allowance

Non-PPO:
25%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

Not
covered: Reversal of

voluntary
surgical
sterilization

Genetic

counseling

All
charges

Infertility
services
Diagnosis
and
treatment

of
infertility,

except
as
shown

in
Not

covered.

Note:
Benefits

are
limited

to
a
maximum

of
$3,000

per
calendar

year
per
person.

PPO:
15%
of
the

Plan

allowance

Non-PPO:
35%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

PPO:
10%
of
the

Plan

allowance

Non-PPO:
25%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

Not
covered: Infertility

services
after
voluntary

sterilization

Fertility

drugs

Assisted

reproductive

technology
(ART)
procedures,

such
as:

Artificial

insemination

In
vitro

fertilization

Embryo

transfer
and
GIFT

Intravaginal

insemination
(IVI)

Intracervical

insemination
(ICI)

Intrauterine

insemination

(IUI)

Services

and
supplies

related
to
ART

procedures

Cost

of
donor

sperm

Cost

of
donor

egg

All
charges

All
charges 28.
28 Page 29 30
2003
GEHA

26
Section
5( a)

You
Pay

Allergy
care

Standard
Option

High
Option

Testing
and
treatment,

including
materials
(such
as
allergy

serum)

Allergy
testing
is
limited

to
$500

per
person

per
calendar

year

Allergy
injections

PPO:
15%
of
the

Plan

allowance

Non-PPO:
35%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

PPO:
10%
of
the

Plan

allowance

Non-PPO:
25%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

Not
covered: Clinical ecology

and
environmental

medicine

Provocative

food
testing

and
sublingual

allergy
desensitization

All
charges

Treatment
therapies

Antibiotic

therapy

Outpatient

cardiac
rehabilitation

Chemotherapy

and
radiation

therapy

Note:
High-dose

chemotherapy

in
association

with
autologous

bone
marrow

transplants

limited
to
those

transplants

listed
on
page

39.

Dialysis

hemodialysis

and
peritoneal

dialysis

Intravenous

(IV)/
Infusion

Therapy

Growth

hormone

therapy
(GHT)

Note:
GHT
is
covered

under
the
prescription

drug
benefit.

We
only

cover

GHT
when
we

preauthorize
the
treatment.

Call
(800)

821-6136

for
preauthorization.

We
will
ask
you

submit
information

that
establishes

that
the
GHT

is
medically

necessary.

Ask
us
to
authorize

GHT
before

you
begin

treatment;

otherwise,
we
will

only
cover

GHT
services

from
the
date

you
submit

the
information.

If
you

do
not

ask
or
if
we

determine

GHT
is
not

medically

necessary,
we
will

not
cover

the
GHT

or
related

services

and
supplies.

See
Services

requiring

our
prior

approval

in
Section

Respiratory

and
inhalation

therapies

Note

Some

medications

required
for
treatment

therapies
may
be
available

through
the
Home

Delivery
Pharmacy

service
or
a
Medco

Participating

Pharmacy.
Medications

obtained
from

these
sources

are
covered

under
the
Prescription

Drug
Benefits

in
Section

5
(f).

PPO:
15%
of
the

Plan

allowance

Non-PPO:
35%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

PPO:
10%
of
the

Plan

allowance

Non-PPO:
25%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

Treatment
therapies

continued

next
page 29.
29 Page 30 31
2003
GEHA

27
Section
5( a)

You
Pay

Treatment
therapies

(continued)

Standard
Option

High
Option

Not
covered: Chelation

therapy
except
for
acute

arsenic,

gold
or
lead

poisoning

Maintenance

cardiac
rehabilitation

All
charges

Physical
and
occupational

therapies

60
visits

per
calendar

year
for
the
combined

services
of
the
following:

qualified

physical
therapists

and

qualified

occupational

therapists

Prior
to
beginning

physical
therapy
treatments,

you
should

contact

our
Medical

Management
Department,
(800)
821-6136,

to
preauthorize

benefits.
Continuing

physical

therapy
claims
will
be
subject

to
concurrent

review
for
medical

necessity.

Physical

therapy
claims
will
be
denied

if
we

determine

the
therapy

is
not

medically

necessary.

Please
preauthorize.

PPO:
15%
of
the

Plan

allowance

Non-PPO:
35%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

PPO:
10%
of
the

Plan

allowance

Non-PPO:
25%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

Note:
We
only

cover

therapy

to
restore

bodily
function

when
there
has
been

a
total

or
partial

loss
of
bodily

function

due
to
illness

or
injury

and
when

a
physician:

1)
orders

the
care;

2)
identifies

the
specific

professional

skills
the
patient

requires

and
the
medical

necessity

for

skilled
services;

and

3)
indicates

the
length

of
time

the
services

are
needed.

Note:
When
you
receive

medically

necessary
physical
or
occupational

therapy
on
an
outpatient

basis

from
a
qualified

professional

therapist
at
a
skilled

nursing

facility,
your
therapy

is
covered

up
to
plan

limits. Not covered: Exercise
programs

Long-

term
rehabilitative

therapy

All
charges

All
charges 30.
30 Page 31 32
2003
GEHA

28
Section
5( a)

You
Pay

Speech
therapy

Standard
Option

High
Option

30
visits

per
calendar

year
for
the
services

of
a
qualified

speech
therapist.

Note:
We
only

cover

speech

therapy

when
a
physician:

1)
Orders

the
care;

2)
Identifies

the
specific

professional

skills
the
patient

requires

and
the
medical

necessity
for
skilled

services;

and

3)
Indicates

the
length

of
time

the
services

are
needed.

Note:
When
you
receive

medically

necessary
speech
therapy

on
an
outpatient

basis
from
a
qualified

speech
therapist

at
a
skilled

nursing

facility,
your
therapy

is
covered

up
to
plan

limits

PPO:
15%
of
the

Plan

allowance

Non-PPO:
35%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

PPO:
10%
of
the

Plan

allowance

Non-PPO:
25%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

Not
covered: Computer

devices
to
assist

with
communications

Computer

programs
of
any

type,

including

but
not
limited

to
those

to
assist

with

speech
therapy

All
charges

Hearing
services
(testing,
treatment,

and
supplies)

Diagnostic
hearing
tests
performed

by
a
M.

D.,

D.
O.

or
audiologist.

PPO:
15%
of
the

Plan

allowance

Non-PPO:
35%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

PPO:
10%
of
the

Plan

allowance

Non-PPO:
25%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

Not
covered: Hearing aids,

testing
and
examinations

for
them

All
charges

All
charges 31.
31 Page 32 33
2003
GEHA

29
Section
5( a)

You
Pay

Vision
services

(testing,
treatment,

and
supplies)

Standard
Option

High
Option

First

pair
of
contact

lenses
or
ocular

implant

lenses
if
required

to
correct

impairment
existing
after
intraocular

surgery
or
accidental

injury.

30
outpatient

vision
therapy

visits
by
an
ophthalmologist

or
optometrist

per
person

per

lifetime

PPO:
15%
of
the

Plan

allowance

Non-PPO:
35%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

PPO:
10%
of
the

Plan

allowance

Non-PPO:
25%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

Not
covered: Computer

programs

of
any

type,

including

but
not
limited

to
those

to
assist

with
vision

therapy. Eyeglasses Radial keratotomy
and
other

refractive

surgeries

All
charges

Foot
care
Routine

foot
care
only
when

you
are
under

active
treatment

for
a
metabolic

or
peripheral

vascular
disease,
such
as
diabetes.

PPO:
$10
copayment

for
office

visits
to
primary

care
physicians;

$25
copayment

for
office

visits
to

specialists
(No
deductible)

plus
15%

of
the

Plan

allowance

for
other

services
performed

during
the
visit

Non-PPO:
35%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

PPO:
$20
copayment

for
the

office
visit
(No
deductible)

plus
10%

of
the

Plan

allowance
for
other

services

performed
during
the
visit

Non-PPO:
25%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

Not
covered: Cutting or

trimming
of
toenails

or
removal

of
corns,

calluses,

or
similar

routine

treatment
of
conditions

of
the

foot,

except

as
stated

above.

All
charges

All
charges 32.
32 Page 33 34
2003
GEHA

30
Section
5( a)

You
Pay

Orthopedic
and
prosthetic

devices

Standard
Option

High
Option

Artificial

limbs
and
eyes;

stump

hose

Externally

worn
breast
prostheses

and
surgical

bras,
including

necessary
replacements

following
a
mastectomy

Internal

prosthetic

devices,
such
as
artificial

joints,
pacemakers,

cochlear
implants,

and

surgically
implanted
breast
implant

following

mastectomy.

Note:
See
Section

5
(b)

for
coverage

of
the

surgery

to
insert

the
device.

PPO:
15%
of
the

Plan

allowance

Non-PPO:
35%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

PPO:
10%
of
the

Plan

allowance

Non-PPO:
25%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

Not
covered: Orthopedic

and
corrective

shoes

Arch

supports

Foot

orthotics Heel pads and

heel
cups

Diabetic

shoes

All
charges

Durable
medical
equipment

(DME)

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,

such
as
oxygen

and
dialysis

equipment.

Under
this
benefit,

we
also

cover: Hospital
beds;

Wheelchairs; Crutches; and Walkers.

PPO:
15%
of
the

Plan

allowance

Non-PPO:
35%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

PPO:
10%
of
the

Plan

allowance

Non-PPO:
25%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount DME -continued

next
page 33.
33 Page 34 35
2003
GEHA

31
Section
5( a)

You
Pay

Durable
medical
equipment

(DME)
-( continued)

Standard
Option

High
Option

Note:
Call
us
at
(800)

821-6136

as
soon

as
your

physician

prescribes

this
equipment.

will
arrange

with
a
health

care
provider

to
rent

or
sell

you
durable

medical
equipment

discounted
rates
and
will
tell
you

more

about

this
service

when
you
call.

Note:
Benefits

for
durable

medical
equipment

are
limited

to
$10,000

per
person,

lifetime

maximum.

PPO:
15%
of
the

Plan

allowance

Non-PPO:
35%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

PPO:
10%
of
the

Plan

allowance

Non-PPO:
25%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

Not
covered: Computer

devices
to
assist

with
communications

Computer

programs
of
any

type,

including

but
not
limited

to
those

to
assist

with
vision

therapy
or
speech

therapy

Air
purifiers,

air
conditioners,

heating
pads,
cold
therapy

units,
whirlpool

bathing

equipment,
sun
and
heat
lamps,

exercise

devices
(even
if
ordered

by
a
doctor),

and
other

equipment
that
does

not
meet

the
definition

of
durable

medical
equipment

(page
86)

Lifts,

such
as
seat,

chair

or
van

lifts

Wigs

All
charges

Home
health
services

25
in-home

visits
per
calendar

year,
not
to
exceed

one
visit

up
to
two

hours

per
day
when:

A
registered

nurse
(R.
N.),

licensed

practical
nurse
(L.
P.
N.)

provides

the
services;

The

attending

physician
orders
the
care;

The

physician

identifies
the
specific

professional

skills
required

by
the
patient

and
the

medical
necessity

for
skilled

services;

and

The

physician

indicates
the
length

of
time

the
services

are
needed.

Note:
Covered

services
are
based

on
our

review

for
medical

necessity.

PPO:
15%
of
the

Plan

allowance

Non-PPO:
35%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

PPO:
10%
of
the

Plan

allowance

Non-PPO:
25%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

Home
Health

services

-
continue

on
next

page 34.
34 Page 35 36
2003
GEHA

32
Section
5( a)

You
Pay

Home
health
services

-( continued)

Standard
Option

High
Option

Not
covered: Nursing care

requested
by,
or
for

the
convenience

of,
the
patient

or
the
patient's

family; Services
primarily

for
hygiene,

feeding,
exercising,

moving
the
patient,

homemaking,

companionship
or
giving

oral
medication;

Home

care
primarily

for
personal

assistance

that
does

not
include

a
medical

component
and
is
not

diagnostic,

therapeutic,

or
rehabilitative;

Custodial

Care;

Services

or
supplies

furnished

by
immediate

relatives
or
household

members,
such
as

spouse,
parents,
children,
brothers
or
sisters

by
blood,

marriage

or
adoption;

Inpatient

private
duty
nursing.

All
charges

Chiropractic Chiropractic services
limited
to:

30
visits

per
calendar

year
for
manipulation

of
the

spine

X-rays,

used
to
detect

and
determine

nerve
interferences

due
to
spinal

subluxations

misalignments Note: No other benefits
for
the
services

of
a
chiropractor

are
covered

under
any
other

provision
of
this

Plan.

In
medically

underserved

areas,
services

of
a
chiropractor

that
are

listed
above

are
subject

to
the

stated

limitations.

In
medically

underserved

areas,
services

of
a
chiropractor

that
are
within

the
scope

of
his/

her
license

and
are
not
listed

above

are

eligible
for
regular

Plan
benefits.

PPO
and
Non-PPO:

All
charges

in
excess

of
$9

per

visit All charges
in
excess

of
$25

for
X-rays

of
the

spine

Note:
Visits
and
charges

exceeding
these
amounts

are

not
applied

toward
the

calendar
year
deductible.

PPO
and
Non-PPO:

All
charges

in
excess

of
$9

per
visit All charges

in
excess

of
$25

for
X-rays

of
the

spine

Note:
Visits
and
charges

exceeding
these
amounts

are

not
applied

toward
the

calendar
year
deductible.

Not
covered: Any treatment

not
specifically

listed
as
covered;

Adjunctive

procedures

such
as
ultrasound,

electrical
muscle
stimulation,

vibratory

therapy,
and
cold

pack
application.

All
Charges

All
Charges 35.
35 Page 36 37
2003
GEHA

33
Section
5( a)

You
Pay

Alternative
treatments

Standard
Option

High
Option

Acupuncture Benefits are limited
to
20
procedures

per
calendar

year
for
medically

necessary

acupuncture
treatments
if
performed

by
a
Medical

Doctor
(M.
D.)

or
Doctor

Osteopathy
(D.
O.).

PPO:
15%
of
the

Plan

allowance

Non-PPO:
35%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

PPO:
10%
of
the

Plan

allowance

Non-PPO:
25%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

Not
covered: All other alternative

treatments,
including
clinical
ecology
and
environmental

medicine Any treatment
not
specifically

listed
as
covered

Naturopathic

services

(Note:
benefits

of
certain

alternative

treatment
providers
may
be
covered

in
medically

underserved
areas;
see
page

10.)

All
charges

Educational
classes
and
programs

Coverage
is
limited

to:

Smoking

Cessation

to
$100

to
aid

in
smoking

cessation-per

person
per
lifetime,

including
related
expenses

such
as
drugs.

PPO:
all
charges

in
excess

of
$100

Non-PPO:
all
charges

in
excess

$100

PPO:
all
charges

in
excess

$100 Non-
PPO:

all
charges

in
excess

of
$100 36.
36 Page 37 38
2003
GEHA

34
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
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.

The

calendar

year
deductible

is
$350

per
person

($
700

per
family)

under
the
High

Option

and
$450

per
person

($
900

per
family)

under
the
Standard

Option.
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.

The

non-PPO

benefits
are
the
standard

benefits
of
this

Plan.

PPO
benefits

apply
only
when

you
use
a
PPO

provider.

When
no
PPO

provider
is
available,

non-PPO
benefits
apply.

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
with

Medicare. The amounts
listed
below

are
for
the
charges

billed
by
a
physician

or
other

health

care
professional

for
your

surgical

care.
Look
in

Section
5
(c)

for
charges

associated

with
the
facility

(i.
e.
hospital,

surgical
center,
etc.).

YOU

MUST

GET
PRECERTIFICATION

OF
SOME

SURGICAL

PROCEDURES.

Please
refer
to
the
precertification

information
shown
in
Section

3
to

sure

which

services

require
precertification.

When

you
use
a
PPO

hospital

the
professionals

who
provide

services

to
you

in
a
hospital

may
not
all
be
preferred

providers.

If
they

are
not,

they

will
be
paid

by
this

plan

as
non-PPO

providers.
However,
if
the

services

are
rendered

at
a
PPO

hospital,

we
will

pay
the

services
of
radiologists,

anesthesiologists

and
pathologists

who
are
not
preferred

providers

at
the

preferred

provider
rate.
This
non-

standard
benefit
does
not
include

the
services

of
emergency

room
physicians.

I M P O R T A N T 37.
37 Page 38 39
2003
GEHA

35
Section
5( b)

Benefit
Description

You
pay

After
the
calendar

year
deductible

NOTE:
The
calendar

year
deductible

applies
to
almost

all
benefits

in
this

Section.

We
say
"(
No

deductible)"

when
it
does

not
apply.

Surgical
procedures

Standard
Option

High
Option

A
comprehensive

range
of
services,

such
as:

Operative

procedures

Treatment

of
fractures,

including
casting

Normal

pre-
and
post-operative

care
by
the
surgeon

Correction

of
amblyopia

and
strabismus

Endoscopy

procedures

Biopsy

procedures

Electroconvulsive

therapy

Removal

of
tumors

and
cysts

Correction

of
congenital

anomalies
-
limited

to
children

under
the
age

of
18
unless

there
is

a
functional

deficit.
(See
Reconstructive

surgery)

Surgical

treatment

of
morbid

obesity

eligible

members

must
be
age

18
or
over.

Criteria

regarding
complications

of
obesity

and
body

mass
index

must
be
met.

Treatment

must
be

precertified. Insertion of
internal
prostethic

devices.
See
Section

5
(a)

Orthopedic

and
prosthetic

devices
for
device

coverage

information

Voluntary

sterilization

(e.
g.,
Tubal

ligation,

Vasectomy)

Surgically

implanted
contraceptives

and
intrauterine

devices
(IUDs)

Treatment

of
burns

Assistant

surgeons
are
covered

up
to
20%

of
our

allowance

for
the
surgeon's

charge
for

procedures
when
it
is
medically

necessary
to
have

an
assistant

surgeon.

Note:
Post
operative

care
is
considered

to
be
included

in
the

fee
charged

for
a
surgical

procedure
by
a
doctor.

Any
additional

fees
charged

by
a
doctor

are
not
covered

unless
such

charge
is
for

an
unrelated

condition.

PPO:
15%
of
the

Plan

allowance

Non-PPO:
35%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

PPO:
10%
of
the

Plan

allowance

Non-PPO:
25%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

Surgical
procedures

continued

on
next

page 38.
38 Page 39 40
2003
GEHA

36
Section
5( b)

You
Pay

Surgical
procedures

(continued)

Standard
Option

High
Option

When
multiple

or
bilateral

surgical
procedures

performed
during
the
same

operative

session
add
time

or
complexity

to
patient

care,
our
benefits

are:

For

the
primary

procedure

based
on:

Full
Plan
allowance

For

the
secondary

procedure(
s)
based

on:

One-half

of
the

Plan

allowance

For

the
subsequent

procedure(
s)
based

on:

25%

of
the

Plan

allowance

Note:
Multiple

or
bilateral

surgical
procedures

performed
through
the
same

incision

are

"incidental"
to
the

primary

surgery.

That
is,
the
procedure

would
not
add
time

complexity
to
patient

care.
We
do
not

pay
extra

for
incidental

procedures.

PPO:
15%
of
the

Plan

allowance

Non-PPO:
35%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

PPO:
10%
of
the

Plan

allowance

Non-PPO:
25%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

Not
covered: Reversal of

voluntary
sterilization

Services

of
a
standby

physician

or
surgeon

Routine

treatment

of
conditions

of
the

foot;

see
Foot

care

All
charges

All
charges 39.
39 Page 40 41
2003
GEHA

37
Section
5( b)

You
Pay

Reconstructive
surgery

Standard
Option

High
Option

Surgery

to
correct

a
functional

defect

Surgery

to
correct

a
condition

caused
by
injury

or
illness

if:

the
condition

produced
a
major

effect
on
the
member's

appearance

and

the
condition

can
reasonably

be
expected

to
be
corrected

by
such

surgery

Surgery

to
correct

a
condition

that
existed

at
or
from

birth
and
is
a
significant

deviation

from
the
common

form
or
norm

limited

to
children

under
the
age

of
18
unless

there
is
a

functional
deficit.
Examples

of
congenital

anomalies
are:
cleft

lip;
cleft

palate;

birth

marks;
and
webbed

fingers
and
toes.

All
stages

of
breast

reconstruction

surgery
following

a
mastectomy,

such
as:

Surgery

to
produce

a
symmetrical

appearance
on
the

other

breast

Treatment

of
any

physical

complications,

such
as
lymphedemas

Breast

prostheses;

and
surgical

bras
and
replacements

(see
Prosthetic

devices
for

coverage) Note: We pay for
internal
breast
prostheses

as
hospital

benefits
if
billed

by
a
hospital.

included
with
the
surgeon's

bill,
surgery

benefits

will
apply.

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.

PPO:
15%
of
the

Plan

allowance

Non-PPO:
35%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

PPO:
10%
of
the

Plan

allowance

Non-PPO:
25%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

Not
covered: Cosmetic

surgery

any

surgical

procedure

(or
any
portion

of
a
procedure)

performed

primarily
to
improve

physical
appearance

through
change
in
bodily

form,
except

repair
of
accidental

injury
if
repair

is
initiated

promptly

or
as
soon

as
the
member's

medical
condition

permits.

Surgeries

related
to
sex
transformation

or
sexual

dysfunction

Surgeries

to
correct

congenital

anomalies
for
individuals

age
18
and

older

unless

there
is
a
functional

deficit.

All
charges

All
charges 40.
40 Page 41 42
2003
GEHA

38
Section
5( b)

You
Pay

Oral
and
maxillofacial

surgery

Standard
Option

High
Option

Oral
surgical

procedures,

limited
to:

Reduction

of
fractures

of
the

jaws

or
facial

bones;

Surgical

correction

of
cleft

lip,
cleft

palate;

Excision

of
cysts

and
incision

of
abscesses

unrelated
to
tooth

structure;

Extraction

of
impacted

(unerupted

or
partially

erupted)
teeth;

Alveoloplasty,

partial
or
radical

removal

of
the

lower

jaw
with

bone
graft;

Excision

of
tori,

tumors,

leukoplakia,

premalignant

and
malignant

lesions,
and
biopsy

hard
and
soft
oral
tissues;

Open

reduction

of
dislocations

and
excision,

manipulation,

aspiration
or
injection

temporo-
mandibular

joints;

Removal

of
foreign

body,
skin,
subcutaneous

areolar
tissue,
reaction-producing

foreign

bodies
in
the
musculoskeletal

system
and
salivary

stones
and
incision/ excision

of
salivary

glands
and
ducts;

Repair

of
traumatic

wounds;

Incision

of
the

sinus

and
repair

of
oral

fistulas;

Surgical

treatment

of
trigeminal

neuralgia;

Repair

of
accidental

injury
to
sound

natural

teeth
such
as:
expenses

for
X-rays,

drugs,

crowns,
bridgework,

inlays
and
dentures.

Masticating

(biting
or
chewing)

incidents
are
not

considered
to
be
accidental

injuries.
Accidental

dental
injury
is
covered

at
100%

for

charges
incurred

within
72
hours

of
an
accident

(see
page

50).

Orthognathic

surgery
but
only

for
treatment

of
severe

sleep
apnea

and
only

after

conservative
treatment
of
sleep

apnea

has
failed.

Orthognathic

surgery
for
any

other

condition
is
not

covered.

Other

oral
surgery

procedures

that
do
not
involve

the
teeth

or
their

supporting

structures.

PPO:
15%
of
the

Plan

allowance

Non-PPO:
35%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

PPO:
10%
of
the

Plan

allowance

Non-PPO:
25%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and

the
billed

amount

Not
covered: Oral implants

and
transplants

Procedures

that
involve

the
teeth

or
their

supporting

structures
(such
as
the
periodontal

membrane,
gingiva,
and
alveolar

bone)

Orthodontic

treatment

Any

oral

or
maxillofacial

surgery
not
specifically

listed
as
covered

Orthognathic

surgery
(except
as
outlined

above
for
severe

sleep
apnea),

even
if

necessary
because
of
TMJ

dysfunction

or
disorder.

All
charges

All
charges 41.
41 Page 42 43
2003
GEHA

39
Section
5( b)

You
Pay

Organ/
tissue
transplants

Standard
Option

High
Option

Limited
to:

Cornea Heart Heart/ lung Kidney Kidney/

Pancreas

Liver Lung:

Single

or
double

lung
transplants,

limited
to
patients

for
the
following

end-stage

pulmonary
diseases:
(1)
Pulmonary

fibrosis,
(2)
Primary

pulmonary

hypertension,

(3)
Emphysema,

or
(4)

cystic

fibrosis

Pancreas

(limited
to
patients

whose
condition

is
not

treatable

by
insulin

therapy)

Allogeneic

bone
marrow

transplants

only

for
patients

with
acute
leukemia,

advanced

Hodgkin's
lymphoma,
Advanced
non-Hodgkin's

lymphoma,
Advanced
neuroblastoma

(limited
to
children

over
age
one),

Aplastic

anemia,
Chronic
myelogenous

leukemia,

Infantile
malignant

osteopetrosis,

Severe
combined

immunodeficiency,

Thalassemia

major,
or
Wiskott-

Aldrich
syndrome

Intestinal

transplants

(small
intestine),

small
intestine

with
the
liver,

small
intestine

with

multiple
organs
such
as
the

liver,

stomach,

and
pancreas

Autologous

bone
marrow

transplants

(autologous

stem
cell
support)

and
autologous

peripheral
stem
cell
support

-
limited

to
patients

with
Acute

lymphocytic,

or
non-

lymphocytic
leukemia,
Advanced
Hodgkin's
lymphoma,
Advanced
non-Hodgkin's

lymphoma,
Advanced
neuroblastoma

(limited
to
children

over
age
one),

Breast

cancer

or
Testicular,

Mediastinal,

Retroperitoneal

and
Ovarian

germ
cell
tumors,

Multiple

myeloma
or
Epithelial

ovarian
cancer.

Note:
We
cover

related

medical

and
hospital

expenses

of
the

donor

when
we
cover

the

recipient.

PPO:
15%
of
the

Plan

allowance

Non-PPO:
35%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and

the
billed

amount

PPO:
10%
of
the

Plan

allowance

Non-PPO:
25%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and

the
billed

amount

Organ/ tissue
transplants

continued

on
next

page 42.
42 Page 43 44
2003
GEHA

40
Section
5( b)

You
Pay

Organ/
tissue
transplants( continued)

Standard
Option

High
Option

Note:
All
allowable

charges
incurred

for
a
surgical

transplant,

whether
incurred

by
the

recipient
or
donor

will
be
considered

expenses
of
the

recipient

and
will
be
covered

the

same
as
for

any

other

illness

or
injury

subject

to
the

limits

stated
below.

This
benefit

applies
only
if
the

recipient

is
covered

by
us
and

if
the

donor's

expenses

are
not
otherwise

covered. Transportation
Benefit

We

will
also
provide

up
to
$10,

000
per
covered

transplant

for
transportation

(mileage

or
airfare)

to
a
plan

designated

facility
and
reasonable

temporary
living
expenses

(i.
e.

lodging
and
meals)

for
the
recipient

and
one
other

individual

(or
in
the

case

of
a
minor,

two
other

individuals),

if
the

recipient

lives
more
than
100
miles

from
the
designated

transplant
facility.
Transportation

benefits
are
payable

for
follow-

up
care

up
to
one

year
following

the
transplant.

The
transportation

benefit
is
not

available

for
cornea

kidney
transplants.

You
must
contact

Customer

Service
for
what

are
considered

reasonable
temporary
living
expenses.

PPO:
15%
of
the

Plan

allowance

Non-PPO:
35%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

PPO:
10%
of
the

Plan

allowance

Non-PPO:
25%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and

the
billed

amount

Limited
Benefits

The

process

for
preauthorizing

organ
transplants

is
more

extensive

that
the
normal

precertification
process.
Before
your
initial

evaluation

as
a
potential

candidate

for
a

transplant
procedure,

you
or
your

doctor

must
contact

our
Medical

Director
so
we

can

arrange
to
review

the
clinical

results
of
the
evaluation

and
determine

if
the

proposed

procedure
meets
our
definition

of
"medically

necessary"
and
is
on

the

list
of
covered

transplants.
Coverage
for
the
transplant

must
be
authorized

in
advance,

in
writing

our
Medical

Director.

(Cornea
and
kidney

transplants

do
not
require

preauthorization

by
GEHA's

Medical
Director.)

Organ/ tissue
transplants
-
continued

on
next

page 43.
43 Page 44 45
2003
GEHA

41
Section
5( b)

You
Pay

Organ/ tissue
transplants(
continued)

Standard
Option

High
Option

will
pay
for
a
second

transplant

evaluation
recommended

by
a
physician

qualified

to
perform

the
transplant,

if:
the
transplant

diagnosis
is
covered

and
the
physician

not
associated

or
in
practice

with
the
physician

who
recommended

and
will
perform

the
organ

transplant.

A
third

transplant

evaluation

is
covered

only
if
the

second

evaluation
does
not
confirm

the
initial

evaluation.

The

transplant

must
be
performed

at
a
Plan-designated

organ
transplant

facility
to

receive
maximum

benefits.

If
benefits

are
limited

to
$100,000

per
transplant,

included
in
the

maximum

are
all

charges
for
hospital,

medical
and
surgical

care
incurred

while
the
patient

hospitalized
for
a
covered

transplant

surgery
and
subsequent

complications

related
to

the
transplant.

Outpatient
expenses
for
chemotherapy

and
any
process

of
obtaining

stem
cells
or
bone

marrow

associated

with
bone
marrow

transplant

(stem
cell
support)

are
included

in
benefits

limit
of
$100,000

per
transplant.

Tandem
bone
marrow

transplants
approved
as
one

treatment

protocol
are
limited

to
$100,000

when
not

performed
at
a
Plan

designated

facility.
Expenses

for
aftercare

such
as
outpatient

prescription
drugs
are
not
a
part

of
the

$100,000

limit.

PPO:
$10
copayment

for

office
visits
to
primary

care

physicians;
$25
copayment

for
office

visits
to
specialists

(no
deductible) Non-PPO: 35%

of
the

Plan

allowance
and
any
difference

between
our
allowance

and

the
billed

amount

If
prior

approval

is
not

obtained
or
a
Plan-designated

organ
transplant

facility
is
not

used,
the
benefits

will
be

limited
to
15%

for
PPO

hospital
expenses,

15%
for

PPO
physician

expenses
or

35%
of
our

allowance

for

non-PPO
hospital
and
surgery

expenses
up
to
a
maximum

$100,000
per
transplant.

we
cannot

refer
a
member

need
of
a
transplant

to
a

designated
facility,
the

$100,000
maximum

will
not

apply.

PPO:
$20
copayment

(no

deductible) Non-PPO: 25%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and

the
billed

amount

If
prior

approval

is
not

obtained
or
a
Plan-designated

organ
transplant

facility
is
not

used,
the
benefits

will
be

limited
to
10%

for
PPO

hospital
expenses,

10%
for

PPO
physician

expenses
or

25%
of
our

allowance

for

non-PPO
hospital
and
surgery

expenses
up
to
a
maximum

$100,000
per
transplant.

we
cannot

refer
a
member

need
of
a
transplant

to
a

designated
facility,
the

$100,000
maximum

will
not

apply.
Organ/ tissue
transplants
-
continued

on
next

page 44.
44 Page 45 46
2003
GEHA

42
Section
5( b)

You
Pay

Organ/ tissue
transplants(
continued)

Standard
Option

High
Option

Chemotherapy

and
procedures

related
to
bone

marrow

transplantation

must
be
performed

only
at
a
Plan-designated

organ
transplant

facility
to
receive

maximum

benefits.

Simultaneous

transplants
such
as
kidney/

pancreas,

heart/
lung,
heart/
liver
are
considered

one
transplant

procedure
and
are
limited

to
$100,

000
when

not
performed

at
a
Plan-

designated
organ
transplant

facility.

PPO:
15%
of
the

Plan

allowance

Non-PPO:
35%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

PPO:
10%
of
the

Plan

allowance

Non-PPO:
25%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

Not
covered: Services or

supplies
for
or
related

to
surgical

transplant

procedures
(including

administration
of
high-

dose
chemotherapy)

for
artificial

or
human

organ/
tissue

transplants
not
listed

as
specifically

covered.

Donor

screening

tests
and
donor

search
expenses,

except
those
performed

for
the
actual

donor. Donor
search
expense

for
bone

marrow

transplants.

All
charges

Anesthesia Professional fees
for
the
administration

of
anesthesia

Hospital

(inpatient)

Hospital

outpatient

department

Ambulatory

surgical
center

Office

PPO:
15%
of
the

Plan

allowance

Non-PPO:
35%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

PPO:
10%
of
the

Plan

allowance

Non-PPO:
25%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount 45.
45 Page 46 47
2003
GEHA

43
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
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.

In
this

Section,

unlike
Sections

5
(a)

and

5
(b),

the
calendar

year
deductible

applies
to
only

a
few

benefits.

In
that

case,

we
added

"(
calendar

year
deductible

applies)".
The
calendar

year
deductible

is
$350

per
person

($ 700
per
family)

under
the
High

Option

and

$450
per
person

($
900

per
family)

under
the
Standard

Option.

A
High

Option

per
admission

deductible
applies
of
$100

(PPO)

and
$300

(non-PPO)

for
inpatient

hospital
services
up
to
a
maximum

of
two

per
person,

per
calendar

year.

The

non-PPO

benefits
are
the
standard

benefits
of
this

Plan.

PPO
benefits

apply
only
when

you
use
a
PPO

provider.

When
no
PPO

provider
is
available,

non-PPO
benefits
apply.

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
with
Medicare.

The

amounts

listed
below

are
for
the
charges

billed
by
the
facility

(i.
e.
hospital

or
surgical

center)
or
ambulance

service
for
your

surgery
or
care.

Any
costs
associated

with
the
professional

charge
(i.
e.
physicians,

etc.)
are
in
Sections

5
(a)

or
(b).

When

you
use
a
PPO

hospital

the
professionals

who
provide

services

to
you

in
a
hospital

may
not
all
be
preferred

providers.

If
they

are

not,
they

will
be
paid

by
this

plan

as
non-PPO

providers.
However,
if
the

services

are
rendered

at
a
PPO

hospital,

we
will

pay
the

services
of
radiologists,

anesthesiologists

and
pathologists

who
are
not
preferred

providers

at
the

preferred

provider
rate.
This
non-

standard
benefit
does
not
include

the
services

of
emergency

room
physicians.

YOU

MUST

GET
PRECERTIFICATION

OF
HOSPITAL

STAYS;
FAILURE

TO
DO
SO
WILL

RESULT

IN
A

MINIMUM
$500
PENALTY.

Please
refer
to
the
precertification

information
shown
in
Section

3
to

sure

which

services

require

precertification.

I M P O R T A N T 46.
46 Page 47 48
2003
GEHA

44
Section
5( c)

Benefit
Description

You
pay

NOTE:
The
calendar

year
deductible

applies
ONLY
when
we
say
below:

"(
calendar

year
deductible

applies)".

Inpatient
Hospital

Standard
Option

High
Option

Room
and
board,

such
as:

Ward,

semiprivate,

or
intensive

care
accommodations;

General

nursing
care;
and

Meals

and
special

diets.

NOTE:
We
only

cover

a
private

room
if
we

determine

it
to

be
medically

necessary.

Otherwise,
we
will

pay
the
hospital's

average
charge
for
semiprivate

accommodations.

The
remaining

balance
is
not

a
covered

expense.

If
the

hospital

only
has
private

rooms,

we
will

cover

the
private

room
rate.

NOTE:
When
the
hospital

bills
a
flat

rate,

we
prorate

the
charges

to
determine

how
to
pay

them,
as
follows:

30%
room

and
board

and
70%

other
charges.

PPO:
15%
of
the

Plan

allowance

(calendar
year
deductible

applies)

Non-PPO:
35%
of
the

Plan

allowance
(calendar
year

deductible
applies)

PPO:
Nothing Non-PPO: Nothing

Other
hospital

services
and
supplies,

such
as:

Operating,

recovery
and
other

treatment

rooms

Prescribed

drugs
and
medicines

Diagnostic

laboratory
tests
and
X-rays

Blood

or
blood

plasma,

if
not

donated

or
replaced

Dressings,

splints,
casts,
and
sterile

tray
services

Medical

supplies
and
equipment,

including
oxygen

Anesthetics,

including
nurse
anesthetist

services

Take-home

items

Medical

supplies,
appliances,

medical
equipment,

and
any
covered

items
billed

by
a

hospital
for
use

at
home

(Note:

calendar

year
deductible

applies.)

NOTE:
We
base

payment

on
whether

the
facility

or
a
health

care
professional

bills
for

the
services

or
supplies.

For
example,

when
the
hospital

bills
for
its
nurse

anesthetists'

services,
we
pay
Hospital

benefits
and
when

the
anesthesiologist

bills,
we
pay
Surgery

benefits.

PPO:
15%
of
the

Plan

allowance

(calendar
year
deductible

applies)

Non-PPO:
35%
of
the

Plan

allowance
(calendar
year

deductible
applies)

PPO:
10%
of
the

Plan

allowanc e

($
100

per
admission

deductible

up
to
a
maximum

of
2
per

person
per
calendar

year

applies) Non-PPO:
25%
of
the

Plan

allowance
($
300

per
admission

deductible
up
to
a
maximum

2
per

person

per
calendar

year

applies)
Inpatient
hospital

continued

on
next

page 47.
47 Page 48 49
2003
GEHA

45
Section
5( c)

Inpatient
hospital
(continued)

You
Pay

Standard
Option

High
Option

Maternity
Care

Inpatient

Hospital

Room
and
board,

such
as:

Ward,

semiprivate,

or
intensive

care
accommodations

General

nursing
care;
and

Meals

and
special

diets

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
must

precertify.

Other
hospital

services
and
supplies,

such
as:

Delivery

room,
recovery,

and
other

treatment

rooms

Prescribed

drugs
and
medicines

Diagnostic

laboratory
tests
and
X-rays

Blood

or
blood

plasma,

if
not

donated

or
replaced

Dressings

and
sterile

tray
services

Medical

supplies
and
equipment,

including
oxygen

Anesthetics,

including
nurse
anesthetist

services

Take-home

items

Medical

supplies,
appliances,

medical
equipment,

and
any
covered

items
billed

by
a

hospital
for
use

at
home

(Note:

calendar

year
deductible

applies.)

cover

routine

nursery

care
of
the

newborn

child
during

the
covered

portion
of
the

mother's
maternity

stay.

PPO:
Nothing Non-PPO: 35%

of
the

Plan

allowance
(calendar
year

deductible
applies)

PPO:
Nothing Non-PPO: Nothing

for
room

and

board;
25%
of
the

Plan

allowance
for
other

hospital

services($
300
per
admission

deductible
up
to
a
maximum

2
per

person

per
calendar

year

applies)
Inpatient
hospital

continued

on
next

page 48.
48 Page 49 50
2003
GEHA

46
Section
5( c)

You
Pay

Inpatient
hospital
(continued)

Standard
Option

High
Option

Maternity
Care

Inpatient

Hospital
-
continued

will
cover

other
care
of
an
infant

who
requires

non-routine

treatment
if
we

cover

the

infant
under
a
Self

and
Family

enrollment.

PPO:
15%
of
the

Plan

allowance

(calendar
year
deductible

applies) Non-PPO:
35%
of
the

Plan

allowance
(calendar
year

deductible
applies)

PPO:
Nothing

for
room

and

board;
10%
of
the

plan

allowance
for
other

hospital

services
($
100

per
admission

deductible
up
to
a
maximum

2
per

person

per
calendar

year

applies) Non-PPO:
Nothing
for
room

and
board;

25%
of
the

Plan

allowance
for
other

hospital

services
($
300

per
admission

deductible
up
to
a
maximum

2
per

person

per
calendar

year

applies)

Not
covered: Any part of

a
hospital

admission

that
is
not

medically

necessary
(see
definition),

such

as
when

you
do
not

need

acute
hospital

inpatient
(overnight)

care,
but
could

receive

care
in
some

other
setting

without
adversely

affecting
your
condition

or
the

quality

your
medical

care.
Note:
In
this

event,

we
pay

benefits

for
services

and
supplies

other

than
room

and
board

and
in-
hospital

physician

care
at
the

level

they
would

have
been

covered
if
provided

in
an
alternative

setting

Custodial

care;
see
definition

Non-

covered

facilities,

such
as
nursing

homes,
schools

Personal

comfort
items,
such
as
telephone,

television,
barber
services,

guest
meals

and

beds Private
nursing
care

All
charges

All
charges 49.
49 Page 50 51
2003
GEHA

47
Section
5( c)

You
Pay

Outpatient
hospital
or
ambulatory

surgical
center

Standard
Option

High
Option

Operating,

recovery,
and
other

treatment

rooms

Prescribed

drugs
and
medicines

Diagnostic

laboratory
tests,
X-rays,

and
pathology

services

Administration

of
blood,

blood
plasma,

and
other

biologicals

Blood

and
blood

plasma,

if
not

donated

or
replaced

Pre-surgical

testing

Dressings,

casts,
and
sterile

tray
services

Medical

supplies,
including
oxygen

Anesthetics

and
anesthesia

service

Cardiac

rehabilitation NOTE: We cover hospital

services
and
supplies

related
to
dental

procedures

when

necessitated
by
a
non-dental

physical
impairment.

We
do
not

cover

the
dental

procedures.

PPO:
15%
of
the

Plan

allowance

(calendar
year
deductible

applies)

Non-PPO:
35%
of
the

Plan

allowance
(calendar
year

deductible
applies)

PPO:
10%
of
the

Plan

allowance

(calendar
year
deductible

applies)

Non-PPO:
25%
of
the

Plan

allowance
(calendar
year

deductible
applies)

Not
covered: Urgent care

facilities
except
for
services

of
covered

physicians,

xray
and
laboratory

services. Maintenance
cardiac
rehabilitation

All
charges

Maternity
Care

Outpatient

hospital

Delivery

room,
recovery,

and
other

treatment

rooms

Prescribed

drugs
and
medicines

Diagnostic

laboratory
tests
and
X-rays,

and
pathology

services

Administration

of
blood,

blood
plasma,

and
other

biologicals

Blood

and
blood

plasma,

if
not

donated

or
replaced

Pre-surgical

testing

Dressings

and
sterile

tray
services

Medical

supplies,
including
oxygen

Anesthetics

and
anesthesia

services

PPO:
Nothing Non-PPO: 35%

of
the

Plan

allowance
(calendar
year

deductible
applies)

PPO:
Nothing Non-PPO: 25%

of
the

Plan

allowance
(calendar
year

deductible
applies) 50.
50 Page 51 52
2003
GEHA

48
Section
5( c)

You
Pay

Extended
care
benefits/

Skilled
nursing

care
facility

benefits

Standard
Option

High
Option

No
benefits

All
charges

Hospice
care
Hospice
is
a
coordinated

program
of
maintenance

and
supportive

care
for
the
terminally

ill
provided

by
a
medically

supervised

team
under

the
direction

of
a
Plan-approved

independent
hospice
administration.

pay
$2000

for
hospice

care
on
an
outpatient

basis.

pay
$150

per
day

for
room

and
board

and
care

while

an
inpatient

in
a
hospice

up
to

a
maximum

of
$3,000.

These
benefits

will
be
paid

if
the

hospice

care
program

begins
after
a
person's

primary

doctor
certifies

terminal
illness
and
life
expectancy

of
six

months

or
less

and
any
services

or
inpatient

hospice
stay
that
is
part

of
the

program

is:

Provided

while
the
person

is
covered

by
this

Plan;

Ordered

by
the
supervising

doctor;

Charged

by
the
hospice

care
program;

and

Provided

within
six
months

from
the
date

the
person

entered

or
re-entered

(after
a

period
of
remission)

a
hospice

care
program.

Remission
is
the

halt

or
actual

reduction

in
the
progression

of
illness

resulting

discharge
from
a
hospice

care
program

with
no
further

expenses

incurred.

A
readmission

within
three
months

of
a
prior

discharge

is
considered

as
the

same

period

of
care.

A
new

period
begins
after
three
months

from
a
prior

discharge

with
maximum

benefits
available.

PPO:
Nothing

up
to
the

Plan

limits
(calendar

year

deductible
applies)
Non-PPO:
Nothing
up
to
the

Plan
limits

(calendar

year

deductible
applies)

PPO:
Nothing

up
to
the

Plan

limits
(calendar

year

deductible
applies)
Non-PPO:
Nothing
up
to
the

Plan
limits

(calendar

year

deductible
applies)

Not
covered: Charges incurred

during
a
period

of
remission,

charges
incurred

for
treatment

of
a

sickness
or
injury

of
a
family

member

that
are
covered

under
another

Plan
provision,

charges
incurred

for
services

rendered

by
a
close

relative,

bereavement

counseling,

funeral
arrangements,

pastoral
counseling,

financial
or
legal

counseling,

homemaker

or
caretaker

services.

All
charges

All
charges 51.
51 Page 52 53
2003
GEHA

49
Section
5( c)

You
Pay

Ambulance

accidental

injury

Standard
Option

High
Option

Ambulance
service
within
72
hours

of
an
accident

is
covered

as
follows:

Local

ambulance

service
(within
100
miles)

to
the

first

hospital

where
treated,

from

that
hospital

to
the

next

nearest

one
if
necessary

treatment
is
unavailable

or
unsuitable

at
the

first

hospital,

then
to
either

the
home

(if
ambulance

transport
is
medically

necessary)
or
other

medical

facility
(if
required

for
the
patient

to
receive

necessary

treatment
and
if
ambulance

transport
is
medically

necessary).

Air
ambulance

to
nearest

facility
where
necessary

treatment
is
available

is
covered

if
no

emergency
ground
transportation

is
available

or
suitable

and
the
patient's

condition

warrants
immediate

evacuation.

Air
ambulance

will
not
be
covered

if
transport

is
beyond

the
nearest

available

suitable
facility,
but
is
requested

by
patient

or
physician

for

continuity
of
care

or
other

reasons.

PPO:
Nothing

up
to
the

Plan

allowance Non-PPO:
Nothing
up
to
the

Plan
allowance

PPO:
Nothing

up
to
the

Plan

allowance Non-PPO:
Nothing
up
to
the

Plan
allowance

Ambulance

non-accidental

injury

Local

ambulance

service
(within
100
miles)

to
the

first

hospital

where
treated,

from

that
hospital

to
the

next

nearest

one
if
necessary

treatment
is
unavailable

or
unsuitable

at
the

first

hospital,

then
to
either

the
home

(if
ambulance

transport
is
medically

necessary)
or
other

medical

facility
(if
required

for
the
patient

to
receive

necessary

treatment
and
if
ambulance

transport
is
medically

necessary).

Air
ambulance

to
nearest

facility
where
necessary

treatment
is
available

is
covered

if
no

emergency
ground
transportation

is
available

or
suitable

and
the
patient's

condition

warrants
immediate

evacuation.

Air
ambulance

will
not
be
covered

if
transport

is
beyond

the
nearest

available

suitable
facility,
but
is
requested

by
patient

or
physician

for

continuity
of
care

or
other

reasons.

PPO:
15%
of
the

Plan

allowance

(calendar
year
deductible

applies) Non-PPO:
35%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

(calendar

year

deductible
applies)

PPO:
10%
of
the

Plan

allowance

(calendar
year
deductible

applies) Non-PPO:
25%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

(calendar

year

deductible
applies)

Not
covered: Transportation

by
ambulance

is
not

covered

when
the
patient

does
not
require

the

assistance
of
medically

trained
personnel

and
can
be
safely

transferred

(or
transported)

by
other

means.

All
charges

All
charges 52.
52 Page 53 54
2003
GEHA

50
Section
5( d)

Section
5
(d).

Emergency

services/
accidents

I M P O R T A N T
Here
are
some

important

things
to
keep

in
mind

about

these
benefits:

Please

remember

that
all
benefits

are
subject

to
the
definitions,

limitations,
and
exclusions

in
this

brochure

and
are
payable

only

when
we
determine

they
are
medically

necessary.

The

calendar

year
deductible

is
$350

per
person

($
700

per
family)

under
the
High

Option

and
$450

per
person

($
900

per
family)

under
the
Standard

Option.
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.

The

non-PPO

benefits
are
the
standard

benefits
of
this

Plan.

PPO
benefits

apply
only
when

you
use
a
PPO

provider.

When
no

PPO
provider

is
available,

non-PPO
benefits
apply.

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
with

Medicare. When you
use
a
PPO

hospital

the
professionals

who
provide

services

to
you

in
a
hospital

may
not
all
be
preferred

providers.

they
are
not,

they

will
be
paid

by
this

plan

as
non-PPO

providers.
However,
if
the

services

are
rendered

at
a
PPO

hospital,

we
will

pay
the
services

of
radiologists,

anesthesiologists

and
pathologists

who
are
not
preferred

providers

at
the

preferred

provider
rate.

This
non-standard

benefit
does
not
include

the
services

of
emergency

room
physicians.

I M P O R T A N T

What
is
an
accidental

injury?

An
accidental

injury
is
a
bodily

injury
sustained

solely
through

violent,
external,

and
accidental

means,
such
as
broken

bones,
animal
bites,
and
poisonings.

Benefit
Description

You
pay

After
the
calendar

year
deductible

NOTE:
The
calendar

year
deductible

applies
to
almost

all
benefits

in
this

Section.

We
say
"(
No

deductible)"

when
it
does

not
apply.

Accidental
injury

Standard
Option

High
Option

If
you

receive

care
for
your

accidental

injury
within

72
hours,

we
cover:

Treatment

outside
a
hospital

or
in
the

outpatient/

emergency

room
department

of
a
hospital

Related

outpatient

physician
care

Note:
Emergency

room
charges

associated

directly
with
an
inpatient

admission

are
considered

"Other
charges"

under
Inpatient

Hospital
Benefits
(see
page

44)
and
are
not
part

of
this

benefit,
even
though

an
accidental

injury
may
be
involved.

Expenses
incurred
after
72
hours,

even
if
related

to
the

accident,

are
subject

to
regular

benefits

and
are
not
paid

at
100%.

This

provision
also
applies

to
dental

care
required

as
a
result

of
accidental

injury
to
sound

natural

teeth.
Masticating

(chewing)
incidents
are
not
considered

to
be
accidental

injuries.

PPO:
Nothing

(No
deductible)

Non-PPO:
Only
the
difference

between
our
allowance

and
the

billed
amount

(No
deductible)

PPO:
Nothing

(No
deductible)

Non-PPO:
Only
the
difference

between
our
allowance

and
the

billed
amount

(No
deductible)

Accidental
injury

continued

on
next

page 53.
53 Page 54 55
2003
GEHA

51
Section
5( d)

You
Pay

Accidental
injury
(continued)

Standard
Option

High
Option

If
you

receive

care
for
your

accidental

injury
after
72
hours,

we
cover:

Non-

surgical

physician

services
and
supplies

Surgical

care

Note:
We
pay
Hospital

benefits
if
you

are
admitted.

PPO:
15%
of
the

Plan

allowance

Non-PPO:
35%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

PPO:
10%
of
the

Plan

allowance

Non-PPO:
25%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

Medical
emergency Outpatient medical or surgical

services
and
supplies

billed
by
a
hospital

for
emergency

room
treatment. Note: We pay Hospital

benefits
if
you

are
admitted.

PPO:
15%
of
the

Plan

allowance

Non-PPO:
35%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

PPO:
10%
of
the

Plan

allowance

Non-PPO:
25%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

Ambulance

accidental

injury

Ambulance
service
within
72
hours

of
an
accident

is
covered

as
follows:

Local

ambulance

service
(within
100
miles)

to
the

first

hospital

where
treated,

from

that
hospital

to
the

next

nearest

one
if
necessary

treatment
is
unavailable

or
unsuitable

at
the

first

hospital,

then
to
either

the
home

(if
ambulance

transport
is
medically

necessary)
or
other

medical

facility
(if
required

for
the
patient

to
receive

necessary

treatment
and
if
ambulance

transport
is
medically

necessary).

Air

ambulance

to
nearest

facility
where
necessary

treatment
is
available

is
covered

if
no

emergency
ground
transportation

is
available

or
suitable

and
the
patient's

condition

warrants
immediate

evacuation.

Air
ambulance

will
not
be
covered

if
transport

is
beyond

the
nearest

available

suitable
facility,
but
is
requested

by
patient

or
physician

for

continuity
of
care

or
other

reasons.

PPO:
Nothing

up
to
the

Plan

allowance
(no
deductible)

Non-PPO:
Nothing
up
to
the

Plan
allowance

(no
deductible)

PPO:
Nothing

up
to
the

Plan

allowance
(no
deductible)

Non-PPO:
Nothing
up
to
the

Plan
allowance

(no
deductible)

Ambulance

continued

on
next

page 54.
54 Page 55 56
2003
GEHA

52
Section
5( d)

You
Pay

Ambulance

non-accidental

injury

Standard
Option

High
Option

Local

ambulance

service
(within
100
miles)

to
the

first

hospital

where
treated,

from

that
hospital

to
the

next

nearest

one
if
necessary

treatment
is
unavailable

or
unsuitable

at
the

first

hospital,

then
to
either

the
home

(if
ambulance

transport
is
medically

necessary)
or
other

medical

facility
(if
required

for
the
patient

to
receive

necessary

treatment
and
if
ambulance

transport
is
medically

necessary).

Air
ambulance

to
nearest

facility
where
necessary

treatment
is
available

is
covered

if
no

emergency
ground
transportation

is
available

or
suitable

and
the
patient's

condition

warrants
immediate

evacuation.

Air
ambulance

will
not
be
covered

if
transport

is
beyond

the
nearest

available

suitable
facility,
but
is
requested

by
patient

or
physician

for

continuity
of
care

or
other

reasons.

PPO:
15%
of
the

Plan

allowance

(calendar
year
deductible

applies) Non-PPO:
35%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

(calendar

year

deductible
applies)

PPO:
10%
of
the

Plan

allowance

(calendar
year
deductible

applies) Non-PPO:
25%
of
the

Plan

allowance
and
any
difference

between
our
allowance

and
the

billed
amount

(calendar

year

deductible
applies)

Not
covered: Transportation

by
ambulance

is
not

covered

when
the
patient

does
not
require

the

assistance
of
medically

trained
personnel

and
can
be
safely

transferred

(or
transported)

by
other

means.

All
charges

All
charges 55.
55 Page 56 57
2003
GEHA

53
Section
5( e)

Section
5
(e).

Mental

health
and
substance

abuse
benefits

I M P O R T A N T
You
may
choose

to
get

care

In-Network

or
Out-of-

Network.

When
you
receive

In-Network

care,
you
must

get
our
approval

for
services

and

follow
a
treatment

plan
we
approve.

If
you

do,
cost-sharing

and
limitations

for
In-Network

mental
health
and
substance

abuse
benefits

will
be

no
greater

than
for
similar

benefits

for
other

illnesses

and
conditions.

Here
are
some

important

things
to
keep

in
mind

about

these
benefits:

Please

remember

that
all
benefits

are
subject

to
the
definitions,

limitations,
and
exclusions

in
this

brochure

and
are
payable

only
when

determine
they
are
medically

necessary.

The

separate

calendar
year
mental

health/
substance

abuse
deductible

applies
to
almost

all
benefits

in
this

Section.

We
added

"( No

deductible)"
to
show

when

a
deductible

does
not
apply.

A
High

Option

per
admission

deductible
applies
of
$100

(PPO)

and
$300

(non-PPO)

for
inpatient

hospital
services
up
to
a
maximum

two
per
person,

per
calendar

year.

Be
sure

to
read

Section

4,
Your

costs
for
covered

services,

for
valuable

information

about
how
cost
sharing

works.
Also
read
Section

about
coordinating

benefits
with
other
coverage,

including
with
Medicare.

YOU

MUST

GET
PREAUTHORIZATION

OF
THESE

SERVICES.

See
the
instructions

after
the
benefits

descriptions

below.

In-Network

mental
health
and
substance

abuse
benefits

are
below,

then
Out-of-

Network

benefits
begin
on
page

57.

I M P O R T A N T

Benefit
Description

You
pay

After
the
mental

health/ substance

abuse

calendar
year
deductible

NOTE:
The
mental

health/
substance

abuse
calendar

year
deductible

applies
to
almost

all
benefits

in
this

Section.

We
say
"(
No

deductible)"

when

it
does

not
apply.

In-Network
benefits

Standard
Option

High
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: In-
Network
benefits
are
payable

only
when

we
determine

the
care

is
clinically

appropriate
to
treat

your
condition

and
only

when

you
receive

the
care

as
part

of
a
treatment

plan
that
we
approve.

Your
cost
sharing

responsibilities

are
no

greater
than
for
other

illness

or
conditions.

Your
cost
sharing

responsibilities

are
no

greater
than
for
other

illness

or
conditions.

In-
Network

benefits
-
continued

on
next

page 56.
56 Page 57 58
2003
GEHA

54
Section
5( e)

You
Pay

In-Network
benefits
(continued)

Standard
Option

High
Option

Professional

services,
including
individual

or
group

therapy

by
providers

such
as

psychiatrists,
psychologists,

or
clinical

social
workers

Medication

management

Psychological

tests

$25
copayment

per
office

visit
(No
deductible)

$20
copayment

per
office

visit
(No
deductible)

Inpatient

professional

fees

Diagnostic

tests

Laboratory

tests
to
monitor

the
effect

of
drugs

prescribed

for
your

condition

15%
of
the

Plan

allowance

10%
of
the

Plan

allowance

Inpatient
hospital
Room
and
board,

such
as:

Ward,

semiprivate,

or
intensive

care
accommodations

General

nursing
care;
and

Meals

and
special

diets

NOTE:
We
only

cover

a
private

room
if
we

determine

it
to

be
medically

necessary.

Otherwise,
we
will

pay
the
hospital's

average
charge
for
semiprivate

accommodations.

The
remaining

balance
is
not

a
covered

expense.

If
the

hospital

only
has
private

rooms,

we
will

cover

the
private

room
rate.

NOTE:
When
the
hospital

bills
a
flat

rate,

we
prorate

the
charges

to
determine

how
to
pay

them,
as
follows:

30%
room

and
board

and
70%

other
charges.

15%
of
the

Plan

allowance

Nothing
(No
deductible)

Other
hospital

services
and
supplies

Services

provided

by
a
hospital

or
other

facility

Services

in
approved

alternative

care
settings

such
as
partial

hospitalization,

half-way

house,
residential

treatment,
full-day
hospitalization,

and
facility-based

intensive

outpatient
treatment

15%
of
the

Plan

allowance

10%
of
the

Plan

allowance

($
100

per
admission

deductible

up
to
a
maximum

of
2
per

person

per
calendar

year
applies)

In-
Network

benefits
-
continued

on
next

page 57.
57 Page 58 59
2003
GEHA

55
Section
5( e)

You
Pay

In-Network
benefits
(continued)

Standard
Option

High
Option

Outpatient
hospital
Services
provided

by
a
hospital

15%
of
the

Plan

allowance

10%
of
the

Plan

allowance

Emergency
room

non-accidental

injury

Outpatient
services
and
supplies

billed
by
a
hospital

for
emergency

room
treatment

Note:
We
pay
Hospital

benefits
if
you

are
admitted.

15%
of
the

Plan

allowance

10%
of
the

Plan

allowance

Not
covered:

Services
we
have

not
approved.

Note:
OPM
will
base

its
review

of
disputes

about
treatment

plans
on
the
treatment

plan's

clinical
appropriateness.

OPM
will
generally

not
order

us
to
pay

or
provide

one
clinically

appropriate
treatment
plan
in
favor

of
another.

All
charges

Preauthorization
To
be
eligible

to
receive

these
enhanced

mental
health
and
substance

abuse
benefits

you
must

obtain

a
treatment

plan
and

follow
all
of
the

following

network
authorization

processes:

You
must

call
United

Behavioral

Health
at
(877)

564-7505

to
receive

authorization

for
inpatient

and
outpatient

care

from
a
Network

provider.

They
will
authorize

any
covered

treatment

and
tell
you

what

Network

providers

are

available
for
your

treatment.

If
you

do
not
receive

preauthorization

for
care

from

a
Network

provider,
Out-of-
Network

benefits
will
be
paid

for

covered
services.

In-
Network

benefits

continued

on
next

page 58.
58 Page 59 60
2003
GEHA

56
Section
5( e)

In-Network
benefits
(continued)

Network
deductibles

and
There
is
a
separate

calendar
year
deductible

and
separate

catastrophic

protection
out-of-
pocket
maximum

for
mental

catastrophic
protection

h
ealth/

substance

abuse
treatment.

out-of-
pocket
maximums

The
separate

deductible

is
$350

per
person,

$700
per
family

(High
Option);

or
$450

per
person,

$900
per
family

(Standard

O
ption).

This
separate

deductible

covers
both
in-network

and
out-of-

network

services
combined

and
applies

to
almost

all
of

the
benefits

in
this

section.

The
separate

catastrophic

protection
out-of-
pocket
maximum

is
$3,000

Self
Only,

$3,500

Self
and
Family

(High
Option);

$4,000
Self
Only,

$4, 500

Self
and
Family

(Standard

Option).
After
you
meet

this
catastrophic

protection
out-of-
pocket
maximum,

we
pay

100%

of
our

allowable

amount
for
the
remainder

of
the

calendar

year.
The
separate

mental
health/ substance

abuse

deductible
does
not
apply

to
this

mental

health/ substance

abuse
catastrophic

protection
out-of-
pocket
maximum.

Out-of-
pocket
expenses

for
this

mental

health/ substance

abuse
benefit

are:

The

10%

you
pay
for
other

hospital

services
and
supplies,

inpatient
professional

fees,
emergency

room
physician

services
and

diagnostic
services
under
the
High

Option.

The

15%

you
pay
for
hospital

services,
inpatient
professional

fees,
emergency

room
physician

services
and
diagnostic

services

under
the
Standard

Option.

Note:
In
addition,

expenses
which
apply
to
the

in-network

mental
health/ substance

abuse
catastrophic

protection
out-of-
pocket

maximums
are
also

applied

to
the

out-of-

network

mental
health/ substance

abuse
catastrophic

protection
out-of-
pocket
maximum.

Network
deductibles

and
The
following

cannot
be
included

in
the
accumulation

of
mental

health/
substance

abuse
catastrophic

protection

catastrophic
protection

out-of-
pocket
expenses:

out-of-
pocket
maximums

Expenses

in
excess

of
the

Plan

allowance

or
maximum

benefit
limitations.

The
$20
copayment

(High
Option)

and
$25
copayment

(Standard
Option)
for
office

professional

services
and
medication

management. $350 (High Option)
and
$450

(Standard

Option)
calendar

year
mental

health/ substance

abuse
deductible.

The
$100

per
in-hospital

admission
deductible.

Any
amounts

you
pay
because

benefits
have
been
reduced

for
non-compliance

with
our
cost
containment

requirements

(see

pages
12
and

13).

Expenses

for
prescription

drugs
purchased

through
retail
or
Home

Delivery

Pharmacy

service.

Network
limitation

If
you

do
not
obtain

an
approved

treatment
plan,
we
will

provide

only
Out-of-

Network

benefits. In-Network
benefits
continued

on
next

page 59.
59 Page 60 61
2003
GEHA

57
Section
5( e)

In-Network
benefits
(continued)

How
to
submit

network

claims
You
or
your

provider

should
submit
claims
to:

United
Behavioral

Health

P. O.
Box
744926

Houston,
TX
77274-4926

If
you

need

help
in
filing

your
claim,

get
in
touch

with
United

Behavioral

Health
at
(877)

564-7505

or
GEHA

(816)
257-5500,

toll-free
(800)
821-6136;

TDD
(800)
821-4833.

Out-of-
Network

Benefits

Here
are
some

important

things
to
keep

in
mind

about

these
benefits:

Please

remember

that
all
benefits

are
subject

to
the
definitions,

limitations,
and
exclusions

in
this

brochure

and
are
payable

only
when

we
determine

they
are
medically

necessary. See pages
53-57
for
In-Network

benefits.

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
with
Medicare.

Benefit
Description

You
Pay

Out-of-
Network

mental
health

And
substance

abuse
benefits

Standard
Option

High
Option

Inpatient

Hospital/
Facility
for
treatment

of
mental

health

100
day
limit

per
calendar

year

Precertification

required

Inpatient

Hospital/
Facility
treatment

of
alcoholism

and
drug

abuse

30
day

maximum

per
lifetime

Precertification

required

Outpatient

Hospital/ Intensive

Day
Treatment

Program
for
mental

health

/substance
abuse

60
day

limit

per
calendar

year

50%
of
the

Plan

allowance

and
any
difference

between

our
allowance

and
the
billed

amount;
$500
inpatient

hospital
and
outpatient

hospital
/intensive

day

treatment
deductible

applies

per
person,

per
year

50%
of
the

Plan

allowance

and
any
difference

between

our
allowance

and
the
billed

amount;
$500
inpatient

hospital
and
outpatient

hospital
/intensive

day

treatment
deductible

applies

per
person,

per
year

Out-
of-
Network

benefits
-
continued

on
next

page 60.
60 Page 61 62
2003
GEHA

58
Section
5( e)

You
Pay

Out-of-
Network

Benefits
(continued)

Standard
Option

High
Option

Inpatient

Visits
for
Psychotherapy

100
inpatient

visits
limit
per
calendar

year

Outpatient

Visits
for
Psychotherapy

and
group

sessions

and
psychological

testing

30
session

limit
per
calendar

year
for
treatment

of
mental

health
and
substance

abuse

50%
of
the

Plan

allowance

and
any
difference

between

our
allowance

and
the
billed

amount,
$450
mental

health

calendar
year
deductible

applies Both Network

and
Out-of-

Network
expenses
will

apply
to
the

mental

health

deductible

50%
of
the

Plan

allowance

and
any
difference

between

our
allowance

and
the
billed

amount,
$350
mental

health

calendar
year
deductible

applies Both Network

and
Out-of-

Network
expenses
will

apply
to
the

mental

health

deductible

Not
covered

out-
of-network:

Services

by
pastoral,

marital,
drug/ alcohol

and
other

counselors

including
therapy
for

sexual
problems

Treatment

for
learning

disabilities

and
mental

retardation

Telephone

Therapy

Travel

time
to
the

member's

home
to
conduct

therapy

Services

rendered

or
billed

by
schools,

residential

treatment
centers
or
halfway

houses

or
members

of
their

staffs

All
charges

Lifetime
Maximum

Out-of-
Network

inpatient
care
for
the
treatment

of
alcoholism

and
drug

abuse

is
limited

to
a
30

day

maximum

per
lifetime.

Precertification
The
medical

necessity

of
your

admission

to
a
hospital

or
other

covered

facility
for
mental

health
or
substance

abuse
must
be

precertified
to
receive

Out-of-
Network

benefits.
Emergency

admissions
must
be
reported

within
two
business

days

following
the
day

of
admission

even
if
you

have

been
discharged.

Otherwise,
the
benefits

payable
will
be
reduced

by
$500.

See
Section

3
for

details.

Call
United

Behavioral

Health
at
(877)

564-7505

to
precertify.

Out-
of-
Network

benefits
-
continued

on
next

page 61.
61 Page 62 63
2003
GEHA

59
Section
5( e)

Out-of-
Network

Benefits
(continued)

Out-of-
Network

Deductible

The
calendar

year
mental

health/
substance

abuse
deductible

is
$350

per
person

($
700

per
family)

under
the
High

Option

calendar
year
maximums

&
and
$450

per
person

($
900

per
family)

under
the
Standard

Option.

catastrophic
protection
out-of-
pocket
maximums

The
calendar

year
deductible

applies
to
all
mental

health/
substance

abuse
benefits

in
this

Section

except
inpatient

and

outpatient
hospital
facility
charges.

There
is
a
separate

$500
hospital

inpatient

and
outpatient

hospital/
intensive

day
treatment

mental
health/
substance

abuse

deductible,
per
person,

per
calendar

year.
Inpatient

hospital
care
for
mental

health
is
limited

to
100

days

per
calendar

year.
Intensive

Day
Treatment

is
limited

to
60

visits

per
calendar

year.

Inpatient
care
for
the
treatment

of
alcoholism

and
drug

abuse

is
available

up
to
a
30

day

maximum

per
lifetime.

Inpatient
visits
for
psychotherapy

sessions
are
limited

to
100

visits

per
calendar

year.

Home
and
office

visits
for
psychotherapy

and
group

sessions

for
mental

health/
substance

abuse
are
limited

to
30

sessions
per
calendar

year.

When
the
deductibles

and
coinsurance

for
all
covered

family
members

(or
an
individual

under
Self
Only)

exceeds

$8,000

for
the
treatment

of
mental

health
(inpatient

or
outpatient)

and
outpatient

substance
abuse
in
any

one
calendar

year,
we
will

pay
in
full

all
remaining

allowable
charges
incurred

during
the
remainder

of
that

same

year .

Out-of-
pocket
expenses

for
this

mental

health/
substance

abuse
benefit

are:

The

$500

deductible

for
Inpatient

and
Outpatient

Hospital/
Intensive

Day
Treatment

of
mental

health/
substance

abuse

The

50%

you
pay
for
inpatient

and
outpatient

hospital
and
intensive

day
treatment

expenses;

The

50%

you
pay
for
inpatient

visits;

The

50%

you
pay
for
outpatient

care.

In
addition,

expenses
which
apply
to
the

in-network

mental
health/
substance

abuse
catastrophic

protection
out-of-
pocket

maximums
are
also

applied

to
the

out-of-

network

mental
health/
substance

abuse
catastrophic

protection
out-of-
pocket

maximum. The following
cannot
be
included

in
the
accumulation

of
catastrophic

protection
out-of-
pocket
expenses:

Expenses

in
excess

of
the

Plan

allowance

or
maximum

benefit
limitations;

Expenses

for
outpatient

psychotherapy

sessions
in
excess

of
30
sessions

per
year;

Expenses

for
inpatient

care
in
excess

of
100

days

per
year;

$350

calendar

year
deductible

for
High

Option;

$450

calendar

year
deductible

for
Standard

Option;

Out-
of-
Network

benefits
-
continued

on
next

page 62.
62 Page 63 64
2003
GEHA

60
Section
5( e)

Out-of-
Network

Benefits
(continued) Expenses

for
intensive

day
treatment

in
excess

of
60
days

per
year;

Any

amounts

you
pay
because

benefits
have
been
reduced

for
non-compliance

with
our
cost
containment

requirements

(see
pages

12
and

13);

Expenses

for
prescription

drugs
purchased

through
retail
or
Home

Delivery

Pharmacy

service;

Expenses

in
excess

of
the

50%

of
our

allowable

amount
for
inpatient

substance

abuse
charges.

How
to
submit

You
or
your

provider

should
submit
claims
to:

out-of-
network

claims

United
Behavioral

Health

P. O.
Box
744926

Houston,
TX
77274-4926

If
you

need

help
in
filing

your
claim,

get
in
touch

with
United

Behavioral

Health
at
(877)

564-7505

or
GEHA

(816)
257-5500,

toll-free
(800)
821-6136;

TDD
(800)
821-4833. 63.
63 Page 64 65
2003
GEHA

61
Section
5( f)

Section
5
(f).

Prescription

drug
benefits

I M P O R T A N T
Here
are
some

important

things
to
keep

in
mind

about

these
benefits

and
features

you
should

be
aware

of:

cover

prescribed

drugs
and
medications,

as
described

in
the

chart

beginning

on
page

65.

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.

There

is
no
calendar

year
deductible

for
prescription

drugs.

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
with

Medicare. Under the
High
Option

plan,
if
Medicare

is
your

primary

insurance

and
you
have

both
Medicare

Part
A
&
B
coverage,

you
pay
less

for
your

prescriptions

(see
page

66).

Some

medications

are
limited

in
quantity

based
on
manufacturer's

and
FDA

guidelines.

Some

medications

must
be
approved

by
GEHA

before
you
may
purchase

them.

Each

new
enrollee

will
receive

a
description

of
our

prescription

drug
program,

a
combined

prescription

drug/ Plan
identification

card,

and
a
mail

order

form,
questionnaire,

and
reply

envelope.

Who

can
write

your
prescription.

A
licensed

physician

or
a
licensed

dentist
must
write
the
prescription.

For
Medco

Health
home

delivery
prescriptions,

the
physician

must
be
licensed

in
the
United

States.
In
addition,

your
mailing

address
must
be
within

the

United
States
or
include

an
APO

address.

Where

you
can
obtain

them.
You
may
fill
the
prescription

at
a
participating

network
retail
pharmacy,

a
non-network

pharmacy,
or

by
the
Medco

Health
Home
Delivery

Pharmacy

Service.
We
pay
a
higher

level
of
benefits

when
you
use
a
network

pharmacy.

For

medications
you
may

take
on
a
regular,

long-term

basis,
we
pay

a
higher

level
of
benefits

through
the
home

delivery

service.

I M P O R T A N T

Covered
medications

and
supplies

You
may
purchase

the
following

medications

and
supplies

prescribed

by
a
physician

from
either

a
pharmacy

or
by
mail:

Drugs

and
medicines

(including
those
administered

during
a
non-covered

admission
or
in
a
non-covered

facility)
that
by
Federal

law
of
the

United

States

require
a
physician's

prescription

for
their

purchase,

except
those
listed
as
Not

Covered

Insulin Needles

and
syringes

for
the
administration

of
covered

medications

Contraceptive

drugs

Ostomy

supplies
(please
include
the
manufacturer's

product
number
to
ensure

accurate

fill
of
the

product)

Note:
A
generic

equivalent

will
be
dispensed

if
it
is
available

unless
you
or
your

physician

specifies
that
the
prescription

be
dispensed

as
written,

when
a
Federally

approved
generic
drug
is
available.

Prescription
drug
benefits

-
continued

on
next

page 64.
64 Page 65 66
2003
GEHA

62
Section
5( f)

Prescription
drug
benefits

(continue d)

High
Option

-
three-tier

drug
benefit

Under
the
High

Option,

we
divide

prescription

drugs
into
three

categories

or
tiers:

generic,

single-source

brand
name,
and
multi-source

brand
name.

When
an

approved
generic
equivalent

is
available,

that
is
the

drug

you
will
receive,

unless
you
or
your

physician

specify
that
the
prescription

must
be
filled

as
written.

When
an
approved

generic
equivalent

is
not

available,

you
will
pay
the
brand

name
single-source

copayment.
If
an
approved

generic
equivalent

is
available,

but

you
or
your

physician

specify
that
the
prescription

must
be
filled

as
written,

you
will
pay
the
brand

name
multi-source

copayment.

Generic

drugs:
are
chemically

and
therapeutically

equivalent
to
the
corresponding

brand
drug,
but
are
available

at
a
lower

price.
Equivalent

generic

products
for
brand

name
medications

become
available

after
a
patent

and
other

exclusivity

rights
for
the
brand

expire.

The
Food

and
Drug
Administration

must
approve

all
generic

versions

of
a
drug

and
assure

that
they

meet

strict
standards

for
quality,

strength

and
purity.

The
FDA

requires

that
generic

equivalent
medications

contain
the
same

active
ingredients

and
be
equivalent

in
strength

and
dosage

to
brand

name
drugs.

The
main
difference

between
a

generic
and
its
brand

name
drug
is
the

cost

of
the

product.

Single-

source
brand
name
drugs
are
available

from
only
one
manufacturer

and
are
patent-protected.

No
generic

equivalent

is
available.

Multi-

source

brand
name
drugs
are
available

from
more
than
one
manufacturer

and
have

a
least

one
generic

equivalent

alternative
available.

Coordinating
with
other

drug
coverage

If
you

also
have

drug
coverage

through
another
group
health
insurance

plan
and
we
are
your

secondary

insurance,
follow
these
procedures:

At
participating

pharmacies,
do
not
present

your
GEHA

drug
card.

Purchase

your
drug
and
submit

the
bill

to
your

primary

insurance.

When
they
have
made

payment,
file
the
claim

and
the
Explanation

of
Benefits

(EOB)
with
GEHA

(see
page

75).
If
you

use
GEHA's

prescription

drug
card
when

another

insurance

primary,
you
will
be
responsible

for
reimbursing

us
any

amount

in
excess

of
our

secondary

benefit.

Drugs
purchased

at
non-participating

pharmacies
should
be
submitted

to
our

claims

office
(see
page

76)
along

with
the
primary

insurance

EOB.
We
will
accept

either
the
drug

receipts

or
a
Medco

Health
drug
claim

form.
Submit

these
claims

to
GEHA,

P.
O.

4665,

Independence,

MO
64051-

4665,
when
we
are

your

secondary
insurance.
If
another

insurance

is
primary,

you
should

use
their

drug
benefit.

If
you

elect

to
use

the
Home

Delivery

Pharmacy

service,
Medco
Health
will
bill
you
directly.

Pay
Medco

Health
the
amount

billed
and
submit

the
bill

to
your

primary

insurance.

When
your
primary

insurance

makes
payment,

file
the
claim

and
their

EOB

us
(see

page

75).

In
some

cases,
Medicare

covers
prescription

drugs
and
supplies.

If
Medicare

is
your

primary

insurance

and
you
use
prescription

drugs
or
supplies

covered
by

Medicare,
we
will

attempt

to
recover

the
cost

of
the

drug

or
supply

from
Medicare.

Please
help
us
obtain

this
reimbursement

by
signing

and
returning

to
us
an

authorization
form
for
Medicare

reimbursement.

This
form

is
sent

to
you

automatically

when
you
utilize

medications

that
are
allowable

for
submission

to
Medicare.

we
are
unsuccessful

in
recovering

our
payment

from
Medicare,

we
reserve

the
right

to
require

you
to
purchase

the
medication

and
then

file
a
claim

with
Medicare.

After
Medicare

makes
payment,

you
may

file
a
claim

with
us
for

the
out-of-

pocket
cost,
in
excess

of
your

GEHA

copayment.

Should
Medicare

rules
change

on
prescription

drug
coverage,

we
reserve

the
right

to
require

you
to
use

your

Medicare

coverage
as
the

primary

insurance

for
these

drugs.
Prescription
drug
benefits

continue

on
next

page 65.
65 Page 66 67
2003
GEHA

63
Section
5( f)

Prescription
drug
benefits

(continued )

Medco
Health
voluntary

formulary

Your
prescription

drug
program

includes
a
voluntary

"formulary"

feature.
The
Medco

Health
Drug
Formulary

is
a
list

of
selected

FDA
approved

prescription

medications
reviewed
by
an
independent

group
of
distinguished

health
care
professionals.

Prescription
drugs
are
subjected

to
rigorous

clinical
analysis

from
the

standpoint
of
efficacy,

safety,
side
effects,

drug-to-
drug
interactions,

dosage
and
cost-benefit

in
determining

whether
they
are
included

on
or
excluded

from
the

formulary. A formulary
is
a
list

of
commonly

prescribed
medications

from
which

your
physician

may
choose

to
prescribe.

The
formulary

is
designed

to
inform

you
and
your

physician
about
quality

medications

that,
when
prescribed

in
place

of
other

non-formulary

medications,
can
help

contain

the
increasing

cost
of
prescription

drug

coverage
without
sacrificing

quality.
In
many

therapeutic

categories,
there
are
several

drugs
of
similar

effectiveness.

Many
doctors

are
often

unaware

of
the

significant
variations
in
price

among

these
similar

drugs
and,
as
a
result,

their
prescribing

decisions
often
do
not
consider

cost.
However,

when
the
cost
difference

brought
to
their

attention,

doctors
will
frequently

prescribe
the
less

costly

medications.

Your
physicians

will
be
contacted

to
discuss

their
prescribing

decision.
No
change

in
the

medication

prescribed
will
be
made

without

your
physicians'

approval.

Compliance
with
this
formulary

list
is
voluntary

and
there

is
no
financial

penalty
for
obtaining

drugs
not
on
the
formulary

list.

Any
rebates

or
savings

received

by
the

Plan

on
the

cost

of
drugs

purchased

under
this
plan

from

drug
manufacturers

are
credited

to
the

health

plan
and

are
used

to
reduce

health
care
costs.

Patient
Safety
GEHA
has
several

programs

to
promote

patient
safety.
Through

these
programs,

we
work

to
ensure

safe
and
appropriate

quantities
of
medication

are
being

dispensed.

The
result

is
improved

care
and
safety

for
our
members.

Patient
safety
programs

include:

Prior

approval

Approval

must
be
obtained

for
certain

prescription

drugs
and
supplies

before
providing

benefits
for
them.

Quantity

allowances

Specific

allowances

are
in
place

for
certain

medications,

based
on
manufacturer

and
FDA
recommended

guidelines.

Pharmacy

utilization

GEHA

reserves

the
right

to
maximize

your
quality

of
care

as
it
relates

to
the

utilization

of
pharmacies.

GEHA
will
participate

in
other

approved

managed
care
programs,

as
deemed

necessary,

to
insure

patient

safety.

Prescription

drug
benefits

-
continued

on
next

page 66.
66 Page 67 68

2003
GEHA

64
Section
5( f)

Prescription
drug
benefits

(continued)

How
to
use

Medco

Health
network

pharmacies

(retail)

You
may
fill
your

prescription

at
any

participating

retail
pharmacy.

For
the
names

of
participating

pharmacies,
call
(800)

551-7675

or
visit

www.
medcohealth.

com.
To
receive

maximum

savings
you
must

present

your
card
at
the

time

of
each

purchase,

and
your
enrollment

information

must
be
current

and
correct.

In
most

cases,

you
simply

present

the
card

together

with
the
prescription

to
the
pharmacist.

Each
purchase

is
limited

to
a
30-day

supply.

Any

prescription
purchased
twice
at
retail,

regardless

of
the

quantity

purchased

is
considered

maintenance

medication.
We
pay

a
higher

level
of
benefits

for

maintenance
medication
through
the
home

delivery

service.

Refills
cannot
be
obtained

until
75%

of
the

drug

has
been

used.

Refills

for
maintenance

medications
are
not
considered

new
prescriptions

except
when
the
doctor

changes
the
strength

or
180

days

has
elapsed

since
the
previous

purchase.

As
part

of
the
administration

of
the
prescription

drug
program,

we
reserve

the
right

maximize
your
quality

of
care

as
it
relates

to
the

utilization

of
pharmacies.

Some
medications

may
require

prior
approval

by
Medco

Health
or
GEHA.

How
to
use

the
Medco

Health
Home
Delivery

Pharmacy

Service
(mail
order)

Through
this
service,

you
may

receive

up
to
a
90-day

supply
of
maintenance

medications
for
drugs

which
require

a
prescription,

ostomy
supplies,

diabetic

supplies
and
insulin,

syringes

and
needles

for
covered

injectable

medications,

and
oral
contraceptives.

Some
medications

may
not
be
available

in
a
90-day

supply

from
Medco

Health
even
though

the
prescription

is
for

90
days.

Even
though

insulin,
syringes,

diabetic
supplies
and
ostomy

supplies

do
not
require

a
physician's

prescription,
to
obtain

through

home
delivery,

you
should

obtain
a
prescription

(including
the
product

number
for
ostomy

and
insulin

pump
supplies)

from
your

physician
for
a
90-day

supply.

Some
medications

may
require

approval

by
Medco

Health
or
GEHA.

Not
all
drugs

are
available

through
the
Home

Delivery

Pharmacy

service.
In
order

to
use

the
Home

Delivery

Pharmacy

service,
your
prescriptions

must
be
written

by
a
physician

licensed
in
the

United

States.

In
addition,

your
mailing

address
must
be

within
the
United

States
or
include

an
APO

address.

Each
enrollee

will
receive

a
kit

that

includes

a
brochure

describing

the
Home

Delivery

Pharmacy

service,
an
order

form,

a
questionnaire,

and
a
return

envelope.

To
order

new
prescriptions,

ask
your

doctor

to
prescribe

needed
medication

for
up
to
a
90-day

supply,
plus
refills,

if
appropriate.

Complete
the
Health,

Allergy,

&
Medication

Questionnaire

the
first

time

you
order

through

this
service.

Complete

the
information

on
the
Ordering

Medication

Form,
enclose

your
prescription

and
the
correct

copayment.

Mail
to:

Medco
Health
P.
O.

Box

98830

Las
Vegas,

NV
89195-0249

You
should

receive

your
medication

within
14
days

from
the
date

you
mail

your
prescription.

You
will
also
receive

reorder
instructions.

If
you

have

any
questions

or
need

an
emergency

consultation

with
a
registered

pharmacist,

you
may

call
Medco

Health
toll-free

at
(800)

551-7675

available
24
hours

a
day,

7
days

a
week

except
Thanksgiving

and
Christmas.

Forms
necessary

for
refills

will
be
provided,

each
time
you
receive

a
supply

of
medication

from
the
service.

Refilling
your
medication:

to
be

sure

you
never

run
short

of
your

prescription

medication,
you
should

re-order

on
or
after

the
refill

date
indicated

on
the

refill

slip

or
when

you
have
approximately

14
days

of
medication

left.

To
order

by
phone:

Call
Member

Services
at
(800)

551-7675.

Have
your
refill
slip
with

the
prescription

information
ready.

To
order

by
mail:

Simply
mail
your
refill
slip
and
copayment

To
order

online:

Go
to
www.

geha. com/

online
pharmacy.

html
then
click

on
the

link

to
Medco

Health,

or
go

to
www.

medcohealth.

com

the
return

envelope.

.
Prescription
drug
benefits

-
continued

on
next

page 67.
67 Page 68 69
2003
GEHA

65
Section
5( f)

You
Pay

Prescription
drug
benefits

(continued)

Standard
Option

High
Option

Covered
medications

and
supplies

when

GEHA

is
primary

Medco
Health
Network

Pharmacy

(retail)

All
copayments

are
for
up
to
a
30-day

supply.

If
the

cost

of
the
medication

or
supply

less
than

the
applicable

copayment,

you
are
only

responsible

for
the
cost

of
the
medication,

not
the
full
copayment.

A
generic

equivalent

will
be
dispensed

if
it
is
available

unless
you
or
your

physician

specifies
that
the
prescription

be
dispensed

as
written

(DAW),

when
a
Federally

approved

generic
drug
is
available.

If
there

is
no

generic

equivalent

available,
you
pay
the
brand

name
copayment.

$5
generic 50% brand

name

Initial
amount

prescribed,

for

up
to
a
30-day

supply

$5
generic, $20 single-

source
brand
name,

$35
multi-source

brand
name

Initial
fill
not

to
exceed

a
30-

day
supply,

and
the
first

refill.

For
all
subsequent

refills,
you

pay
the
greater

of
50%

or
the

copayments
described
above.

Non-
Network

Retail

If
a
participating

pharmacy
is
not

available

where
you
reside

or
you

do
not

use
your

identification
card,
you
must

submit

your
claim

to:

Medco
Health
P.
O.

Box

2187

Lee's
Summit,

MO
64063-2187

Your
claim

will
be
calculated

on
the

50%

coinsurance

or
the
appropriate

copayments.

Reimbursement
will
be
based

on
GEHA's

costs
had
you
used

a
participating

pharmacy.

You
must
submit

original

drug
receipts.

All
copayments

are
for
up
to
a
30-day

supply.

If
the

cost

of
the
medication

or
supply

less
than

the
applicable

copayment,

you
are
only

responsible

for
the
cost

of
the
medication.

Note:
When

a
claim

is
submitted

for
direct

reimbursement

of
a
compound

medication,

the

pricing
is
based

on
the
contractual

Average
Wholesale

Price
(AWP)

cost
of
each

active

prescription
component
submitted.
The
professional

fee
and
applicable

sales
tax
and

copayments
are
also

included

in
the

pricing.

$5
generic 50% brand

name

(and
any
difference

between
our

allowance
and
the
cost

of
the

drug)

$5
generic, $20 single-

source
brand
name,

$35
multi-source

brand
name,

(and
any
difference

between
our

allowance
and
the
cost

of
the

drug) Initial
fill
not

to
exceed

a
30-

day
supply,

and
the
first

refill.

For
all
subsequent

refills,
you

pay
the
greater

of
50%

or
the

copayments
described
above

and
any
difference

between
our

allowance
and
the
cost

of
the

drug.

Medco
Health
Home
Delivery

Pharmacy

Service

All
copayments

are
for
up
to
a
90-day

supply.

If
the

cost

of
the
medication

or
supply

is
less

than
the
applicable

copayment,

you
are
only

responsible

for
the
cost

of
the
medication.

A
generic

equivalent

will
be
dispensed

if
it
is
available

unless
you
or
your

physician

specifies

that
the
prescription

be
dispensed

as
written

(DAW),

when
a
Federally

approved
generic
drug

is
available.

If
there

is
no

generic

equivalent

available,
you
pay
the
brand

name
copayment.

$15
generic 50% brand name

$10
generic, $40 single-source

brand
name,

$55
multi-source

brand
name

Prescription
drug
benefits

continued

on
next

page 68.
68 Page 69 70
2003
GEHA

66
Section
5( f)

You
Pay

Prescription
drug
benefits

(continued)

Standard
Option

High
Option

Covered
medications

and
supplies

Medicare

A
&

B
primary

Medco
Health
Network

Pharmacy

(retail)

All
copayments

are
for
up
to
a
30-day

supply.

If
the

cost

of
the
medication

or
supply

is
less

than
the
applicable

copayment,

you
are
only

responsible

for
the
cost

of
the
medication,

not

the
full
copayment. A generic equivalent

will
be
dispensed

if
it
is
available

unless
you
or
your

physician

specifies
that
the
prescription

be
dispensed

as
written,

(DAW)
when
a
Federally

approved

generic
drug
is
available.

If
there

is
no

generic

equivalent

available,
you
pay
the
brand

name
copayment.

$5
generic 50% brand

name

Initial
amount

prescribed,

for

up
to
a
30-day

supply

$3
generic, $10 single-

source
brand
name,

$25
multi-source

brand
name

Initial
fill
not

to
exceed

a
30-

day
supply,

and
the
first

refill.

For
all
subsequent

refills,
you

pay
the
greater

of
50%

or
the

copayments
described
above.

Non-
Network

Retail

If
a
participating

pharmacy
is
not

available

where
you
reside

or
you

do
not

use
your

identification
card,
you
must

submit

your
claim

to:

Medco
Health
P.
O.

Box

2187

Lee's
Summit,

MO
64063-2187

Your
claim

will
be
calculated

on
the

50%

coinsurance

or
the
appropriate

copayments.

Reimbursement
will
be
based

on
GEHA's

costs
had
you
used

a
participating

pharmacy.

You
must
submit

original

drug
receipts.

All
copayments

are
for
up
to
a
30-day

supply.

If
the

cost

of
the
medication

or
supply

less
than

the
applicable

copayment,

you
are
only

responsible

for
the
cost

of
the
medication.

Note:
When

a
claim

is
submitted

for
direct

reimbursement

of
a
compound

medication,

the

pricing
is
based

on
the
contractual

Average
Wholesale

Price
(AWP)

cost
of
each

active

prescription
component
submitted.
The
professional

fee
and
applicable

sales
tax
and

copayments
are
also

included

in
the

pricing.

$5
generic 50% brand

name

(and
any
difference

between
our

allowance
and
the
cost

of
the

drug)

$3
generic, $10 single-

source
brand
name,

$25
multi-source

brand
name,

(and
any
difference

between
our

allowance
and
the
cost

of
the

drug) Initial
fill
not

to
exceed

a
30-

day
supply,

and
the
first

refill.

For
all
subsequent

refills,
you

pay
the
greater

of
50%

or
the

copayments
described
above

and
any
difference

between
our

allowance
and
the
cost

of
the

drug.

Medco
Health
Home
Delivery

Pharmacy

Service

All
copayments

are
for
up
to
a
90-day

supply.

If
the

cost

of
the
medication

or
supply

is
less

than
the
applicable

copayment,

you
are
only

responsible

for
the
cost

of
the
medication.

A
generic

equivalent

will
be
dispensed

if
it
is
available

unless
you
or
your

physician

specifies

that
the
prescription

be
dispensed

as
written

(DAW),

when
a
Federally

approved
generic
drug

is
available.

If
there

is
no

generic

equivalent

available,
you
pay
the
brand

name
copayment.

$15
generic 50% brand name

$5
generic, $20 single-

source
brand
name,

$35
multi-source

brand
name

Prescription
drug
benefits

-
continued

on
next

page 69.
69 Page 70 71
2003
GEHA

67
Section
5( f)

You
Pay

Prescription
drug
benefits

(continued)

Standard
Option

High
Option

Non-covered
medications
and
supplies

The
following

medications

and
supplies

are
not
covered

under
the
GEHA

health
plan.

Drugs

and
supplies

for
cosmetic

purposes

Vitamins,

nutrients
and
food
supplements

even
if
a
physician

prescribes

or
administers

them
including

enteral
formula
available

without
a
prescription

Nonprescription

medicines

Drugs

to
aid

in
smoking

cessation

except
those
limited

to
the

$100

lifetime

maximum

part
of
the

smoking

cessation

benefit
(see
page

33).
You
may
not
obtain

smoking

cessation
drugs
with
your
Medco

Health
Prescription

card
or
through

the
home

delivery

service.
You
must
purchase

these
drugs

and
file
the
claim

with
us.

Medical

supplies
such
as
dressings

and
antiseptics

Drugs

which
are
investigational

Drugs

prescribed

for
weight

loss

Drugs

to
treat

infertility

Drugs

to
treat

impotency

All
charges

All
charges 70.
70 Page 71 72
2003
GEHA

68
Section
5( g)

Section
5
(g).

Special

features

Special
features

Description

Flexible
benefits
option

Under
the
flexible

benefits
option,
we
determine

the
most

effective

way
to
provide

services.

may

identify

medically

appropriate

alternatives
to
traditional

care
and
coordinate

other
benefits

as
a
less

costly

alternative
benefit.

Alternative

benefits
are
subject

to
our

ongoing

review.

By
approving

an
alternative

benefit,
we
cannot

guarantee

you
will
get
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.
Services
for
deaf

and

hearing
impaired

TDD
service

is
available

at
(800)

821-4833

for
members

who
are
hearing

impaired.

High
risk
pregnancies

To
participate

in
our

enhanced

maternity
program,
call
(800)

747-GEHA

at
any

time

as
soon

as
you

think

you
or

your
covered

dependent

may
be
pregnant.

Early
participation

in
the

program

guarantees

you
ongoing

communication

with
a
registered

nurse
throughout

the
pregnancy.

Complimentary

educational
materials
include
the
book

"From

Here
to
Maternity". 71.
71 Page 72 73
2003
GEHA

Section
5( h)

Section
5
(h).

Dental

benefits

I M P O R T A N T
Here
are
some

important

things
to
keep

in
mind

about

these
benefits:

Please

remember

that
all
benefits

are
subject

to
the
definitions,

limitations,
and
exclusions

in
this

brochure

and
are
payable

only

when
we
determine

they
are
medically

necessary.

There

is
no
calendar

year
deductible

for
dental

benefits.

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

with
Medicare. Note: We cover

hospitalization

for
dental

procedures

only
when

a
non-dental

physical
impairment

exists
which
makes

hospitalization
necessary
to
safeguard

the
health

of
the

patient.

We
do
not

cover

the
dental

procedure.

See
Section

5
(c)

for

inpatient
hospital
benefits.

I M P O R T A N T

Accidental
injury
benefits

We
cover

restorative

services
and
supplies

necessary

to
promptly

repair
sound
natural

teeth.
The
need

for
these

services

must
result

from
an
accidental

injury.

The
repair

of
accidental

injury
to
sound

natural

teeth
includes

but
is
not

limited

to,
expenses

for
X-rays,

drugs,
crowns,

bridgework,

inlays,
and
dentures.

Masticating
(biting
or
chewing)

incidents
are
not
considered

to
be
accidental

injuries.
Accidental

dental
injury
is
covered

at
100%

for
charges

incurred

within
72

hours
of
an
accident.

Services
incurred
after
72
hours

are
paid

at
regular

Plan
benefits.

Dental
benefits

Standard
Option

Scheduled
Allowance

High
Option

Scheduled
Allowance

Service
We
pay

You
pay

We
pay

You
pay

Diagnostic
and
preventive

services,
limited
to
two

visits

per
year

including

examination,

prophylaxis
(cleaning),

X-rays
of
all
types

and
fluoride

treatment.

Benefits
are

payable
per
visit

not
per
service

50%
up
to
the

plan

allowance
for
diagnostic
and
preventive
services
(maximum

two
visits
per
year)

50%
up
to
the

plan

allowance
and
all

charges
in
excess

of
the

plan

allowance

for
diagnostic
and
preventive
services

$22
per
visit

(maximum

two
visits

per
year)

All
charges

excess
of
the

scheduled

amount
listed
to
the

left

Dental
benefits

continued

on
next

page 72.
72 Page 73 74
2003
GEHA

Section
5( h)

Dental
benefits

(continued)

Standard
Option

Scheduled
Allowance

High
Option

Scheduled
Allowance

Service
We
pay

You
pay

We
pay

You
pay

Amalgam
restorations Resin-Based Composite

Restorations

Gold
Foil
Restorations Inlay/ Onlay Restorations

$21
One
surface,

$28
Two

or
more

surfaces

All
charges

in
excess

of
the
scheduled amounts listed to

the

left

$21
One
surface,

$28
Two

or
more

surfaces

All
charges

in
excess

of
the
scheduled amounts listed to

the

left

Simple
Extractions

$21
Simple

extraction

All
charges

in
excess

of
the
scheduled amount listed to

the

left

$21
Simple

extraction

All
charges

in
excess

of
the
scheduled amount listed to

the

left 73.
73 Page 74 75

2003 GEHA Section 5( i) 71
Section 5 (i). Non-FEHB benefits available to Plan members
The benefits on pages 71 and 72 are not part of the FEHB contract or premium, and you cannot file an FEHB disputed claim about them. Fees you pay for these services do not count toward FEHB deductibles or
catastrophic protection out-of-pocket maximums.
Non-Covered Prescription Drugs (800) 417-1893
Certain prescription drugs not covered by GEHA's Prescription Drug Program are available to GEHA health plan members at a discount. If your physician writes a prescription for a non-covered drug to treat impotency or hair
loss, you may purchase it through the Home Delivery Pharmacy Service, paying 100% of the discounted amount. To order, complete the form called Ordering Medications from the Home Delivery Pharmacy Service. Mail this form
along with your prescription and check or credit card number to:
Medco Health P. O. Box 98830

Las Vegas, NV 89195-0249
If paying by a check, please call first to obtain the cost of the medication. Full payment must be included with your order.

Online Shopping
GEHA health plan members have access to special features offered on the Medco Health web site, www. medcohealth. com. On this web site, you can refill mail order prescriptions and manage your mail order

account. A new feature is online shopping for thousands of non-prescription drugstore products available from CVS, America's leading retail pharmacy chain. Items available include nonprescription medications, vitamins,
herbal remedies and personal care products.
CONNECTION Hearing (877) 674-3594 www. miracle-ear. com
Free to all GEHA health plan members, CONNECTION Hearing offers cost savings at participating Miracle-Ear locations nationwide. The program provides a free hearing evaluation, a 20% discount off the retail price of hearing

aids, the Miracle-Ear Hearing Care Guarantee, a 30-day satisfaction refund guarantee, free unlimited follow-up visits, and free annual checkups for hearing aids. Program benefits are available to GEHA health plan members and
their families, including parents and grandparents. Call (877) 674-3594 for a Miracle-Ear managed care program location in your area.

CONNECTION Vision (800) 800-EYES www. 800800eyes. com
Free to all GEHA health plan members, CONNECTION Vision offers cost savings at more than 10,000 eye care locations nationwide. This program is offered through Coast to Coast Vision. GEHA health plan members get
discounts off the retail price of lenses, frames and specialty items such as tints, lightweight plastics and scratch-resistant coatings. Discounts are available for surgical procedures (including LASIK and PRK) not covered under
the GEHA health plan. For discounts on mail-order contact lenses, call (800) 878-3901. For discounts on mail-order sunglasses, call (800) 736-9587 or visit the program's website. To locate providers in your area, call
(800) 800-EYES. When you purchase the CONNECTION Dental Plus plan, but not GEHA health insurance, you also have free access to the CONNECTION Vision program.

CONNECTION Dental (800) 296-0776 www. geha. com
Free to all GEHA health plan members, CONNECTION Dental can reduce your costs for dental care. CONNECTION Dental is a network of approximately 22,000 participating dentists who have agreed to limit their

charges to a reduced fee for GEHA health plan members. As a GEHA health plan member, you can take advantage of this program in addition to basic dental benefits provided under the GEHA health plan. Just show your
CONNECTION ID card before you receive services. To find a participating CONNECTION Dental provider in your area, call (800) 296-0776 or visit www. geha. com and click on Provider Search. 74.
74 Page 75 76

2003 GEHA Section 5( i) 72
CONNECTION Dental Plus (800) 793-9335 www. geha. com
Available for an additional premium, CONNECTION Dental Plus is a supplemental dental plan that pays benefits for a wide variety of procedures, from cleanings and X-rays to crowns, dentures and orthodontia for children. This
optional dental insurance is provided directly by GEHA. Certain waiting periods and limitations apply.
Enrollment is now open to all federal employees, retirees and annuitants, including those who are not members of the GEHA health plan. When you also join the GEHA health plan, you pay a lower premium for CONNECTION
Dental Plus. When you purchase CONNECTION Dental Plus you also have free access to GEHA's CONNECTION Vision program.

Benefit Covered Services Calendar Year
Deductible Per Person
Provider Participation
1 st Year 2 nd Year 3 rd Year

In-Network 100% 100% 100% Class A
Specified Diagnostic and

Preventative

$0
Out-of-Network 60% 80% 80%

In-Network 70% 75% 80% Class B
Other Diagnostic, Preventative,

Restorative & Specified Oral
Surgery

$50
Out-of-Network 50% 55% 60%

In-Network 40% 50% Class C
Endodontics, Periodontics,

Prosthodontics & Crowns,
Inlays, Onlays

$100
Out-of-Network
0% 12 Month
Waiting Period 30% 40%

In-Network $50 per month Class D
Orthodontics-Comprehensive

Case (ages 6-17)

$0
Out-Network
0% 24 Month
of-Waiting
Period

0% 24 Month
Waiting Period $25 per month

This is a partial summary of the terms, conditions and limitations of CONNECTION Dental Plus. To get an enrollment packet or more information on coverage and rates, please call CONNECTION Dental Plus at
(800) 793-9335, or visit www. geha. com.

Benefits described on pages 71 and 72 are not part of the FEHB contract or premium, and you cannot file a FEHB disputed claim about them. Fees you pay for these services do not count toward FEHB deductibles or catastrophic
protection out-of-pocket maximums. The GEHA PPO copayment does not apply. GEHA does not guarantee that providers are available in all areas or that prices at a participating provider are lower than prices that may be
available from a non-participating provider. 75.
75 Page 76 77
2003 GEHA 73 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;

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 or supplies for which no charge would be made if the covered individual had no health insurance coverage;

Services, drugs, or supplies you receive without charge while in active military service;
Services or supplies furnished by immediate relatives or household members, such as spouse, parents, children, brothers or sisters by blood, marriage or adoption;

Services or supplies furnished or billed by a noncovered facility, except that medically necessary prescription drugs and physical, speech and occupational therapy rendered by a qualified professional
therapist on an outpatient basis are covered subject to plan limits;
Services or supplies for cosmetic purposes;
Surgery to correct congenital anomalies for individuals age 18 and older unless there is a functional deficit;
Services or supplies not specifically listed as covered;
Services or supplies not reasonably necessary for the diagnosis or treatment of an illness or injury, except for routine physical examinations and immunizations;

Any portion of a provider's fee or charge ordinarily due from the enrollee but that has been waived. If a provider routinely waives (does not require the enrollee to pay) a deductible, copay or coinsurance, we will
calculate the actual provider fee or charge by reducing the fee or charge by the amount waived;
Charges the enrollee or Plan has no legal obligation to pay, such as excess charges for an annuitant age 65 or older who is not covered by Medicare Parts A and/ or B (see page 18), doctor charges exceeding the amount

specified by the Department of Health and Human Services when benefits are payable under Medicare (limiting charge) (see page 19), or State premium taxes however applied;

Charges in excess of the "Plan allowance" as defined on page 88;
Biofeedback, educational, recreational or milieu therapy, either in or out of a hospital;
Inpatient private duty nursing;
Stand-by physicians and surgeons;
Clinical ecology and environmental medicine;
Chelation therapy except for acute arsenic, gold, or lead poisoning; 76.
76 Page 77 78
2003 GEHA 74 Section 6
Treatment for impotency, even if there is an organic cause for impotency. (Exclusion applies to medical/ surgical treatment as well as prescription drugs.);
Treatment other than surgery of temporomandibular joint dysfunction and disorders (TMJ);
Computer devices to assist with communications; or
Computer programs of any type, including but not limited to those to assist with vision therapy or speech therapy. 77.
77 Page 78 79

2003 GEHA 75 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 about our benefits, contact us at (800) 821-6136, or at our web site at
www. geha. com.
In most cases, providers and facilities file claims for you. Your physician must file on the form HCFA-1500, Health Insurance Claim
Form. Your facility will file on the UB-92 form.
Mail to: GEHA P. O. Box 4665
Independence, MO 64051-4665
For claims questions and assistance, call us at (800) 821-6136.
When you must file a claim --such as for services you receive overseas or when another group health plan is primary --submit it on the HCFA-1500
or a claim form that includes the information shown below. 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, or balance due statements are not acceptable substitutes for itemized bills.

In addition:
You must send a copy of the explanation of benefits (EOB) 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 and should include nursing notes.

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. 78.
78 Page 79 80
2003 GEHA 76 Section 7
Claims for prescription drugs and supplies that are not purchased through the Prescription Drug Program must include receipts that
include the prescription number, name of drug or supply, prescribing physician's name, date, and charge.

To control administrative costs, we will not issue benefit checks that do not exceed $1.

Records Keep a separate record of the medical expenses of each covered family member as deductibles and maximum allowances apply separately to
each person. Save copies of all medical bills, including those you accumulate to satisfy a deductible. 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 all of the documents for your claim as soon as possible. You must submit the claim by December 31 of the year after the year you
received the service, unless timely filing was prevented by administrative operations of Government or legal incapacity, provided
the claim was submitted as soon as reasonably possible. Once we pay benefits, there is a three-year limitation on the reissuance of uncashed
checks.

Overseas claims For covered services you receive in hospitals outside the United States and Puerto Rico and performed by physicians outside the United States,
send itemized bills that include an English translation. Charges should be converted to U. S. dollars using the exchange rate applicable at the
time the expense was incurred. If possible, include a receipt showing the exchange rate on the date the claimed services were performed.

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. 79.
79 Page 80 81
2003 GEHA 77 Section 8
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your claim or request for services, drugs, or supplies including a request for preauthorization/ prior approval:

Step Description
1 Ask us in writing to reconsider our initial decision. You must: (a) Write to us within 6 months from the date of our decision; and
(b) Send your request to us at: GEHA, P. O. Box 4665, Independence, MO 64051-4665; and
(c) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure; and

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

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

request go to step 3.

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

4 If you do not agree with our decision, you may ask OPM to review it. You must write to OPM within:
90 days after the date of our letter upholding our initial decision; or
120 days after you first wrote to us --if we did not answer that request in some way within 30 days; or
120 days after we asked for additional information.

Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Health Benefits Contracts Division II, 1900 E Street, NW, Washington, D. C. 20415-3620. 80.
80 Page 81 82
2003 GEHA 78 Section 8
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.

5 OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct. OPM will send you a final decision within 60 days. There are no other administrative appeals.
If you do not agree with OPM's decision, your only recourse is to sue. If you decide to sue, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received
the disputed services, drugs, or supplies or from the year in which you were denied precertification or prior approval. This is the only deadline that may not be extended.

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

NOTE: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and
(a) We haven't responded yet to your initial request for care or preauthorization/ prior approval, then call us at (800) 821-6136 and we will expedite our review; or
(b) We denied your initial request for care or preauthorization/ prior approval, then:
If we expedite our review and maintain our denial, we will inform OPM so that they can give your claim expedited treatment too, or

You may call OPM's Health Benefits Contracts Division II at 202/ 606-3818 between 8 a. m. and 5 p. m. eastern time. 81.
81 Page 82 83
2003 GEHA 79 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 have coverage or auto insurance under another group health plan or have automobile insurance that pays
health care expenses without regard to fault. This is called "double coverage."

When you have double coverage, one plan normally pays its benefits in full as the primary payer and the other plan pays a reduced benefit as
the secondary payer. We, like other insurers, determine which coverage is primary according to the National Association of Insurance
Commissioners' guidelines.
When we are the primary payer, we will pay the benefits described in this brochure.

When we are the secondary payer, we will determine our allowance. After the primary plan pays, we will pay what is left of our allowance,
up to our regular benefit. We will not pay more than our allowance. There is no change in benefit limits or maximums when we are the
secondary payer.

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

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

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

Social Security check or your retirement check.
If you are eligible for Medicare, you may have choices in how you get your health care. Medicare + Choice is the term used to describe the

various health plan choices available to Medicare beneficiaries. The information in the next few pages shows how we coordinate benefits
with Medicare, depending on the type of Medicare + Choice plan you have. 82.
82 Page 83 84

2003 GEHA 80 Section 9
The Original Medicare Plan The Original Medicare Plan (Original Medicare) is available (Part A or Part B) everywhere in the United States. It is the way everyone used to get
Medicare benefits and is the way most people get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist, or
hospital that accepts Medicare. The Original Medicare Plan pays its share and you pay your share. Some things are not covered under
Original Medicare, like prescription drugs.
When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care.

Claims process when you have the Original Medicare Plan You probably will never have to file a claim form when you have both our
Plan and the Original Medicare Plan.
When we are the primary payer, we process the claim first.
When Original Medicare is the primary payer, Medicare processes your claim first. In most cases, your claim will be coordinated

automatically and we will then provide secondary benefits for covered charges. When Medicare does not cover the charge, we
will determine our Plan allowable and pay our benefit up to that amount. You will not need to do anything. To find out if you need
to do something to file your claim, call us at (800) 821-6136 or visit our web site at www. geha. com.

We waive some costs if the Original Medicare Plan is your primary payer --We will waive some out-of-pocket costs, as follows:
Inpatient Hospital Benefits: If you are enrolled in Medicare Part A, we waive the deductible and coinsurance
Medical and Surgery Benefits and Mental Health/ Substance Abuse care: If you are enrolled in Medicare Part B, we waive the
deductible and coinsurance.
Office Visits PPO Providers: If you are enrolled in Medicare Part B, we waive the copayments for PPO office visits.

Prescription Drugs: If you have Medicare Parts A and B, you will pay a copayment for drugs through the Home Delivery Pharmacy
service and at retail pharmacies as shown on page 66.
Chiropractic Benefits: There is no change in benefit limits or maximums for chiropractic care when Medicare is primary. See

page 32 for benefits.
Physical, Speech and Occupational Therapy Benefits: There is no change in benefit limits or maximums for therapy when

Medicare is primary. 83.
83 Page 84 85
2003 GEHA 81 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) Areanactiveemployee withtheFederalgovernment (includingwhenyouor afamilymemberare eligibleforMedicaresolely becauseofadisability), .

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

4) Are a Federal judge who retired under title 28, U. S. C., or a Tax Court judge who retired under Section 7447 of title 26, U. S. C. (or if
your covered spouse is this type of judge), .
5) Are enrolled in Part B only, regardless of your employment status, . (for Part B
services)

.
(for other services)

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

.
(except for claims related to Workers'

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

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

b) Are an active employee, .

c) Are a former spouse of an annuitant, .
d) Are a former spouse of an active employee. . 84.
84 Page 85 86

2003 GEHA 82 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. 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 enroll in a
Medicare managed care plan, tell us. We will need to know whether you are in the Original Medicare Plan or in a Medicare managed care
plan so we can correctly coordinate benefits with Medicare.
Suspended FEHB coverage to enroll in a Medicare managed care plan: If you are an annuitant or former spouse, you can suspend your
FEHB coverage to enroll in a Medicare managed care plan, eliminating your FEHB premium. (OPM does not contribute to your Medicare
managed care plan premium). For information on suspending your FEHB enrollment, contact your retirement office. If you later want to
re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage or move out
of the Medicare managed care plan's service area.
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 Original

Medicare. Should you sign an agreement, neither you nor the physician can bill Medicare. 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 Original Medicare's payment.
You will be financially responsible for the entire balance following any payment we make.

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

TRICARE 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 85.
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2003 GEHA 83 Section 9
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 re-enroll in the FEHB Program,
generally you may do so only at the next Open Season unless you involuntarily lose coverage under the program.

Workers' Compensation We do not cover services that:
you need because of a workplace-related illness or injury that the Office of Workers' Compensation Programs (OWCP) or a similar
Federal or State agency determines they must provide; or
OWCP or a similar agency pays for through a third party injury settlement or other similar proceeding that is based on a claim you

filed under OWCP or similar laws.
Once OWCP or similar agency pays its maximum benefits for your treatment, we will cover your care.

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 We do not cover services and supplies when a local, State, are responsible for your care or Federal Government agency directly or indirectly pays for them.
When others are responsible If you or a dependent suffer injuries in an accident or become ill for injuries because of another person's act or omission, and you later receive
compensation from that person and/ or your own or other insurance, you are required to refund GEHA. We will make conditional payments,
subject to our contractual benefits. Included in GEHA's lien are any services and supplies to diagnose or treat the injuries or illness. You
are required to reimburse GEHA for the benefit payments even if the total compensation received is not sufficient to compensate you or your
dependent for the damages sustained. In other words, unless we agree otherwise in writing, you are bound to reimburse the Plan in full even if
you are not "made whole" for all of the damages by the compensation. GEHA's lien is not subject to reduction for attorney's fees or costs
under the "common fund" doctrine without GEHA's written consent.
GEHA enforces our right of reimbursement by asserting a lien against any and all compensation that you or your dependent receive, whether
by court order or out-of-court settlement, and regardless of how that compensation is characterized, such as "pain and suffering". GEHA's
lien includes payments from any source, including Medpay, Personal Injury Protection, no-fault coverage, third-party, and uninsured and
underinsured motorists coverage. You must cooperate with GEHA by promptly notifying our subrogation unit when you or a dependent file a
claim against some other person( s) for compensation. You must supply 86.
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2003 GEHA 84 Section 9
GEHA with all relevant information relating to the claim, and sign any releases GEHA requires to obtain information about that claim from
other sources. You must promptly disclose to GEHA all information relating to any settlement or recovery received. In addition, you must:
accept GEHA's lien for the full amount of the benefits paid; assign any proceeds from third-parties, your own, or other insurance to GEHA
when asked to do so; and sign a Reimbursement Agreement if asked by GEHA to do so. However, a Reimbursement Agreement is not
necessary to enforce the lien. The lien extends to all related expenses incurred prior to the settlement or judgment date, whether or not those
expenses were submitted in a timely manner to GEHA. Related expenses incurred after all settlements are not included in the lien. In
short, GEHA is entitled to be reimbursed for all benefits paid for medical care resulting from the injury or illness through the date of
settlement of your claim, unless we agree in writing to accept less than 100% of the lien. The lien remains the member's obligation until it is
satisfied in full. Failure to reimburse GEHA or cooperate with our reimbursement efforts may result in an overpayment that can be
collected from you or any dependent.

Please contact GEHA's Subrogation unit at (800) 821-4742, Ext. 5503, or Ext. 5735, to report your claim or discuss this process. 87.
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2003 GEHA 85 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. Also included are animal
bites, poisonings, and dental care required to repair injuries to sound natural teeth as a result of an accidental injury, not from biting or
chewing.

Admission The period from entry (admission) into a hospital or other covered facility until discharge. In counting days of inpatient care, the date of
entry and the date of discharge are counted as the same day.

Assignment An authorization by an enrollee or spouse for the Plan to issue payment of benefits directly to the provider. The Plan reserves the right to pay
the member 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.

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 15-16.

Congenital anomaly A condition existing at or from birth which is a significant deviation from the common form or norm. For purposes of this Plan, congenital
anomalies include cleft lips, cleft palates, birthmarks, webbed fingers or toes and other conditions that the Plan may determine to be
congenital anomalies. Surgical correction of congenital anomalies is limited to children under the age of 18 unless there is a functional
deficit. In no event will the term congenital anomaly include conditions relating to teeth or intra-oral structures supporting the teeth.

Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 15.
Cosmetic Any procedure or any portion of a procedure performed primarily to improve physical appearance and/ or treat a mental condition through
change in bodily form.

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 could be rendered safely and reasonably by a
person not medically skilled, or that are designed mainly to help the patient with daily living activities. These activities include but are not
limited to: (1) personal care such as help in: walking; getting in and out of bed;
bathing; eating by spoon, tube or gastrostomy; exercise; 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 88.
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2003 GEHA 86 Section 10
(6) treatment or services that any person may be able to perform with minimal instruction, including but not limited to recording
temperature, pulse, and respirations, or administration and monitoring of feeding systems.

The Carrier determines which services are custodial care. (Custodial care that lasts 90 days or more is sometimes known as long term care.)

Deductible A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits
for those services. See page 15.

Durable medical equipment Equipment and supplies that:
(1) are prescribed by your attending doctor; (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.

Effective date The date the benefits described in this brochure are effective:
(1) January 1 for continuing enrollments and for all annuitant enrollments;
(2) the first day of the first full pay period of the new year for enrollees who change plans or options or elect FEHB coverage
during the open season for the first time; or (3) for new enrollees during the calendar year, but not during the open
season, the effective date of enrollment as determined by the employing office or retirement system.

Elective surgery Any non-emergency surgical procedure that may be scheduled at the patient's convenience without jeopardizing the patient's life or causing
serious impairment to the patient's bodily functions.

Expense An expense is "incurred" on the date the service or supply is rendered.
Experimental or A drug, device, or biological product is experimental or investigational investigational services 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.
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. 89.
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2003 GEHA 87 Section 10
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 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 medical treatment or procedure.
Determination of experimental/ investigational status may require review of appropriate government publications such as those of the
National Institute of Health, National Cancer Institute, Agency for Health Care Policy and Research, Food and Drug Administration, and
National Library of Medicine. Independent evaluation and opinion by Board Certified Physicians who are professors, associate professors, or
assistant professors of medicine at recognized United States Medical Schools may be obtained for their expertise in subspecialty areas.

Group health coverage Health care coverage that a member or covered dependent is eligible for because of employment by, membership in, or connection with, a
particular organization or group that provides payment for hospital, medical, dental or other health care services or supplies, including
extension of any of these benefits through COBRA.

Infertility The inability to conceive after a year of unprotected intercourse or the inability to carry a pregnancy to term.

Intensive day treatment Outpatient treatment of mental condition or substance abuse rendered at and billed by a facility that meets the definition of a hospital.
Treatment program must be established which consists of individual or group psychotherapy and/ or psychological testing.

Medical necessity Services, drugs, supplies or equipment provided by a hospital or covered provider of the health care services that the Plan determines:
(1) are appropriate to diagnose or treat the patient's condition, illness or injury;
(2) are consistent with standards of good medical practice in the United States;
(3) are not primarily for the personal comfort or convenience of the patient, the family, or the provider,
(4) are not a part of or associated with the 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 a covered provider has prescribed, recommended, or approved a service, supply, drug or equipment does not, in itself, make
it medically necessary. 90.
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2003 GEHA 88 Section 10
Mental health/ Conditions and diseases listed in the most recent edition of the Substance abuse International Classification of Diseases (ICD) as psychoses, neurotic
disorders, or personality disorders; other nonpsychotic mental disorders listed in the ICD, to be determined by the Plan; or disorders listed in
the ICD requiring treatment for abuse or dependence upon substances such as alcohol, narcotics, or hallucinogens.

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. We determine our Plan allowance as follows:

We consult standard industry guides, such as national databases of prevailing health care charges from Ingenix and Medical Data
Resource. We use the 70th percentile. This means that out of every 100 reports, 30 charges billed may be more, but 70 charges will be the
allowed amount or less. Charges determined in this way include, but are not limited to, ambulatory surgery centers, surgery, doctor's
services, physical therapy, speech therapy, occupational therapy, lab testing and X-ray expenses; and under the Standard Option diagnostic
and preventive dental services.
Charges for some Plan allowances are stated in this brochure. These include limited benefits such as chiropractic care and routine dental care.

Some Plan allowances may be submitted to medical consultants who recommend allowances based on special industry guidelines. We may also
conduct independent surveys to determine the usual cost of a service or supply in a geographic area.

If we negotiate a reduced fee amount on an individual claim for services or supplies which is lower than the Plan allowance, covered benefits will be
limited to the negotiated amount. Your coinsurance will be based on the reduced fee amount. If you choose to use a provider other than the one we
negotiated a reduction with, you will be responsible for the difference in these amounts.

Our PPO allowances are negotiated with each provider who participates in the network. PPO allowances may be based on a standard reduction or on a
negotiated fee schedule. For these allowances, the PPO provider has agreed to accept the negotiated reduction and you are not responsible for this discounted
amount. In these instances, the benefit paid plus your coinsurance equals payment in full.

For more information, see Differences between our allowance and the bill in Section 4.

Primary care physician For purposes of the office visit copayment for the Standard Option benefits, primary care physicians are individual doctors (M. D. or D. O.)
whose medical practice is limited to Family/ General Practice, Internal Medicine, Pediatrics/ Adolescent Medicine or Obstetrics/ Gynecology
(OB/ Gyn). Doctors listed in provider directories or advertisements under any other medical specialty or sub-specialty area (such as
Internal Medicine doctors also listed under Cardiology or Geriatrics, or Pediatric sub-specialties such as Pediatric Allergy) are considered
specialists, not primary care physicians. Chiropractors, eye doctors, dentists, audiologists, and mental health/ substance abuse providers are
not considered primary care physicians. 91.
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2003 GEHA 89 Section 10
Sound natural tooth Sound and Natural Tooth is a whole or properly restored tooth that has no condition that would weaken the tooth, or predispose it to injury,
prior to the accident, such as decay, periodontal disease, or other impairments. For purposes of the Plan, damage to a restoration, such as
a prosthetic crown or prosthetic dental appliances (i. e. bridgework), would not be covered as there is no injury to the natural tooth structure.

Us/ We Us and we refer to Government Employees Hospital Association, Inc.
You You refers to the enrollee and each covered family member. 92.
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2003 GEHA 90 Section 11
Section 11. FEHB facts
No pre-existing condition We will not refuse to cover the treatment of a condition that you had limitation before you enrolled in this Plan solely because you had the condition
before you enrolled.

Where you can get information See www. opm. gov/ insure. Also, your employing or retirement office about enrolling in the can answer your questions and give you a Guide to Federal Employees

FEHB Program Health Benefits Plans, brochures for other plans, and other materials you need to make an informed decision about 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 Self Only coverage is for you alone. Self and Family coverage is for for you and your family you, your spouse, and your unmarried dependent children under age 22,
including any foster children or stepchildren your employing or retirement office authorizes coverage for. Under certain circumstances,
you may also continue coverage for a disabled child 22 years of age or older who is incapable of self-support.

If you have a Self Only enrollment, you may change to a Self and Family enrollment if you marry, give birth, or add a child to your family. You
may change your enrollment 31 days before to 60 days after that event. The Self and Family enrollment begins on the first day of the pay period
in which the child is born or becomes an eligible family member. When you change to Self and Family because you marry, the change is effective
on the first day of the pay period that begins after your employing office receives your enrollment form; benefits will not be available to your
spouse until you marry.
Your employing or retirement office will not notify you when a family member is no longer eligible to receive health benefits, nor will we.
Please tell us immediately when you add or remove family members from your coverage for any reason, including divorce, or when your child
under age 22 marries or turns 22.
If you or one of your family members is enrolled in one FEHB plan, that person may not be enrolled in or covered as a family member by another
FEHB plan. 93.
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2003 GEHA 91 Section 11
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; 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 The benefits in this brochure are effective on January 1. If you joined this premiums start 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.

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). 94.
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2003 GEHA 92 Section 11
When you lose benefits
When FEHB coverage ends You will receive an additional 31 days of coverage, for no additional premium, when:

Your enrollment ends, unless you cancel your enrollment, or
You are a family member no longer eligible for coverage.
You may be eligible for spouse equity coverage or Temporary Continuation of Coverage.

Spouse equity If you are divorced from a Federal employee or annuitant, you may not coverage continue to get benefits under your former spouse's enrollment. This is
the case even when the court has ordered your former spouse to supply health 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 If you leave Federal service, or if you lose coverage because you no of Coverage (TCC) 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 You may convert to a non-FEHB individual policy if: individual coverage
Your coverage under TCC or the spouse equity law ends (If you canceled your coverage or did not pay your premium, you cannot
convert);
You decided not to receive coverage under TCC or the spouse equity law; or

You are not eligible for coverage under TCC or the spouse equity law.

If you leave Federal service, your employing office will notify you of your right to convert. You must apply in writing to us within 31 days
after you receive this notice. However, if you are a family member who is losing coverage, the employing or retirement office will not notify
you. You must apply in writing to us within 31 days after you are no longer eligible for coverage. 95.
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2003 GEHA 93 Section 11
Your benefits and rates will differ from those under the FEHB Program; however, you will not have to answer questions about your health and we
will not impose a waiting period or limit your coverage due to pre-existing conditions.

Getting a Certificate of The Health Insurance Portability and Accountability Act of 1996 Group Health Plan Coverage (HIPAA) is a Federal law that offers limited Federal protections for
health coverage availability and continuity to people who lose employer group coverage. If you leave the FEHB Program, we will give you a
Certificate of Group Health Plan Coverage that indicates how long you have been enrolled with us. You can use this certificate when getting
health insurance or other health care coverage. Your new plan must reduce or eliminate waiting periods, limitations, or exclusions for health-related
conditions based on the information in the certificate, as long as you enroll within 63 days of losing coverage under this Plan. If you have
been enrolled with us for less than 12 months, but were previously enrolled in other FEHB plans, you may also request a certificate from
those plans.
For more information, get OPM pamphlet RI 79-27, Temporary Continuation of Coverage (TCC) under the FEHB Program. See also the
FEHB web site (www. opm. gov/ insure/ health); refer to the "TCC and HIPAA" frequently asked questions. These highlight HIPAA rules, such
as the requirement that Federal employees must exhaust any TCC eligibility as one condition for guaranteed access to individual health
coverage under HIPAA, and have information about Federal and State agencies you can contact for more information. 96.
96 Page 97 98

2003 GEHA 94 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. 97.
97 Page 98 99
2003 GEHA 95 Index
Index Do not rely on this page; it is for your convenience and may not show all pages where the terms appear.
Accidental injury 38, 50-51, 85 Abortion 24, 73
Allergy tests 26 Allogeneic (donor) bone marrow
transplant 39 Alternative treatment 33
Ambulance 49, 51-52 Ambulatory surgical center 10, 47
Anesthesia 42 Artificial insemination 25
Assignment 85 Assisted reproductive technology 25
Autologous bone marrow Transplant 39

Biopsies 35 Blood and blood plasma 44, 45, 47
Breast cancer screening 23 Breast Prosthesis 30

Calendar year Deductible 15, 56, 59
Cardiac Rehabilitation 26, 27, 47 Casts 44, 47
Catastrophic protection out-of-pocket maximum 16, 17, 56, 59
Changes for 2003 8, 9 Chemotherapy 26, 41, 42
Childbirth 24, 45, 46, 47, 88 Children's Equity Act 91
Chiropractic 32 Cholesterol tests 23
Circumcision 24 Claims 75, 76
Coinsurance 15, 85 Colorectal cancer screening 23
Congenital anomalies 35, 37, 85 Contact lenses 29
Contraceptive devices and drugs 25, 61
Conversion 92 Coordination of benefits 79-82
Cosmetic surgery 37, 85 Cost containment 12, 13, 14
Covered charges 85 Covered facility 10, 11
Covered providers 10 Crutches 30
Custodial care 32, 85-86
Days certified 12, 13 Deductible 15, 56, 59, 86
Definitions 85-89 Dental care 69, 70
Diabetic supplies 61, 64 Diagnostic services 21, 22, 54

Disputed claims review 77, 78 Donor expenses (transplants) 39, 40, 42
Dressings 44, 45, 47 Durable medical equipment 30, 31, 86

Educational classes and programs 33 Effective date of enrollment 86
Emergency 22, 50, 51, 52 Environmental medicine 26, 33
Experimental or investigational 86-87 Eye exams 23, 29
Eyeglasses 29
Family limit 15, 56, 59 Family planning 25
Fecal occult blood test 23 Flexible benefits option 68
Foot care 29 Fraud 5
Freestanding ambulatory facilities 10, 47

Gamete intrafallopian transfer (GIFT) 25
General exclusions 73, 74
Hearing services 28 Home health services 31, 32
Home uterine devices 24 Hospice care 11, 48
Home delivery pharmacy service 61 67
Home nursing care 31, 32 Hospital 11, 12, 43-47

Immunizations 23 Impacted teeth 38
Incidental procedures 36 Infertility 25, 87
Inhospital physician care 22, 54, 58 Inpatient Hospital Benefits 44-46
Insulin 61, 64 Intensive day treatment 57, 87

Laboratory and pathological services 22
Lifetime maximums 29, 31, 57, 58 Long Term Care 94

Magnetic Resonance Imagings (MRIs) 14, 22
Mammograms 23 Maternity Benefits 13, 24, 45, 46, 47
Medicaid 83 Medical necessity 87
Medically underserved area 10

Medicare 18, 19, 79, 80, 81, 82 Members 4, 89
Mental Health/ Substance Abuse Benefits 53-60, 88

Newborn care 23, 24 No-fault 79, 83
Non-FEHB Benefits 71, 72 Nurse
Licensed Practical Nurse 31 Nurse Anesthetist 10
Nurse Midwife 10 Nurse Practitioner 10
Registered Nurse 31 Nursery charges 24, 45
Nursing School Administered Clinic 10

Obstetrical care 24 Occupational therapy 27
Ocular injury 29 Office visits 21
Oral and maxillofacial surgery 38 Oral contraceptives 61, 64
Organ/ tissue transplant 39, 40, 41, 42
Orthopedic devices 30 Ostomy and catheter supplies 61
64 Out-of-pocket expenses 15, 16,
17, 56, 59 Outpatient facility care 47
Overseas claims 76 Oxygen 30, 44, 45, 47

Pap test 22, 23 Physical examination 21
Physical therapy 27 Physician 10, 88
Plan allowance 16, 88 Pre-admission testing 47
Precertification 12, 13, 14, 43, 53, 57
Preferred Provider Organization (PPO) 6, 16, 17
Prescription drugs 61-67 Preventive care, adult 23
Preventive care, children 23 Prior approval 14
Private room 44, 54 Prostate cancer screening 23
Prosthetic devices 30, 37 Psychologist 10, 54
Psychotherapy 54, 58 98.
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2003 GEHA 96 Index
Radiation therapy 26 Renal dialysis 26
Room and board 44, 45, 46, 48 Routine services 23

Second surgical opinion 21, 41 Sigmoidoscopy 23
Skilled nursing facility care 27, 28, 48 Smoking cessation 33
Social Worker 10, 54 Speech therapy 28
Splints 44 Sterilization procedures 25, 36
Subrogation 83, 84 Substance abuse 53-60, 88
Surgery 34 Anesthesia 42
Assistant surgeon 35 Multiple procedures 36
Oral 38 Reconstructive 35, 37
Syringes 61, 64
Temporary continuation of coverage 92 Temporomandibular Joints 38, 74
Transplants 39-42 Treatment therapies 26, 27

Vision services 23, 29, 31, 71 Vitamins 71
Well child care 23 Wheelchairs 30
Workers' compensation 83
X-rays 22, 44, 45, 47, 69 99.
99 Page 100 101
2003 GEHA 97 Summary
Summary of benefits for GEHA 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 $450 calendar year deductible. And, after we pay, you generally pay any difference between our allowance and the billed amount if you use a Non-PPO physician or
other health care professional.
Benefits You Pay Pages
Medical services provided by physicians: Diagnostic and treatment services

provided in the office ..
PPO: $10 copay primary care physician; $25 copay specialist for covered office visits and 15%* of other
covered professional services including X-ray and lab
Non-PPO: 35%* of covered professional services

21-42

Services provided by a hospital: Inpatient ..
Outpatient .
PPO: 15%* of covered hospital charges
Non PPO: 35%* of covered hospital charges
43-49

Emergency benefits: Accidental injury
Medical emergency
other professional services

Nothing up to plan allowance of covered charges incurred within 72 hours of an accident
Regular benefits*
50-52

Non-network pharmacy: Member pays $5 for generic drugs/ 50% brand name and any difference between our
allowance and the cost of the drug.
By mail: Member pays $15 for generic drugs/ 50% brand name for 90-day supply

61-67

Dental Care ... 50% up to plan allowance for diagnostic and preventive services and charges in excess of the scheduled amounts for
restorations and extractions
69-70

Special features: Flexible benefits option, services for deaf and hearing impaired, high-risk pregnancies 68
Protection against catastrophic costs (your catastrophic protection out-of-

pocket maximum)
Nothing after $4000/ Self Only or $4,500/ Family enrollment per year for PPO providers;

Nothing after $5,000/ Self Only or $5,500/ Family enrollment per year for Non-PPO providers.
Some costs do not count toward this protection

16-17 100.
100 Page 101 102
2003 GEHA 98 Summary
Summary of benefits for GEHA High 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 $350 calendar year deductible. And, after we pay, you
generally pay any difference between our allowance and the billed amount if you use a Non-PPO physician or other health care professional.

Benefits You Pay Pages
Medical services provided by physicians: Diagnostic and treatment services

provided in the office .
PPO: $20 copay per covered office visit and 10%* of other covered professional services including x-ray and lab

Non-PPO: 25%* of covered professional services
21-42

Services provided by a hospital: Inpatient .
Outpatient*
PPO: Nothing for room and board, 10% of other hospital charges, inpatient $100 per admission deductible applies

Non-PPO: Nothing for room and board, 25% of other hospital charges, inpatient $300 per admission deductible
applies

43-49

Emergency benefits: Accidental injury
Medical emergency
other professional services .

Nothing up to plan allowance of covered charges incurred within 72 hours of an accident
Regular benefits*
50-52

Mental health and substance abuse treatment .. In-Network: Regular cost sharing Out-of-Network: Benefits are limited 53-60
Prescription drugs Network pharmacy: Member pays $5 for generic drugs/$ 20 single-source brand name/$ 35 multi-source brand name for
up to 30 day supply for the initial fill and first refill. Subsequent fills are the greater of 50% or the copays listed
above.
Non-network pharmacy: Member pays $5 for generic drugs/$ 20 single-source brand name/$ 35 multi-source brand

name for up to a 30 day supply for the initial fill and first refill and any difference between our allowance and the cost
of the drug. Subsequent fills are the greater of 50% or the copays listed above and any difference between our
allowance and the cost of the drugs.
By mail: Member pays $10 for generic drugs/ $40 single-source brand name/$ 55 multi-source brand name for 90-day

supply.

61-67

Dental Care .. Charges in excess of the scheduled amounts for diagnostic and preventive services, restorations, and extractions 69-70
Special features: Flexible benefits option, services for deaf and hearing impaired, high-risk pregnancies 68
Protection against catastrophic costs (your catastrophic protection out-of-

pocket maximum)
Nothing after $3,000/ Self Only or $3,500/ Family enrollment per year for PPO providers;

Nothing after $4,000/ Self Only or $4,500/ Family enrollment per year for Non PPO providers.
Some costs do not count toward this protection

16-17 101.
101 Page 102
2003 Rate Information for Government Employees Hospital Association, Inc. (GEHA)
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

High Option
Self Only 311 $109.30 $67.17 $236.82 $145.53 $129.03 $47.44

High Option
Self and Family 312 $249.62 $134.44 $540.84 $291.29 $294.70 $89.36

Standard Option
Self Only 314 $82.50 $27.50 $178.75 $59.58 $97.63 $12.37

Standard Option
Self and Family 315 $187.50 $62.50 $406.25 $135.42 $221.88 $28.12 102.

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