Pages 1--72 from Foreign Service Benefit Plan

Foreign Service Benefit Plan

Federal Employees Health Benefits Program
2003 Plan Brochure
Accessible Version

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

Foreign Service Benefit Plan 2003
Sponsored and administered by: American Foreign Service Protective Association
Who may enroll in this Plan: You must be, or become, a member of the American Foreign Service Protective Association.
To become a member: When you enroll in the Foreign Service Benefit Plan, you automatically become a member of the Protective Association. New membership in the Protective Association is
limited to American Foreign Service personnel and direct hire employees (i. e., eligible for FEHB insurance) working for (1) the Department of State (2) the Department of Defense (3) the Agency
for International Development (4) the Foreign Commercial Service (5) the Foreign Agricultural Service; and to Executive Branch civilian employees assigned overseas or to U. S. possessions and
territories; and the direct hire domestic employees assigned to support those activities.
Direct hire employees and Executive Branch civilian employees must enroll in the Health Plan when actively employed in order to retain or choose the Plan in retirement. Only annuitants who are
eligible under the Foreign Service Retirement System may enroll under this Plan as annuitants.
Membership dues: There are no membership dues. Membership is for life.
Enrollment codes for this Plan:
401 High Option -Self Only 402 High Option -Self and Family

RI 72-001

A fee-for-service plan with a preferred provider organization
http:// www. afspa. org

Mutual of Omaha Insurance Company, the underwriter for the FOREIGN SERVICE
BENEFIT PLAN, has received accreditation from URAC (also known as the American Accreditation
Healthcare Commission) for Health Utilization Manage-ment Standards. See the 2003 Guide for more informa-tion
on accreditation.

For changes
in benefits see page 7. 1.
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

Page 2 3
2.
2 Page 3 4

Notice of the Office of Personnel Management's Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW
IT CAREFULLY.
By law, the Office of Personnel Management (OPM), which administers the Federal Employees Health Benefits (FEHB) Program, is required to protect the privacy of your personal medical information. OPM is also required to give you this notice to

tell you how OPM may use and give out (" disclose") your personal medical information held by OPM.
OPM will use and give out your personal medical information:
To you or someone who has the legal right to act for you (your personal representative), To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is protected,

To law enforcement officials when investigating and/ or prosecuting alleged or civil or criminal actions, and Where required by law.

OPM has the right to use and give out your personal medical information to administer the FEHB Program. For example:
To communicate with your FEHB health plan when you or someone you have authorized to act on your behalf asks for our assistance regarding a benefit or customer service issue.

To review, make a decision, or litigate your disputed claim. For OPM and the General Accounting Office when conducting audits.

OPM may use or give out your personal medical information for the following purposes under limited circumstances:
For Government healthcare oversight activities (such as fraud and abuse investigations), For research studies that meet all privacy law requirements (such as for medical research or education), and

To avoid a serious and imminent threat to health or safety.
By law, OPM must have your written permission (an "authorization") to use or give out your personal medical information for any purpose that is not set out in this notice. You may take back (" revoke") your written permission at any time, except if OPM

has already acted based on your permission.
By law, you have the right to:
See and get a copy of your personal medical information held by OPM. Amend any of your personal medical information created by OPM if you believe that it is wrong or if information is

missing, and OPM agrees. If OPM disagrees, you may have a statement of your disagreement added to your personal medical information.
Get a listing of those getting your personal medical information from OPM in the past 6 years. The listing will not cover your personal medical information that was given to you or your personal representative, any information that you
authorized OPM to release, or that was given out for law enforcement purposes or to pay for your health care or a disputed claim.
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. 3.
3 Page 4 5

Table of Contents
2003 Foreign Service Benefit Plan 2 Table of Contents
Introduction .............................................................................................................................................................................................. 4
Plain Language......................................................................................................................................................................................... 4
Stop Health Care Fraud!......................................................................................................................................................................... 4-5
Section 1. Facts about this fee-for-service plan ................................................................................................................................... 6
Section 2. How we change for 2003 ..................................................................................................................................................... 7
Section 3. How you get care ............................................................................................................................................................. 8-11
Identification cards ............................................................................................................................................................... 8
Where you get covered care ................................................................................................................................................ 8
Covered providers ...................................................................................................................................................... 8-9
Covered facilities ........................................................................................................................................................ 9
What you must do to get covered care .......................................................................................................................... 10-11
How to get approval for .................................................................................................................................................. 10-11
Your hospital stay (precertification) ..................................................................................................................... 10-11
Other services .............................................................................................................................................................. 11
Section 4. Your costs for covered services ...................................................................................................................................... 12-16
Copayments ................................................................................................................................................................. 12
Deductible.................................................................................................................................................................... 12
Coinsurance ................................................................................................................................................................. 12
Differences between our allowance and the bill .................................................................................................. 12-14
Your catastrophic protection out-of-pocket maximum ....................................................................................................... 14
When government facilities bill us ...................................................................................................................................... 14
If we overpay you ................................................................................................................................................................ 14
When you are age 65 or over and you do not have Medicare .......................................................................................... 15
When you have Medicare .................................................................................................................................................... 16
Section 5. Benefits ............................................................................................................................................................................ 17-49
Overview ............................................................................................................................................................................... 17
(a) Medical services and supplies provided by physicians and other health care professionals ............................... 18-26
(b) Surgical and anesthesia services provided by physicians and other health care professionals............................ 27-30
(c) Services provided by a hospital or other facility, and ambulance services .......................................................... 31-34
(d) Emergency services/ accidents .................................................................................................................................. 35-36
(e) Mental health and substance abuse benefits ........................................................................................................... 37-42
(f) Prescription drug benefits ........................................................................................................................................ 43-46
(g) Special features .............................................................................................................................................................. 47
Flexible benefits option ............................................................................................................................................ 47
Centers of excellence for tissue and organ transplants .......................................................................................... 47
Disease management programs ................................................................................................................................ 47
(h) Dental benefits ............................................................................................................................................................... 48
(i) Non-FEHB benefits available to Plan members .......................................................................................................... 49 4.
4 Page 5 6

Section 6. General exclusions things we don't cover .................................................................................................................... 50
Section 7. Filing a claim for covered services ............................................................................................................................... 51-52
Section 8. The disputed claims process .......................................................................................................................................... 53-54
Section 9. Coordinating benefits with other coverage ................................................................................................................... 55-59
When you have other health coverage ..................................................................................................................... 55
What is Medicare? ................................................................................................................................................ 55-57
Medicare managed care plan ..................................................................................................................................... 58
TRICARE and CHAMPVA ...................................................................................................................................... 58
Workers' Compensation ............................................................................................................................................ 58
Medicaid ..................................................................................................................................................................... 59
When other Government agencies are responsible for your care ........................................................................... 59
When others are responsible for injuries .................................................................................................................. 59
Section 10. Definitions of terms we use in this brochure ............................................................................................................... 60-62
Section 11. FEHB facts ..................................................................................................................................................................... 63-65
Coverage information ..................................................................................................................................................... 63-64
No pre-existing condition limitation ......................................................................................................................... 63
Where you get information about enrolling in the FEHB Program ....................................................................... 63
Types of coverage available for you and your family............................................................................................. 63
Children's Equity Act ........................................................................................................................................... 63-64
When benefits and premiums start ........................................................................................................................... 64
When you retire ......................................................................................................................................................... 64
When you lose benefits .................................................................................................................................................. 64-65
When FEHB coverage ends ...................................................................................................................................... 64
Spouse equity coverage ............................................................................................................................................. 64
Temporary Continuation of Coverage (TCC) .......................................................................................................... 64
Converting to individual coverage ............................................................................................................................ 65
Getting a Certificate of Group Health Plan Coverage ............................................................................................. 65
Long term care insurance is still available ............................................................................................................................................. 66
INDEX...................................................................................................................................................................................................... 67
Summary of benefits ........................................................................................................................................................................... 68-69
Rates ........................................................................................................................................................................................... Back cover

2003 Foreign Service Benefit Plan 3 Table of Contents 5.
5 Page 6 7

2003 Foreign Service Benefit Plan 4 Introduction/ Plain Language/ Stop Health Care Fraud
Introduction
This brochure describes the benefits of the Foreign Service Benefit Plan under our contract (CS 1062) with the Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. This plan is underwritten by

Mutual of Omaha. The address for the Foreign Service Benefit Plan administrative offices is:
Foreign Service Benefit Plan Phone: 202/ 833-4910 1716 N Street, NW Fax: 202/ 833-4918
Washington, DC 20036-2902 E-mail: afspa@ afspa. org
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 page 7. Rates are shown at the end of this brochure.

Plain Language
All FEHB brochures are written in plain language to make them responsive, accessible, and understandable to the public. For instance,

Except for necessary technical terms, we use common words. For instance, "you" means the enrollee or family member; "we"
means the Foreign Service Benefit Plan.

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

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

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. 6.
6 Page 7 8
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 202/ 833-4910 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.

2003 Foreign Service Benefit Plan 5 Introduction/ Plain Language/ Stop Health Care Fraud 7.
7 Page 8 9

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 reside in a PPO area and use a PPO provider, you will receive covered services at reduced cost. Mutual of Omaha 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. Access our PPO directory either through Mutual of Omaha's web site, www. mutualofomaha. com, or as a link through our web site www. afspa. org or call 202/ 833-4910 for
information concerning the PPO. You can also go to our web page, which you can reach through the FEHB web site, www. opm. gov/ insure. Contact the Foreign Service Benefit Plan to request a PPO directory.

The non-PPO benefits are the standard benefits of this Plan. PPO benefits apply only when you use a PPO provider and reside in a PPO Network Area. Provider networks may be more extensive in some areas than others. We cannot guarantee the availability
of every specialty in all areas. The selection of PPO providers is solely Mutual of Omaha's responsibility. We cannot guarantee the continued participation of any specific provider. In the PPO Network Areas, if no PPO provider is available or you do not
use a PPO provider, the standard non-PPO benefits apply. Follow these procedures when you use a PPO provider in order to receive PPO benefits:

Verify with us that your address of record is in a PPO area. Our records must reflect that you reside in a PPO area;
Verify that the provider is in the PPO network when you make your appointment;
Present your PPO Identification Card at the time you visit your health care provider, confirming your PPO participation to be eligible for PPO benefits. If you do not present your PPO ID Card, the provider may not accept

our PPO discount; and
Do not pay a PPO provider at the time of service. PPO providers must bill us directly. We must reimburse the provider directly. PPO providers will bill you for any balance after our payment to them.

This Plan offers its members in certain areas the opportunity to reduce out-of-pocket expenses by choosing facilities and providers that participate in the Plan's Preferred Provider Organization (PPO). The following are considered PPO Network Areas:
The Washington, D. C. metropolitan area and certain areas in all states except for Hawaii, Vermont and Wyoming.
Consider the PPO cost savings when you review Plan benefits, and if you live in these areas, check with the Plan to find out which local facilities and providers are PPO providers. Check with your doctor to see if he or she has admitting privileges at a

PPO hospital.
How we pay providers
We generally reimburse our PPO providers based on an agreed-upon fee schedule. We do not offer them additional financial incentives based on care provided or not provided to you. Our standard provider agreements do not contain any contractual

provisions that include incentives to restrict the providers' ability to communicate with and advise you of any appropriate treatment options. Also, we have no compensation, ownership or other influential interests that are likely to affect provider advice
or treatment decisions.
We may, through a negotiated arrangement with some health care providers, apply a discount to Covered Services that you receive from any such health care provider.

To locate a provider from whom a discount may be available, call the number on your Identification Card.
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 web site (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. Years in existence and profit status The American Foreign Service Protective Association was established in 1929 and
was incorporated in 1941 as a 501( c)( 9) not-for-profit organization. The Foreign Service Benefit Plan is provided in conjunction with the Mutual of Omaha Insurance Company. The Mutual of Omaha Insurance Company was organized in 1909
as a mutual legal reserve system (private). Licensing and certification The Mutual of Omaha Insurance Company meets all State and Federal licensing and
certification requirements. Fiscal solvency, confidentiality and transfer of medical records The Mutual of Omaha Insurance Company meets all
requirements for fiscal solvency, confidentiality and transfer of medical records.
If you want more information about us, call 202/ 833-4910, or write to the Foreign Service Benefit Plan, 1716 N Street, NW, Washington, DC 20036-2902. You may also contact us by fax at 202/ 833-4918, by e-mail at afspa@ afspa. org or visit our web

site at www. afspa. org.

2003 Foreign Service Benefit Plan 6 Section 1 8.
8 Page 9 10
2003 Foreign Service Benefit Plan 7 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.

Changes to this Plan
Your share of the premium will increase by 4.9% for Self Only and 5.7% for Self and Family.
We have increased your benefits for members who reside overseas. When you reside overseas, we pay overseas providers at the PPO coinsurance rate for each respective benefit that has a PPO coinsurance. We have also eliminated the $200

copayment for overseas hospitals when you reside overseas (Sections 5( a) through 5( h)).
We have added to your PPO service area. In addition to the states that had PPO providers last year, portions of the following states are now also considered within the PPO service area: Alaska, Idaho, Kansas, Kentucky, Mississippi, Montana,

Nebraska, North Dakota and South Dakota (Section 1).
We have changed your cost for a 30-day supply of prescription drugs to 25% coinsurance with a $10 minimum for generic drugs and a $20 minimum for brand name drugs at network pharmacies; and for a 30 to 90-day supply of prescription drugs

to $20 for generic drugs and $40 for brand name drugs at Home Delivery (Section 5( f)).
We have increased your Preventive care, adult benefit to include one routine colonoscopy screening every 10 years for members age 50 and older subject to the calendar year deductible and appropriate coinsurance (Section 5( a)).

We have increased your Preventive care, adult benefit to include one routine Double Contrast Barium Enema (DCBE) every 5 years for members age 50 and older subject to the calendar year deductible and appropriate coinsurance (Section 5( a)).
We have increased your Preventive care, adult benefit to include one routine fasting lipoprotein profile test every 5 years for members age 20 and older subject to the calendar year deductible and appropriate coinsurance (Section 5( a)).
We have eliminated the Special Outpatient Care Benefit under Maternity benefits to comply with Federal law (Section 5( a)).
We now pay preadmission testing the same as other X-ray, laboratory, pathology and machine diagnostic tests (Section 5( a)).
We now pay X-ray, laboratory, pathology and machine diagnostic tests performed within 72 hours of outpatient surgery the same as other X-ray, laboratory, pathology and machine diagnostic tests (Section 5( a) and 5( c)).

We have removed the separate definition of a new period of confinement for Skilled Nursing Facilities and increased your coverage from 60 to 90 days per calendar year for precertified admissions; and from 30 to 45 days per calendar year for non-precertified
admissions (Section 5( c)).
We now pay your ambulance services as a result of an accident at the appropriate coinsurance levels not subject to the calendar year deductible (Section 5( d)).

We have removed the 72 hour time limit under your Accidental injury benefit and now pay at 100% of the Plan allowance for Emergency Room (ER) facility charges and the ER physician's charge or the initial physician's office visit for services
received due to an accidental injury (Section 5( d)).
We now pay day care (Mental health and substance abuse benefits) under the partial hospitalization benefit. We have also removed the 20-day per calendar year limitation for out-of-network members (Section 5( e)).

We now pay 100% of all charges up to $60 per visit for up to 50 visits per person per calendar year for inpatient individual therapy under your Mental health and substance abuse benefit for In-Network area non-PPO benefits (Section 5( e)).
We now pay 100% of $20 for 30 chiropractic visits per calendar year subject to the calendar year deductible (Section 5( a)).
We now pay 100% of $20 for 30 acupuncture visits per calendar year subject to the calendar year deductible (Section 5( a)).
We now administer your Smoking cessation benefit on a calendar year basis; and the Plan has increased the benefit so that you pay nothing for the first $100 of covered charges (Section 5( a)).

We have increased your benefits for Alveolectomy (Section 5( h)).
We no longer offer the Optum Nurseline due to underutilization. 9.
9 Page 10 11

2003 Foreign Service Benefit Plan 8 Section 3
Section 3. How you get care
Identification cards We will send you a combined Foreign Service Benefit Plan/ Medco Health Prescription Drug 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. Call us if you need to purchase prescriptions and have not received your card.
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 202/ 833-4910 or write to us at
1716 N Street, NW, Washington, DC 20036-2902. You may also request replacement cards through our web site: www. afspa. org.

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 reside in the PPO area and use our preferred providers, you will pay less.
Covered providers We consider the following to be covered providers when they perform covered services within the scope of their license or certification:

Physician Doctors of medicine (M. D.), osteopathy (D. O.), podiatric medicine (D. P. M.) and for certain specified services covered by this Plan, doctors of dental
surgery (D. D. S.), medical dentistry (D. M. D.), optometry (O. D.), chiropractic (D. C.), and Oriental Medicine (O. M. D.)

Qualified Clinical Psychologist An individual who has earned either a Doctoral or Masters Clinical Degree in psychology or an allied discipline and who is licensed
or certified in the state where services are performed (such as Licensed Professional Counselors).

Nurse Midwife A person who is certified by the American College of Nurse Midwives or is licensed or certified as a nurse midwife in states requiring licensure
or certification.
Nurse Practitioner / Clinical Specialist A person who
1) Has an active R. N. license in the United States;
2) Has a baccalaureate or higher degree in nursing; and
3) Is licensed or certified as a nurse practitioner or clinical nurse specialist in states requiring licensure or certification.

Clinical Social Worker A social worker who
1) Has a Masters or Doctoral degree in social work;
2) Has at least two years of clinical social work practice; and
3) In states requiring licensure, certification, or registration, is licensed, certified, or registered as a social worker where the services are rendered.

Nursing School Administered Clinic A clinic that is
1) Licensed or certified in the state where the services are performed; and
2) Provides ambulatory care in an outpatient setting primarily in rural or inner city areas where there is a shortage of physicians. Services billed by these clinics

are considered outpatient "office" services rather than facility charges.
Physician Assistant A person who is licensed, registered or certified in the state where services are performed. 10.
10 Page 11 12
Licensed Professional Counselor or Master's Level Counselor A person who is licensed, registered, or certified in the state where services are performed.
Audiologist A person who is licensed, registered or certified in the state where services are performed.
Licensed Acupuncturist (L. Ac.) An individual who has completed the required schooling and licensure to perform acupuncture in the state where services are
performed (see definition of acupuncture, Section 5( a)).
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:
Birthing Center A licensed facility that is equipped and operated solely to provide prenatal care, to perform uncomplicated spontaneous deliveries and to

provide immediate postpartum care.
Hospice Care Facility A facility providing Hospice Care Services that is appropriately licensed or certified as such under the law of the jurisdiction in which

it is located, and that:
1) Is certified (or is qualified and could be certified) under Medicare;
2) Is accredited by the Joint Commission on the Accreditation of Healthcare Organizations; or

3) Meets the standards established by the National Hospice Organization.
Hospital
1) An institution that is accredited as a hospital under the hospital accreditation program of the Joint Commission on Accreditation of Healthcare Organizations

(JCAHO); or
2) Any other institution that is operated pursuant to law, under the supervision of a staff of doctors and with 24-hour-a-day nursing services, and that is primarily

engaged in providing:
a) 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 under its control; or
b) Specialized inpatient medical care and treatment of sick or injured persons through medical and diagnostic facilities (including X-ray and

laboratory) on its premises, under its control, or through a written agreement with a hospital (as defined above) or with a specialized
provider of those facilities.
3) For inpatient and outpatient treatment of alcohol and drug abuse, the term hospital also includes a free-standing alcohol and drug abuse treatment

facility approved by the JCAHO.
In no event shall the term hospital include a convalescent nursing home or institution or part thereof that:

1) Is used principally as a convalescent facility, rest facility, nursing facility or facility for the aged;
2) Furnishes primarily domiciliary or custodial care, including training in the routines of daily living; or
3) Is operated as a school.
Skilled Nursing Facility An institution or that part of an institution, which provides convalescent skilled nursing care 24-hours-a-day and is classified as a
skilled nursing facility under Medicare.

2003 Foreign Service Benefit Plan 9 Section 3 11.
11 Page 12 13
2003 Foreign Service Benefit Plan 10 Section 3
What you must do to It depends on the kind of care you want to receive. You can go to any covered 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 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 specialist based on the above circumstances, you can continue 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 202/ 833-4910.
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;
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: You, your representative, your doctor, or your hospital must call us at 1-800/ 593-2354 at least seven days before admission.

If you have an emergency admission due to a condition that you reasonably believe puts your life in danger or could cause serious damage to bodily function, you, your
representative, the physician, 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;
Name of hospital, facility or home health agency; Name and phone number of admitting doctor; and
Number of planned days of hospital stay or care.
We will then tell the physician and/ or hospital the number of approved inpatient days and we will send written confirmation of our decision to you, your physician,

and the hospital. 12.
12 Page 13 14
2003 Foreign Service Benefit Plan 11 Section 3
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 within 2 business days for precertification of additional days for your baby.

If your hospital stay If your hospital stay including for maternity care needs to be extended, you, your needs to be extended: representative, your doctor or the hospital must ask us to approve the additional days.
What happens when you If no one contacts us, we will decide whether the hospital stay was medically do not follow the 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 hospital 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 covered 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 50 United States.
You have another group health insurance policy that is the primary payer for the hospital stay.

Your Medicare Part A is the primary payer for the hospital stay. Note: If you exhaust your Medicare hospital benefits and do not want to use your Medicare
lifetime reserve days or you have no Medicare lifetime reserve days left, then we will become the primary payer and you must precertify.

Other services Other services require precertification or prior authorization. You, your representative, your doctor, or treating facility must call us at 1-800/ 593-2354 at least seven days
before the admission or care, such as:
Home health care (see Section 5( a));
Hospice care (see Section 5( c));
Organ/ tissue transplants (see Section 5( b));
Skilled nursing facility admission (see Section 5( c)); and
Mental health and substance abuse treatment (see Section 5( e)).

If no one contacted us for specified services such as Home health care, Hospice care, Skilled nursing facility care or Mental health and substance abuse care, we will pay a

reduced benefit as referenced in the appropriate benefit section.
Note: We do not require precertification, preauthorization or concurrent review if you receive treatment outside of the United States or when Medicare Part A and/ or Part B,

or another group health insurance policy is the primary payer. Precertification, preauthorization and concurrent review is required, however, when Medicare or the
other group health insurance policy stops paying benefits for any reason. 13.
13 Page 14 15
2003 Foreign Service Benefit Plan 12 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 purchase prescriptions from the Medco Health Home Delivery Pharmacy Service by mail, you pay a copayment of $20 for generic or $40 for brand name

prescriptions.
When you are admitted to a non-PPO hospital or an Out-of-Network hospital, you pay $200 per person per hospital stay.

We do not reimburse you for copayments.
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. We do not
reimburse you for the deductible. Benefits paid by us do not count towards the deductible. Copayments and the amount you pay after coinsurance does not count
toward any deductible.
The calendar year deductible is $300 per person. Under a family enrollment, the deductible is satisfied for all family members when the combined covered expenses

applied to the calendar year deductible for family members reach $600. Expenses are "incurred" on the date on which the service or supply is received.

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.

Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care.
Example: You pay 10% of the Plan allowance for surgery performed by a PPO provider.

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.

For example, if your non-PPO physician ordinarily charges $100 for a service but routinely waives your 30% coinsurance, the actual charge is $70. We will pay $49
(70% of the actual charge of $70).
Differences between Our "Plan allowance" is the amount we use to calculate our payment for covered our allowance and services. Fee-for-service plans arrive at their allowances in different ways, so their
the bill 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.
When you live in the Plan's PPO area, you should use a PPO provider. The following two examples explain how we will handle your bill when you go to a PPO provider

and when you go to a non-PPO provider. When you use a PPO provider, the amount you pay is much less. 14.
14 Page 15 16
2003 Foreign Service Benefit Plan 13 Section 4
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. Here is an example about coinsurance: You live in one of our PPO areas and 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, 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. Follow these procedures when you use a PPO
provider in order to receive PPO benefits:
Verify with us that your address of record is in a PPO area;
When you phone for an appointment, verify that the physician or facility is still a PPO provider;

Present your PPO ID card confirming your PPO participation in order to receive PPO benefits; and
Do not pay a PPO provider at the time of service. PPO providers must bill us directly. We must reimburse the provider directly. PPO providers will
bill you for any balance after our payment to them.
Non-PPO providers, on the other hand, have no agreement to limit what they will bill you. For instance:

When you reside in the PPO network area and 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. If you have met
your deductible, you are responsible for your coinsurance, so you pay 30% of our $100 allowance ($ 30). 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.

When you reside outside of the PPO Network area you will pay your deductible and coinsurance plus any difference between our allowance and
charges on the bill. As in the example above, once you have met your deductible, you are responsible for your coinsurance. You will pay 20% of our allowance
($ 20) and the physician can bill you for the $50 difference between our allowance and his bill.

Overseas providers' charges are generally not subject to a Plan allowance. Similar to the PPO example above, when you reside overseas and you meet your deductible,
you are responsible for your coinsurance. You will pay just 10% of the charge ($ 15).

The following table illustrates the examples of how much you have to pay out-of-pocket for medical services from a PPO physician vs. a non-PPO physician vs. a
domestic Out-of-Network physician and vs. an overseas 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 Domestic Out-of-Network Overseas Physician Physician when you reside overseas
Physician's charge $150 $150 $150 $150
Our allowance We set it at: 100 We set it at: 100 We set it at: 100 We set it at: 150
We pay 90% of our allowance: 90 70% of our allowance: 70 80% of our allowance: 80 90% of our allowance: 135
You pay:
Coinsurance 10% of our allowance: 10 30% of our allowance: 30 20% of our allowance: 20 10% of our allowance: 15
+Difference up to charge? No: 0 Yes: 50 Yes: 50 No: 0
TOTAL YOU PAY 10 80 70 15 15.
15 Page 16 17
2003 Foreign Service Benefit Plan 14 Section 4
Regardless of the provider you choose, we subject benefits to all provisions of the Plan. Also, we do not supervise, control or guarantee the health care services of a
preferred provider or any other provider.

Your catastrophic protection For those services with coinsurance, we pay 100% of the Plan allowance for the out-of-pocket maximum for remainder of the calendar year when out-of-pocket expenses for coinsurance,
deductibles, coinsurance, and deductibles and inpatient hospital copayment in that calendar year exceed copayments $3,000 for Self Only and $3,500 for Self and Family enrollment (PPO and overseas
providers)
$4,000 for Self Only and $4,500 for Self and Family enrollment (non-PPO providers and Out-of-Network area providers).

This catastrophic protection out-of-pocket maximum is combined for medical/ surgical and mental health/ substance abuse.
The following cannot be counted toward catastrophic protection out-of-pocket expense:
Expenses in excess of Plan allowances, maximum benefit or visit limitations;
Expenses for dental care;
Any amounts you pay because benefits have been reduced for non-compliance with precertification or preauthorization requirements (see Section 3);

Coinsurance and copayments you pay for prescription drugs;
Expenses for prescriptions purchased at pharmacies in the 50 United States without using the Plan's combined Foreign Service Benefit Plan/ Medco Health Prescription

Drug Identification Card or purchased from a source other than the Plan's Medco Health Home Delivery Pharmacy Service; and

Non-covered services and supplies.
Lifetime maximums We have the following lifetime maximums:
We limit the Hospice benefit to $7,500 per person when you precertify hospice care and to $4,500 when you do not precertify.

We limit the Orthodontic benefit to $1,000 per person.
We limit diagnosis and treatment of infertility to a maximum benefit of $5,000.

When government facilities Facilities of the Department of Veterans Affairs, the Department of Defense, and the bill us 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. If we paid your claim in error for any reason, we shall make a diligent
effort to recover an overpayment to you from you or, if to the provider, from the provider. We may reduce subsequent benefit payments to you or to a provider on
behalf of the member to offset overpayments. 16.
16 Page 17 18
2003 Foreign Service Benefit Plan 15 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.
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 your deductibles and coinsurance; Medicare assignment for the claim and is a

PPO provider,
Participates with Medicare and is a non-PPO your deductibles, coinsurance, and any balance or Out-of-Network provider, up to the Medicare approved amount;

Does not participate with Medicare (PPO, your deductibles, coinsurance, and any balance non-PPO or Out-of-Network providers), 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 your physician or hospital can collect from you. If your physician or hospital tries to collect more than allowed by law, ask your 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. 17.
17 Page 18 19
2003 Foreign Service Benefit Plan 16 Section 4
When you have the We limit our payment to an amount that supplements the benefits that Medicare Original Medicare Plan would pay, under Medicare Part A (Hospital insurance) and Medicare Part B (Medical
(Part A, or Part B, or both) 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 you pay nothing for covered charges.

If your physician does not accept Medicare assignment, then you pay the difference between our payment combined with Medicare's payment and the charge.

Note: 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. 18.
18 Page 19 20

2003 Foreign Service Benefit Plan 17 Section 5
Section 5. Benefits OVERVIEW
(See page 7 for how our benefits changed this year and pages 68-69 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 by phone at 202/ 833-4910, e-mail at afspa@ afspa. org or at our web site at www. afspa. org.

(a) Medical services and supplies provided by physicians and other health care professionals ................................................... 18-26
Diagnostic and treatment services Hearing services (testing, treatment, and supplies) Lab, X-ray, and other diagnostic tests Vision services (testing, treatment, and supplies)

Preventive care, adult Foot care Preventive care, children Orthopedic and prosthetic devices
Maternity care Durable medical equipment (DME) Family planning Home health services
Infertility services Chiropractic Allergy care Alternative treatments
Treatment therapies Educational classes and programs Physical, occupational and speech therapies

(b) Surgical and anesthesia services provided by physicians and other health care professionals ............................................... 27-30
Surgical procedures Organ/ tissue transplants Reconstructive surgery Anesthesia

Oral and maxillofacial surgery
(c) Services provided by a hospital or other facility, and ambulance services .............................................................................. 31-34
Inpatient hospital Hospice care Outpatient hospital or ambulatory surgical center Ambulance

Extended care benefits/ Skilled nursing care facility benefits
(d) Emergency services/ Accidents ................................................................................................................................................... 35-36
Accidental injury Ambulance Medical emergency

(e) Mental health and substance abuse benefits .............................................................................................................................. 37-42
(f) Prescription drug benefits ........................................................................................................................................................... 43-46
(g) Special features ................................................................................................................................................................................ 47
Flexible benefits option Centers of excellence for tissue and organ transplants

Disease management programs
(h) Dental benefits ................................................................................................................................................................................. 48
(i) Non-FEHB benefits available to Plan members ............................................................................................................................. 49
SUMMARY OF BENEFITS .............................................................................................................................................................. 68-69 19.
19 Page 20 21
2003 Foreign Service Benefit Plan 18 Section 5( a)
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: $300 per person ($ 600 per family). The calendar year deductible applies to almost all benefits in this Section. We added "( No deductible)" to show
when the calendar year deductible does not apply.
The non-PPO benefits are the standard benefits of this Plan. PPO benefits apply only when you use a PPO provider and reside in a Network area or when you reside overseas. When no

PPO provider is available in a Network area, non-PPO benefits apply. When you reside Out-of-Network, Out-of-Network benefits apply. When you reside overseas, all covered overseas
providers are paid at the PPO coinsurance rate.
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.

I M
P O
R T
A N
T

Section 5 (a). Medical services and supplies provided by physicians and other health care professionals

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
Professional services of physicians during a hospital stay, skilled nursing facility stay, in the physician's office, at home, or consultations

Office consultation including second opinion
Psychological tests and pharmacological visits
Drugs and medical supplies billed by a physician

Not covered: All charges.
Telephone consultations
Procedures, services, drugs, and supplies related to impotency, sex
transformations, sexual dysfunction, or sexual inadequacy

Office visits by a dentist in relation to the removal of impacted teeth and other dental services. Office visits by a dentist in relation to

covered oral and maxillofacial surgical procedures are covered.

Lab, X-ray and other diagnostic tests
X-ray, laboratory and pathology services and machine diagnostic tests

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference between our allowance and

the billed amount
Out-of-Network Area: 20% of the Plan allowance and any difference between our

allowance and the billed amount
Overseas Providers: 10% of the Plan allowance when you reside overseas

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference between our allowance and the

billed amount
Out-of-Network Area: 20% of the Plan allowance and any difference between our

allowance and the billed amount
Overseas Providers: 10% of the Plan allowance when you reside overseas 20.
20 Page 21 22
Preventive care, adult You pay
Routine physical examination limited to a maximum charge of $750 per person, per calendar year

In addition Routine Cancer Screenings limited to:
Colorectal Cancer Screening, limited to
Fecal occult blood test one annually for members age 40 and older
Sigmoidoscopy, screening one every five years for members age 50 and older

Colonoscopy, screening one every 10 years for members age 50 and older
Double Contrast Barium Enema (DCBE) one every five years for members age 50 and older

Breast Cancer Screening (Mammogram) one annually for women age 35 and older
Cervical Cancer Screening Pap smear one annually for women age 18 and older
Prostate Cancer Screening Prostate Specific Antigen (PSA) one annually for men age 40
and older
Other Routine Services limited to:
Non-fasting total blood cholesterol test once every three consecutive calendar years

Chlamydial screening
Fasting lipoprotein profile test one every five years for members age 20 and older

Routine immunizations limited to:
Tetanus-diphtheria (Td) booster one every 10 consecutive calendar years for members age 22 and older

Influenza vaccine and pneumococcal vaccine one every calendar year for members age 65 and older

Note: These benefits do not apply to children under age 22 (See Preventive care, children).

2003 Foreign Service Benefit Plan 19 Section 5( a)

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference between our allowance and the

billed amount
Out-of-Network Area: 20% of the Plan allowance and any difference between our

allowance and the billed amount
Overseas Providers: 10% of the Plan allowance when you reside overseas

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference between our allowance and

the billed amount
Out-of-Network Area: 20% of the Plan allowance and any difference between our

allowance and the billed amount
Overseas Providers: 10% of the Plan allowance when you reside overseas 21.
21 Page 22 23
2003 Foreign Service Benefit Plan 20 Section 5( a)
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference between our allowance and

the billed amount
Out-of-Network Area: 20% of the Plan allowance and any difference between our

allowance and the billed amount
Overseas Providers: 10% of the Plan allowance when you reside overseas

PPO: Nothing (No deductible)
Non-PPO: Only the difference between our allowance and the billed amount (No

deductible)
Out-of-Network Area: Only the difference between our allowance and the billed amount

(No deductible)
Overseas Providers: Nothing (No deductible) when you reside overseas

Preventive care, children You pay
Preventive care for children is limited to:
All healthy newborn visits including routine screening (inpatient or outpatient)

The following routine services as recommended by the American Academy of Pediatrics for children up to the age of 22, including children
living, traveling or adopted from outside the United States:
Routine physical examinations
Routine hearing tests
Laboratory tests
Related office visits

Immunizations for children are limited to:
Childhood immunizations recommended by the American Academy of Pediatrics are covered for members under age 22.

Maternity care
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
One Routine sonogram

Note: Here are some things to keep in mind:
You do not need to precertify your normal delivery; see Section 3 for other circumstances when you must precertify, 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.

For facility care related to maternity, including care at birthing facilities, we pay at the inpatient hospital rate in accordance with Section 5( c) of
the Brochure. We pay surgeon services (delivery) the same as for illness and injury. See Surgical benefits Section 5( b).

We consider bassinet or nursery charges during the covered portion of the mother's maternity stay to be the expenses of the mother and not
expenses of the newborn child. We consider expenses of the child after the mother's discharge to be the expenses of the child. We cover these
expenses only if the child is covered by a Self and Family enrollment. See Surgical benefits (Section 5( b)) for routine circumcision.

Not covered: All charges.
Procedures, services, drugs, and supplies related to abortions except when
the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest

PPO: 10% of the Plan allowance (No deductible)
Non-PPO: 30% of the Plan allowance and any difference between our allowance and
the billed amount (No deductible)
Out-of-Network Area: 10% of the Plan allowance and any difference between our

allowance and the billed amount (No deductible)

Overseas Providers: 10% of the Plan allowance (No deductible) when you reside
overseas

See Hospital benefits (Section 5( c)) and Surgical benefits (Section 5( b)).
Note: If your child stays after your discharge and is covered under a Self and Family
enrollment, you must pay a separate hospital copayment of $200 for non-PPO and Out-of-Network
facilities. If your child is not covered under a Self and Family enrollment
you pay all of your child's charges after your discharge. 22.
22 Page 23 24
2003 Foreign Service Benefit Plan 21 Section 5( a)
Infertility services continued on next page

Family planning You pay
A range of voluntary family planning services limited to surgery, medicine and IUDs.

Surgery limited to (See Surgical benefits Section 5( b)):
Voluntary sterilization
Surgery to implant contraceptives (such as Norplant)

Medicine and IUDs limited to:
Injectable contraceptive drugs (such as Depo provera)
Intrauterine devices (IUDs)
Diaphragms
Note: We cover FDA-approved drugs, prescriptions, and devices for birth control covered under the Prescription drug benefit in Section 5( f).

Not covered: All charges.
reversal of voluntary surgical sterilization
genetic counseling

Infertility services
Diagnosis and treatment of infertility, except as shown in Not covered, includes:

Initial diagnostic tests and procedures done only to identify the cause of infertility;
Fertility drugs, hormone therapy and related services; and
Medical or surgical procedures done to create or enhance fertility.

Note: The Plan will pay up to $5,000 per person per lifetime for covered infertility services, including prescription drugs.

PPO: 10% of the Plan allowance (No deductible on surgery)
Non-PPO: 30% of the Plan allowance and any difference between our allowance and
the billed amount (No deductible on surgery)
Out-of-Network Area: 20% of the Plan allowance and any difference between our

allowance and the billed amount (No deductible on surgery)

Overseas Providers: 10% of the Plan allowance (No deductible on surgery) when
you reside overseas

allowance and the billed amount (No deductible)

Overseas Providers: 10% of the Plan allowance (No deductible) when you reside
overseas

PPO: 10% of the Plan allowance until benefits stop at $5,000 and all charges after
the Plan's maximum payment of $5,000
Non-PPO: 30% of the Plan allowance and any difference between our allowance and the

billed amount until benefits stop at $5,000 and all charges after the Plan's maximum
payment of $5,000
Out-of-Network Area: 20% of the Plan allowance and any difference between our

allowance and the billed amount until benefits stop at $5,000 and all charges after
the Plan's maximum payment of $5,000
Overseas Providers: 10% of the Plan allowance until benefits stop at $5,000 when

you reside overseas and all charges after the Plan's maximum payment of $5,000 23.
23 Page 24 25
Infertility services (continued) You pay
Not covered: All charges.
Infertility services after voluntary sterilization
Assisted reproductive technology (ART) procedures, such as:
artificial insemination
in vitro fertilization
embryo transfer and gamete intrafallopian transfer (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

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

Not covered: All charges.
Provocative food testing, end point titration techniques, sublingual allergy
desensitization, RAST tests and hair analysis

Treatment therapies
Chemotherapy and radiation therapy (includes radium and radioactive isotopes)

Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed in Surgical
benefits Section 5( b), Organ/ tissue transplants
Intravenous (IV)/ Infusion Therapy (supplies) Home IV and antibiotic therapy (supplies)

Note: See also Home health services, this Section.
Growth hormone therapy
Respiratory and inhalation therapies (includes oxygen and equipment for its administration)

2003 Foreign Service Benefit Plan 22 Section 5( a)

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference between our allowance and the

billed amount
Out-of-Network Area: 20% of the Plan allowance and any difference between our

allowance and the billed amount
Overseas Providers: 10% of the Plan allowance when you reside overseas

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference between our allowance and the

billed amount
Out-of-Network Area: 20% of the Plan allowance and any difference between our

allowance and the billed amount
Overseas Providers: 10% of the Plan allowance when you reside overseas

Treatment therapies continued on next page 24.
24 Page 25 26
2003 Foreign Service Benefit Plan 23 Section 5( a)
Treatment therapies (continued) You pay
Renal dialysis
Note: This benefit includes only the actual charge for the dialysis treatment. Other covered charges associated with the dialysis treatment are

payable under Section 5( a) Lab, X-ray and other diagnostic tests.

Not covered: All charges.
Chelation therapy, except for acute arsenic, gold, mercury, or lead poisoning

Physical, occupational and speech therapies
Physical therapy, occupational therapy, and speech therapy: 90 total combined visits per calendar year for all three listed therapies provided by:

Licensed physical therapists;
Licensed physicians;
Licensed speech therapists; and
Licensed occupational therapists

Note: We only cover physical, occupational and 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 frequency and length of time the services are needed.
Note: We only cover physical and occupational therapy to restore bodily function when there has been a total or partial loss of bodily function due to

illness or injury.
Not covered: All charges.
Custodial care (see definition Section 10)
Exercise programs

Hearing services (testing, treatment, and supplies)
Limited to:
Initial hearing exam

Not covered: All charges.
Hearing aids and examinations for them, except for the initial exam

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference between our allowance and the

billed amount
Out-of-Network Area: 20% of the Plan allowance and any difference between our

allowance and the billed amount
Overseas Providers: 10% of the Plan allowance when you reside overseas

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference between our allowance and

the billed amount
Out-of-Network Area: 20% of the Plan allowance and any difference between our

allowance and the billed amount
Overseas Providers: 10% of the Plan allowance when you reside overseas

PPO: Nothing (No deductible)
Non-PPO: Only the difference between our allowance and the billed amount

(No deductible)
Out-of-Network Area: Only the difference between our allowance and

the billed amount (No deductible)
Overseas Providers: Nothing (No deductible) when you reside overseas 25.
25 Page 26 27
2003 Foreign Service Benefit Plan 24 Section 5( a)
Vision services (testing, treatment, and supplies) You pay
One pair of eyeglasses or contact lenses per incident if required to correct an impairment directly caused by:

Accidental ocular injury or
Specifically ordered by the doctor in connection with a diagnosis of
Cataract
Keratoconus
Glaucoma

Note: Expenses in relation to an accident or removal of cataract or keratoconus must be incurred within one year of the date of the accident

or surgery.
Not covered: All charges.
Routine eye examinations
Eyeglasses and contact lenses, except as shown above
Eye exercises and visual training (orthoptics)
Refractions
All refractive surgeries

Foot care
We do not provide benefits for routine foot care. Routine foot care would All charges. include such items as:

treatment or removal of corns and calluses, or trimming of toenails
orthopedic shoes, orthotics and other supportive devices for the feet

Orthopedic and prosthetic devices
Artificial limbs and eyes to replace natural 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, intraocular lenses, cochlear implants, and surgically implanted breast
implants following mastectomy
Note: A prosthetic device is surgically inserted or physically attached to the body to restore a bodily function or replace a physical portion of the body.

Note: See Section 5( b), for coverage of the surgery to insert the device and Section 5( c) if billed by the facility.

Not covered: All charges.
Orthopedic shoes, orthotics and other supportive devices for the feet,
such as:

Arch supports
Heel pads and heal cups
Corsets
Elastic stocking and support hose that do not require a physician's
written prescription

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference between our allowance and the

billed amount
Out-of-Network Area: 20% of the Plan allowance and any difference between our

allowance and the billed amount
Overseas Providers: 10% of the Plan allowance when you reside overseas

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference between our allowance and

the billed amount
Out-of-Network Area: 20% of the Plan allowance and any difference between our

allowance and the billed amount
Overseas Providers: 10% of the Plan allowance when you reside overseas 26.
26 Page 27 28
Home health services continued on next page
2003 Foreign Service Benefit Plan 25 Section 5( a)

Durable medical equipment (DME) You pay
Rental, up to the purchase price, or purchase (at our option), including necessary repair and adjustment, of durable medical equipment such as:

Wheelchairs Hospital beds
Oxygen and equipment for its administration Dialysis equipment
Crutches Braces
Casts, splints, and trusses Walkers

Also included are:
Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home (Note: calendar year deductible applies).

Durable medical equipment (DME) is equipment and supplies that:
Are prescribed by your attending physician (i. e., the physician who is treating your illness or injury);

Are medically necessary; Are primarily and customarily used only for a medical purpose;
Are generally useful only to a person with an illness or injury; Are designed for prolonged use; and
Serve a specific therapeutic purpose in the treatment of an illness or injury.
Not covered: All charges.
Other items that do not meet the definition of durable medical
equipment such as sun or heat lamps, whirlpool baths, heating pads, air purifiers, humidifiers, air conditioners, and exercise devices

Home health services
For services provided on a part-time basis (less than an 8-hour shift):
If you precertify your home health care, 90 visits per calendar year up to a maximum Plan payment of $80 per visit when:

A Registered Nurse (R. N.) or Licensed Practical Nurse (L. P. N.) provides the services;
A licensed therapist provides physical, occupational or speech therapy; A licensed social worker provides the services (limited to two visits per
calendar year); A home health aide provides services under the supervision of a Registered
Nurse (R. N.) consisting of mainly medical care and therapy provided solely for the care of the insured person;
The attending physician orders the care; and The physician identifies the specific professional skills required by the
patient and the medical necessity for skilled services; and indicates the length of time the services are needed.

A home health agency (or visiting nurses where services of a home health agency are not available) must furnish the care in accord with a home
health care plan (see definition below). The home health care plan must be certified by your doctor and furnished in your home.

Note: We define Home Health Agency as a public or private agency or organization appropriately licensed, qualified and operated under the law
of the state in which it is located.
Note: We define Home Health Care Plan as a written plan, approved in writing by a Physician, for continued care and treatment of a plan member:

(a) Who is under the care of a Physician; and (b) Who would need a continued stay in a Hospital or Skilled Nursing Facility
without the home health care.

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference between our allowance and the

billed amount
Out-of-Network Area: 20% of the Plan allowance and any difference between our

allowance and the billed amount
Overseas Providers: 10% of the Plan allowance when you reside overseas

For precertified home health care: Nothing (No deductible) up to $80 per visit up to 90
visits per calendar year; All charges above $80 per visit and/ or 90 visits per calendar
year and all charges above one visit per day 27.
27 Page 28 29
2003 Foreign Service Benefit Plan 26 Section 5( a)
Home health services (continued) You pay
For services provided on a part-time basis (less than an 8-hour shift):
If you do not precertify your home health care, 40 visits per calendar year up to a maximum plan payment of $40, subject to the provisions on

the previous page

For private duty nursing we pay $12 per hour when provided on a full-time basis (more than an 8-hour shift) by a Registered Nurse (R. N.) or Licensed
Practical Nurse (L. P. N.) when:
The care is ordered by the attending physician; and
Your physician identifies the specific professional nursing skills that you require, as well as the length of time needed.

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

Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative
Custodial care as defined in Section 10, Definitions
Chiropractic
Covered services are limited to:
Manipulation of the spine and extremities
Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy and cold pack application

Note: Chiropractic is a system of therapy that attributes disease to abnormal function of the nervous system and attempts to restore normal function by
manipulation of the spinal column and other body structures.
Alternative treatments
Acupuncture only when performed by an M. D, D. O., O. M. D., or L. Ac.
Note: The Plan defines acupuncture as the practice of insertion of needles into specific exterior body locations to relieve pain, to induce surgical

anesthesia, or for therapeutic purposes.

Not covered: All charges.
Chelation therapy except for acute arsenic, gold, mercury or lead poisoning
Naturopathic services and medicines
Homeopathic services and medicines

(Note: Services of certain alternative treatment providers may be covered in
medically underserved areas; see Section 3, Covered providers)

Educational classes and programs
Coverage is limited to:
Smoking Cessation Office visits, individual and group counseling and purchase of over-the-counter smoking cessation drugs and supplies up

to a maximum payable of $100 for one program per person per calendar year.

Note: Prescription drugs are covered only under the Prescription drug benefit not subject to the $100 limitation (see Section 5( f)).
Note: Over-the-counter smoking cessation drugs and supplies you receive in conjunction with a smoking cessation program cannot be purchased with
your drug card. You must file a claim for them.

For non-precertified home health care: Nothing (No deductible) up to $40 per visit
up to 40 visits per calendar year; All charges above $40 per visit and/ or 40 visits per
calendar year and all charges above one visit per day

Nothing (No deductible) up to $12 per hour; All charges after $12 per hour and all
charges after 500 hours per calendar year

PPO, Non-PPO, Out-of-Network and Overseas Providers: Nothing up to the Plan
maximum of $20 per visit and all charges above $20 per visit and/ or 30 visits per
person per calendar year

PPO, Non-PPO, Out-of-Network, and Overseas Providers: Nothing up to $100 and
all charges after $100 28.
28 Page 29 30
2003 Foreign Service Benefit Plan 27 Section 5( b)
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: $300 per person ($ 600 per family). The calendar year deductible does not apply to any benefits in this Section. We added "( No deductible)" to
show that 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 and reside in a Network area or when you reside overseas. When no

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.).

I M
P O
R T
A N
T

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

Surgical procedures continued on next page
PPO: 10% of the Plan allowance (No deductible)
Non-PPO: 30% of the Plan allowance and any difference between our allowance and
the billed amount (No deductible)
Out-of-Network Area: 10% of the Plan allowance and any difference between our

allowance and the billed amount (No deductible)

Overseas Providers: 10% of the Plan allowance (No deductible) when you reside
overseas

Benefit Description You pay After the calendar year deductible
NOTE: The calendar year deductible does not apply to benefits in this Section. We say "( No deductible)" when it does not apply.
Surgical procedures
A comprehensive range of services, such as: Operative procedures

Treatment of fractures, including casting Normal post-operative care by the surgeon
Correction of amblyopia and strabismus Endoscopy procedures
Biopsy procedures Removal of tumors and cysts
Surgical treatment of morbid obesity a condition in which an individual: 1) is the greater of 100 pounds or 100% over his or her normal weight (in
accordance with the Plan's underwriting standards) with complicating conditions; and 2) has been so for at least five years, despite documented
unsuccessful attempts to reduce under a doctor-monitored diet and exercise program. Eligible members must be age 18 and older.
Insertion of internal prosthetic devices. See Section 5( a) Orthopedic and prosthetic devices for device coverage information.
Voluntary sterilization (e. g. Tubal ligation, Vasectomy) Surgical implantation of Norplant (a contraceptive) and intrauterine devices
(IUDs) Treatment of burns
Amniocentesis Routine circumcision of a newborn child (only when the child is covered
under a Self and Family enrollment)
Note: Office surgery and office visits on the day of surgery and up to 90 days following surgery are covered under Section 5( b) of the brochure.

Note: Second opinion is covered under Section 5( a) Diagnostic and treatment services. 29.
29 Page 30 31
Surgical procedures (continued) You pay
Assistant Surgeon (inpatient/ outpatient)

When multiple or bilateral surgical procedures performed during the same operative session add time or complexity to patient care, we pay:
For the primary procedure:
PPO: 90% of the Plan allowance
Non-PPO: 70% of the Plan allowance
Out-of-Network: 90% of the Plan allowance

For the secondary procedure( s):
PPO: 90% of 50% of the Plan allowance
Non-PPO: 70% of 50% of the Plan allowance
Out-of-Network: 90% of 50% of the Plan allowance.

Note: For certain surgical procedures, we may apply a value of less than 50% for subsequent procedures.

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 or complexity to patient care. We do not pay extra for incidental procedures.

Not covered: All charges.
Cosmetic surgery except for the repair of accidental injuries sustained
while covered under the FEHB Program; to correct a congenital anomaly;
or for the reconstruction of a breast following a mastectomy

Note: We define cosmetic surgery as any operative procedure or any
portion of a procedure performed primarily to improve physical
appearance and/ or treat a mental condition through change in bodily form.

All refractive surgeries
Routine surgical treatment of conditions of the foot (see Section 5( a)
Foot care)

Services of a standby surgeon
Reversal of voluntary sterilization
Surgeries related to impotency, sex transformation, sexual dysfunction or sexual inadequacy

2003 Foreign Service Benefit Plan 28 Section 5( b)

PPO: 20% of the Plan allowance (based on 20% of the Plan allowance allocated to the
surgery charge) (No deductible)
Non-PPO and Out-of-Network Area: 20% of the Plan allowance (based on 20% of the Plan

allowance allocated to the surgery charge) and any difference between our allowance
and the billed amount (No deductible)
Overseas Providers: 20% of the Plan allowance (based on 20% of the Plan

allowance allocated to the surgery charge) (No deductible) when you reside overseas

PPO: 10% of the Plan allowance for the primary procedure and 10% of 50% of the
Plan allowance for the secondary procedure( s) (No deductible)

Non-PPO: 30% of the Plan allowance for the primary procedure and 30% of 50% of the
Plan allowance for the secondary procedure( s); and any difference between our
allowance and the billed amount (No deductible)

Out-of-Network Area: 10% of the Plan allowance for the primary procedure and
10% of 50% of the Plan allowance for the secondary procedure( s); and any difference
between our allowance and the billed amount (No deductible)

Overseas Providers: 10% of the Plan allowance for the primary procedure and
10% of 50% of the Plan allowance for the secondary procedure( s) (No deductible) when
you reside overseas 30.
30 Page 31 32
2003 Foreign Service Benefit Plan 29 Section 5( b)
Reconstructive surgery You pay
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 (Congenital anomaly).

Examples of congenital anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks; webbed fingers and toes and other conditions
that we may determine to be congenital anomalies. We will not consider the term congenital anomaly to include conditions relating to teeth or
intra-oral structures supporting the teeth.
All stages of breast reconstruction surgery following a mastectomy, such as:
surgery to produce a symmetrical appearance on the other breast;
surgical treatment of any physical complications, such as lymphedemas;
breast prostheses; and surgical bras and replacements (see Section 5( a) Orthopedic and prosthetic devices for coverage)

Note: If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48 hours
after the procedure.
Not covered: All charges.
Cosmetic surgery except for the repair of accidental injuries sustained while
covered under the FEHB Program; to correct a congenital anomaly; or for the reconstruction of a breast following a mastectomy

Note: We define cosmetic surgery as any operative procedure or any
portion of a procedure performed primarily to improve physical appearance and/ or treat a mental condition through change in bodily form.

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

Oral and maxillofacial surgery
Oral surgical procedures, limited to:
Reduction of fractures of the jaws or facial bones
Surgical correction of cleft lip, cleft palate or severe functional malocclusion (when we determine the correction of the malocclusion to be

medically necessary)
Removal of stones from salivary ducts
Excision of leukoplakia or malignancies
Excision of non-dentigerous cysts and incision of non-dentigerous abscesses
Surgical correction of temporomandibular joint (TMJ) dysfunction
Surgical removal of impacted teeth, including anesthesia charges
Other surgical procedures that do not involve the teeth or their supporting structures

Not covered: All charges.
Oral implants and transplants
Procedures that involve the teeth or their supporting structures (such as
the periodontal membrane, gingival and alveolar bone) except as provided under Dental benefits (see Section 5( h))

Pre-and post-operative medical examinations
Excision of non-impacted teeth

allowance and the billed amount (No deductible)

Overseas Providers: 10% of the Plan allowance (No deductible) when you reside
overseas

PPO: 10% of the Plan allowance (No deductible)
Non-PPO: 30% of the Plan allowance and any difference between our allowance and the
billed amount (No deductible)
Out-of-Network Area: 10% of the Plan allowance and any difference between our

allowance and the billed amount (No deductible)

Overseas Providers: 10% of the Plan allowance (No deductible) when you reside
overseas 31.
31 Page 32 33
Organ/ tissue transplants You pay
Limited to the following transplants:
Cornea Heart
Kidney Liver
Pancreas Heart/ lung
Lung: Single only for the following end-stage pulmonary diseases: pulmonary fibrosis, primary pulmonary hypertension, or emphysema;

Double only for patients with cystic fibrosis
Intestinal transplants (small intestine) and the small intestine with the liver or small intestine with multiple organs such as the liver, stomach, and

pancreas for irreversible intestinal failure
Bone marrow and stem cell support as follows:
Allogeneic bone marrow transplants only for patients with acute leukemia, advanced Hodgkin's disease

Autologous bone marrow transplants (autologous stem cell support) and autologous peripheral stem cell support for
1) Acute lymphocytic or non-lymphocytic leukemia; 2) Advanced Hodgkin's and non-Hodgkin's lymphoma;
3) Advanced neuroblastoma; 4) Testicular, mediastinal, retroperitoneal and ovarian germ cell tumors;
5) Breast cancer; 6) Multiple myeloma; and
7) Epithelial ovarian cancer
Note: We cover related medical and hospital expenses of the donor when we cover the recipient. You are a recipient when you surgically receive a

body organ( s) transplant. You are a donor when you surgically donate a body organ( s) for transplant surgery. Transplant surgery means transfer of a
body organ( s) from the donor to the recipient.
Note: Mutual of Omaha has special arrangements with facilities to provide services for tissue and organ transplants its Medical Specialty Network. The

network was designed to give you an opportunity to access providers that demonstrate high quality medical care for transplant patients. Your physician
can coordinate arrangements by calling a case manager in Mutual of Omaha's Medical Management Department at 1-800/ 593-2354. For additional
information regarding the transplant network, please call this number.
Not covered: All charges.
Donor screening tests and donor search expenses, except those performed for the actual donor

Services or supplies for, or related to, surgical transplant procedures for
artificial or human organ transplants not listed as covered

Transplants not listed as covered

Anesthesia
Professional services provided in:
Hospital (inpatient)
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center
Office
Note: Anesthesia rendered by a dentist only in relation to covered oral and maxillofacial surgery is also covered (see Oral and maxillofacial surgery,

this Section).

2003 Foreign Service Benefit Plan 30 Section 5( b)

allowance and the billed amount (No deductible)

Overseas Providers: 10% of the Plan allowance (No deductible) when you reside
overseas

allowance and the billed amount (No deductible)

Overseas Providers: 10% of the Plan allowance (No deductible) when you reside
overseas 32.
32 Page 33 34
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 the other subsections in Section 5, the calendar year deductible applies to only a few benefits. In that case, we added "( calendar year deductible
applies)". The calendar year deductible is: $300 per person ($ 600 per family).
The non-PPO benefits are the standard benefits of this Plan. PPO benefits apply only when you use a PPO provider and reside in a Network area or when you reside overseas. When no

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), (b), (d) or (e).
YOU MUST GET PRECERTIFICATION OF HOSPITAL STAYS; FAILURE TO DO SO WILL RESULT IN A $500 PENALTY. Please refer to the precertification information

shown in Section 3 for additional details on precertification.
YOU MUST ALSO GET PRECERTIFICATION OF CARE YOU RECEIVE IN SKILLED NURSING FACILITIES and HOSPICE and also HOME HEALTH CARE.

Please refer to this section (Skilled Nursing Facilities and Hospice) and Section 5( a) (Home Health Care) for details on how your benefits are affected if you do not precertify. Also,
please refer to the precertification information shown in Section 3 for additional details on precertification.

2003 Foreign Service Benefit Plan 31 Section 5( c)

I M
P O
R T
A N
T

Section 5 (c). Services provided by a hospital or other facility, and ambulance services

Inpatient hospital continued on next page
Benefit Description You pay
NOTE: The calendar year deductible applies ONLY when we say below: "( calendar year deductible applies)".
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 when you must be isolated to prevent contagion. Otherwise, we will pay the hospital's average charge for

semiprivate accommodations. If the hospital only has private rooms, we base our payment on the average semiprivate rate of the most comparable
hospital in the area.

PPO: Nothing
Non-PPO: $200 copayment per hospital stay and 20% of charges.

Out-of-Network Area: $200 copayment per hospital stay
Overseas Providers: Nothing when you reside overseas 33.
33 Page 34 35
Inpatient hospital (continued) You pay
Other services and supplies you receive while in a hospital, such as: See previous page.
Use of operating, recovery, maternity and other treatment rooms
Prescribed drugs and medicines for use in the hospital
X-ray, laboratory and pathology services and machine diagnostic tests
Blood or blood plasma, if not donated or replaced, and its administration
Dressings, splints, casts and sterile tray services
Medical supplies and equipment, including oxygen
Anesthetics, including nurse anesthetist services
Medical supplies, medical equipment, prosthetic and orthopedic devices and any covered items billed by a hospital for use at home (Note: We

cover these items only under Section 5( a) and the calendar year deductible and coinsurance apply.)

Special Overseas Benefit Inpatient private duty nursing services by an R. N. or L. P. N. when the services are rendered outside of North America

Note: We provide specified benefits for professional services of a doctor, even when billed by the hospital. For example, when the hospital bills for
such professional services as surgery, anesthesiology, medical or therapy services, etc., we pay the specific surgery, anesthesia, medical or therapy
benefit.
Note: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment to safeguard the

health of the patient, even though we may not cover the services of dentists or doctors in connection with the dental treatment.

Not covered: All charges.
Admission to nursing homes, rest homes, places for the aged, convalescent homes, or any place that is not a hospital, skilled nursing

care facility, or hospice (see Section 3, Covered providers and Covered facilities)

Custodial care (see definition Section 10)
Any part of a hospital admission that is not medically necessary (see definition Section 10), 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 of 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 we would have covered if provided in an alternative setting.

Inpatient private duty nursing except as provided above
Personal comfort items such as radio, television, beauty and barber services, identification tags, baby beads, footprints, guest cots and meals,

newspapers and similar items
Inpatient hospital services and supplies for surgery that we do not cover except as noted above for non-covered dental procedures

2003 Foreign Service Benefit Plan 32 Section 5( c) 34.
34 Page 35 36
2003 Foreign Service Benefit Plan 33 Section 5( c)
PPO: 10% of the Plan allowance (calendar year deductible applies)
Non-PPO: 30% of the Plan allowance and any difference between our allowance and the
billed amount (calendar year deductible applies)

Out-of-Network Area: 10% of the Plan allowance and any difference between our
allowance and the billed amount (calendar year deductible applies)

Overseas Providers: 10% of the Plan allowance (calendar year deductible applies)
when you reside overseas

Outpatient hospital or ambulatory surgical center You pay
Services and supplies such as:
Operating, recovery and other treatment rooms
Prescribed drugs and medicines for use in the facility
X-ray, laboratory and pathology services and machine diagnostic tests
Blood and blood plasma, if not donated or replaced, and its administration
Dressings, casts and sterile tray services
Medical supplies and equipment, including oxygen
Anesthetics and anesthesia service
Drugs, medical supplies, medical equipment, prosthetic and orthopedic devices and any covered items billed by a hospital for use at home

(Note: We cover these items only under Section 5( a) and the calendar year deductible and coinsurance apply.)

Note: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment to safeguard the
health of the patient, even though we may not cover the services of dentists or doctors in connection with the dental treatment.

Not covered: All charges.
Outpatient hospital services and supplies for surgery that we do not cover
except as noted above for non-covered dental procedures

Extended care benefits/ Skilled nursing care facility benefits
If you precertify your admission, we cover semiprivate room, board, For precertified care: Nothing up to the Plan services and supplies in a Skilled Nursing Facility (SNF) for up to 90 days allowance for up to 90 days per calendar

per calendar year when the admission is: year and all charges after 90 days
1) Medically necessary; and
2) Under the supervision of a physician.

If you do not precertify your admission, we cover semiprivate room For precertified care: 20% up to the Plan and board, services and supplies in a Skilled Nursing Facility (SNF) for up allowance for up to 45 days per calendar

to 45 days per calendar year subject to the above conditions. year and all charges after 45 days
Not covered: All charges.
Custodial care (see definition Section 10)

Hospice care
If you precertify your Hospice care, we pay up to a lifetime maximum of For precertified care: Nothing up to the $7,500. Plan allowance until benefits stop at

Note: This benefit does not apply to services covered under any other $7,500 and all charges after $7,500 provisions of the Plan.
Note: We define Hospice Care Program as a coordinated program of home or inpatient pain control and supportive care for a terminally ill patient and the
patient's family. Care must be provided by a medically supervised team under the direction of an independent hospice administration that we approve.

If you do not precertify your Hospice care, we pay up to a lifetime For non-precertified care: Nothing up to the maximum of $4,500. The note and definition above apply. Plan allowance until benefits stop at $4,500
and all charges after $4,500 35.
35 Page 36 37
Ambulance You pay
Professional ambulance service to or from the hospital.
Note: This benefit includes air ambulance service when medically necessary to transport you to the nearest facility equipped to handle your medical

condition.
Note: See Section 5( d) for ambulance services as a result of an accident.

Not covered: All charges.
Ambulance transport for you or your family's convenience

2003 Foreign Service Benefit Plan 34 Section 5( c)

PPO: 10% of the Plan allowance (calendar year deductible applies)
Non-PPO: 30% of the Plan allowance and any difference between our allowance and
the billed amount (calendar year deductible applies)

Out-of-Network Area: 20% of the Plan allowance and any difference between our
allowance and the billed amount (calendar year deductible applies)

Overseas Providers: 10% of the Plan allowance (calendar year deductible applies)
when you reside overseas 36.
36 Page 37 38
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: $300 per person ($ 600 per family). The calendar year deductible applies to some 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 and reside in a Network area or when you reside overseas. When

no PPO provider is available in a Network area, non-PPO benefits apply. When you reside Out-of-Network, Out-of-Network benefits apply. When you reside overseas, all covered
overseas providers are paid at the PPO coinsurance rate.
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.

I M
P O
R T
A N
T

2002 Foreign Service Benefit Plan 35 Section 5( d)

Section 5 (d). Emergency services/ accidents
What is an accidental injury?
An accidental injury is a bodily injury that requires immediate medical attention and is sustained solely through violent, external, and accidental means, such as broken bones, animal bites, insect bites and stings, and poisonings. We cover dental

care required as a result of an accidental injury under Section 5( h), Dental benefits.

PPO: Nothing (No deductible)
Non-PPO: Only the difference between the Plan allowance and the billed amount (No

deductible)
Out-of-Network Area: Only the difference between the Plan allowance and the billed

amount (No deductible)
Overseas Providers: Nothing (No deductible) when you reside overseas

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
We pay 100% of the Plan allowance for the following care you receive as a result of an accidental injury:

Emergency Room (ER) facility charge
ER physician's charge or initial office visit

Note: We pay for services performed outside the ER facility under the appropriate plan benefit.

Note: We pay for services received in the ER, but billed separately from the hospital bill (such as X-ray, lab, pathology and machine diagnostic tests)
under the appropriate Plan benefit (see Section 5( a)).
Note: We pay Hospital benefits as specified in Section 5( c) if you are admitted to the hospital.

Note: We pay for services performed at the time of the initial office visit such as: x-rays, laboratory tests, drugs, or any supplies, or other services
under the appropriate Plan benefit (see Section 5( a)). 37.
37 Page 38 39
Medical emergency You pay
Regular Plan benefits apply to care you receive because of a medical emergency (non-accident). Items covered include:

Outpatient medical services and supplies
Physician services and supplies
X-ray, laboratory and pathology services and machine diagnostic tests

Ambulance
If you use a professional ambulance service as a result of an accident
Note: See Section 5( c) for non-emergency service.
Note: This benefit includes air ambulance service when medically necessary to transport you to the nearest facility equipped to handle your medical

condition.

Not covered: All charges.
Ambulance transport for you or your family's convenience

2003 Foreign Service Benefit Plan 36 Section 5( d)

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference between our allowance and

the billed amount
Out-of-Network Area: 20% of the Plan allowance and any difference between our

allowance and the billed amount
Overseas Providers: 10% of the Plan allowance when you reside overseas

PPO: 10% of the Plan allowance (No deductible)
Non-PPO: 30% of the Plan allowance and any difference between our allowance and
the billed amount (No deductible)
Out-of-Network Area: 20% of the Plan allowance and any difference between our

allowance and the billed amount (No deductible)

Overseas Providers: 10% of the Plan allowance (No deductible) when you reside
overseas 38.
38 Page 39 40
2003 Foreign Service Benefit Plan 37 Section 5( e)
You may choose to get care from a PPO or non-PPO provider if you live in the PPO area and from an Out-of-Network Area provider if you do not live in the PPO area. When you receive
any care, you must get our approval for services and follow a treatment plan we approve. If you do, cost-sharing and limitations for PPO and Out-of-Network Area 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 we determine they are medically necessary.

The calendar year deductible or, for facility care, the inpatient copayment apply 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 and reside in a Network area or when you reside overseas. When no

read Section 9 about coordinating benefits with other coverage, including with Medicare.
YOU MUST GET PRECERTIFICATION/ PREAUTHORIZATION OF THESE SERVICES. The Plan will reduce your benefits if you fail to get precertification/

preauthorization for these services. See the precertification information shown in Section 3 and the instructions after the benefits descriptions below (pages 39, 41 and 42).

PPO and Overseas Provider Mental health and substance abuse benefits are below and on the next page, non-PPO benefits begin on page 39 and Out-of-Network benefits begin on page
41.

I M
P O
R T
A N
T

Section 5 (e). Mental health and substance abuse benefits

In-Network Area benefits PPO and Overseas Providers continued on next page
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.
IN-NETWORK AREA AND OVERSEAS PROVIDER BENEFITS
PPO (when you reside in the PPO area and use a PPO provider)
Overseas Providers (when you reside overseas and use an overseas provider)

All covered diagnostic and treatment services contained in a treatment plan Your cost sharing responsibilities are no that we approve. The treatment plan may include services, drugs, and greater than for other illnesses or conditions.

supplies described elsewhere in this brochure.
Note: 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.
Note: If you receive care outside of the United States, we do not require precertification, preauthorization or concurrent review for continuing

care. See Section 3 for details. 39.
39 Page 40 41
In-Network Area benefits PPO and Overseas Providers (continued) You pay
Professional services including:
Individual and group therapy when rendered by covered providers
Medication management Note: We cover this under Section 5( a) pharmacological visits, no preauthorization required.

Diagnostic tests including psychological testing PPO: 10% of the Plan allowance
Overseas Providers: 10% of the Plan allowance when you reside overseas

Services provided by a hospital or other facility PPO Inpatient Facility: Nothing for room and board and other services (No deductible)
Overseas Providers: Nothing for room and board and other services (No deductible)
when you reside overseas
Services in approved outpatient care settings such as:
Intensive Outpatient Programs (IOP). These programs offer time-limited services that:

Are coordinated, structured, and intensively therapeutic;
Are designed to treat a variety of individuals with moderate to marked impairment in at least one area of daily life resulting from

psychiatric or addictive disorders; and
Offer 3-4 hours of active treatment per day at least 2-3 days per week.

Partial Hospitalization. Partial hospitalization is a time limited, ambulatory, active treatment program that:

Offers therapeutically intensive, coordinated and structured clinical services within a stable therapeutic milieu; and
Provides at least 20 hours of scheduled programming extended over a minimum of 5 days per week in either a licensed or JCAHO
accredited facility.
Not covered: All charges.
Services we have not approved
All charges for chemical aversion therapy, conditioned reflex treatments, narcotherapy or any similar aversion treatments and all related charges

(including room and board)
Any provider not specifically listed as covered
Counseling or therapy for marital, educational, sexual, or behavioral
problems, or related to mental retardation or learning disabilities

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.

2003 Foreign Service Benefit Plan 38 Section 5( e)

PPO: 10% of the Plan allowance
Overseas Providers: 10% of the Plan allowance when you reside overseas

In-Network Area benefits PPO and Overseas Providers continued on next page 40.
40 Page 41 42
2003 Foreign Service Benefit Plan 39 Section 5( e)
In-Network Area benefits Non-PPO continued on next page

Non-PPO Professional fees:
Individual therapy inpatient: Nothing up to $60 per visit and all charges above $60

per visit; and all visits above 50 per person per calendar year

Group therapy inpatient: Nothing up to $30 per session and all charges above
$30 per session

In-Network Area benefits PPO and Overseas Providers (continued)
Precertification/ Preauthorization To be eligible to receive mental health and substance abuse benefits you must obtain and follow a treatment plan and follow all of our authorization processes and

your treatment plan. This applies to all inpatient and outpatient hospital care, and all inpatient, outpatient or office care you receive from doctors and other covered
providers. See Section 3 for more detail. These include:
Precertification to establish the medical necessity of your admission to a hospital or other facility for you to receive full Plan benefits. If you do not

precertify, we will reduce the benefits payable by $500. You must report emergency admissions within two business days following the day of admission
even if you have been discharged.
Preauthorization to establish the medical necessity for all levels of outpatient or office care whether in or out-of-network. If you do not preauthorize, we will

reduce any available benefits by 50% of what we would have paid had you preauthorized your care.

Concurrent review (which means review of continuing treatment) to establish the medical necessity for all levels of continuing outpatient or office care whether
in or out-of-network. If you do not obtain concurrent review or follow your treatment plan, we will reduce any available benefits by 50% of what we would
have paid had you obtained concurrent review or followed your treatment plan.
To precertify or preauthorize care and obtain concurrent review for continuing care, you, your representative, your doctor or your hospital must call

Mutual of Omaha's Care Review Unit at 1-800/ 593-2354 prior to the admission or care.

Note: We do not require precertification, preauthorization or concurrent review for continuing care for services you receive outside of the United States or when
Medicare Part A and/ or B, or another group health insurance policy is the primary payer. Precertification, preauthorization and concurrent review for continuing care is
required, however, when Medicare or the other group health insurance policy stops paying benefits for any reason.

PPO limitation We will limit your benefits if you do not follow all of our preauthorization processes and your treatment plan and reside in a PPO area.

IN-NETWORK AREA BENEFITS You pay
Non-PPO (when you live in the PPO area and use a non-PPO provider) After the calendar year deductible

All covered diagnostic and treatment services contained in a treatment plan Your cost sharing responsibilities are that we approve. The treatment plan may include services, drugs, and greater and limitations apply when you
supplies described elsewhere in this brochure. use a non-PPO provider.
Note: Benefits are payable only when we determine the care is clinically appropriate to treat your condition and only when you receive the care as

part of a treatment plan that we approve.
Professional inpatient services when rendered by covered providers including:

Non-PPO inpatient individual therapy limited to 50 visits per person per calendar year and a maximum payable of $60 per visit

Non-PPO inpatient group therapy limited to actual charges up to a maximum payable of $30 per session 41.
41 Page 42 43
In-Network Area benefits Non-PPO (continued) You pay
Professional outpatient services when rendered by covered providers including:
Non-PPO outpatient individual therapy benefits limited to 60 visits per person per calendar year

Non-PPO outpatient group therapy benefits limited to $40 per session
Medication management Note: We cover this under Section 5( a) Non-PPO medication management: 30% of pharmacological visits, no preauthorization required and not subject to the the Plan allowance and any difference
Plan's maximum visit limitation. between our allowance and the billed amount
Diagnostic tests including psychological testing Non-PPO: 30% of the Plan allowance
Services provided by a hospital or other facility Non-PPO Inpatient Facility: $200 copayment per person per hospital stay and 30% of

covered charges for room and board and other services (No deductible)

Services in approved outpatient care settings such as:
Intensive Outpatient Programs (IOP). These programs offer time-limited services that:

Are coordinated, structured, and intensively therapeutic;
Are designed to treat a variety of individuals with moderate to marked impairment in at least one area of daily life resulting from

psychiatric or addictive disorders; and
Offer 3-4 hours of active treatment per day at least 2-3 days per week.

Partial Hospitalization. Partial hospitalization is a time limited, ambulatory, active treatment program that:

(including room and board)
Any provider not specifically listed as covered
Counseling or therapy for marital, educational, sexual, or behavioral problems, or related to mental retardation or learning disabilities

Treatments for mental retardation and learning disabilities
Community-based programs such as self-help groups or 12 step programs
Services by pastoral, marital, or drug/ alcohol counselors
Biofeedback, conjoint therapy, hypnotherapy
Interpretation/ preparation of reports
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.

2003 Foreign Service Benefit Plan 40 Section 5( e)

Non-PPO Professional fees:
Individual therapy outpatient: 30% of the Plan allowance and any difference

between our allowance and the billed amount up to 60 visits per person per
calendar year; and all visits after 60 per person per calendar year

Group therapy outpatient: 50% of the Plan allowance per session and all charges
above $40 per session

Non-PPO: 30% of the Plan allowance and any differences between our allowance and
the billed amount

In-Network Area benefits Non-PPO continued on next page 42.
42 Page 43 44
2003 Foreign Service Benefit Plan 41 Section 5( e)
Out-of-Network Area benefits continued on next page

In-Network Area benefits Non-PPO (continued)
Precertification/ Preauthorization We have the same precertification, preauthorization and concurrent review (which means review of continuing treatment) requirements for non-PPO (within Network

Area) services and Out-of-Network Area in the United States as we do for PPO (within Network Area). See page 39 for details.

Non-PPO limitation We will limit your benefits if you do not follow all of our authorization processes and your treatment plan.

OUT-OF-NETWORK AREA BENEFITS You Pay After the calendar year deductible
All covered diagnostic and treatment services contained in a treatment plan Your cost sharing responsibilities are no that we approve. The treatment plan may include services, drugs, and greater than for other illness or conditions.
supplies described elsewhere in this brochure.
Note: Benefits are payable only when we determine the care is clinically appropriate to treat your condition and only when you receive the care as

part of a treatment plan that we approve.
Professional services including:
Individual and group therapy when rendered by covered providers

Medication management Note: We cover this under Section 5( a) pharmacological visits, no preauthorization required.
Diagnostic tests including psychological testing Out-of-Network Area: 20% of the Plan allowance
Services provided by a hospital or other facility Out-of-Network Area Inpatient Facility: $200 copayment per person per hospital stay (No
deductible)
Services in approved outpatient care settings such as:
Intensive Outpatient Programs (IOP). These programs offer time-limited services that:

Are coordinated, structured, and intensively therapeutic;
Are designed to treat a variety of individuals with moderate to marked impairment in at least one area of daily life resulting from

psychiatric or addictive disorders; and
Offer 3-4 hours of active treatment per day at least 2-3 days per week.

Partial Hospitalization. Partial hospitalization is a time limited, ambulatory, active treatment program that:

Out-of-Network Area: 20% of the Plan allowance and any difference between our
allowance and the billed amount

Out-of-Network Area Professional fees:
Individual therapy inpatient and outpatient: 20% of the Plan allowance and any

difference between our allowance and the billed amount

Group therapy inpatient and outpatient: 20% of the Plan allowance and any
difference between our allowance and the billed amount

Out-of-Network medication management: 20% of the Plan allowance and any difference
between our allowance and the billed amount 43.
43 Page 44 45
2003 Foreign Service Benefit Plan 42 Section 5( e)
Out-of-Network Area Benefits (continued) You pay
Not covered: All charges.
Services we have not approved
All charges for chemical aversion therapy, conditioned reflex treatments,
narcotherapy or any similar aversion treatments and all related charges (including room and board)

Any provider not specifically listed as covered
Counseling or therapy for marital, educational, sexual, or behavioral problems, or related to mental retardation or learning disabilities

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.

Precertification/ Preauthorization We have the same precertification, preauthorization and concurrent review (which means review of continuing treatment) requirements for non-PPO (within Network
Area) services and Out-of-Network Area in the United States as we do for PPO (within Network Area). We waive these requirements for treatment you receive
outside of the United States. See page 39 for details.
Out-of-Network Area Limitation We will limit your benefits if you do not follow all of our authorization processes and your treatment plan except for care received outside of the U. S.

See these sections of the brochure for more valuable information about these benefits:
Section 4, Your costs for covered services, for information about catastrophic protection for these benefits.
Section 7, Filing a claim for covered services, for information about submitting non-PPO and Out-of-Network claims. 44.
44 Page 45 46

Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart beginning on page 45.
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: $300 per person ($ 600 per family). The calendar year deductible applies only to prescriptions purchased outside of the 50 United States in this
Section. We added "( No deductible)" to show when the calendar year deductible does not 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.

I M
P O
R T
A N
T

2003 Foreign Service Benefit Plan 43 Section 5( f)

I M
P O
R T
A N
T

Section 5 (f). Prescription drug benefits

There are important things you should be aware of. These include:
Who can write your prescription. A licensed physician must write the prescription.
When you have to purchase a prescription.
We will provide you with a combination Foreign Service Benefit Plan/ Medco Health Prescription Drug Identification (ID) Card. The Medco Health Logo will appear on the front of the card:

In most cases, you simply present the card together with the prescription to a network pharmacy. You do not file a prescription card claim with the Plan.
Where you can obtain your prescription.
Network Pharmacies within the 50 United States You must fill your prescription at a network pharmacy participating with Medco Health. You may obtain the

names of network pharmacies by calling 1-800/ 818-6717, on the internet at www. medcohealth. com, or as a link through our web site at www. afspa. org. You must present your combined Foreign Service Benefit Plan/
Medco Health Prescription Drug ID Card when filling your prescription in order to receive this benefit. Prescriptions you purchase at network pharmacies without the use of your card are not covered.

Non-Network Pharmacies in the 50 United States Prescriptions you purchase at non-network pharmacies in the 50 United States are not covered.
Mail Order You will receive forms for refills and future prescription orders each time you receive drugs or supplies under
the Medco Health Mail Service Pharmacy (Home Delivery Pharmacy Service). You may also order refills over the internet directly from Home Delivery Pharmacy Service by visiting www. medcohealth. com. If you have any
questions about a particular drug or a prescription, or to request your order forms, you may call 1-800/ 818-6717 in the United States or 1-800/ 497-4641 (available in over 140 countries) from overseas. You can also call
Medco Health collect at 973/ 560-6100 if the overseas number does not work for you. Your doctor must be licensed in the United States. If you are posted, living or traveling overseas, you may request up to a 1-year
supply of most medications. Prescriptions you purchase by mail order from a source other than the Medco Health Home Delivery Pharmacy Service are not covered.

To order by mail: 1) Complete the initial mail order form; 2) Enclose your prescription and copayment; 3) Mail your order to Home Delivery Pharmacy Service; and 4) Allow approximately two weeks for delivery.
Retail Pharmacies outside of the 50 United States Fill your prescription as you normally do. Use the Plan's claim form to claim benefits for prescription drugs and
supplies you purchased through a retail pharmacy outside of the 50 United States. Claims must include receipts that show the name of the patient, prescription number, name of drug( s), name of the prescribing
doctor, name of the pharmacy, date, and the charge. You may obtain claim forms by calling 202/ 833-4910 or from our web site at www. afspa. org. Mail claims to the Plan's address shown in Section 7. 45.
45 Page 46 47
2003 Foreign Service Benefit Plan 44 Section 5( f)
These are the dispensing limitations.
The Plan follows Food and Drug Administration (FDA) guidelines.
You may purchase up to a 30-day supply of medication at a network pharmacy. Refills cannot be obtained until 50% of the drug has been used. You may not obtain more than a 30-day supply through the network

pharmacy arrangement.
You may purchase long-term (up to a 90-day supply) prescription needs through the Home Delivery Pharmacy Service to receive higher benefits. Home Delivery Pharmacy Service will fill your prescription.

We cover all drugs and supplies listed except for those that require constant refrigeration, are too heavy to mail, or that must be administered by a physician.

Per Federal regulations, Home Delivery Pharmacy Service can only mail to addresses in the United States or to APO and FPO addresses.
You may not obtain hormone therapy treatment with your combined Foreign Service Benefit Plan/ Medco Health Prescription Drug ID Card or through the Home Delivery Pharmacy Service.

If a Federally-approved generic equivalent to the prescribed drug is available, the Home Delivery Pharmacy Service will dispense the generic equivalent instead of the brand name unless your physician specifies that the
brand name is required. Your physician must note "Dispense as Written" (DAW) for you to receive the name brand.

Why use generic drugs?
Generic drugs offer a safe and economic way to meet your prescription drug needs. The generic name of a drug is its chemical name; the brand name is the name under which the manufacturer advertises and sells a

drug. Under Federal law, generic and brand name drugs must meet the same standards for safety, purity, strength, and effectiveness.

You can save money by using generic drugs. However, you and your physician have the option to request a brand name drug if a generic is available. To do so, make sure your physician notes "Dispense as Written"
(DAW) for you to receive the brand name.
When you have to file a claim.
See the previous page for instructions when you purchase prescriptions from a pharmacy outside of the 50 United States.

Contact us for instructions on how to receive reimbursement if you purchase a prescription and any of the following apply such as:
You recently enrolled in the Plan and you do not have your combined Foreign Service Benefit Plan/ Medco Health Prescription Drug ID Card;
Your participating pharmacy does not accept your ID card (such as enrollment issues, compound prescription medication, etc); or
You are in a nursing home that requires unit dosing or the purchase of medication from a non-network pharmacy.

Prescription drug benefits (continued)

Prescription drug benefits begin on next page 46.
46 Page 47 48
2003 Foreign Service Benefit Plan 45 Section 5( f)
Benefit Description You pay
NOTE: The calendar year deductible applies only to prescriptions purchased outside of the 50 United States.
We say "( No deductible)" when it does not apply.

Covered medications and supplies
You must present your combined Foreign Service Benefit Plan/ Medco Health Prescription Drug ID Card when filling your prescription at a

network pharmacy.
You may purchase the following medications and supplies prescribed by a physician from either a network pharmacy or by mail through the Home
Delivery Pharmacy Service:
Drugs that by Federal law of the United States require a doctor's prescription for their purchase except those listed as not covered

Insulin and diabetic supplies
FDA-approved drugs, prescriptions, and devices for birth control
Prescription drugs for smoking cessation
Needles and syringes for the administration of covered medications

Prescription drugs you receive from a physician or facility are covered only as specified under Section 5( a) and 5( c) and below.

The following are covered: 20% of the Plan Allowance
If you are overseas and purchase prescriptions from your overseas retail pharmacy;

If you do not use your prescription drug card to purchase colostomy or ostomy supplies

Network Retail (including Medicare Part B):
25% generic ($ 10 minimum) (No deductible)
25% brand name ($ 20 minimum) (No deductible)

Non-Network Retail (in the 50 United States, including Medicare Part B): 100%
of cost
Non-Network Retail pharmacies (outside of the 50 United States, including

Medicare Part B): 20% of cost
Network Mail Order the Home Delivery Pharmacy Service (including Medicare

Part B): $20 generic (No deductible)
$40 brand name (No deductible)
Note: If there is no generic equivalent available, you will still have to pay the brand

name coinsurance/ copay.
Note: When Medicare Part B is the primary payer, the Plan does not waive the

coinsurance/ copayment applicable to covered drugs and supplies purchased at a network
pharmacy or through the Home Delivery Pharmacy Service.

Covered medications and supplies continued on next page 47.
47 Page 48 49
2003 Foreign Service Benefit Plan 46 Section 5( f)
Covered medications and supplies (continued) You Pay
Not covered: All charges.
Drugs and supplies you purchase at a non-network pharmacy in the
United States except as covered under Section 5( a) and 5( c)

Drugs and supplies you purchase without using your combined Foreign Service Benefit Plan/ Medco Health Prescription Drug ID Card at a

network pharmacy except as covered under Section 5( a) and 5( c)
Drugs and supplies you purchase by mail order from a source other than the Plan's Medco Health Home Delivery Pharmacy Service

Prescription Drug Card coinsurance
Home Delivery Pharmacy Service copays
Non-prescription medicines (over-the-counter medications)
Drugs and supplies for cosmetic purposes
Nutritional supplements and vitamins
Medication that under Federal law does not require a prescription, even
if your doctor prescribes it or State law requires it or for which there is a
non-prescription equivalent available

Hormone therapy to diagnose or treat infertility except that limited to the
$5,000 lifetime maximum as part of the diagnosis and treatment of
infertility (See Section 5( a) Infertility services). You may not obtain hormone therapy treatment with your combined Foreign Service Benefit

Plan/ Medco Health Prescription Drug ID Card or through the Home
Delivery Pharmacy Service.

Drugs and supplies related to impotency, sex transformations, sexual
dysfunction, or sexual inadequacy 48.
48 Page 49 50
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.
We 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.

Centers of excellence for Mutual of Omaha has special arrangements with facilities to provide services for tissue tissue and organ transplants and organ transplants its Medical Specialty Network. The network was designed to
give you an opportunity to access providers that demonstrate high quality medical care for transplant patients. Your physician can coordinate arrangements by calling a case
manager in Mutual of Omaha's Medical Management Department at 1-800/ 593-2354. For additional information regarding the transplant network, please call this number.

Disease management Healthydirections sm , a disease management program for members and covered programs dependents with asthma, diabetes, or congestive heart failure (CHF).
Healthydirections sm is provided at no additional cost to participants. The program provides:
Nurse support;
Education about the disease and how it affects the body; and
Proper medical management that can help lead to a healthier lifestyle.

We will contact candidates and ask them to participate voluntarily. The participant and his/ her physician remain in charge of the participant's treatment plan.

If you would like to contact Mutual of Omaha for more information about this program, please call 1-800/ 593-2354.

2003 Foreign Service Benefit Plan 47 Section 5( g) 49.
49 Page 50 51
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: $300 per person ($ 600 per family). The calendar year deductible does not apply to most benefits in this Section. We added "( calendar year
deductible applies)" to show when the calendar year deductible does 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.
NOTE: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment to safeguard the health of the patient, even

though we may not pay benefits for services of dentists or doctors in connection with the dental treatment. See Section 5( c) for inpatient hospital benefits.

2003 Foreign Service Benefit Plan 48 Section 5( h)

I M
P O
R T
A N
T

Section 5 (h). Dental benefits

Accidental injury benefit You pay
We cover dental work (including dental X-rays) to repair or initially replace sound natural teeth under the following conditions:

You must receive these services as a result of an accidental injury to the jaw or sound natural teeth.
You must be covered by this Plan when the accident occurred. You must receive these services while covered under this Plan and within
24 months of the accident.
Note: We cover dental care required as a result of accidental injury from an external force such as a blow or fall to sound natural teeth (not from biting

or chewing) that requires immediate attention.
Note: We define a sound natural tooth as a tooth which is whole or properly restored;

is without impairment, periodontal or other conditions; and does not need treatment for any reason other than an accidental injury.

Dental benefits (Only those services listed below are covered)
Service We pay You pay (scheduled allowance)
Preventive care, limited to two services per person per calendar year
Oral exam $13 per exam Prophylaxis (cleaning), adult $23 per cleaning
Prophylaxis, child (thru age 14) $16 per cleaning All charges in excess of the Prophylaxis with fluoride, child (thru age 14) $26 per cleaning scheduled amounts listed to the left

Surgery Apicoectomy (tooth root amputation) $50 per root
Alveolectomy (excision of alveolar bone) $40 per quadrant Alveolar abscess, incision and drainage $10 per abscess
Gingivectomy (excision of gum tissue) $50 per quadrant
Note: Excision of impacted teeth and non-dental oral surgical procedures are covered under

Oral and maxillofacial surgery Section 5( b).
Orthodontic Services
We define orthodontics as the realignment of 50% of Plan allowance up to a 50% of Plan allowance until benefits natural teeth or correction of malocclusion. lifetime maximum of $1,000 per stop at $1,000 and all charges

person after $1,000

PPO: 20% of Plan allowance (calendar year deductible applies)
Non-PPO and Out-of-Network Area: 20% of Plan allowance and any difference between
our allowance and the billed amount (calendar year deductible applies)

Overseas Providers: 20% of the Plan allowance (calendar year deductible applies)
when you reside overseas 50.
50 Page 51 52

2003 Foreign Service Benefit Plan 49 Section 5( i)
Section 5 (i). Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed claim about them. Fees you pay for these services do not count toward FEHB deductibles, copayments or catastrophic

protection out-of-pocket maximums.
The importance of Long Term Care insurance has never been clearer. The government will present its own offering in October of this year and you can read about it on page 66 of this
brochure. AFSPA members are eligible for our plans NOW. We offer two excellent policies with group rates and deep discounts. Both plans provide benefits for all levels of nursing home care
(skilled, intermediate, custodial), assisted living facility, home health care, adult day care and respite care. The underwriters, Mutual of Omaha and John Hancock, are highly respected pillars
of the insurance industry.
Mutual of Omaha John Hancock $100 daily benefit $50 to $500 daily benefit

5% simple inflation 5% simple or compound inflation Benefit Increase Option 100% of benefit for home health care
International coverage 2 year to lifetime benefit period Return-of-premium feature International coverage

Discount on You may purchase non-covered (off-plan) prescription drugs at a discount directly from Medco Non-Covered Health such as:
Prescription Dermatologicals (Retin-A) Anorexiants Rx Vitamins Drugs Drugs labeled for cosmetic indications (Propecia) Erectile dysfunction agents (Viagra)
You pay 100% of the discounted price. You cannot file a claim with us for off-plan prescriptions.
Call Medco Health first at 1-800/ 818-6717 to find out the price of off-plan prescriptions. Obtain the prescription from your doctor.
Complete the mail order envelope and enclose your prescription along with your check or credit card number. You must include full payment with your order for prescriptions.

Term Life Up to $200,000 of coverage Insurance Includes acts of terrorism or war
Simple, inexpensive, straightforward protection
Expanded Varied Plans offered: Dental Benefits DENTAQUEST (Available DC/ MD/ VA Only) No claim forms, deductibles, or waiting period

for pre-existing conditions CIGNA Dental National coverage with a choice of a dental HMO or PPO with an out-of-network
option CIGNA International International coverage for our overseas members. Based on
coinsurance at 100%, 80% and 50%; Overseas dental referrals; Claims processed in any language and most currencies

Long Distance Calling Card and, for those overseas, Callback Service Telephone No sign-up fees, no monthly fees, excellent domestic and international rates, and no hidden
Services costs
Senior Living At no cost to our members, we offer information on senior living facilities throughout the U. S. Services

Legal Services Three firms located in the Washington Metropolitan area serve our members at special rates
Travel Emergency medical evacuation; On-the-spot medical payments; Worldwide medical referrals Assistance and medical monitoring; Prescription replacement assistance; Repatriation of remains benefit

Services
For information and written material on any of the above programs, please contact us at:
American Foreign Service Protective Association 202/ 833-4910 1716 N Street, NW 202/ 833-4918 (fax)

Washington, D. C. 20036-2902 E-mail: afspa@ afspa. org Web site: www. afspa. org

Long Term Care 51.
51 Page 52 53
2003 Foreign Service Benefit Plan 50 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. The

fact that one of our covered providers has prescribed, recommended or approved a service or supply does not make it medically necessary or eligible for coverage under this Plan.

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 impotency, sex transformations, sexual dysfunction or sexual inadequacy;
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program;
Any part of a provider's fee or charge ordinarily due from you that has been waived. If a provider routinely waives (does not require you to pay) a deductible, copayment or coinsurance, we will calculate the actual provider fee or charge by reducing

the fee or charge by the amount waived;
Charges you or we have no obligation to pay, such as excess charges for an annuitant 65 or older who is not covered by Medicare Part A and/ or Part B (see Section 4), provider charges exceeding the amount specified by the Department of Health

and Human Services when benefits are payable under Medicare (limiting charge) (see Section 4), or State premium taxes however applied;

Services, drugs, or supplies you receive without charge while in active military service;
Services, drugs or supplies for which you would not be charged if you had no health insurance coverage;
Services and supplies not recommended or approved by a covered provider;
Services for cosmetic purposes;
Services, drugs, or supplies related to weight control or any treatment of obesity except surgery for morbid obesity as described in Section 5( b);

Services, drugs, or supplies furnished or billed by a noncovered facility, except that medically necessary prescription drugs are covered;
Services, drugs, or supplies you receive from immediate relatives or household members, such as spouse, parents, child, brother or sister by blood, marriage, or adoption;
Services, drugs, or supplies not specifically listed as covered; and
Charges that we determine are over our Plan allowance.

Listed below are examples of some of our exclusions:
Milieu therapy;
Charges for completion of reports or forms, interest, and missed or cancelled appointments;
Custodial care;
Mutually exclusive procedures. These are procedures that are not typically provided to the same patient on the same date of service;

Non-medical services such as social services, recreational, educational, visual and nutritional counseling;
Non-surgical treatment of temporomandibular joint (TMJ) dysfunction including dental appliances, study models, splints and other devices;

Telephone consultations, mailings, faxes, e-mails or any other communication to or from a physician, hospital or other medical provider; and
Treatment for learning disabilities and mental retardation.
Note: An exclusion that is primarily identified with a single benefit category is listed along with that benefit category, but may apply to other categories. 52.
52 Page 53 54

2003 Foreign Service Benefit Plan 51 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 by mail at Foreign Service Benefit Plan, 1716 N Street, NW, Washington,
DC 20036-2902, by phone at 202/ 833-4910, by fax at 202/ 833-4918, by e-mail at afspa@ afspa. org or at our web site at www. afspa. org.

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.
When you must file a claim such as for non-PPO or out-of-network providers, overseas claims 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. The Plan cannot accept a claim as an e-mail

attachment.
In addition:
Generally, you need to fill out only one claim form per year. You should fill out a claim form if you submit a claim due to accidental injury or you have changed your

address, or if the member's other insurance/ Medicare status has changed.
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. See Section 9 for

Medicare claims.
Bills for private duty nursing care must show that the nurse is a Registered (R. N.) or Licensed Practical Nurse (L. P. N.). You should also include the initial history and

physical, treatment plan indicating expected duration and frequency from your attending physician and the nursing notes from the nurse.

Claims for rental or purchase of durable medical equipment must include the purchase price, a prescription and a statement of medical necessity including the
diagnosis and estimated length of time needed.
Claims for physical, occupational, and speech therapy must include an initial evaluation and treatment plan indicating length of time needed for therapy and

progress (therapy) notes for each date of service from the therapist.
Claims for dental services must include a copy of the dentist's itemized bill (including the information required above) and the dentist's Federal Tax I. D.

Number. We do not have separate dental claim forms. 53.
53 Page 54 55
2003 Foreign Service Benefit Plan 52 Section 7
Overseas (foreign) claims The Foreign Service Benefit Plan pays claims for overseas providers at the same PPO coinsurance rate as PPO providers in the United States when you reside
overseas.
If you are posted overseas and both the Medical and Health Program of the Department of State Office of Medical Services (OMS) and we cover you,

submit claims to us as described on the previous page or as directed by OMS, through your Administrative Office.

If the Medical and Health Program of the Department of State does not cover you, you should submit claims directly to us as described on the previous page.
You may include an English translation (not required) and a currency exchange rate (recommended). We will translate claims and will convert to U. S. Dollars
using the exchange rate applicable at the time the expense was incurred if you do not supply us with a translation or conversion.

We have special billing arrangements with hospitals in several countries, including Brazil, Germany, Italy, Korea and Panama. We also have a fast
track payment process if you are posted in Korea. In addition, overseas Seventh-day Adventist Hospitals and Clinics participate in our special billing
arrangement. Please contact us for more information on these arrangements if you are in these locations.

After you complete a claim form and attach proper documentation, send your claims to:
Foreign Service Benefit Plan 1716 N Street, NW
Washington, DC 20036-2902
If you are overseas and have access to the Department of State pouch mail, you may send your claims in care of Department of State, Washington, DC 20520. Note:

Do not use this address if you are in the United States. It will delay your claim.
Plan telephone number: 202/ 833-4910

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 provide you with a record of expenses you submit and benefits we paid for each claim that you file (explanation of benefits (EOB)). You are responsible for
keeping these. 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 within 90 days after you incur the expense, but in no event later than 2
years from the date you incur the expense. We can extend this deadline if you were prevented from filing your claim timely by administrative operations of Government
or legal incapacity, provided you file the claim as soon as reasonably possible. Once we pay benefits, there is a three-year limitation on the reissuance of uncashed
checks.

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. 54.
54 Page 55 56
2003 Foreign Service Benefit Plan 53 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: Foreign Service Benefit Plan, 1716 N Street NW, Washington, DC 20036-2902; and
(c) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure; and

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

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

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

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

90 days after the date of our letter upholding our initial decision; or
120 days after you first wrote to us if we did not answer that request in some way within 30 days; or
120 days after we asked for additional information.
Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Contracts Division 2, 1900 E Street, NW, Washington, D. C. 20415-3620

The Disputed Claims process
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. 55.
55 Page 56 57
2003 Foreign Service Benefit Plan 54 Section 8
The Disputed Claims process (continued)
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 based on the terms of the contract. 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 202/ 833-4910 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 2 at 202/ 606-3818 between 8 a. m. and 5 p. m. eastern time. 56.
56 Page 57 58
2003 Foreign Service Benefit Plan 55 Section 9
Section 9. Coordinating benefits with other coverage
When you have other health You must tell us if you or a covered family member have coverage under another coverage group health plan or have automobile insurance that pays health care expenses without

regard to fault. This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in full as the primary payer and the other plan pays a reduced benefit as the secondary payer. We,

like most 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. You must send us your primary plan's explanations of benefits (EOBs) if we ask for them. After the

primary plan pays, we will pay what is left of our allowance, up to the lesser of:
Our benefits in full; or
A reduced amount that, when added to the benefits payable by the primary plan, does not exceed 100% of covered expenses.

We will not pay more than our allowance. The combined payments from both plans might not equal the entire amount billed by the provider.

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.

The Original Medicare Plan The Original Medicare Plan (Original Medicare) is available everywhere in (Part A or Part B) 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. We do not require
precertification of inpatient hospital stays when Medicare Part A is primary. We do not require preauthorization and concurrent review of Mental health and substance abuse
treatment when Medicare Part B is primary. However, when Medicare stops paying benefits for any reason, you must follow our precertification, preauthorization and
concurrent review procedures. 57.
57 Page 58 59
2003 Foreign Service Benefit Plan 56 Section 9
Claims process when you have the Original Medicare Plan Send us a copy of your Medicare Card when we are secondary to Medicare. We need this information
in order to start electronic crossover of your claims. Electronic crossover is a process that assures, in most cases, you do not have to file a claim when Medicare is primary.
Call us at 202/ 833-4910 or contact us at afspa@ afspa. org to find out if your claims are being electronically filed or you have questions about the process described below.

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, we will coordinate your claim automatically and we will then provide

secondary benefits for covered charges. There are exceptions:
If you have not sent us a copy of your Medicare card as stated above, you will need to send us your claims and Medicare Summary Notices (MSN) until you

have sent us your Medicare Card and we have had time to set up electronic crossover.

If Medicare rejects your claim completely, send us your claim and your MSN. You must send them in order for us to begin processing your claim.
If Medicare rejects a part of your claim or pays a reduced amount, you may need to send us your claim and MSN. In that case, we will ask you for a copy of
them. You must send them to us in order for us to continue processing your claim.

We waive some costs when you have the Original Medicare Plan When Original Medicare is the primary payer, we will waive some out-of-pocket costs, as follows:
Medical services and supplies provided by physicians and other health care professionals in Section 5( a).
If you are enrolled in Medicare Part B, we will waive your calendar year deductible and coinsurance.

Surgical and anesthesia services provided by physicians and other health care professionals in Section 5( b).
If you are enrolled in Medicare Part B, we will waive your coinsurance.
Services provided by a hospital or other facility, and ambulance services in Section 5( c).

If you are enrolled in Medicare Part A, we will waive your inpatient hospital copayment and coinsurance for inpatient hospital stays.
If you are enrolled in Medicare Part B, we will waive the deductible and coinsurance for outpatient hospital, ambulatory surgical center and ambulance.

Services provided by facilities and providers covered under Emergency services/ accidents in Section 5( d).
If you are enrolled in Medicare Part B, we will waive the deductible and coinsurance.

Services provided by Mental health and substance abuse facilities and providers in Section 5( e).
If you are enrolled in Medicare Part A, we will waive the inpatient hospital copayment and coinsurance for inpatient hospital stays.
If you are enrolled in Medicare Part B, we will waive the deductible and coinsurance.

Services provided under Prescription benefits Section 5( f).
We do not waive the prescription coinsurance or copay.

Services provided under Dental benefits in Section 5( h).
We do not waive the coinsurance under Dental benefits. 58.
58 Page 59 60
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
A. When either you or your covered spouse are age 65 Then the primary payer is or over and
Original Medicare This Plan

1) Are an active employee with the Federal government (including when you or a family member are eligible for Medicare solely 3
because of a disability),
2) Are an annuitant, 3
3) Are a reemployed annuitant with the Federal government when
a) The position is excluded from FEHB, or 3

b) The position is not excluded from FEHB 3
(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 3

your covered spouse is this type of judge),
5) Are enrolled in Part B only, regardless of your employment status, 3 3 (for Part B (for other

services) services)
6) Are a former Federal employee receiving Workers' Compensation 3 and the Office of Workers' Compensation Programs has determined (except for claims

that you are unable to return to duty, related to Workers' Compensation.)

B. When you or a covered family member have Medicare based on end stage renal disease (ESRD) and
1) Are within the first 30 months of eligibility to receive Part A benefits solely because of ESRD, 3
2) Have completed the 30-month ESRD coordination period and are still eligible for Medicare due to ESRD, 3
3) Become eligible for Medicare due to ESRD after Medicare became primary for you under another provision, 3
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 3
b) Are an active employee 3
c) Are a former spouse of an annuitant 3
d) Are a former spouse of an active employee 3

2003 Foreign Service Benefit Plan 57 Section 9
Also, this Plan is primary if you receive services or incur charges:
Overseas; or
On board a ship not in a U. S. port or more than six hours before arrival at, or after departure from a U. S. port, even if the ship is of U. S. registry.

Note: Medicare remains primary in certain bordering areas of Canada and Mexico. 59.
59 Page 60 61

2003 Foreign Service Benefit Plan 58 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 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, 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.

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

TRICARE and CHAMPVA TRICARE is the health care program for eligible dependents of military persons, and retirees of the military. TRICARE includes the CHAMPUS program. CHAMPVA
provides health coverage to disabled Veterans and their eligible dependents. If TRICARE or CHAMPVA and this Plan cover you, we pay first. See your TRICARE
or CHAMPVA Health Benefits Advisor if you have questions about these programs.
Suspended FEHB coverage to enroll in TRICARE or CHAMPVA: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of

these programs, eliminating your FEHB premium. (OPM does not contribute to any applicable plan premiums.) For information on suspending your FEHB enrollment,
contact your retirement office. If you later want to 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 a similar agency pays its maximum benefits for your treatment, we will cover your care. 60.
60 Page 61 62
2003 Foreign Service Benefit Plan 59 Section 9
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, or Federal Government are responsible for your care agency directly or indirectly pays for them.

When others are responsible We have the right to recover payment we have made to you from any recovery for injuries you receive because of illness or injury caused by the act or omission of a third party
(another person or organization).
If you do not seek damages you must agree to let us try. This is called subrogation. We are also subrogated to your present and future claims against the third party.

If you suffer an injury or illness through the act or omission of a third party, you agree:
to reimburse us for benefits paid up to the recovery amount; and
that we are subrogated to your rights to the extent of benefits paid, including the right to bring suit.

All recoveries must be used to reimburse us for benefits paid. Unless we agree in writing to a reduction, you cannot reduce our share of the recovery because you do not
receive the full amount of damages claimed.
If we invoke this provision:
We will pay benefits for the injury or illness as long as you:
take no action to prejudice our ability to recover benefits; and
reasonably assist us in recovery.

Our reimbursement right extends only to the amount we paid or would pay because of the injury or illness.

We may insist on a proceeds assignment and may withhold payment of benefits otherwise due until the assignment is provided. Failure to request or obtain
assignment prior to us paying benefits will in no way diminish our rights of reimbursement and subrogation.

We will have a lien on the proceeds of your claim to the third party to reimburse ourselves the full amount of benefits we have paid or may pay. Our lien will apply to
any and all recoveries for the claim and will be satisfied in full out of the proceeds before the satisfaction of any individual's claim.

You are required to notify us promptly of any claim that you may have for damages as a result of the act or omission of a third party, for which we have paid or may pay
benefits. In addition, you are required to notify us of any recovery that you obtain, and you are required to reimburse us in full for the benefits paid or to be paid. Any
reduction of our lien for payment of associated costs must be approved by us prior to payment. 61.
61 Page 62 63
2003 Foreign Service Benefit Plan 60 Section 10
Section 10. Definitions of terms we use in this brochure
Admission The period from entry (admission) into a hospital or other covered facility until discharge. In counting days of inpatient care, we count the date of entry and the date
of discharge as the same day.

Assignment You authorize us to issue payment of benefits directly to the provider of services. 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 The percentage of our allowance that you must pay for your care. You may also be responsible for additional amounts. See Section 4.

Copayment A fixed amount of money you pay to the provider when you receive covered services. See Section 4.
Covered services Services we provide benefits for, as described in this Brochure.
Custodial care Treatment or services, regardless of who recommends them or where they are provided, that a person not medically skilled could render safely and reasonably, or
that help you mainly 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; exercising; dressing;
2) Homemaking, such as preparing meals or special diets;
3) Moving you;
4) Acting as companion or sitter;
5) Supervising medication that you can usually take yourself; or
6) Treatment or services that you may be able to perform with minimal instruction, including but not limited to recording temperature, pulse, respirations, or

administration and monitoring of feeding systems.
We determine which services are custodial care.

Deductible A fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for those services. See Section 4.

Effective date The date the benefits described in this Brochure become effective:
1) January 1 for all continuing enrollments;
2) The first day of the first full pay period of the new year if you change plans or options or elect FEHB coverage during the Open Season for the first time; or

3) The date determined by your employing or retirement system if you enroll during the calendar year, but not during the Open Season.

Expense The cost incurred for a covered service or supply ordered or prescribed by a covered provider. You incur an expense on the date the service or supply is received. Expense
does not include any charge:
1) for a service or supply that is not medically necessary; or
2) that is in excess of the Plan's allowance for the service or supply. 62.
62 Page 63 64
2003 Foreign Service Benefit Plan 61 Section 10
Experimental or A drug, device or biological product is experimental or investigational if the drug, Investigational Services 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.
Reliable evidence means 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.

If you need additional information regarding the determination of experimental and investigational, please contact us.

Group health coverage Health care coverage that you are eligible for because of employment, membership in, or connection with, a particular organization or group that provides payment for any
health care services or supplies, or that pays a specific amount for each day or period of hospitalization if the specified amount exceeds $200 per day, including extension of
any of these benefits through COBRA.

Hospital stay An admission (or series of admissions separated by less then 60 days) to a hospital as an inpatient for any illness or injury. You start a new hospital stay (1) when the
admission is for a cause unrelated to the previous admission; (2) when an employee returns to work for at least one day before the next admission; or (3) when the hospital
stays are separated by at least 60 days for a dependent or retiree.

Medical emergency The sudden and unexpected onset of a condition or an injury that you believe endangers your life or could result in serious injury or disability and requires
immediate medical or surgical care that you receive within 72 hours after the onset. Medical emergencies include deep cuts, broken bones, heart attacks, cardiovascular
accidents, poisonings, loss of consciousness or respiration, convulsions, and such other acute conditions that we determine to be medical emergencies.

Medically necessary Services, drugs, supplies or equipment provided by a hospital or covered provider of the health care services that we determine:
1) Are appropriate to diagnose or treat your condition, illness or injury;
2) Are consistent with standards of good medical practice in the United States;
3) Are not primarily for your, a family member's or a provider's personal comfort or convenience;

4) Are not a part of or associated with your scholastic education or vocational training; 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. 63.
63 Page 64 65
2003 Foreign Service Benefit Plan 62 Section 10
Mental Conditions/ Conditions and diseases listed in the most recent edition of the International Substance Abuse Classification of Diseases (ICD) as psychoses, neurotic disorders, or personality
disorders; other nonpsychotic mental disorders listed in the ICD, to be determined by us; or disorders listed in the ICD requiring treatment for abuse of or dependence upon
substances such as alcohol, narcotics, or hallucinogens.

Plan allowance 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 allowance as follows:
PPO Providers Our Plan allowance is a negotiated amount between us and the provider. Neither you nor the provider can unilaterally change the negotiated amount.
We base our coinsurance on this negotiated amount. This applies to all benefits in Section 5 of this Brochure.

Non-PPO and Out-of-Network Providers We base our Plan allowance on reasonable and customary charges (R& C). We define R& C as charges that are:
Comparable to those made by other providers for similar services and supplies under comparable circumstances in the same geographic area;
Developed from actual claims we receive from each Zip Code area throughout the United States, as compiled by the Health Insurance Association of America;
Updated twice a year; and
Are within the 90th percentile of the charges. We chose the 90th percentile to assure that as broad a range of charges are considered to be within R& C as possible under

the FEHB Program.
We use this method for determining our allowance for all benefits in Section 5 of this Brochure. For certain specific services in Section 5, exceptions to this general

method for determining the Plan's allowances may exist.
Overseas Providers We generally do not reduce overseas providers' claims to a Plan allowance. However, we reserve the right to request information that will enable us to
determine an allowance on charges that we deem to be excessive.
We determine what is a reasonable and customary charge and what is within our Plan allowance.

For more information, see Differences between our allowance and the bill in Section 4.
Routine testing/ screening Healthcare services provided to an individual without apparent signs and symptoms of an illness, injury or disease for the purpose of identifying or excluding an undiagnosed
illness, disease or condition.

Us/ We Us and we refer to the Foreign Service Benefit Plan.
You You refers to the enrollee and each covered family member. 64.
64 Page 65 66
2003 Foreign Service Benefit Plan 63 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 can answer your about enrolling in the questions, and give you a Guide to Federal Employees Health Benefits Plans,
FEHB Program brochures for other plans, and other materials you need to make an informed decision about:
When you may change your enrollment;
How you can cover your family members;
What happens when you transfer to another Federal agency, go on leave without pay, enter military service, or retire;

When your enrollment ends; and
When the next open season for enrollment begins.

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

Types of coverage available Self Only coverage is for you alone. Self and Family coverage is for you, your spouse, for you and your family and your unmarried dependent children under age 22, including any foster children or
stepchildren your employing or retirement office authorizes coverage for. Under certain circumstances, you may also continue coverage for a disabled child 22 years of
age or older who is incapable of self-support.
If you have a Self Only enrollment, you may change to a Self and Family enrollment if you marry, give birth, or add a child to your family. You may change your

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

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

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

Children's Equity Act OPM has implemented the Federal Employees Health Benefits Children's Equity Act of 2000. This law mandates that you be enrolled for Self and Family coverage in the
Federal Employees Health Benefits (FEHB) Program, if you are an employee subject to a court or administrative order requiring you to provide health benefits for your
child( ren).
If this law applies to you, you must enroll for Self and Family coverage in a health plan that provides full benefits in the area where your children live or provide

documentation to your employing office that you have obtained other health benefits coverage for your children. If you do not do so, your employing office will enroll you
involuntarily as follows:
If you have no FEHB coverage, your employing office will enroll you for Self and Family coverage in the Blue Cross and Blue Shield Service Benefit Plan's Basic

Option; 65.
65 Page 66 67
2003 Foreign Service Benefit Plan 64 Section 11
If you have a Self Only enrollment in a fee-for-service plan or in an HMO that serves the area where your children live, your employing office will change your
enrollment to Self and Family in the same option of the same plan; or
If you are enrolled in an HMO that does not serve the area where the children live, your employing office will change your enrollment to Self and Family in the Blue

Cross and Blue Shield 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 Plan premiums start during Open Season, your coverage begins on the first day of your first pay period that
starts on or after January 1. Annuitants' coverage and premiums begin on January 1. If you joined at any other time during the year, your employing office will tell you the
effective date of coverage.

When you retire When you retire, you can usually stay in the FEHB Program. Generally, you must have been enrolled in the FEHB Program for the last five years of your Federal service. If you
do not meet this requirement, you may be eligible for other forms of coverage, such as temporary continuation of coverage (TCC).

When you lose benefits
When FEHB coverage ends You will receive an additional 31 days of coverage, for no additional premium, when:
Your enrollment ends, unless you cancel your enrollment, or
You are a family member no longer eligible for coverage.

You may be eligible for spouse equity coverage or TCC.

Spouse equity If you are divorced from a Federal employee or annuitant, you may not continue to coverage 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 web site, www. opm. gov/ insure.

Temporary Continuation If you leave Federal service, or if you lose coverage because you no longer qualify as of Coverage (TCC) a family member, you may be eligible for 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. 66.
66 Page 67 68
2003 Foreign Service Benefit Plan 65 Section 11
Converting to You may convert to a non-FEHB individual policy if: individual coverage
Your coverage under TCC or the spouse equity law ends (If you canceled your coverage or did not pay your premium, you cannot convert.);

You decided not to receive coverage under TCC or the spouse equity law; or
You are not eligible for coverage under TCC or the spouse equity law.

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

Getting a Certificate of The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a Group Health Plan Coverage 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. 67.
67 Page 68 69
2003 Foreign Service Benefit Plan 66 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 web site 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. 68.
68 Page 69 70
2003 Foreign Service Benefit Plan 67 Index
Index
Do not rely on this page; it is for your convenience and may not show all pages where the terms appear. This Index references both covered and non-covered services and supplies.

Accidental injury ............................. 7, 35, 48
Acupuncture ....................................... 7, 9, 26
Allergy care ................................................. 22
Ambulance ........................................ 7, 34, 36
Anesthesia ............................................ 29, 30
Authorization (mental health
services) ....................................... 11, 37-42

Birthing centers ...................................... 9, 20
Bone marrow transplant .............................. 30
Breast prosthesis ................................... 24, 29

Cancer screening ......................................... 19
Catastrophic (out-of-pocket) protection ...... 14
Changes for 2003 .......................................... 7
Chemotherapy ............................................. 22
Chiropractic ........................................ 7, 8, 26
Claiming benefits ................ 44, 51-52, 55-56
Coinsurance .............. 7, 12-14, 45, 50, 56, 60
Contact lenses .............................................. 24
Contraceptive devices and drugs ............ 21, 45
Coordination of benefits ....................... 55-58
Copayment .......... 7, 12, 14, 31, 40-41, 45, 60
Cosmetic services ...................... 28-29, 46, 50
Covered facilities .......................................... 9
Covered providers ..................................... 8-9
Custodial care ........... 9, 23, 26, 32-33, 50, 60

Deductible ............. 12, 14-15, 18, 27, 31, 35,
37, 43, 48, 56, 60
Dental benefits ................................. 7, 29, 48
Diagnostic and treatment services ......... 7, 18
Disputed claims process ........................ 53-54
Drug card ........................................... 8, 43-46

Effective date of enrollment ...... 8, 10, 12, 60
Emergency .......... 7, 10, 16, 35-36, 39, 56, 61
Equipment, medical ............. 25, 32-33, 51, 61
Experimental or investigational .............. 50, 61
Eyeglasses ................................................... 24

Family planning .......................................... 21
Flexible benefits option .............................. 47
Foot care ...................................................... 24
Fraud .......................................................... 4-5

Group therapy ....................................... 38-41

Hearing services .......................................... 23
Home Delivery Pharmacy Service ....... 43-46
Home health services ................ 11, 25-26, 31
Hospice ..................................... 11, 14, 31, 33
Hospital ..................... 9-11, 15, 18-20, 31-35,
38-41, 48

Identification cards .................. 6, 8, 13, 43-46
Impacted teeth, removal of ............ 18, 29, 48
Impotency ................................. 18, 28, 46, 50
Individual therapy ................................. 38-41
Infertility services ...................... 14, 21-22, 46
Insulin .......................................................... 45
Investigative or experimental ............... 50, 61

Laboratory, X-rays and other diagnostic
tests ...................................................... 7, 18
Lifetime maximums ........... 14, 21, 33, 46, 48

Mail order prescription drugs (Home
Delivery Pharmacy Service) .......... 7, 43-46
Maternity care ............................ 7, 11, 20, 32
Medco Health ........................................ 43-46
Medically necessary ........... 10-11, 18, 27, 31,
34-37, 39, 43, 48, 50
Medicare ........................ 9, 11, 15-16, 39, 45,
50-51, 55-58
Mental health/ substance Abuse ............ 7, 11,
37-42, 55, 62

Newborn care .............................................. 20
No-fault insurance ....................................... 59
Non-FEHB benefits ..................................... 49

Obesity, morbid .................................... 27, 50
Obstetrical care ....................................... 7, 20
Occupational therapy ..................... 23, 25, 51
Office visits ................................................. 18
Organ/ tissue transplants .............................. 30
Orthodontics ......................................... 14, 48
Orthopedic devices .................... 24, 27, 32-33
Out-of-pocket expenses ......................... 12-14
Overseas (outside of U. S.)
claims .......................... 7, 11, 13, 32, 42-45
Oxygen ...................................... 22, 25, 32-33

Pharmacy drug card .......................... 8, 43-46
Physical therapy ............................. 23, 25, 51
Physician ........................ 8-13, 15-18, 23, 25,
31-32, 35-36, 43-46, 50-56

Plan allowance .............. 12-14, 18-42, 50, 62
Preauthorization (Mental health
services) ........................... 11, 37, 39, 41-42
Precertification ....... 10-11, 14, 20, 25-26, 31,
33, 37, 39, 41-42
Preferred Provider Organization
(PPO) ........... 6-7, 10, 12-15, 18-42, 48, 62
Prescription drug card ....................... 8, 43-46
Prescription drugs .......... 7, 12, 14, 21, 43-46,
49-51, 56
Preventive care ............................ 7, 19-20, 48
Private duty nursing ........................ 25-26, 32
Prosthetic devices ................ 24, 27, 29, 32-33

Radiation therapy ........................................ 22
Reasonable and customary (R& C) ............. 62
Renal dialysis .............................................. 23
Routine physical examination and
services .......................................... 7, 19-20

Second opinion ..................................... 18, 27
Skilled nursing facility (SNF) .. 7, 9, 11, 30-33
Smoking Cessation ........................... 7, 26, 45
Speech therapy ............................... 23, 25, 51
Sterilization procedures .............. 21-22, 27-28
Subrogation provision ................................. 59
Substance abuse ............. 7, 11, 37-42, 55, 62
Surgery ........ 19-22, 24, 27-30, 32-33, 48, 50
Surgical center ...................................... 30, 33

Take-home items ................................... 32-33
Temporary continuation of coverage
(TCC) ................................................. 64-65
Temporomandibular joint (TMJ)
dysfunction ....................................... 29, 50
Tests X-ray, laboratory and other
diagnostic .......................................... 7, 18
Third party liability ..................................... 59
Transplants .................................................. 30
Treatment therapies ............................... 22-23

Vision services ............................................ 24
Weight control ..................................... 27, 50
Well child care ............................................ 20
Workers' compensation .............................. 58

X-rays, laboratory and other diagnostic
tests ..................................................... 7, 18 69.
69 Page 70 71
2003 Foreign Service Benefit Plan 68 Summary
Summary of benefits for the Foreign Service Benefit Plan 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 $300 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 and Out-of-Network Area physician or
other health care professional.
Benefits You Pay Page

Medical services provided by physicians: PPO: 10% of our allowance*
Diagnostic and treatment services provided in the Non-PPO: 30% of our allowance and any 18-26 hospital and office . . . . . . . . . . . . . . . . . . . . . . . . . . . difference between our allowance and the

billed amount*
Out-of-Network Area: 20% of our allowance and any difference between our allowance and

the billed amount*
Overseas Providers: 10% of our allowance when you reside overseas*

Services provided by a hospital: Inpatient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PPO: Nothing 31-32
Non-PPO: $200 per hospital stay and 20% of charges
Out-of-Network Area: $200 per hospital stay
Overseas Providers: Nothing when you reside overseas

Outpatient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Surgical: 33
PPO: 10% of our allowance*
Non-PPO: 30% of our allowance and any difference between our allowance and the

billed amount*
Out-of-Network Area: 10% of our allowance and any difference between our allowance and

the billed amount*
Overseas Providers: 10% of our allowance when you reside overseas*

Medical: 33
PPO: 10% of our allowance*
Non-PPO: 30% of our allowance and any difference between our allowance and

the billed amount*
Out-of-Network Area: 20% of our allowance and any difference between our allowance

and the billed amount*
Overseas Providers: 10% of our allowance when you reside overseas* 70.
70 Page 71 72
2003 Foreign Service Benefit Plan 69 Summary
Benefits You Pay Page
Emergency benefits: PPO: Nothing
Accidental injury (for emergency room charges and Non-PPO and Out-of-Network Area: Only the 35 emergency room physician charge or initial office difference between our allowance and the

visit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . billed amount
Overseas Providers: Nothing when you reside overseas

Medical emergency . . . . . . . . . . . . . . . . . . . . . . . . . . Regular benefits* 36
Mental health and substance abuse treatment . . . . . . . . . . PPO and Out-of-Network Area: Regular cost 37-42 sharing*

Non-PPO: Benefits are limited*
Overseas Providers: Regular cost sharing when you reside overseas*

Prescription drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Network Pharmacies in the 50 United States: 43-46 Note You must show your Plan ID card:
Generic: 25% ($ 10 minimum) for up to a 30-day supply
Brand name: 25% ($ 20 minimum) for up to a 30-day supply

Non-Network Pharmacies in the 50 United States: You pay 100% and cannot claim
reimbursement from the Plan (no coverage)
Retail Pharmacies outside of the 50 United States: 20%* (claim reimbursement from the

Plan)
Mail Order (Home Delivery Pharmacy Service): Generic: $20 for up to a 90-day supply

Brand name: $40 for up to a 90-day supply
Dental Care 48
Routine preventive care and surgical procedures . . . . . . The difference between our scheduled allowances and the actual billed amounts

Orthodontics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50% of our allowance up to our maximum payment of $1,000 and 100% after our
maximum payment of $1,000
Special features:
Flexible benefits option Disease management 47 Centers of excellence for tissue and organ transplants

Protection against catastrophic costs PPO and Overseas Providers: Nothing after (your catastrophic protection out-of-pocket maximum) . . . . $3,000/ Self Only or $3,500/ Family enrollment
per year 14
Non-PPO and Out-of-Network Area Providers: Nothing after $4,000/ Self Only or $4,500/ Family

enrollment per year
Note: Benefit maximums still apply and some costs do not count toward this protection. 71.
71 Page 72
Premium
Biweekly Monthly
Type of Gov't Your Gov't Your Enrollment Code Share Share Share Share

Self Only 401 $109.30 $ 39.26 $236.82 $ 85.06
Self & Family 402 $249.62 $111.19 $540.84 $240.92

2003 Foreign Service Benefit Plan

2003 Rate Information for
Foreign Service Benefit Plan

2003 rates for this Plan follow. If you are in a special enrollment category, refer to an FEHB Guide for that category or contact the agency that maintains your health benefits enrollment. 72.

Page Navigation Panel

1 2 3 4 5 6 7 8 9
10 11 12 13 14 15 16 17 18 19
20 21 22 23 24 25 26 27 28 29
30 31 32 33 34 35 36 37 38 39
40 41 42 43 44 45 46 47 48 49
50 51 52 53 54 55 56 57 58 59
60 61 62 63 64 65 66 67 68 69
70 71 72