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HMSA Plan

Federal Employees Health Benefits Program
2003 Plan Brochure
Accessible Version

Document Outline

HMSA Plan
Director's Letter
Privacy Practices
Table of Contents
Introduction
Plain Language
Stop Health Care Fraud!
Section 1. Facts about this HMO Plan
- We also have Point-of-Service (POS) benefits
- How we pay providers
- Your Rights
- Service Area
Section 2. How we change for 2003
- Program-wide changes
- Changes to this Plan
Section 3. How you get care
- Identification cards
- Where you get covered care
- What you must do to get covered care
- Circumstances beyond our control
- Services requiring our prior approval
Section 4. Your costs for covered services
- Copayments
- Deductible
- Eligible Charges
- Coinsurance
- Your catastrophic protection out-of-pocket maximum for coinsurance and copayments
Section 5. Benefits
- Overview
- Section 5 (a). Medical services and supplies provided by physicians and other health care professionals
- Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
- Section 5 (c). Services provided by a hospital or other facility, and ambulance services
- Section 5 (d). Emergency services/accidents
- Section 5 (e). Mental health and substance abuse benefits
  - Mental health and substance abuse benefits
- Section 5 (f). Prescription drug benefits
  - Important features you should be aware of
  - Covered medications and supplies
- Section 5 (g). Special features
- Section 5 (h). Dental benefits
- Section 5 (i). Point-of-service benefits
  - Point-of-service (POS) Benefits
  - What is covered and not covered
- Section 5 (j). Non-FEHB benefits available to Plan members
  - CancerCare Plan
Section 6. General exclusions -- things we don't cover
Section 7. Filing a claim for covered services
- Medical, Hospital and Drug Benefits
- Deadline for filing your claim
- When we need more information
Section 8. The disputed claims process
Section 9. Coordinating benefits with other coverage
- When you have other health coverage
- What is Medicare?
- TRICARE and CHAMPVA
- Workers Compensation
- Medicaid
- When other Government agencies are responsible for your care
- When others are responsible for injuries
Section 10. Definitions of terms we use in this brochure
Section 11. FEHB facts
- No pre-existing condition limitation
- Where you can get information about enrolling in the FEHB Program
- Types of coverage available for you and your family
- Childrens Equity Act
- When benefits and premiums start
- When you retire
- When you lose benefits
Long Term Care Insurance Is Still Available
Index
Summary of benefits for the HMSA Plan 2003
2003 Rate Information

Pages 1--72

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

HMSA Plan http:// www. hmsa. com 2003
A Health Maintenance Organization with a point of service product
Serving: All of Hawaii
Enrollment in this Plan is limited. You must live in our Geographic service area to enroll. See page 8 for requirements.

This Plan has "Full" Accreditation from NCQA. See the 2003 Guide for more
information on accreditation.

Enrollment codes for this Plan:
871 Self Only 872 Self and Family

RI 73-010 1.
1 Page 2 3

2.
2 Page 3 4
Notice of the Office of Personnel Management's
Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT
CAREFULLY.
By law, the Office of Personnel Management (OPM), which administers the Federal Employees Health Benefits (FEHB) Program, is required to protect the privacy of your personal medical information. OPM is also required to give you this notice to tell you
how OPM may use and give out (" disclose") your personal medical information held by OPM.
OPM will use and give out your personal medical information:
To you or someone who has the legal right to act for you (your personal representative), To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is protected,
To law enforcement officials when investigating and/ or prosecuting alleged or civil or criminal actions, and Where required by law.

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

OPM may use or give out your personal medical information for the following purposes under limited circumstances:
For Government healthcare oversight activities (such as fraud and abuse investigations), For research studies that meet all privacy law requirements (such as for medical research or education), and
To avoid a serious and imminent threat to health or safety.
By law, OPM must have your written permission (an "authorization") to use or give out your personal medical information for any purpose that is not set out in this notice. You may take back (" revoke") your written permission at any time, except if OPM has
already acted based on your permission.
By law, you have the right to:
See and get a copy of your personal medical information held by OPM. Amend any of your personal medical information created by OPM if you believe that it is wrong or if information is
missing, and OPM agrees. If OPM disagrees, you may have a statement of your disagreement added to your personal medical information.
Get a listing of those getting your personal medical information from OPM in the past 6 years. The listing will not cover your personal medical information that was given to you or your personal representative, any information that you
authorized OPM to release, or that was given out for law enforcement purposes or to pay for your health care or a disputed claim. 3.
3 Page 4 5

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

If you believe OPM has violated your privacy rights set out in this notice, you may file a complaint with OPM at the following address:
Privacy Complaints Office of Personnel Management
P. O. Box 707 Washington, DC 20004-0707

Filing a complaint will not affect your benefits under the FEHB Program. You also may file a complaint with the Secretary of the Department of Health and Human Services.
By law, OPM is required to follow the terms in this privacy notice. OPM has the right to change the way your personal medical information is used and given out. If OPM makes any changes, you will get a new notice by mail within 60 days of the change.
The privacy practices listed in this notice will be effective April 14, 2003. 4.
4 Page 5 6

2003 HMSA Plan Table of Contents 3
Table of Contents (continued)
(g) Special features.................................................................................................................................... 41
Integrated Case Management...................................................................................................... 41

2003 HMSA Plan 5 Introduction/ Plain Language/ Advisory
Introduction
This brochure describes the benefits of Hawaii Medical Service Association (HMSA), an independent licensee of the Blue Cross and Blue Shield Association under our contract (CS 1058) with the Office of Personnel Management (OPM), as
authorized by the Federal Employees Health Benefits law. The address for HMSA administrative offices is:
Hawaii Medical Service Association 818 Keeaumoku Street
Honolulu, Hawaii 96814
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 9. Rates are shown at the end of this brochure.

Plain Language
All FEHB brochures are written in plain language to make them responsive, accessible, and understandable to the public. For instance,
Except for necessary technical terms, we use common words. For instance, "you" means the enrollee or family member; "we" means HMSA.
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.
Continued on next page 8.
8 Page 9 10
2003 HMSA Plan 6 Introduction/ Plain Language/ Advisory
Stop Health Care Fraud! (continued)
Avoid using health care providers who say that an item or service is not usually covered, but they know how to bill us to get it paid.
Carefully review explanations of benefits (EOBs) that you receive from us. Do not ask your doctor to make false entries on certificates, bills or records in order to get us to pay for an item or
service. If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service,
or misrepresented any information, do the following: Call the provider and ask for an explanation. There may be an error.
If the provider does not resolve the matter, call us at 808/ 948-5166 and explain the situation. If we do not resolve the issue:

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

CALL --THE HEALTH CARE FRAUD HOTLINE 202-418-3300
OR WRITE TO: The United States Office of Personnel Management
Office of the Inspector General Fraud Hotline 1900 E Street, NW, Room 6400
Washington, DC 20415 9.
9 Page 10 11
2003 HMSA Plan 7 Section 1
Section 1. Facts about this HMO Plan
This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and other providers that contract with us. These Plan providers coordinate your health care services. The Plan is solely responsible
for the selection of these providers in your area. Contact the Plan for a copy of their most recent provider directory.
HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in addition to treatment for illness and injury. Our providers follow generally accepted medical practice when prescribing any
course of treatment.
When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You only pay the copayments, coinsurance, and deductibles described in this brochure. When you receive emergency services from non-Plan
providers, you may have to submit claim forms.
You should join an HMO because you prefer the Plan's benefits, not because a particular provider is available. You cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician,
hospital, or other provider will be available and/ or remain under contract with us.
We also have Point-of-Service (POS) benefits
Our HMO offers Point-of-Service (POS) benefits. This means you can receive covered services from a participating provider without a referral, or from a non-participating provider. These out-of-network benefits have higher out-of-pocket
costs than our in-network benefits.
How we pay providers
We have over 3,500 Plan doctors, dentists, and other health care providers in Hawaii who agree to keep their charges for covered services below our eligible charge guidelines. When you go to a Plan provider, you are assured that your
copayments or coinsurance will not be more than the amount shown in this brochure.
You may go to a non-Plan provider, however, the Plan pays a reduced benefit for certain services from non-Plan providers. In addition, because non-Plan providers are not under contract to limit their charges, you are responsible for any charges in
excess of eligible charges.
When you need covered services outside the state of Hawaii, you are encouraged to contact the Blue Cross and/ or Blue Shield Plan in the area where you need services for information regarding specific Plan providers in their area. Benefit
payment for covered services received out-of-state are based on contracts negotiated between the out-of-state Blue Cross and/ or Blue Shield Plans and their Plan providers.

When out-of-state Blue Cross and/ or Blue Shield Plan providers participate in the BlueCard Program, the amount you pay for covered services provided by these Plan providers is usually calculated on the lower of: 1) the actual billed charges for
your covered services, or 2) the negotiated price that the on-site Blue Cross and/ or Blue Shield Plan passes on to us.
In some cases, this "negotiated price" is a simple discount. In other cases, the negotiated price may be an estimate. In calculating this estimated price, we may consider the following factors:

Expected settlements, withholds, any other contingent payment arrangements, and other non-claims transactions with Plan providers
An average expected savings Prior price estimations

A few states do not allow Blue Cross/ or Blue Shield Plans to calculate your payment based on the methods outlined above. When you receive covered health care services in one of these states, your payment will be calculated according to the law
of that state.
Continued on next page 10.
10 Page 11 12

2003 HMSA Plan 8 Section 1
Section 1. Facts about this HMO Plan (continued)
In order to receive Plan Provider benefits for covered out-of-state services under this Plan, the services you receive must be rendered by a BlueCard PPO provider. Non-Plan provider benefits are applied for covered services rendered by non-PPO
providers, even if they participate in other Blue Cross and/ or Blue Shield programs.
Your Rights
OPM requires that all FEHB Plans provide certain information to their FEHB members. You may get information about us, our networks, providers, and facilities. OPM's FEHB website (www. opm. gov/ insure) lists the specific types of
information that we must make available to you. Some of the required information is listed below.
We are currently in compliance with state licensing requirements. We are in our 64 th year of continuous service to the people of Hawaii.

We were founded in 1938 as a non-profit mutual benefit society.
If you want more information about us, call 808/ 948-6499, or write to P. O. Box 860, Honolulu, HI 96808. You may also contact us by fax at 808/ 948-5567 or visit our website at www. hmsa. com.

Service Area
To enroll with us, you must live in our service area. This is where our providers practice. Our service area is the islands of Hawaii, Kauai, Maui, Oahu, Molokai and Lanai.

If you or a covered family member move outside of our service area, you may remain in the Plan or you can enroll in another plan. If your dependents live out of the area (for example, if your child goes to college in another state), you may
remain in the Plan or you can consider enrolling in a fee-for-service Plan or an HMO that has agreements with affiliates in other areas. If you or a family member move, you do not have to wait until Open Season to change plans. Contact your
employing or retirement office. 11.
11 Page 12 13

2003 HMSA Plan Section 2 9
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.
By law, the DoD/ FEHB Demonstration project ends on December 31, 2002.
Changes to this Plan
Your share of the non-Postal premium will increase by 12% for Self Only or 12% for Self and Family.
Certain kinds of drugs listed in our Select Prescription Drug Formulary require precertification. A list of these drugs has been distributed to Plan providers.

Fecal Occult Blood tests provided by HealthPass will be available from age 50, one per calendar year.
The preventive care benefit screenings have been expanded to include sigmoidoscopy, colonoscopy, and double contrast barium enema for certain age groups.

We cover diagnostic laboratory tests, X-rays, pathology services, and pre-surgical testing for outpatient medical services not associated with outpatient surgery. Your coinsurance for Plan providers is 20% of eligible charges. For Non-plan
providers, your coinsurance is 30% of eligible charges and any difference between our payment and the actual charge.
Assisted Reproductive Technology benefits will be limited to in vitro fertilization in accord with Hawaii State Law.
For mental health and substance abuse services, you are no longer required to obtain precertification. There will be a required registration process for a care management program administered by Behavioral Care Connection that your Plan

provider will be responsible for. Non-plan providers will not be required to register you. 12.
12 Page 13 14
2003 HMSA Plan Section 3 10
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive
services from a Plan provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the Health Benefits Election Form,

SF-2809, your health benefits enrollment confirmation (for annuitants), or your Employee Express confirmation letter.

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 808/ 948-6499 or write to
us at P. O. Box 860, Honolulu, HI 96808. You may also request replacement cards through our website at www. hmsa. com.

Where you get covered care You get care from "Plan providers" and "Plan facilities." You will only pay copayments and/ or coinsurance, and you will not have to file claims. If you use
our Point-of-service program, you can also get care from non-Plan providers, but it will cost you more.

We look at some or all the following criteria to determine if a provider is recognized and approved by us:
Is the provider accredited by a recognized accrediting agency? Is the provider appropriately licensed?
Is the provider certified by the proper government authority? Are the services rendered within the lawful scope of the provider's
respective licensure, certification, and /or accreditation?
Plan providers Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our members. We

credential Plan providers according to national standards.
In order to receive Plan Provider benefits for covered out-of-state services under this Plan, the services must be provided by a BlueCard PPO provider.

We list Plan providers in a provider directory, which we update periodically.
Non-Plan providers Non-Plan providers are physicians and other health care professionals who are not under contract with this Plan.

For out-of-state services under this Plan, non-Plan provider benefits are applied for covered services rendered by non-Blue Cross and/ or Blue Shield programs.

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

What you must do to get covered care You are encouraged to coordinate your care with a primary care physician who will provide or arrange most of your health care.

Primary care Your primary care physician can be a family practitioner, internist obstetrician/ gynecologist or pediatrician. Your primary care physician will
provide most of your health care, or can refer you to see a specialist.

Continued on next page 13.
13 Page 14 15
2003 HMSA Plan Section 3 11
Section 3. How you get care (continued)
Specialty care You have direct access to Plan specialists when needed. However, you may wish to coordinate your specialty care with your primary care physician, who can help
you arrange for the specialty care service you will need.
Here are other things you should know about specialty care:
If you are seeing a specialist when you enroll in our Plan, you are encouraged to coordinate your specialty care with your primary care

physician. If he or she decides to refer you to a different specialist, you may ask to see your current specialist.

If you are seeing a specialist and your specialist leaves our Plan, talk to your primary care physician, who will arrange for you to see another specialist.
If you decide to continue seeing your specialist, you will pay a copayment/ coinsurance plus the difference between the eligible charge and
the specialist billed charge.
If you have a chronic or disabling condition and lose access to your specialist because we:

terminate our contract with your specialist for other than cause; or drop out of the Federal Employees Health Benefits (FEHB) Program
and you enroll in another FEHB Plan; or reduce our service area and you enroll in another FEHB Plan,

you may be able to continue seeing your specialist for up to 90 days after you receive notice of the change. Contact us or, if we drop out of the
Program, contact your new plan.
If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can continue to see

your specialist until the end of your postpartum care, even if it is beyond the 90 days.

Hospital care Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled
nursing or other type of facility.
If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:

You are discharged, not merely moved to an alternative care center; or The day your benefits from your former plan run out; or
The 92 nd day after you become a member of this Plan, whichever happens first.

These provisions apply only to the benefits of the hospitalized person.
Continued on next page 14.
14 Page 15 16
2003 HMSA Plan Section 3 12
Section 3. How you get care (continued)
Circumstances beyond our control Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In that case, we will
make all reasonable efforts to provide you with the necessary care.
Services requiring our prior approval Your primary care physician has authority to refer you for most services. For certain services, however, you or your physician must obtain approval from us.
Before giving approval, we consider if the service is covered, and follows generally accepted medical practice.

We call this review and approval process precertification. Precertification is a special approval process to ensure that certain medical treatments, procedures,
place of treatment or devices meet medical necessity criteria prior to the services being rendered. If you are under the care of:

An HMSA participating physician or contracting physician, he or she will :
obtain approval for you; and accept any penalties for failure to obtain approval.
A BlueCard PPO, BlueCard Plan provider or a non-Plan provider, you are responsible for obtaining precertification. If you do not receive
precertification and receive any of the services described in this Section, benefits may be denied.

You or your physician must obtain precertification for the following services such as:
. Autologous chondrocyte implants
. Custom durable medical equipment

Certain kinds of drugs listed in our Select Prescription Drug Formulary (see section 5( f) and 5( g) for more information

. Growth hormone therapy
. In vitro fertilization
. Integrated Case Management
. Magnetic Resonance Angiography (MRA)
. Organ and tissue transplants listed in Section 5( b)
. Physical Therapy Visits

You must receive approval from HMSA for any outpatient visits beyond the first 10 visits.

. Positron Emission Tomography (PET)
. Routine care associated with clinical trials listed in Section 5( g) of this

brochure . Stereo radiosurgery utilizing particle beams

. Surgeries, therapies or procedures employing new technology
. Surgery to correct morbid obesity
. Transplant evaluations, except for cornea and kidney transplant evaluations
. Wound VAC (Vacuum-assisted closure of chronic wound)

This list of services requiring precertification may change periodically. To ensure your treatment or procedure is covered, call us at 808/ 948-6499. 15.
15 Page 16 17
2003HMSA Plan Section 4 13
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive services.

Example: When you use your Plan pharmacy, you pay a copayment of $5 for generic drugs.

Deductible We do not have a deductible.
Eligible Charges We calculate our payment and your copayment/ coinsurance based on eligible charges. The eligible charge is the lower of either the provider's actual charge or the
amount we established as the maximum allowable fee.
Non-Plan providers are not under contract to limit their charges to our eligible charges. You are responsible for any charges in excess of eligible charges.

Coinsurance Coinsurance is the percentage of our eligible charge that you must pay for your care.
Example: When you see your physician, you pay a coinsurance of 20% per office visit.

Your catastrophic protection out-of-pocket
maximum for coinsurance and copayments

After your coinsurance totals $2,500 per person or $7, 500 per family enrollment in any calendar year, you do not have to pay any more for covered services. However,
coinsurance/ copayments for the following services do not count toward your catastrophic protection out-of-pocket maximum, and you must continue to pay
coinsurance/ copayments for these services:
Dental Care Prescription Drugs

Vision Care
Any payment from the difference of the actual and eligible charge for non-Plan service does not count toward meeting your catastrophic protection out-of-pocket

maximum.
Be sure to keep accurate records of your coinsurance/ copayment. We will also keep records of your coinsurance/ copayment and track your catastrophic protection
out-of-pocket maximum. 16.
16 Page 17 18

2003 HMSA Plan Section 5 14
Section 5. Benefits OVERVIEW
(See page 9 for how our benefits changed this year and page 68 for a benefits summary.)

Note: This benefits section is divided into subsections. Please read the important things you should keep in mind at the beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the following
subsections. To obtain claim forms, claims filing advice, or more information about our benefits, contact us at 808/ 948-6499 or at our website at www. hmsa. com.

(a) Medical services and supplies provided by physicians and other health care professionals........................................ 15-25
Diagnostic and treatment services Lab, X-ray, and other diagnostic tests
Preventive care, adult Preventive care, children
Maternity care Family planning
Infertility services Allergy care
Treatment therapies Physical and occupational therapies

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

(b) Surgical and anesthesia services provided by physicians and other health care professionals .................................... 26-29
Surgical procedures Reconstructive surgery
Oral and maxillofacial surgery
Organ/ tissue transplants Anesthesia

(c) Services provided by a hospital or other facility, and ambulance services .................................................................. 30-32
Inpatient hospital Outpatient hospital or ambulatory
surgical center
Extended care benefits/ skilled nursing care facility benefits Hospice care
Ambulance
(d) Emergency services/ accidents...................................................................................................................................... 33-34
Medical emergency Ambulance

(e) Mental health and substance abuse benefits...................................................................................................................... 35
(f) Prescription drug benefits ............................................................................................................................................ 36-40
(g) Special features ................................................................................................................................................................. 41

Integrated Case Management Routine Care Associated With Clinical Trials
Drug Benefit Management Program

(h) Dental benefits ............................................................................................................................................................. 42-43
(i) Point-of-service benefits (POS) ................................................................................................................................... 44-45
(j) Non-FEHB benefits available to Plan members................................................................................................................ 46

Summary of benefits ................................................................................................................................................................ 68 17.
17 Page 18 19

2003 HMSA Plan Section 5( a) 15
Section 5 (a). Medical services and supplies provided by physicians and other health care professionals
I M
P O
R T
A N
T

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

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

Medicare.

I M
P O
R T
A N
T

Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
In physician's office
During a hospital stay
In a skilled nursing facility
Medical consultations inpatient and outpatient
At home

Plan Providers 20% of eligible charges
Non-Plan Providers 30% of eligible charges and any
difference between our payment and the actual charge

Lab, X-ray and other diagnostic tests
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
Pre-surgical testing
X-rays
Non-routine Mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG

Plan Provider 20% of eligible charges
Non-Plan Provider 30% of eligible charges and any
difference between our payment and the actual charge

Preventive care, adult
Routine screenings, limited to:
Total Blood Cholesterol one per calendar year
Colorectal Cancer Screening, including

Fecal occult blood test one per calendar year, age 50 and above

Sigmoidoscopy, screening every 3-5 years starting at age 50

Nothing, if you receive services as a HealthPass screening

Preventive care, adult -continued on next page 18.
18 Page 19 20
2003 HMSA Plan Section 5( a) 16
Preventive care, adult (continued) You pay
Routine Prostate Specific Antigen (PSA) test one per calendar year for men age 50 and older

Routine pap test one per calendar year
Routine mammogram covered for women age 35 and older, as follows:

From age 35 through 39, one during this five year period From age 40 and older, one every calendar year
Note: A woman of any age may receive the screening more often if she has a history of breast cancer or if her mother or
sister has a history of breast cancer

Plan Providers Nothing
Non-Plan Providers 30% of eligible charges and any
difference between our payment and the actual charge

Complete Blood Count one per calendar year
Routine Chest X-ray one per calendar year
TB Tine Test one per calendar year
Urinalysis one per calendar year
Glucose screening one every 3 years, age 45 and above
Fasting lipoprotein profile (Total cholesterol, LDL, HDL, and triglycerides), once every 5 years

Fecal Occult Blood one every calendar year, age 50 and above
Sigmoidoscopy screening every 5 years, age 50 and above
Colonoscopy once every 10 years, age 50 and above
Double contrast barium enema (DCBE) once every 5-10 years, age 50 and above

Plan Providers 20% of eligible charges
Non-Plan Providers 30% of eligible charges and any
difference between our payment and the actual charge

. Routine Physical Exam
. Well Woman Exam
Plan Providers Nothing

Non-Plan Providers 30% of eligible charges and any
difference between our payment and the actual charge

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

Immunizations are covered in accord with guidelines set by the Advisory Committee on Immunization Practices (ACIP)
. Standard Immunizations
. Immunizations for high risk conditions such as Hepatitis B
. Travel Immunizations

Plan Provider 20% of eligible charges
Non-Plan Provider 30% of eligible charges plus any
difference between the Plan's payment and the actual charges

Preventive care, adult -continued on next page 19.
19 Page 20 21
2003 HMSA Plan Section 5( a) 17
Preventive care, adult (continued) You pay
HealthPass
You and any dependent defined below are eligible for one routine physical exam or HealthPass exam listed in this section per

calendar year.
HealthPass is a screening program that provides you with information about how to build a healthier life by looking at your

current lifestyle, health habits, and family medical history. For members age 14 to 17, HealthPass for Teens offers an interactive
computer program, screenings and individual counseling.

Plan Provider Nothing
Non-Plan Provider Not a benefit

You are eligible to receive a health risk assessment through HealthPass during the period from 30 days before or after the
subscriber's birthday. For more information, contact the Customer Service Department at 808/ 948-6499.

After your assessment, we will work with you to develop a personal health action plan. We can also recommend other health
improvement activities and provide support to help you meet your health goals. Yearly visits will enable you to measure your
progress and alert you to any changes that might require additional actions to meet your health goals.

After you call the HealthPass office for an appointment, we'll send you a health questionnaire. Your answers will be combined
with the results from your annual screening, which includes:
Height and weight measurements
Body fat analysis
Blood pressure measurement
Blood cholesterol, HDL and glucose screening tests
Physical fitness assessment if you return annually

If applicable, we may recommend that you attend programs to learn more about:

Nutrition
Smoking cessation
Weight management Exercise

If you have certain risk factors that become apparent during your initial screening, you'll be eligible for coverage for additional
screenings. Examples include:
Health maintenance physical examination
Mammogram Sigmoidoscopy

Bone density testing for osteoporosis
The HealthPass program operates under the direction of a physician who serves as the program's medical director.

HealthPass health consultants are specially trained in preventive health, nutrition, and health promotion. 20.
20 Page 21 22
2003 HMSA Plan Section 5( a) 18
Preventive care, children You pay
Childhood immunizations recommended by the American Academy of Pediatrics. Plan Providers Nothing

Non-Plan Providers Any difference between our eligible
charge and the actual charge

Examinations, such as:
Eye exams through age 17 to determine the need for vision correction. See Vision services.
Plan Optometrists $7 per visit

Plan Providers 20% of eligible charges

Non-Plan Providers 30% of eligible charges and any
difference between our payment and the actual charge

Ear exams through age 17 to determine the need for hearing correction.
. Examinations through age 12 according to the following
schedule:

Birth up to 24 months: eight visits Age two through twelve: one visit each calendar year

Plan Provider Nothing
Non-Plan Provider 30% of eligible charges plus any
difference between the Plan's payment and the actual charges

Laboratory tests through age 12:
2 tuberculin tests (tine or skin sensitivity)
3 blood tests (Hemoglobin or Hematocrit)
3 urinalysis

Plan Provider 20% of eligible charges
Non-Plan Provider 30% of eligible charges plus any
difference between the Plan's payment and the actual charges

Maternity care
Complete maternity (obstetrical) care, such as:
Prenatal care
Birthing Center, only for labor
Delivery
Postnatal care

Note: Here are some things to keep in mind:
You do not need to precertify your normal delivery; see page 15, Professional Service of Physicians, and page 30, Hospital

Benefit, for other circumstances, such as extended stays for you or your baby

You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. Your physician
will extend your inpatient stay if medically necessary.

Plan Provider 20% of eligible charges
Non-Plan Provider 30% of eligible charges plus any
difference between the Plan's payment and the actual charges

Maternity care -continued on next page 21.
21 Page 22 23

2003 HMSA Plan Section 5( a) 19
Maternity care (continued) You Pay
We cover routine nursery care of the newborn child during the covered portion of the mother's maternity stay. We will

cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self and
Family enrollment.
We cover newborn circumcision under the surgical procedures benefits. See Section 5( b) Surgery benefits.

We pay hospitalization and surgeon services (delivery) the same as for illness and injury. See Section 5( c) Hospital
benefits and Section 5( b) Surgery benefits.
You have no coinsurance when you use a birthing center (for labor only) that is a Plan provider

Plan Provider 20% of eligible charges
Non-Plan Provider 30% of eligible charges plus any
difference between the Plan's payment and the actual charges

Not covered: Routine sonograms to determine fetal age, size or sex All charges
Family planning
A range of voluntary family planning services, limited to:
Voluntary sterilization (See Surgical procedures Section 5( b))
Plan Providers Nothing

Non-Plan Providers 30% of eligible charges and any
difference between our payment and the actual charge

Surgically implanted contraceptives (such as Norplant)
Injectable contraceptive drugs (such as Depo provera)
Intrauterine devices (IUDs)
Diaphragms/ Cervical Caps
Note: Benefit payment for contraceptives is limited to one contraceptive method per period of effectiveness. We

cover oral contraceptives under the prescription drug benefits. See Section 5( f) for benefit level.

Plan Providers 20% of eligible charges
Non-Plan Providers 30% of eligible charges and any
difference between our payment and the actual charge

Not covered: .
Reversal of voluntary surgical sterilization .
Genetic counseling .
Contraceptives such as condoms, foam, or creams which do not require a prescription

All charges 22.
22 Page 23 24
2003 HMSA Plan Section 5( a) 20
Infertility services You Pay
Diagnosis and treatment of infertility, limited to:
Artificial insemination:
Intravaginal insemination (IVI)
Intracervical insemination (ICI)
Intrauterine insemination (IUI)
In vitro Fertilization
Coverage is limited to a one time only benefit for one outpatient in vitro procedure in accord with Hawaii law

Plan Providers 20% of eligible charges
Non-Plan Providers 30% of eligible charges and any
difference between our payment and the actual charge

Not covered:
Assisted reproductive technology (ART) procedures, such as embryo transfer, gamete GIFT, and zygote ZIFT

Services and supplies related to excluded ART procedures except in vitro fertilization
Cost of donor sperm
Fertility drugs
Cost of donor egg

All charges

Allergy care
Testing (one per calendar year) and treatment
Allergy injection
Treatment materials

Plan Providers 20% of eligible charges
Non-Plan Providers 30% of eligible charges and any
difference between our payment and the actual charge

Allergy serum Plan Providers Nothing
Non-Plan Providers 30% of eligible charges and any
difference between our payment and the actual charge

Not covered: Provocative food testing and sublingual allergy desensitization All charges 23.
23 Page 24 25

2003 HMSA Plan Section 5( a) 21
Treatment therapies You Pay
Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone marrow transplants are limited to those transplants listed

under Organ/ Tissue Transplants on page 28.
Respiratory and inhalation therapy
Dialysis hemodialysis and peritoneal dialysis
Intravenous (IV)/ Infusion Therapy Home IV and antibiotic therapy, self-administered injections, Outpatient injections and

Intravenous nutrient solutions for primary diet.
Medical foods and low-protein modified food products for the treatment of inborn errors of metabolism in accord with

Hawaii Law and Plan guidelines
Growth hormone therapy (GHT)
Note: We will only cover GHT when we precertify the treatment. Call 808/ 948-6499 for more information on

precertification. We will ask you to submit information that establishes that GHT is medically necessary. If you do not ask
or if we determine GHT is not medically necessary, we will not cover GHT or related services and supplies. See services
requiring our prior approval in Section 3.

Plan Providers 20% of eligible charges
Non-Plan Providers 30% of eligible charges and any difference
between our payment and the actual charge

Physical and occupational therapies
Short term therapy for the services of each of the following:
Qualified physical therapists Occupational therapists

Note: We only cover therapy to restore bodily function when there has been a total or partial loss of bodily function due to illness or
injury. If you require more than 10 outpatient physical therapy visits for an injury or illness, a precertification request with a
current progress evaluation and treatment plan should be completed. If the requested services extend beyond a 30-day period, and
updated treatment plan is required with documentation of your progress. Plan providers obtain approval for you, non-Plan
providers do not.

Plan Providers 20% of eligible charges
Non-Plan Providers 30% of eligible charges and any
difference between our payment and the actual charge

Cardiac rehabilitation is covered for up to 2 complete programs per lifetime when:
You are referred by your doctor for cardiac rehabilitation within three months after coronary bypass surgery or
diagnosis of acute myocardial infarction Each program consists of planned exercise to rehabilitate
and strengthen the heart and education to provide information and motivation for behavior/ lifestyle changes
Each treatment program must be completed within 180 days (no benefits are paid if the program is not completed)

Plan Providers 20% of eligible charges
Non-Plan Providers 30% of eligible charges and any
difference between our payment and the actual charge

The Plan's payment is limited to $300

Not covered:
Long-term rehabilitative therapy

Exercise programs

All charges 24.
24 Page 25 26

2003 HMSA Plan Section 5( a) 22
Speech therapy You Pay
25 visits per calendar year Plan Providers 20% of eligible charges

Non-Plan Providers 30% of eligible charges and any
difference between our payment and the actual charge

Hearing services (testing, treatment, and supplies)
Diagnostic hearing test
Hearing Aids one every five years
Note: Hearing testing for children through age 17 (see Section 5( a) Preventive care, children.)

Plan Providers 20% of eligible charges
Non-Plan Providers 30% of eligible charges and any
difference between our payment and the actual charge

Not covered:
All other hearing testing
Repair of hearing aids
Hearing aid evaluation

All charges

Vision services (testing, treatment, and supplies)
One pair of eyeglasses or contact lenses following cataract surgery Plan Providers 20% of eligible charges

Non-Plan Providers 30% of eligible charges and any
difference between our payment and the actual charge

Annual vision exam
Annual eye refractions
Note: For eye exams for children see Section 5( a) Preventive care, children.

Plan Optometrists $7 per visit
Plan Providers 20% of eligible charges
Non-Plan Providers 30% of eligible charges and any
difference between our payment and the actual charge

Not covered:
Eyeglasses or contact lenses except as stated above
Eye exercises and orthoptics
Radial keratotomy and other refractive surgery
Contact lens fitting

All charges 25.
25 Page 26 27
2003 HMSA Plan Section 5( a) 23
Foot care You Pay
Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes

See Orthopedic and prosthetic devices for information on podiatric shoe inserts
Plan Providers 20% of eligible charge
Non-Plan Providers 30% of eligible charges and any
difference between our payment and the actual charge

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

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

(unless the treatment is by open cutting surgery)

All charges

Orthopedic and prosthetic devices
Artificial limbs and eyes
Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy

Prosthetic devices, such as artificial limbs and lenses following cataract removal
Orthopedic devices, such as braces
Internal prosthetic devices such as artificial joints; pacemakers cochlear implants, and surgically implanted

breast implant following mastectomy. Note: See Section 5( b) for coverage of the surgery to insert the device.

Plan Providers 20% of eligible charges
Non-Plan Providers 30% of eligible charges and any
difference between our payment and the actual charge

Not covered:
Orthopedic and corrective shoes
Podiatric shoes
Arch supports
Foot orthotics, except for specific diabetic conditions
Heel pads and heel cups
Lumbosacral supports
Corsets, trusses, elastic stockings, support hose, and other supportive device

Bionic services and devices

All charges 26.
26 Page 27 28
2003 HMSA Plan Section 5( a) 24
Durable medical equipment (DME) You Pay
Rental or purchase, at our option, including repair and adjustment, of durable medical equipment prescribed by your provider, such as

oxygen and dialysis equipment. Under this benefit, we also cover:
Hospital beds
Wheelchairs
Crutches
Walkers
Blood glucose monitors
Insulin pumps

Plan Providers 20% of eligible charges
Non-Plan Providers 30% of eligible charges and any
difference between our payment and the actual charge

Not covered:
Convenience items such as motorized wheel chairs
All charges

Home health services
Home health care ordered by a Plan physician and provided by a qualified home health agency for the treatment of an illness or

injury when you are homebound. Homebound means that due to an illness or injury, you are unable to leave home, unless you use
devices or have assistance from another person. Homebound standards defined by the federal Medicare program apply.

Services provided for up to 150 visits per calendar year
Note: If you need home health care services for more than 30 days, a physician must certify that there is further need for the services

and provide a continuing plan of treatment at the end of each 30-day period of care.

Plan Providers 20% of eligible charges
Non-Plan Providers 30% of eligible charges and any
differences between our payment and the actual charge

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

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

All charges

Chiropractic
No Benefit All charges

Alternative treatments
No Benefit All charges

Not covered:
Biofeedback and other forms of self-care or self-help training and any related diagnostic testing All charges 27.
27 Page 28 29

2003 HMSA Plan Section 5( a) 25
Educational classes and programs You Pay
Smoking Cessation
It is a series of four workshops for smokers who are ready to quit smoking. The copayment is waived for pregnant women

participating in HMSA's The Good Pregnancy He Hapai Pono program, and members who have asthma, diabetes or
cardiovascular disease. For more information call 808/ 948-6499.

$25 per series

Coverage is limited to:
Life Style Management Health Odyssey

HMSA's Health Odyssey programs provide a series of practical, fun-filled health education classes to help you create
a healthier, happier life.
Sessions are interactive and include a broad range of life style topics such as goal setting, developing new habits, stress
management, nutrition and fitness. Call your local HMSA Office for more information or to register for Health Odyssey.

Disease Management
HMSA provides new and individualized programs to help you better manage chronic illnesses. These programs allow you to
take a much larger and more responsible role in controlling your illness.

There are currently three disease management programs offered: Asthma Care Connection, Diabetes Care
Connection, and Cardiac Care Connection. To find out if these programs are right for you, talk with your primary care
physician.

Nothing

Prenatal Care Program The Good Pregnancy He Hapai Pono
He Hapai Pono offers many ways to help you have a healthy pregnancy and delivery. As soon as you become pregnant, you'll
want to have your primary care physician register you in our program. You'll take an automated telephone survey and receive a
personally tailored booklet of information based on your responses. You'll also receive a copy of the pregnancy best seller What to
Expect When You're Expecting and after delivery, we'll send you a copy of What to Expect the First Year to help you and your new
baby get off to a good start. To register call 888/ 400-2776 or visit the web site at www. hmsa. com/ myhealth.

Nothing

Not covered except as offered through HMSA programs:
. Weight reduction programs

. Smoking Cessation programs
. Nutrition Counseling

All charges 28.
28 Page 29 30

2003 HMSA Plan Section 5( b) 26
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
I
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P
O
R
T
A
N
T

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

surgical center, etc.).
YOU MUST GET PRECERTIFICATION FOR SOME SURGICAL PROCEDURES. Please refer to the precertification information shown in Section 3 to be sure which services require

precertification and identify which surgeries require precertification.

I
M
P
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R
T
A
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T

Benefit Description You pay
Surgical procedures
Cutting Surgery includes preoperative and postoperative care.
Note: Non-Plan providers may bill separately for preoperative care, the surgical procedure and post operative care. In such cases,

the total charge is often more than the eligible charge. You are responsible for any amount that exceeds the eligible charge.

Cutting & Non-cutting surgical procedures, such as: Operative Procedures
Treatment of fractures, including casting Acne treatment destruction of localized lesions by
chemotherapy (excluding silver nitrate) Cryotherapy
Diagnostic injections including catheters injections into joints, muscles, and tendons
Electrosurgery Correction of amblyopia and strabismus
Diagnostic and Endoscopy procedures Biopsy procedures
Removal of tumors and cysts Correction of congenital anomalies
(see Reconstructive surgery) Surgical treatment of morbid obesity --a condition in which
an individual weighs 100 pounds or 100% over his or her normal weight according to current underwriting standards;
eligible members must be age 18 or over Insertion of internal prosthetic devices. See Section 5( a)
Orthopedic and prosthetic devices for device coverage information

Plan Providers (cutting) Nothing
(non-cutting) 20% of eligible charges
Non-Plan Provider (cutting and non-cutting)

30% of eligible charges and any difference between our payment and the
actual charge

Surgical procedures -continued on next page 29.
29 Page 30 31
2003 HMSA Plan Section 5( b) 27
Surgical Procedures (continued) You pay
Cutting and Non-cutting surgical procedures (continued)
Voluntary sterilization (e. g., Tubal ligation, Vasectomy)
Treatment of burns
Newborn Circumcision

Plan Providers (cutting) Nothing
(non-cutting) 20% of eligible charges
Non-Plan Provider (cutting and non-cutting)

30% of eligible charges and any difference between our payment and the
actual charge

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

All charges

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

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

Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or
norm. Examples of congenital anomalies are: protruding ear deformities, cleft lip, cleft palate, birth marks, webbed
fingers and webbed toes.
All stages of breast reconstruction surgery following a mastectomy, such as:

surgery to produce a symmetrical appearance on the other breast
treatment of any physical complications, such as lymphedemas
breast prostheses and surgical bras and replacements (see Prosthetic devices)

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

Plan Providers (cutting) Nothing
(non-cutting) 20% of eligible charges
Non-Plan Providers (cutting and non-cutting)

30% of eligible charges and any difference between our payment and the
actual charge

Not covered:
Cosmetic surgery any surgical procedure (or any portion of a procedure) performed primarily to improve physical

appearance through change in bodily form, except repair of accidental injury

Surgeries related to sex transformation

All charges 30.
30 Page 31 32
2003 HMSA Plan Section 5( b) 28
Oral and maxillofacial surgery You pay
Oral surgical procedures, limited to:
Reduction of fractures of the jaws or facial bones
Surgical correction of cleft lip or cleft palate
Removal of stones from salivary ducts
Excision of leukoplakia or malignancies
Excision of cysts and incision of abscesses when done as independent procedures

Other surgical procedures that do not involve the teeth or their supporting structures

Plan Providers (cutting) Nothing
(non-cutting) 20% of eligible charges
Non-Plan Provider (cutting and non-cutting)

30% of eligible charges and any difference between our payment and the
actual charge

Not covered:
Oral implants and transplants Procedures that involve the teeth or their supporting

structures (such as the periodontal membrane, gingiva, and alveolar bone)
Dental surgeries generally done by dentists and not physicians
Services, drugs or supplies for nondental treatment of temporomandibular joint (TMJ) syndrome

All charges

Organ/ tissue transplants
Limited to:
Cornea Heart

Heart/ lung Kidney
Kidney/ Pancreas Liver
Lung: Single Double Allogeneic (donor) bone marrow transplants
Autologous bone marrow transplants (autologous stem cell and peripheral stem cell support) for the following
conditions: acute lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's lymphoma; advanced non-Hodgkin's
lymphoma; advanced neuroblastoma; breast cancer; multiple myeloma; epithelial ovarian cancer; and testicular,
mediastinal, retroperitoneal and ovarian germ cell tumors Treatment for breast cancer, multiple myeloma, and epithlial
ovarian cancer must be provided in an NCI or NIH approved clinical trial at a Plan-designated center of excellence and
approved by the Plan's medical director in accordance with the Plan's protocols
Intestinal transplants (small intestine) and the small intestine with the liver or small intestine with multiple organs such as
the liver, stomach and pancreas
Note: We cover related medical and hospital expenses of the donor when we cover the recipient

Plan Providers (cutting) Nothing
(non-cutting) 20% of eligible charges
Non-Plan Provider (cutting and non-cutting)

30% of eligible charges and any difference between our payment and the
actual charge

Organ/ tissue transplants-continued on next page 31.
31 Page 32 33
2003 HMSA Plan Section 5( b) 29
Organ/ tissue transplants (continued) You pay
This coverage is secondary and the living donor's coverage is primary when:

You are the recipient of an organ from a living donor, and The donor's health coverage provides benefits for organs
donated by a living donor
Transplant evaluations:
Must receive our approval (with the exception of corneal and kidney transplant evaluations)

Means those procedures, including laboratory and diagnostic tests, consultations, and psychological evaluations, which a
hospital or facility uses in evaluating a potential transplant candidate

Transplants (with the exception of corneal and kidney) must:
Receive our approval. Without our approval for specific transplants, benefits are not available.

Be received from a facility that: is under contract with us for that type of transplant; and
accepts you as a transplant candidate. This restriction does not apply to intestinal transplants.

Please refer to the precertification information shown in Section 3

Plan Providers (cutting) Nothing
(non-cutting) 20% of eligible charges
Non-Plan Provider (cutting and non-cutting)

30% of eligible charges and any difference between our payment and the
actual charge

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

Implants of artificial organs
Transplants not listed as covered
Non-human organs

All charges

Anesthesia
Professional services provided in:
Hospital (inpatient)
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center
Office

Plan Providers 20% of eligible charges
Non-Plan Providers 30% of eligible charges and any
difference between our payment and the actual charge

Professional services include:
General anesthesia
Regional anesthesia
Monitored anesthesia when you meet the Plan's high-risk criteria 32.
32 Page 33 34

2003 HMSA Plan 30 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
I M
P O
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A N
T

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

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

(i. e., physicians, etc.) are covered in Sections 5( a) or (b).

I M
P O
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A N
T

Benefit Description You pay
Inpatient hospital
Room and board, such as:
Semiprivate accommodations
General nursing care
Meals and special diets
Note: If you want a private room when it is not medically necessary, you pay the additional charge above the semiprivate

room rate

Plan Provider Nothing
(based on semiprivate room rate)
Non-Plan Provider 30% of eligible charges and any

difference between our payment and the actual charge
(based on semiprivate room rate)

Special care units, such as:
Intensive care
Cardiac care units

Plan Provider Nothing
Non-Plan Provider 30% of eligible charges and any
difference between our payment and the actual charge

Other hospital services and supplies, such as:
Operating, recovery, maternity, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays
Administration of blood and blood products
Blood or blood plasma costs, blood processing, blood bank services

Dressings, splints, casts, and sterile tray services
Medical supplies and equipment, including oxygen
Anesthetics, including nurse anesthetist services
Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home

Plan Provider Nothing
Non-Plan Provider 30% of eligible charges and any
difference between our payment and the actual charge

Inpatient hospital -continued on next page 33.
33 Page 34 35

2003 HMSA Plan 31 Section 5( c)
Inpatient hospital (continued) You pay
Not covered:
Custodial care, rest cures, domiciliary or convalescent care
Non-covered facilities, such as adult day care, intermediate care facilities, schools

Personal comfort items, such as telephone, television, barber services, guest meals and beds
Private nursing care
Additional charges for autologous blood

All charges

Outpatient hospital or ambulatory surgical center
Outpatient medical services provided by a hospital or ambulatory surgical center, such as:

Diagnostic laboratory tests, X-rays, and pathology services
Pre-surgical testing is covered but only when you meet our criteria

Plan Provider 20% of eligible charges
Non-Plan Provider 30% of eligible charges and any
difference between our payment and the actual charge

Services associated with outpatient surgery and provided by a hospital or ambulatory surgical center, such as:
Operating, recovery, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology services
Administration of blood, blood plasma, and other biologicals
Blood and blood plasma cost, blood processing, blood bank services

Dressings, casts, and sterile tray services
Medical supplies, including oxygen
Anesthetics
Anesthesia services (Section 5( b))

Note: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical
impairment. We do not cover the dental procedures except those services that are described in the Dental Benefits section.

Plan Provider Nothing
Non-Plan Provider 30% of eligible charges and any
difference between our payment and the actual charge 34.
34 Page 35 36
2003 HMSA Plan 32 Section 5( c)
Extended care benefits/ skilled nursing care facility benefits You pay
Skilled nursing facility (SNF):
A facility that provides continuous skilled nursing services as ordered and certified by your attending physician

Room and Board is covered, but only for semiprivate rooms when:
You are admitted by your physician
Care is ordered and certified by your physician
We approve the confinement
Confinement is not primarily for comfort, convenience, a rest cure, or domiciliary care

If days exceed 30 the attending physician must submit a report showing the need for additional days at the end of
each 30-day period
The confinement is not longer than 100 days in any one calendar year

Services and supplies are covered, including routine surgical supplies, drugs, dressings, oxygen, antibiotics, blood transfusion
services, and diagnostic and therapy benefits

Plan Provider Nothing (based on semiprivate room)
Non-Plan Provider 30% of eligible charges and any
difference between our payment and the actual charge (based on semiprivate
room rate)

Not covered: Custodial care, rest cures, domiciliary or convalescent care All charges
Hospice care
A hospice program provides care (generally in a home setting) for patients who are terminally ill and who have a life expectancy of

six months or less
Inpatient residential room and board
Referral visits

Plan Provider Nothing
Non-Plan Provider Not a benefit

Not covered:
Independent nursing
Homemaker services

All charges

Ambulance
Ground professional ambulance service is covered when:
Medically appropriate
Services to treat your illness or injury are not available in the hospital or nursing facility where you are an inpatient

Nothing 35.
35 Page 36 37

2003 HMSA Plan 33 Section 5( d)
Section 5 (d). Emergency services/ accidents
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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.

with Medicare.

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

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

What to do in case of emergency:
If you are in an emergency situation, please call your primary care doctor. Your primary care doctor will provide the necessary care, refer you to other Plan providers or make arrangements with other providers. If you are unable to

contact your doctor, contact the local emergency system (e. g., the 911 telephone system) or go to the nearest hospital emergency room. If you are hospitalized in non-Plan facilities and Plan doctors believe care can be better provided
in a Plan hospital, you will be transferred when medically feasible with any ambulance charges covered in full.
Emergencies within and outside our service area:
Emergency care is covered the same as routine care provided by Plan providers, regardless of whether a Plan provider or non-Plan provider is used. Benefits are the same within or outside our Service Area.

Benefit Description You pay
Emergency within our service area
Emergency care at a doctor's office
Emergency care at an urgent care center
Emergency care as an outpatient or inpatient at a hospital, including doctors' services

Emergency care in an emergency room

Plan Provider 20% of eligible charges
Non-Plan Provider 20% of eligible charges

Not covered: Elective care or non-emergency care All charges
Emergency outside our service area
Emergency care at a doctor's office
Emergency care at an urgent care center
Emergency care as an outpatient or inpatient at a hospital, including doctors' services

Emergency care in an emergency room

Plan Provider 20% of eligible charges
Non-Plan Provider 20% of eligible charges

Not covered: Elective care or non-emergency care All charges 36.
36 Page 37 38
2003 HMSA Plan 34 Section 5( d)
Ambulance You Pay
Professional ambulance service when the following apply:
Transportation begins at the place where an injury or illness occurred or first required emergency care

Transportation ends at the nearest facility equipped to furnish emergency treatment
Transportation is for the purpose of emergency treatment

Nothing

Air ambulance is limited to intra-island or inter-island transportation within the state of Hawaii.
See Section 5( c) for non-emergency service.
Plan Provider 20% of eligible charges
Non-Plan Provider 30% of eligible charges and any
difference between our payment and the actual charge 37.
37 Page 38 39

2003 HMSA Plan 35 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
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T

When you get our approval for services and follow a treatment plan we approve, cost-sharing and limitations for Plan mental health and substance abuse benefits will be no greater than for similar
benefits for other illnesses and conditions.
Here are some important things to keep in mind about these benefits:
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.

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage,
including with Medicare.
Behavioral Care Connection, a management program, will develop a treatment plan and provide care management in conjunction with your Plan provider.

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Benefit Description You pay
Mental health and substance abuse benefits

All diagnostic and treatment services recommended by a provider and contained in a treatment plan. The treatment plan may include
services, drugs, and supplies described elsewhere in this brochure.
Note: Plan benefits are payable only when we determine the care is clinically appropriate to treat your condition and only when you

receive the care as part of a treatment plan.

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

Professional services, including individual or group therapy by providers such as psychiatrists, psychologists, clinical
social workers, or advanced practice registered nurses (APRN)

Medication management
Diagnostic tests

Plan Provider 20% of eligible charges
Non-Plan Provider 30% of eligible charges and any
difference between our payment and the actual charge

Inpatient services provided by a hospital or other facility
Inpatient services in approved alternative care settings such as partial hospitalization, residential treatment, full-day

hospitalization

Plan Provider Nothing

Non-Plan Provider 30% of eligible charges and any
difference between our payment and the actual charge

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

All charges 38.
38 Page 39 40

2003 HMSA Plan 36 Section 5( f)
Section 5 (f). Prescription drug benefits
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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 38.
Your provider must obtain precertification for certain drugs.
All benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.

Medicare.

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There are important features you should be aware of. These include:
Who can write your prescription. A licensed practitioner who has the legal authority to prescribe medication.

Where you can obtain them. You may fill the prescription at a Plan or non-Plan pharmacy, by mail or by a Plan or non-Plan physician. We pay a higher level of benefits when you use a Plan provider than if you use
a non-Plan provider.
We use a formulary. Our formulary, called the HMSA Select Prescription Drug formulary is a book that we publish which contains a list of drugs by therapeutic category, and is meant to assist physicians in their

selection of drugs for your treatment. Our formulary consists of:
Generic Drugs. A drug, which is prescribed or dispensed under its commonly used generic (chemical) name, no longer protected by patent laws or as determined by us.

Preferred Drugs. A Brand Name Drug, contraceptive, supply, or insulin that is listed on the HMSA Select Prescription Drug Formulary as Preferred.
Other Brand Drugs. A Brand Name Drug, contraceptive, supply, or insulin that is not classified as Preferred on the HMSA Select Prescription Drug Formulary.

We have an open formulary. If your physician believes a name brand product is necessary or there is no generic available, your physician may prescribe a name brand drug from a formulary list. The list of name
brand drugs includes a preferred list of drugs that have been selected to meet patients' clinical and financial needs. Discuss your options with your physician when you need a new prescription.

These are the dispensing limitations.
Prescription drugs prescribed by a doctor and obtained at a pharmacy will be dispensed with a maximum limit of a 30-day supply or fraction thereof.

Refills are available if indicated on the original prescription, provided that the refill prescription is purchased only after two-thirds of the original prescription has already been used.
A generic equivalent will be dispensed if it is available, unless your physician specifically requires a name brand. If you receive a name brand drug when a federally-approved generic drug is available,
and your physician has not specified Dispense as Written for the name brand drug, you have to pay the full eligible charge of the brand drug. You will then be reimbursed for the value of the generic drug.
The total cost to you will be the generic copayment plus the difference in cost between the name brand drug and the generic.
Mail order prescriptions are limited to prescribed maintenance medications. Mail order prescription drugs are available only from contracted providers. For a list of contracted
providers call us at 808/ 948-6499. Mail order prescription drug copayment amounts are for a maximum 90-day supply or a fraction
thereof. Mail order prescription drugs prescribed by a doctor and obtained through a Plan mail order pharmacy
will be dispensed with a maximum limit of a 90-day supply or fraction thereof.

Continued on next page 39.
39 Page 40 41
2003 HMSA Plan 37 Section 5( f)
Section 5 (f). Prescription drug benefits (continued)
Why use generic drugs? Generic drugs on the formulary are therapeutically equivalent to the brand name drugs and are less expensive. You may reduce your out-of-pocket costs by choosing to use a generic drug.

When you have to file a claim. Refer to Section 7 "Filing a claim for covered services".
Drugs Benefit Management Program. We have arranged with Plan Pharmacies to assist in managing the usage of certain kinds of drugs, including drugs listed in the HMSA Select Prescription Drug Formulary.

We have identified certain kinds of drugs listed in the HMSA Select Prescription Drug Formulary that require precertification. The criteria for precertification are that:
The drug is being used as part of a treatment plan, There are no equally effective drug substitutes, and
The drug meets the "medical necessity" criteria and other criteria as established by us.
A list of these drugs in the HMSA Select Prescription Drug Formulary has been distributed to all Participating Providers.

Plan Pharmacists will dispense a maximum of a 30-day supply or fraction thereof for first time prescriptions of maintenance drugs. For subsequent refills, the Plan pharmacist may dispense a maximum 90-day supply
or fraction thereof after confirming that:
You have tolerated the drug without adverse side effects that may cause you to discontinue using the drug, and

Your doctor has determined that the drug is effective. 40.
40 Page 41 42

2003 HMSA Plan 38 Section 5( f)
Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a licensed practitioner and obtained from a Plan or non-Plan Pharmacy

or through our mail order program:
Drugs and medications that by Federal law of the United States require a physician's prescription for their purchase, except

those listed as Not covered
Injectable drugs limited to:
Imitrex Epinephrine emergency kit

Glucagon
Note: Self administered injectable medication and intravenous fluids and medication for home use are covered under your

medical coverage. See Section 5( a) Treatment therapies.
Nicotine patches for the cessation of smoking by prescription only

Note: Limited to one treatment cycle per calendar year, with a limit of 2 treatment cycles per lifetime
Drugs for sexual dysfunction
Benefits are limited to the following;
Up to four doses every 30 days Up to three months dispensed at a time

(Multiple copayments will apply) Retail pharmacy access only
(not available through mail order) Covered for gender approved by FDA
Physician must certify in advance that the patient has impotence due to organic causes from vascular or
neurological disease
Oral contraceptive

Generic:
Plan Pharmacy -$5 copayment
Non-Plan Pharmacy -$5 plus 20% of remaining eligible charge and any

difference between the actual and eligible charge

Preferred Brand:
Plan Pharmacy -$15 copayment
Non-Plan Pharmacy -$15 plus 20% of remaining eligible charge and any

difference between the actual and eligible charge

Other Brand:
Plan Pharmacy -50% of eligible charge not less than $15

Non-Plan Pharmacy -50% of eligible charge not less than $15 plus any
difference between the actual and eligible charge

Covered medications and supplies continued on next page 41.
41 Page 42 43
2003 HMSA Plan 39 Section 5( f)
Covered medications and supplies (continued) You Pay
Internally implanted time-release contraceptive drugs
Contraceptive drugs injected periodically and intrauterine devices
Plan Provider -20% of eligible charges
Non-Plan Provider -30% of eligible charges and any difference between our

payment and the actual charge

Diaphragms Preferred Diaphragms
Plan Pharmacy -$10 copayment
Non-Plan Pharmacy -$10 copayment plus 20% of remaining eligible charge

and any difference between the actual and eligible charge

Other Brand Diaphragms
Plan Pharmacy -50% of eligible charge not less than $15

Non-Plan Pharmacy -50% of eligible charge not less than $15 plus any
difference between the actual and eligible charge

Insulin
Note: When obtained by prescription, with a copayment charge applied to each 30-day supply or fraction thereof
Preferred Brand Insulin:
Plan Pharmacy -$5 copayment
Non-Plan Pharmacy -$5 plus 20% of eligible charge and any difference

between the actual and eligible charge
Other Brand Insulin:
Plan Pharmacy -$15 copayment
Non-Plan Pharmacy -$15 copayment plus 20% of eligible charge and any

difference between the actual and eligible charge

Diabetic Supplies include:
Insulin syringes
Needles
Lancets
Auto-lancet devices
Glucose test tablets and test tapes
Acetone test tablets

Preferred Brand Diabetic Supplies:
Plan Pharmacy -Nothing
Non-Plan Pharmacy -Any difference between the actual and eligible charge

Other Brand Diabetic Supplies:
Plan Pharmacy -$15 copayment
Non-Plan Pharmacy -$15 copayment plus any difference between the actual

and eligible charge

Covered medications and supplies continued on next page 42.
42 Page 43 44
2003 HMSA Plan 40 Section 5( f)
Covered medications and supplies (continued) You pay
Mail Order Drug Program:
Generic Drugs
Preferred Brand Name Drugs
Other Brand Name Drugs
Preferred Brand Name Insulin
Other Brand Insulin
Preferred Diabetic Supplies
Other Brand Name Diabetic Supplies

$10 Copayment
$35 Copayment
$60 Copayment
$10 Copayment
$35 Copayment
Nothing
$35 Copayment

Not covered:
Drugs and supplies for cosmetic purposes
Drugs to enhance athletic performance
Fertility drugs
Vitamins, nutrients and food supplements even if a physician prescribes or administers them

Nonprescription medicines
Medical supplies such as dressings and antiseptics
Smoking cessation drugs except for nicotine patches and Zyban prescription drug

Drugs related to the diagnosis or treatment of infertility

All charges 43.
43 Page 44 45

2003 HMSA Plan 41 Section 5( g)
Section 5 (g). Special features
Feature Description
Integrated Case Management Integrated Case Management is a special program for certain medical conditions that may require costly, long-term care. A hospital may not be the most
appropriate setting for your treatment. That's why your coverage provides you with the opportunity to receive alternative benefits to help meet health care needs

resulting from extreme illness or injury (providing costs do not exceed inpatient facility costs). You, your physician, and the hospital can work with our case
managers to identify and arrange alternative treatment plans to meet your special needs and to assist in preserving your health care benefits.

Drug Benefits Management
Program

We have arranged with Plan Pharmacies to assist in managing the usage of certain kinds of drugs, including drugs listed in the HMSA Select Prescription Drug
Formulary.
We have identified certain kinds of drugs listed in the HMSA Select Prescription Drug Formulary that require precertification. The criteria for precertification are
that: The drug is being used as part of a treatment plan,

There are no equally effective drug substitutes, and
The drug meets the "medical necessity" criteria and other criteria as established by us.

A list of these drugs in the HMSA Select Prescription Drug Formulary has been distributed to all Participating Providers.
Plan Pharmacists will dispense a maximum of a 30-day supply or fraction thereof for first time prescriptions of maintenance drugs. For subsequent refills, the Plan
pharmacist may dispense a maximum 90-day supply or fraction thereof after confirming that:

You have tolerated the drug without adverse side effects that may cause you to discontinue using the drug, and
Your doctor has determined that the drug is effective.
Routine Care Associated With
Clinical Trials

Routine care associated with clinical trials is covered in accord with criteria established by us.

These services require precertification. Please refer to the precertification information shown in Section 3. 44.
44 Page 45 46

2003 HMSA Plan 42 Section 5( h)
Section 5 (h). Dental benefits
I M
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T

We have no calendar year deductible.
We cover hospitalization for dental procedures only when a nondental physical impairment exists which makes hospitalization necessary to safeguard the health of the patient. See Section 5 (c) for

inpatient hospital benefits. We do not cover the dental procedure unless it is described below.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage,

including with Medicare.

I M
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T

Accidental injury benefit You pay
We cover restorative services and supplies necessary to promptly repair (but not replace) sound natural teeth. The need for these

services must result from an accidental injury.
Plan Provider Nothing

Non-Plan Provider 30% of eligible charges and any
difference between our payment and the actual charge

Dental Benefits
Service You pay

Preventive dental care for permanent teeth only
Annual exam/ visit
Annual cleaning (prophylaxis)

Plan Provider Nothing
Non-Plan Provider 30% of eligible charges and any
difference between our payment and the actual charge

Standard Dental service for permanent teeth only
X-rays (2 annual bite wings and one full mouth series every 5 years)

Fillings (composite resin for anterior teeth and single, stand alone facial surfaces of bicuspids only, amalgam and silicate)
Extractions
Root canal treatment
Treatment for diseases of the gum
Space maintainers
Anesthesia

Plan Provider 30% of eligible charges
Non-Plan Provider 50% of eligible charges and any
difference between our payment and the actual charge

Dental Surgery
Incision and drainage of abscess
Alveolectomy
Excision of cysts

Plan Provider 30% of eligible charges
Non-Plan Provider 50% of eligible charges and any
difference between our payment and the actual charge 45.
45 Page 46 47
2003 HMSA Plan 43 Section 5( h)
Service You pay
Occlusal Splint
When precertified and determined by the Plan occlusal splint therapy is covered for the treatment of temporomandibular disorder
involving the muscles of mastication (chewing). Coverage of occlusal splint therapy is subject to the following limitations.

A removable acrylic appliance is used in conjunction with the therapy
The disorder is present at least one month prior to the start of the therapy and the therapy does not exceed ten weeks
The therapy does not result in any irreversible alteration in the occlusion
It is not intended to be for the treatment of bruxism
It is not for the prevention of injuries of the teeth or occlusion
The benefit is limited to one treatment episode per lifetime
The member must be 15 years of age or older

Plan Provider or non-Plan Provider 50% of eligible charges, plus any
difference between our payment and the actual charge

Note: Maximum Plan payment not to exceed $125

Not covered:
All other dental services, including topical application of fluoride

Dental appliances, such as false teeth, crowns, bridges, and repair of dental appliances
Dental prostheses, dental splints (except as covered under occlusal splint therapy), dental sealants, orthodontia, or other
dental appliances regardless of the symptoms or illness being treated

Osseointegration (dental implants) and all related services

All charges 46.
46 Page 47 48

2003 HMSA Plan Section 5( i) 44
Section 5 (i). Point-of-service benefits
Point-of-service (POS) Benefits
Facts about this Plan's POS option
At your option, you may choose to obtain benefits covered by this Plan from non-Plan doctors and hospitals whenever you need care. When you obtain covered non-emergency medical treatment from a non-Plan doctor, you are subject to a higher

copayment/ coinsurance.
Non-Plan providers are physicians and other health care professionals who are not under contract with this Plan.
For out-of-state services under this Plan, non-Plan provider benefits are applied for covered services rendered by non-Blue Cross and/ or Blue Shield programs.

What is covered and not covered
Medical services and supplies (Section 5( a))
Surgical and anesthesia services (Section 5( b))
Services provided by a hospital or other facility, and ambulance service (Section 5( c))
Emergency services/ accidents (Section 5( d))
Mental health and substance abuse benefits (Section 5( e))
Prescription drug benefits (Section 5( f))
Dental benefits (Section 5( h))
Please refer to the general exclusions listed in Section 6 for additional information.

Precertification
You or your physician must obtain precertification for the services listed in Section 3. A non-Plan provider may not necessarily obtain a precertification on your behalf. You are responsible for ensuring that the services are precertified. Services may not be

covered if you do not obtain precertification. If you need more information, call us at 808/ 948-6499.
You may receive services from a non-Plan provider without a referral. Non-Plan provider services have higher out-of-pocket cost. Please refer to the non-Plan provider benefits in Section 5.

Your cost for covered services from non-Plan providers
There is no calendar year deductible for non-Plan provider services.
We calculate our payment and your copayment/ coinsurance based on eligible charges. The eligible charge is the lower of either the provider's actual charge or the amount we established as the maximum allowable fee.

Non-Plan providers are not under contract to limit their charges to our eligible charges. You are responsible for any charges in excess of eligible charges.
Coinsurance is the percentage of our eligible charge that you must pay for your care. After your coinsurance totals $2,500 per person or $7, 500 per family enrollment in any calendar year, you are no longer responsible for coinsurance/ copayments.
However, when you receive services from a non-Plan provider, you are also responsible for any charges in excess of the eligible charge. In addition coinsurance/ copayments for the following services do not count toward your out-of-pocket maximum, and
you must continue to pay coinsurance/ copayments for these services:
Dental Care
Prescription Drugs
Vision Care

Any payment from the difference of the actual and eligible charge for non-Plan service does not count toward meeting your out-of-pocket maximum.

Continued on next page 47.
47 Page 48 49

2003 HMSA Plan Section 5( i) 45
(Continued)
Be sure to keep accurate records of your coinsurance/ copayment. We will also keep records of your coinsurance/ copayment and track your out-of-pocket maximum.

Hospital/ extended care
Your coinsurance for services from a non-Plan facility is 30% of the eligible charges and any difference between our payment and the actual charge (based on semiprivate room rate). See Section 5( c). The facility's charge does not include any charges for

physician's services. Benefits for physician's services will depend on whether the physician is a Plan provider or non-Plan provider and will be paid according to the benefits listed in Section 5( a). We cannot guarantee that a participating hospital will
have participating physicians on staff. Benefits will be paid according to each individual provider and the type of service rendered by the provider.

Emergency benefits
Emergency care is covered the same as routine care provided by Plan providers, regardless of whether a Plan provider or non-Plan provider is used. Your coinsurance for services from a non-Plan provider is 20% of the eligible charges. See Section 5( d). 48.
48 Page 49 50
2003 HMSA Plan Section 5( j) 46
Section 5 (j). Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed claim about them. Fees you pay for these services do not count toward FEHB deductibles or out-of-pocket
maximums.

CancerCare Plan
Benefit Services of Hawaii, a subsidiary of Blue Cross and Blue Shield of Hawaii, is pleased to make available a supplemental plan called CancerCare, a cancer and specified disease protection plan.

CancerCare provides inpatient and outpatient benefits for cancer and 34 specified diseases. The Plan pays cash benefits directly to you regardless of any other coverage you may already have. The extra funds can
help pay for any out-of-pocket medical expenses and many non-medical expenses such as rent or mortgage, utility bills, etc.

Plan Features: Hospital confinement Surgery Experimental treatment Radiation/ Chemotherapy
Blood Plasma Transportation cost

Two CancerCare Plans are available which vary in benefits and rates. You may also choose two optional riders, the Cancer Diagnosis Benefit Rider and the Intensive Care/ Coronary Care Rider.

If you are a Hawaii resident under the age 65, you can apply for coverage for yourself and your eligible family members. Please call us at 808/ 538-8900 for more information. 49.
49 Page 50 51

2003 HMSA Plan Section 6 47
Section 6. General exclusions --things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not cover it unless your doctor determines it is medically necessary to prevent, diagnose, or treat your illness, disease, injury or
condition.
We do not cover the following:
Services, drugs, or supplies you receive while you are not enrolled in this Plan;
Services, drugs, or supplies that are not medically necessary;
Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice;
Experimental or investigational procedures, treatments, drugs or devices, except routine care associated with clinical trials. Please refer to the information shown in Section 3 (precertification) and Section 5( g);

Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest;
Services, drugs, or supplies related to sex transformations;
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program;
Professional services or supplies when furnished to you by a provider who is within your immediate family (i. e., parent, child, or spouse);

Services when someone else has the legal obligation to pay for your care, and when, in the absence of this brochure, you would not be charged; or
Services, drugs, or supplies you receive without charge while in active military service. 50.
50 Page 51 52
2003 HMSA Plan 48 Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at Plan pharmacies, you will not have to file claims. Just present your identification card and pay your copayment, or coinsurance.

If you need to file the claim, here is the process:
Medical, Hospital and Drug Benefits In most cases, providers, facilities and pharmacies file claims for you. Physicians must file on the form HCFA-1500, Health Insurance Claim Form, facilities must
file on the UB-92 form, dental services must be on the American Dental Association (ADA) form and pharmacies must file on the Universal Drug form.

For claims questions and assistance, call us at 808/ 948-6499.
When you must file a claim --such as for services you receive outside of the Plan's service area --submit it on one of the forms indicated above or a claim

form that includes the information shown below. Bills and receipts should be itemized and show:

Covered member's name and ID number
Name and address of the physician or facility that provided the service or supply

Dates you received the services or supplies
Diagnosis
Type of each service or supply
The charge for each service or supply
A copy of the explanation of benefits, payments, or denial from any primary payer --such as the Medicare Summary Notice (MSN)

Receipts, if you paid for your services

Submit your claims to: For Physician claims HMSA-HCFA 1500 claims
P. O. Box 44500 Honolulu, Hawaii 96804-4500

For Facility claims HMSA-UB92 claims
P. O. Box 32700 Honolulu, Hawaii 96803-2700

For Dental claims HMSA-Dental claims
P. O. Box 13400 Honolulu, Hawaii 96801-3400

For Pharmacy claims HMSA-Drug claims
P. O. Box 13400 Honolulu, Hawaii 96801-3400

Continued on next page 51.
51 Page 52 53
2003 HMSA Plan 49 Section 7
Section 7. Filing a claim for covered services (continued)
Deadline for filing your claim All Plan and most non-Plan providers in the State of Hawaii file claims for you. If your non-Plan provider does not file the claim for you, you must submit an itemized
bill and receipt for the services you received by December 31 of the year after the year you received the service, unless timely filing was prevented by administrative

operations of Government or legal incapacity, provided the claim was submitted as soon as reasonably possible. File a separate claim for each covered family member
and each provider. For more information, please call us at 808/ 948-6499.
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. 52.
52 Page 53 54
2003 HMSA Plan 50 Section 8
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your claim or request for services, drugs, or supplies including a request for precertification:

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: Hawaii Medical Service Association, Attn: Appeals Coordinator, P. O. Box 860, Honolulu, Hawaii 96808, 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 medical 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, DC 20415-3620.

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.

Continued on next page 53.
53 Page 54 55
2003 HMSA Plan 51 Section 8
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. 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 precertification/ prior approval, then call us at 808/ 948-6499 and we will expedite our review; or
(b) We denied your initial request for care or precertification/ prior approval, then:
If we expedite our review and maintain our denial, we will inform OPM so that they can give your claim expedited treatment too, or

You may call OPM's Health Benefits Contracts Division 2 at 202/ 606-3818 between 8 a. m. and 5 p. m. eastern time. 54.
54 Page 55 56
2003 HMSA Plan 52 Section 9
Section 9. Coordinating benefits with other coverage
When you have other health coverage You must tell us if you or a covered family member have coverage under another group health plan or have automobile insurance that pays health care expenses
without regard to fault. This is called "double coverage".
When you have double coverage, one plan normally pays its benefits in full as the primary payer and the other plan pays a reduced benefit as the secondary payer.

We, like other insurers, determine which coverage is primary according to the National Association of Insurance Commissioners' guidelines.

When we are the primary payer, we will pay the benefits described in this brochure.
When we are the secondary payer, we will pay after the primary plan pays. We will pay what is left, up to our eligible charge.

The benefits payable under this plan, when combined with benefits paid under your other coverage, will not exceed the lesser of:
100 percent of eligible charge, or
the amount payable by your other coverage plus any deductible and copayment you would owe if the other coverage were your only coverage.

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 800/ MEDICARE (800/ 633-4227) 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 show how we coordinate benefits with Medicare, depending on the type of
Medicare managed care plan you have.
Continued on next page 55.
55 Page 56 57
2003 HMSA Plan 53 Section 9
Section 9. Coordinating benefits with other coverage (continued)
The Original Medicare Plan (Part A or Part B) The Original Medicare Plan (Original Medicare) is available everywhere in the United States. It is the way everyone used to get Medicare benefits and is the way
most people get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist, or hospital that accepts Medicare. The Original Medicare
Plan pays its share and you pay your share. Original Medicare does not cover everything, like hearing aids.

When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care. Your care must
continue to be precertified as required.
We will not waive any of our copayment/ coinsurance for services or supplies that are not covered by Original Medicare (for example, hearing aids).

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

and we will then provide secondary benefits for covered charges. You will not need to do anything. To find out if you need to do something to
file your claim, call us at 808/ 948-6499. If your Plan physician does not participate in Medicare, you will have to
file a claim with Medicare.
We do not waive any costs if the Original Medicare is your primary payer.
Facilities or Providers Not Eligible or Entitled to Medicare Payment. When services are rendered at a facility or by a provider that is not eligible or entitled to

receive reimbursement from Medicare, and Medicare is allowed by law to be the primary payer, we will limit payment to an amount that supplements the benefits
that would have been payable by Medicare had the facility or provider been eligible or entitled to receive such payments, regardless of whether or not
Medicare benefits are paid.
Continued on next page 56.
56 Page 57 58
2003 HMSA Plan 54 Section 9
The following chart illustrates whether the Original Medicare Plan or this Plan should be the primary payer for you according to your employment status and other factors determined by Medicare. It is critical that you tell us if you or a covered family
member has Medicare coverage so we can administer these requirements correctly.
Primary Payer Chart
Then the primary payer is A. When either you --or your covered spouse --are age 65 or over and

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

2) Are an annuitant, .
3) Are a reemployed annuitant with the Federal government when
a) The position is excluded from FEHB, or .

b) The position is not excluded from FEHB .

(Ask your employing office which of these applies to you.)
4) Are a Federal judge who retired under title 28, U. S. C., or a Tax Court judge who retired under Section 7447 of title 26, U. S. C. (or if your covered spouse

is this type of judge), .
5) Are enrolled in Part B only, regardless of your employment status, . (for Part B
services)

.
(for other services)

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

.
(except for claims related to Workers'

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

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

b) Are an active employee, or .

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

Continued on next page 57.
57 Page 58 59

2003 HMSA Plan 55 Section 9
Section 9. Coordinating benefits with other coverage (continued)
Medicare managed care plan If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare managed care plan. These are health care
choices (like HMOs) in some areas of the country. In most Medicare managed care plans, you can only go to doctors, specialists, or hospitals that are part of

the plan. Medicare managed care plans provide all the benefits that Original Medicare covers. Some cover extras, like prescription drugs. To learn more
about enrolling in a Medicare managed care plan, contact Medicare at 800/ MEDICARE (800/ 633-4227) or at www. medicare. gov.

If you enroll in a Medicare managed care plan, the following options are available to you:
This Plan and our Medicare managed care plan: You may enroll in our Medicare managed care plan and also remain enrolled in our FEHB Plan. In
this case, we do not waive any of our copayments or coinsurance for your FEHB coverage.

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

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

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

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 a 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.
Continued on next page 58.
58 Page 59 60
2003 HMSA Plan 56 Section 9
Section 9. Coordinating benefits with other coverage (continued)
Workers' Compensation We do not cover services that: You need because of a workplace-related illness or injury that the Office
of Workers' Compensation Programs (OWCP) or a similar Federal or State agency determines they must provide; or

OWCP or a similar agency pays for through a third party injury settlement or other similar proceeding that is based on a claim you filed
under OWCP or similar laws.
Once OWCP or similar agency pays its maximum benefits for your treatment, we will cover your care.

Medicaid When you have this Plan and Medicaid, we pay first. Suspended FEHB coverage to enroll in Medicaid or a similar State-sponsored
program of medical assistance: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in a one of these State
programs, eliminating your FEHB premium. For information on suspending your FEHB enrollment, contact your retirement office. If you later want to re-enroll
in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage under the State program.

When other Government agencies are responsible for
your care

We do not cover services and supplies when a local, State, or Federal Government agency directly or indirectly pays for them.

When others are responsible for injuries We may cover your medical or hospital care for an injury or illness that may have been caused by another person. However, you must first fill out and
return to us all papers we require to secure our reimbursement from you for the amounts we paid. We will cover the cost of treatment that exceeds the amount

you received in the settlement. If you need more information, contact us for third party liability procedures. 59.
59 Page 60 61

2003 HMSA Plan 57 Section 10
Section 10. Definitions of terms we use in this brochure
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on December 31 of
the same year.

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

Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 13.
Covered services Care we provide benefits for, as described in this brochure.
Custodial care Helps you meet your daily living activities. This type of care does not require the continuing attention and assistance of licensed medical or trained paramedical
personnel. Custodial care lasting 90 days or more is sometimes known as long term care.

Deductible A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for those services.
We do not have a deductible.

Eligible Charge Eligible charge is the amount we use to determine our payment and your coinsurance for covered services. We determine our eligible charge as the lower
of either the provider's actual charge or the amount we establish as the maximum allowable fee.

The maximum allowable fee is the maximum dollar amount paid for a covered service, supply, or treatment. We use the following method to determine the
maximum allowable fee:
For most services, supplies, or procedures, we consider:
increases in the cost of medical and non-medical services in Hawaii over the previous year;

the relative difficulty of the services compared to other services;
changes in technology; and
payment for the service under federal, state, and other private insurance programs.

For some facility-billed services (not to include practitioner-billed facility services), we use a per case, per treatment, or per day fee (per
diem) rather than an itemized amount (fee for service). For Non-Plan hospitals, our maximum allowable fee for all-inclusive daily rates
established by the hospital will never exceed more than if the hospital had charged separately for services.

Plan providers agree to accept the eligible charge for covered services. Non-Plan providers generally do not. Therefore, if you received services from a non-Plan
provider you are responsible for any difference between the actual charge and the eligible charge.

Continued on next page 60.
60 Page 61 62
2003 HMSA Plan 58 Section 10
Section 10. Definitions of terms we use in this brochure (continued)
Experimental or investigational services A medical treatment, procedure, drug, device, or care is experimental or investigative if:
The drug or device cannot be lawfully marketed without approval of the U. S. Food and Drug administration and approval for marketing has not been
given at the time the drug or device is furnished; or
The drug, device, medical treatment, or procedure, or the patient informed consent document utilized with the drug, device, treatment, or procedure,

was reviewed and approved by the treating facility's Institutional Review Board or other body serving a similar function, or if federal law requires
such review and approval; or
Reliable evidence shows that the drug, device, medical treatment or procedure is the subject of ongoing phase I or phase II clinical trials, is for

the research, experimental, study or investigational arm or ongoing phase III clinical trials, or is otherwise under study to determine its maximum
tolerated dose, its toxicity, its safety, its efficacy or its efficacy as compared with a standard means of treatment or diagnosis; or

Reliable evidence shows that the prevailing opinion among experts regarding the drug, device, medical treatment or procedure is that further studies or
clinical trials are necessary to determine its maximum tolerated dose, toxicity, safety, efficacy, or its efficacy compared with a standard means of
treatment or diagnosis.

Medical necessity Care, treatment, service, or supply, which is all of the following: Appropriate and necessary for the symptoms, diagnosis, and direct care or
treatment of your illness or injury;
Consistent with professionally recognized standards of health care in the United States, and given at the right time and in the right setting;

Not primarily for your convenience or the convenience of your provider;
The most appropriate supply or level of service that can safely be provided; and

Consistent with our medical guidelines and policies.
Us/ We Us and we refer to HMSA.
You You refers to the enrollee and each covered family member. 61.
61 Page 62 63

2003 HMSA Plan 59 Section 11
Section 11. FEHB facts
No pre-existing condition limitation We will not refuse to cover the treatment of a condition that you had before you enrolled in this Plan solely because you had the condition before you enrolled.

Where you can get information about enrolling in the FEHB
Program

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

When you may change your enrollment
How you can cover your family members
What happens when you transfer to another Federal agency, go on leave without pay, enter military service, or retire

When your enrollment ends
When the next open season for enrollment begins

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

Types of coverage available for you and your family Self Only coverage is for you alone. Self and Family coverage is for you, your spouse, and your unmarried dependent children under age 22, including any foster
children or stepchildren your employing or retirement office authorizes coverage for. Under certain circumstances, you may also continue coverage for a disabled child 22

years of age or older who is incapable of self-support.
If you have a Self Only enrollment, you may change to a Self and Family enrollment if you marry, give birth, or add a child to your family. You may change your

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

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

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

Continued on next page 62.
62 Page 63 64
2003 HMSA Plan 60 Section 11
Section 11. FEHB facts (continued)
Children's Equity Act OPM has implemented the Federal Employees Health Benefits Children's Equity Act of 2000. This law mandates that you be enrolled for Self and Family coverage
in the Federal Employees Health Benefits (FEHB) Program, if you are an employee subject to a court or administrative order requiring you to provide health benefits for

your child( ren).
If this law applies to you, you must enroll for Self and Family coverage in a health plan that provides full benefits in the area where your children live or provide
documentation to your employing office that you have obtained other health benefits coverage for your children. If you do not do so, your employing office will enroll
you involuntarily as follows:
If you have no FEHB coverage, your employing office will enroll you for Self and Family coverage in the Blue Cross and Blue Shield Service Benefit Plan's

Basic Option;
if you have a Self Only enrollment in a fee-for-service plan or in an HMO that serves the area where your children live, your employing office will change

your enrollment to Self and Family in the same option of the same plan; or
if you are enrolled in an HMO that does not serve the area where the children live, your employing office will change your enrollment to Self and Family in

the Blue Cross and Blue Shield Service Benefit Plan's Basic Option.
As long as the court/ administrative order is in effect, and you have at least one child identified in the order who is still eligible under the FEHB Program, you cannot

cancel your enrollment, change to Self Only, or change to a plan that doesn't serve the area in which your children live, unless you provide documentation that you
have other coverage for the children. If the court/ administrative order is still in effect when you retire, and you have at least one child still eligible for FEHB
coverage, you must continue your FEHB coverage into retirement (if eligible) and cannot make any changes after retirement. Contact you employing office for further
information.

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

will tell you the effective date of coverage.

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

When you lose benefits
When FEHB coverage ends You will receive an additional 31 days of coverage, for no additional premium, when:

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

Continued on next page 63.
63 Page 64 65

2003 HMSA Plan 61 Section 11
Section 11. FEHB facts (continued)
Spouse equity coverage If you are divorced from a Federal employee or annuitant, you may not continue to get benefits under your former spouse's enrollment. This is the case even when the
court has ordered your former spouse to supply health coverage to you. But, you may be eligible for your own FEHB coverage under the spouse equity law or
Temporary Continuation of Coverage (TCC). If you are recently divorced or are anticipating a divorce, contact your ex-spouse's employing or retirement office to
get RI 70-5, the Guide to Federal Employees Health Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees, or other information about
your coverage choices. You can also download the guide from OPM's website, www. opm. gov/ insure.

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

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

Converting to individual coverage You may convert to a non-FEHB individual policy if:
Your coverage under TCC or the spouse equity law ends (If you canceled your coverage or did not pay your premium, you cannot convert);

You decided not to receive coverage under TCC or the spouse equity law; or
You are not eligible for coverage under TCC or the spouse equity law.
If you leave Federal service, your employing office will notify you of your right to convert. You must apply in writing to us within 31 days after you receive this

notice. However, if you are a family member who is losing coverage, the employing or retirement office will not notify you. You must apply in writing to us within 31
days after you are no longer eligible for coverage.
Your benefits and rates will differ from those under the FEHB Program; however, you will not have to answer questions about your health, and we will not impose a

waiting period or limit your coverage due to pre-existing conditions.

Continued on next page 64.
64 Page 65 66

2003 HMSA Plan 62 Section 11
Section 11. FEHB facts (continued)
Getting a Certificate of Group Health Plan
Coverage

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a Federal law that offers limited Federal protections for health coverage availability
and continuity to people who lose employer group coverage. If you leave the FEHB Program, we will give you a Certificate of Group Health Plan Coverage that
indicates how long you have been enrolled with us. You can use this certificate when getting health insurance or other health care coverage. Your new plan must
reduce or eliminate waiting periods, limitations, or exclusions for health related conditions based on the information in the certificate, as long as you enroll within 63
days of losing coverage under this Plan. If you have been enrolled with us for less than 12 months, but were previously enrolled in other FEHB plans, you may also
request a certificate from those plans. For more information, get OPM pamphlet RI 79-27, Temporary Continuation of Coverage (TCC) under the FEHB Program. See
also the FEHB web site (www. opm. gov/ insure/ health); refer to the "TCC and HIPAA" frequently asked questions. These 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. 65.
65 Page 66 67

2003 HMSA Plan 63 Long Term Care Insurance
Long Term Care Insurance Is Still Available
Open Season for Long Term Care Insurance
You can protect yourself against the high cost of long term care by applying for insurance in the Federal Long Term Care Insurance Program.
Open Season to apply for long term care insurance through LTC Partners ends on December 31, 2002. If you're a Federal employee, you and your spouse need only answer a few questions about your health during Open
Season. If you apply during the Open Season, your premiums are based on your age as of July 1, 2002. After Open Season, your
premiums are based on your age at the time LTC Partners receives your application.
FEHB Doesn't Cover It
Neither FEHB plans nor Medicare cover the cost of long term care. Also called "custodial care", long term care helps you perform the activities of daily living such as bathing or dressing yourself. It can also provide help you may need due to a
severe cognitive impairment such as Alzheimer's disease.
You Can Also Apply Later, But
Employees and their spouses can still apply for coverage after the Federal Long Term Care Insurance Program Open Season ends, but they will have to answer more health-related questions.
For annuitants and other qualified relatives, the number of health-related questions that you need to answer is the same during and after the Open Season.

You Must Act to Receive an Application
Unlike other benefit programs, YOU have to take action you won't receive an application automatically. You must request one through the toll-free number or website listed below.
Open Season ends December 31, 2002 act NOW so you won't miss the abbreviated underwriting available to employees and their spouses, and the July 1 "age freeze"!

Find Out More Contact LTC Partners by calling 1-800-LTC-FEDS (1-800-582-3337) (TDD for the hearing impaired: 1-800-843-3557) or visiting www. ltcfeds. com to get more information and to request an application. 66.
66 Page 67 68

2003 HMSA Plan 64 Index
Index
Do not rely on this page; it is for your convenience and may not show all pages where the terms appear.
Accidental injury 42 Allergy tests 20
Alternative treatment 24 Allogeneic (donor) bone marrow
transplant 28 Ambulance 32, 34
Anesthesia 29 Autologous bone marrow
transplant 28 Biopsy 26
Birthing centers 18 Blood and blood plasma 30, 31
Breast cancer screening 16 Casts 30, 31
Catastrophic protection 13, 68 Changes for 2003 9
Chemotherapy 21 Childbirth 18
Chiropractic 24 Cholesterol tests 15, 16
Claims 48 Coinsurance 13, 57
Colonoscopy 16 Colorectal cancer screening 15
Congenital anomalies 26, 27 Contraceptive devices and drugs 19,
38, 39 Coordination of benefits 52
Covered services 13, 57 Covered providers 10
Crutches 24 Deductible 13, 57
Definitions 57 Dental care 42
Diagnostic services 15 Disputed claims review 50
Donor expenses (transplants) 28 Dressings 30, 31
Durable medical equipment (DME) 24
Educational classes and programs 25 Effective date of enrollment 60
Emergency 33

Experimental or investigational 58
Eyeglasses 22 Family planning 19
Fecal occult blood test 15, 16 General Exclusions 47
Hearing services 22 Home health services 24
Hospice care 32 Home nursing care 24
Hospital 30 Immunizations 16, 18
Infertility 20 Inhospital physician care 15
Inpatient Hospital Benefits 30 Insulin 39
Laboratory and pathological services 15
Machine diagnostic tests 15 Magnetic Resonance
Imagings (MRIs) 15 Mail Order Prescription
Drugs 40 Mammograms 15, 16
Maternity Benefits 18 Medicaid 56
Medically necessary 58 Medicare 52
Mental Conditions/ Substance Abuse Benefits 35
Newborn care 19 Non-FEHB Benefits 46
Nurse Advanced Practice Registered
Nurse 35 Nurse Anesthetist 30
Nursery charges 19 Obstetrical care 18
Occupational therapy 21 Office visits 15
Oral and maxillofacial surgery 28
Orthopedic devices 23

Out-of-pocket expenses 13 Outpatient facility care 31
Oxygen 24, 30 Pap test 15, 16
Physical examination 16 Physical therapy 21
Physician 15 Point-of-service (POS) 44
Precertification 12 Preventive care, adult 15
Preventive care, children 18 Prescription drugs 36
Preventive services 15 Prior approval 12
Prostate cancer screening 16 Prosthetic devices 23
Psychologist 35 Radiation therapy 21
Renal dialysis 21 Room and board 30
Skilled nursing facility care 32 Smoking cessation 25, 38, 40
Speech therapy 22 Splints 30, 43
Sterilization procedures 19 Substance abuse 35
Surgery 26 Anesthesia 29
Oral 28 Outpatient 26
Reconstructive 27 Syringes 39
Temporary continuation of coverage 61
Transplants 28 Treatment therapies 21
Vision services 22 Well child care 18
Wheelchairs 24 Workers' compensation 56
X-rays 15 67.
67 Page 68 69
2003 HMSA Plan 65
NOTES: 68.
68 Page 69 70
2003 HMSA Plan 66
NOTES: 69.
69 Page 70 71
2003 HMSA Plan 67
NOTES: 70.
70 Page 71 72

2003 HMSA Plan 68 Summary
Summary of benefits for the HMSA Plan 2003
Do not rely on this chart alone. All benefits are provided in full unless indicated and are subject to the definitions, limitations, and exclusions in this brochure. On this page we summarize specific expenses we cover; for more detail, look
inside.
If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on your enrollment form.

When you receive services from a non-Plan provider you have a higher out-of-pocket cost. You generally must pay any difference between our eligible charge and the billed amount.

Benefits You Pay Plan Providers Page
Medical services provided by physicians:
Diagnostic and treatment services provided in the office............ 20% of eligible charges 15

Services provided by a hospital:
Inpatient .......................................................................................
Outpatient ....................................................................................
Nothing
20% of eligible charges
30
31

Emergency benefits:
In-area..........................................................................................
Out-of-area ..................................................................................
20% of eligible charges
20% of eligible charges
33
33

Mental health and substance abuse treatment....................................... Regular benefits 35
Prescription drugs ................................................................................ $5 copayment for generic drugs
$15 copayment for preferred name brand drugs

50% copayment of eligible charges not less than $15 copayment for other brand name
drugs

Dental Care .......................................................................................... Nothing for preventive dental care 42
Vision Care .......................................................................................... $7 copayment for optometrist 20% of eligible charges for other Plan
providers
22

Point of Service benefits Yes 44
Protection against catastrophic costs
(your catastrophic protection out-of-pocket maximum).......................
Nothing after $2,500/ Self-Only or $7,500/ Family enrollment per year

Some costs do not count toward this protection
13 71.
71 Page 72
2003 HMSA Plan
2003 Rate Information for Hawaii Medical Service Association Plan
Non-Postal rates apply to most non-Postal enrollees. If you are in a special enrollment category, refer to the FEHB Guide for that category or contact the agency that maintains your health benefits enrollment.
Postal rates apply to career Postal Service employees. Most employees should refer to the FEHB Guide for United States Postal Service Employees, RI 70-2. Different postal rates apply and a special FEHB
guide is published for Postal Service Inspectors and Office of Inspector General (OIG) employees (see RI 70-2IN).

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

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

All of Hawaii
Self Only 871 $90.35 $30.12 $195.77 $65.25 $106.92 $13.55
Self and Family 872 $201.13 $67.04 $435.78 $145.26 $238.00 $30.17 72.

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