Document Outline

• Introduction
• Plain Language
• Stop Health Care Fraud!
• Section 1. Facts about this HMO plan
  • 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
    • Plan providers
    • Plan facilities
  • What you must do to get covered care
    • Primary care
    • Specialty care
    • Hospital care
  • Circumstances beyond our control
  • Services requiring our prior approval
• Section 4. Your costs for covered services
  • Copayments
  • Deductible
  • Coinsurance
  • Fees when you fail to make your copayment or coinsurance
  • Your catastrophic protection out-of-pocket maximum for copayments and coinsurance
• Section 5. Benefits -- Overview
  • (a) Medical services and supplies provided by physicians and other health care professionals
  • (b) Surgical and anesthesia services provided by physicians and other health care professionals
  • (c) Services provided by a hospital or other facility, and ambulance services
  • (d) Emergency services/accidents
  • (e) Mental health and substance abuse benefits
  • (f) Prescription drug benefits
  • (g) Special features
    • Flexible benefit options
    • 24 hour nurse line
    • Services for deaf and hearing impaired
    • Centers of Excellence
    • Travel benefit
    • Services from other Kaiser Permanente plans
  • (h) Dental benefits
  • (i) Non-FEHB benefits available to Plan members
• 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?
    • The Original Medicare Plan (Part A or Part B)
    • Medicare managed care plan
    • If you do enroll in Medicare Part B
    • If you do not enroll in Medicare Part A or Part B
  • 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 used 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
  • Children's Equity Act
  • When benefits and premiums start
  • When you retire
  • When you lose benefits
    • When FEHB coverage ends
    • Spouse equite coverage
    • Temporary continuation of coverage (TCC)
    • Getting a Certificate of Group Health Plan Coverage
    • Converting to individual coverage
• Long Term Care Insurance Is Still Available!
• Index
• Summary of Benefits
• Rates

Pages 1--82 from RI-47 - MAS 2003.DOC

2003
A Health Maintenance Organization

Serving: Metropolitan Washington, DC Area and Metropolitan Baltimore, Maryland Area
Enrollment in this Plan is limited. You must live or work in our geographic service area to enroll. See page 8 for requirements.

Enrollment codes for this Plan:
E31 Self Only E32 Self and Family

RI 73-047

This Plan has commendable accreditation from the NCQA.
See the 2003 Guide for more
information on accreditation.

For changes in benefits
see page 9 1.
1

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

Page 2 3
2.
2 Page 3 4
Notice of the Office of Personnel Management's
Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE
REVIEW IT CAREFULLY.
By law, the Office of Personnel Management (OPM), which administers the Federal Employees Health Benefits
(FEHB) Program, is required to protect the privacy of your personal medical information. OPM is also required to give you this notice to tell you how OPM may use and give out (" disclose") your personal medical information held

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

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

OPM has the right to use and give out your personal medical information to administer the FEHB Program. For example:

To communicate with your FEHB health plan when you or someone you have authorized to act on your
behalf asks for our assistance regarding a benefit or customer service issue.
To review, make a decision, or litigate your disputed claim.
For OPM and the General Accounting Office when conducting audits.

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

By law, OPM must have your written permission (an "authorization") to use or give out your personal medical information for any purpose that is not set out in this notice. You may take back (" revoke") your written permission
at any time, except if OPM has already acted based on your permission.
By law, you have the right to:

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

added to your personal medical information.
Get a listing of those getting your personal medical information from OPM in the past 6 years. The listing will not cover your personal medical information that was given to you or your personal representative, any 3.
3 Page 4 5
information that you authorized OPM to release, or that was given out for law enforcement purposes or to pay for your health care or a disputed claim.
Ask OPM to communicate with you in a different manner or at a different place (for example, by sending materials to a P. O. Box instead of your home address).
Ask OPM to limit how your personal medical information is used or given out. However, OPM may not be able to agree to your request if the information is used to conduct operations in the manner described above.
Get a separate paper copy of this notice.
For more information on exercising your rights set out in this notice, look at www. opm. gov/ insure on the web. You may also call 202/ 606-0191 and ask for OPM's FEHB Program privacy official for this purpose.

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

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

2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 2 Table of Contents
Table of Contents
Introduction ..................................................................................................................................................................................... 5
Plain Language ................................................................................................................................................................................. 5
Stop Health Care Fraud!.................................................................................................................................................................. 5
Section 1. Facts about this HMO plan ......................................................................................................................................... 7
How we pay providers ................................................................................................................................................. 7
Your Rights ................................................................................................................................................................... 7
Service Area................................................................................................................................................................... 8
Section 2. How we change for 2003............................................................................................................................................. 9
Program-wide changes ................................................................................................................................................ 9
Changes to this Plan..................................................................................................................................................... 9
Section 3. How you get care ....................................................................................................................................................... 10
Identification cards..................................................................................................................................................... 10
Where you get covered care ..................................................................................................................................... 10
Plan providers ...................................................................................................................................................... 10
Plan facilities ........................................................................................................................................................ 10
What you must do to get covered care.................................................................................................................... 10
Primary care.......................................................................................................................................................... 11
Specialty care ....................................................................................................................................................... 11
Hospital care ......................................................................................................................................................... 12
Circumstances beyond our control.......................................................................................................................... 12
Services requiring our prior approval...................................................................................................................... 12
Section 4. Your costs for covered services ............................................................................................................................... 14
Copayments.......................................................................................................................................................... 14
Deductible ............................................................................................................................................................. 14
Coinsurance.......................................................................................................................................................... 14
Fees when you fail to make your copayment or coinsurance...................................................................... 14
Your catastrophic protection out-of-pocket maximum for copayments and coinsurance............................. 14
Section 5. Benefits ........................................................................................................................................................................ 15
Overview...................................................................................................................................................................... 15
(a) Medical services and supplies provided by physicians and other health care professionals ............. 16
(b) Surgical and anesthesia services provided by physicians and other health care professionals ......... 28
(c) Services provided by a hospital or other facility, and ambulance services .......................................... 32
(d) Emergency services/ accidents ...................................................................................................................... 36
(e) Mental health and substance abuse benefits .............................................................................................. 38
(f) Prescription drug benefits ............................................................................................................................. 41
(g) Special features ............................................................................................................................................... 45 5.
5 Page 6 7

2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 3 Table of Contents
Flexible benefits option...................................................................................................................................... 45
24 hour nurse line ................................................................................................................................................ 45
Services for deaf and hearing impaired............................................................................................................ 45
Centers of Excellence.......................................................................................................................................... 45
Travel benefit........................................................................................................................................................ 46
Services from other Kaiser Permanente plans................................................................................................ 47
(h) Dental benefits................................................................................................................................................. 48
(i) Non-FEHB benefits available to Plan members ........................................................................................ 57
Section 6. General exclusions things we don't cover........................................................................................................... 58
Section 7. Filing a claim for covered services .......................................................................................................................... 59
Medical, hospital, and drug benefits........................................................................................................................ 59
Deadline for filing your claim................................................................................................................................... 59
When we need more information............................................................................................................................. 59
Section 8. The disputed claims process..................................................................................................................................... 60
Section 9. Coordinating benefits with other coverage ............................................................................................................ 62
When you have other health coverage.................................................................................................................... 62
What is Medicare?................................................................................................................................................ 62
The Original Medicare Plan (Part A or Part B)................................................................................................ 62
Medicare managed care plan............................................................................................................................... 65
If you do enroll in Medicare Part B................................................................................................................... 66
If you do not enroll in Medicare Part A or Part B ........................................................................................... 66
TRICARE and CHAMPVA ...................................................................................................................................... 66
Workers' Compensation............................................................................................................................................ 67
Medicaid ....................................................................................................................................................................... 67
When other Government agencies are responsible for your care ....................................................................... 67
When others are responsible for injuries ................................................................................................................ 67
Section 10. Definitions of terms we use in this brochure ....................................................................................................... 68
Section 11. FEHB facts ................................................................................................................................................................ 70
No pre-existing condition limitation...................................................................................................................... 70
Where you can get information about enrolling in the FEHB Program.......................................................... 70
Types of coverage available for you and your family ........................................................................................ 70
Children's Equity Act............................................................................................................................................... 71
When benefits and premiums start......................................................................................................................... 71
When you retire ......................................................................................................................................................... 71
When you lose benefits ........................................................................................................................................... 71
When FEHB coverage ends............................................................................................................................... 71
Spouse equity coverage...................................................................................................................................... 72
Temporary continuation of coverage (TCC)................................................................................................... 72 6.
6 Page 7 8

2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 4 Table of Contents
Converting to individual coverage.................................................................................................................... 72
Getting a Certificate of Group Health Plan Coverage................................................................................... 72
Long term care insurance is still available!................................................................................................................................ 74
Index .................................................................................................................................................................................... 75
Summary of benefits ...................................................................................................................................................................... 76
Rates.. Back cover 7.
7 Page 8 9
2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 5 Introduction/ Plain Language/ Advisory
Introduction
This brochure describes the benefits of Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc., under our
contract (CS 1763) with the Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. The address for Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 's administrative office

is:
Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 2101 East Jefferson Street
Rockville, Maryland 20852
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" or "Plan" means Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.

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

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

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

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. 8.
8 Page 9 10
2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 6 Introduction/ Plain Language/ Advisory
Protect Yourself From Fraud Here are some things you can do to prevent fraud:
Be wary of giving your plan identification (ID) number over the telephone or to people you do not know, except to your doctor, other provider, or authorized plan or OPM representative.

Let only the appropriate medical professionals review your medical record or recommend services.
Avoid using health care providers who say that an item or service is not usually covered, but they know how to bill us to get it paid.

Carefully review explanations of benefits (EOBs) that you receive from us.
Do not ask your doctor to make false entries on certificates, bills or records in order to get us to pay for an item or service.

If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or misrepresented any information, do the following:
Call the provider and ask for an explanation. There may be an error.
If the provider does not resolve the matter, call us at 301/ 468-6000 inside the Washington, DC metropolitan area or at 800/ 777-7902 outside the Washington, DC metropolitan area, and explain the

situation. Our TTY telephone number is 301/ 879-6380.
If we do not resolve the issue:

CALL THE HEALTH CARE FRAUD HOTLINE
202/ 418-3300
OR WRITE TO:
The United States Office of Personnel Management Office of the Inspector General Fraud Hotline

1900 E Street, NW, Room 6400 Washington, DC 20415

Do not maintain as a family member on your policy:
your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise); or

your child over age 22 (unless he/ she is disabled and incapable of self support).
If you have any questions about the eligibility of a dependent, check with your personnel office if you are employed or with OPM if you are retired.

You can be prosecuted for fraud and your agency may take action against you if you falsify a claim to obtain FEHB benefits or try to obtain services for someone who is not an eligible family member or who is no longer
enrolled in the Plan. 9.
9 Page 10 11
2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 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 our 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 and coinsurance described in this brochure. When you receive emergency services or benefits from non-Plan providers (while you travel) you may have to submit claim forms.

You should join an HMO because you prefer the plan's benefits, not because a particular provider is available. You cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician,
hospital, or other provider will be available and/ or remain under contract with us.

How we pay providers
We pay the Mid-Atlantic Permanente Medical Group, P. C., the Affiliated Primary Care Physician's Network (APCPN) located in Baltimore, Maryland, Affiliate Columbia Gateway (AFCG), APS Healthcare, Maryland Eye
Care, Dental Benefit Providers, and contracted community specialists and ancillary providers to provide your medical,
surgical, mental health, substance abuse, ophthalmology, optometry, and dental services. We contract with local community hospitals to provide hospitalization services. These Plan providers accept a negotiated payment from us.

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.
Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. (Kaiser Permanente), is a federally qualified
Health Maintenance Organization.
This Plan is part of the Kaiser Permanente Medical Care Program, a group of not-for-profit organizations and contracting medical groups that serve over 8 million members nationwide.

Kaiser Permanente is a Maryland non-profit corporation licensed in the Commonwealth of Virginia, the District of Columbia and the State of Maryland.
Kaiser Permanente began delivering prepaid healthcare services to Washington, DC residents in December 1972.
Kaiser Permanente presently serves approximately 525,000 members in the Washington, DC and Baltimore, Maryland metropolitan areas.

Kaiser Permanente credentials its Plan providers in accord with national standards.
If you want more information, call us at 301/ 468-6000 inside the Washington, DC metropolitan area or at 800/ 777-
7902 outside the Washington, DC metropolitan area. Our TTY telephone number is 301/ 879-6380. Write to us at Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc., Attention: Member Services Department, 2101 E.

Jefferson Street, Rockville, Maryland, 20852 or by fax at 301/ 816-6192. You may visit our website at
http:// www. kaiserpermanente. org. 10.
10 Page 11 12
2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 8 Section 1
Service Area
To enroll in this Plan, you must live or work in our service area. This is where our providers practice. Our service
area is:

The District of Columbia
The following Virginia counties:
Arlington
Fairfax
Loudoun
Prince William

The following Virginia cities:
Alexandria
Falls Church
Fairfax
Manassas
Manassas Park

The following Maryland counties:
Anne Arundel
Baltimore
Carroll
Harford
Howard
Montgomery
Prince Georges

Portions of the following Maryland counties, as indicated by the zip codes below, are also within the service area:
Calvert 20639, 20678, 20689, 20714, 20732, 20736, and 20754 zip codes only
Charles 20601, 20602, 20603, 20604, 20612, 20616, 20617, 20637, 20640, 20643, 20646, 20658, 20675,
20677, and 20695 zip codes only
Frederick 21701, 21702, 21703, 21704, 21705, 21709, 21710, 21714, 21716, 21717, 21718, 21754, 21755, 21758, 21759, 21762, 21769, 21770, 21771, 21774, 21775, 21777, 21790, 21792, and 21793 zip

codes only
Baltimore City, MD
Ordinarily, you must receive your care from physicians, hospitals, and other providers who contract with us. However, we are part of the Kaiser Permanente Medical Care Program, and if you are visiting another Kaiser
Permanente service area, you can receive virtually all of the benefits of this Plan at any other Kaiser Permanente facility, including our mail order prescription program. You must pay the charges or copayments imposed by the
Kaiser Permanente Plan you are visiting, with the exception of mail order prescriptions which are administered by
your home Plan. See Section 5( g), Special Features, for more details. We also pay for certain follow-up services or continuing care services while you are traveling outside the service area, as described on page 46; and for emergency

care obtained from any non-Plan provider, as described on page 36. We will not pay for any other health care
services.

If you or a covered family member move outside of our service area, you can enroll in another plan. If your
dependents live out of the area (for example, if your child goes to college in another state), you should consider enrolling in a fee-for-service plan or an HMO that has agreements with affiliates in other areas. If you or a family

member move, you do not have to wait until Open Season to change plans. Contact your employing or retirement
office. 11.
11 Page 12 13
2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 9 Section 2
Section 2. How we change for 2003
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5
Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here is a clarification that does not change benefits.

Program-wide changes
A Notice of the Office of Personnel Management's Privacy Practices is included.
A section on the Children's Equity Act describes when an employee is required to maintain Self and Family coverage.

Program information on TRICARE and CHAMPVA explains how annuitants or former spouses may suspend their FEHB Program enrollment.
Program information on Medicare is revised.
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 15.1% for Self Only or 10.9% for Self and Family.
We increased the office visit copayment for specialty care visits from $10 to $20. Primary care visits, (i. e., family
practice, gynecology, obstetrics, internal medicine, and pediatrics) will remain at a $10 copayment. Specialty care services include all other services.

We cover travel consultations, immunizations, and vaccines.
We decreased the number of visits for outpatient physical therapy to 30 visits or 60 days of coverage (whichever is greater).

Eye refractions for eyeglasses are no longer limited to one per year.
We added coverage for Continuous Positive Airway Pressure (CPAP) equipment for 20% of our allowance for the first three months and 50% of our allowance for every 30 days thereafter.

We cover the procurement and storage of medically necessary cord blood for a known recipient.
We increased the copayment for outpatient surgery from $10 to $50.
We limit the supply of injectable drugs that are self-administered to a 30-day supply.
We added the option to obtain covered medications and supplies at participating network pharmacies at $20 per prescription or refill for generic drugs or $40 per prescription or refill for brand-name drugs.

We changed the copayment for disposable needles and syringes and glucose test strips to 20% of our allowance. 12.
12 Page 13 14
2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 10 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it
whenever you receive services from a Plan provider, or fill a
prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the health benefits election form, SF-2809, your health

benefits enrollment confirmation (for annuitants), your Employee
Express confirmation letter, or write to us at Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc., ATTN: Member Services

Correspondence, 2101 E. Jefferson St., Rockville, MD 20852.
Members may submit inquiries, requests and complaints through our website http:// www. kp. org/ locations/ midatlantic/ index. html. A

Member Services representative will work with you to answer questions
and resolve issues, including ID card issues.

If you do not receive your ID card within 30 days after we have
received your enrollment from your payroll office, or if you need replacement cards, call us at 301/ 468-6000 inside the Washington, DC

metropolitan area or at 800/ 777-7902 outside the Washington, DC
metropolitan area. Our TTY telephone number is 301/ 879-6380.

Where you get covered care You get care from "Plan providers" and "Plan facilities." You will only pay copayments or coinsurance, and you will not have to file claims,
except for emergency, urgent care services outside our service area, and for covered services while you travel.

Plan providers Our 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 contract with the Mid-Atlantic Permanente Medical Group, P. C., to provide or arrange for primary care services and
specialty care services for our members.
Our Provider Directory lists the Plan providers, with locations and phone numbers. Directories are updated annually and are available at
the time of enrollment. However, our online Provider Directory is updated biweekly. Our website address is
http:// www. kaiserpermanente. org.

Plan facilities Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members.

If you are visiting another Kaiser Permanente service area, you may receive health care services at those Kaiser Permanente facilities.
Under the circumstances specified in this brochure you may receive follow-up or continuing care while you travel anywhere.

Our Provider Directory lists the Plan facilities. Directories are updated annually and are available at the time of enrollment. However, our
online Provider Directory is updated biweekly. Our website address is
http:// www. kaiserpermanente. org.

What you must do to get covered care It depends on the type of care you need. First, you and each family member must choose a primary care physician. This decision is
important since your primary care physician provides or arranges for most of your health care. 13.
13 Page 14 15
2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 11 Section 3
To choose a primary care physician you can either select one from our Provider Directory, on our website is http:// www. kaiserpermanente. org
or you can call us at 301/ 468-6000 inside the Washington, DC
metropolitan area or at 800/ 777-7902 outside the Washington, DC metropolitan area. Our TTY telephone number is 301/ 879-6380. We

are happy to assist you in selecting a primary care physician.

Primary care We require you to choose a primary care physician when you enroll. Your primary care physician can be an internal medicine physician, an
obstetrician/ gynecologist, a pediatrician, or a family practice physician. Your primary care physician will provide most of your health care, or
give you a referral to see a specialist.
If you want to change primary care physicians or if your primary care physician leaves the Plan, call us. We will help you select a new one.

Specialty care Your primary care physician will refer you to a specialist for needed care. When you receive a referral from your primary care physician,
you must return to the primary care physician after the consultation, unless your primary care physician authorized a certain number of visits
without additional referrals. The primary care physician must provide
or authorize all follow-up care. Do not go to the specialist for return visits unless your primary care physician gives you a referral. You may

see an optometrist or our mental health and substance abuse Plan
providers without a referral. Members may obtain mental health and substance abuse services without a primary care referral by directly

calling KPMAS' Behavioral Health Access Unit at 866/ 530-8778 to arrange for services.

Here are other things you should know about specialty care:
If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician
will work with the specialist, in consultation with you, to develop a
treatment plan that allows you to see your specialist for a certain number of visits without additional referrals. Your primary care

physician will use our criteria when creating your treatment plan.

If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician. Your primary care physician will
decide what treatment you need. If he or she decides to refer you to a specialist, ask if you can see your current specialist. If your
current specialist does not participate with us, you must receive
treatment from a specialist who does. Generally, we will not pay for you to see a specialist who does not participate with our Plan.

If you are seeing a specialist and your specialist leaves the Plan, call your primary care physician, who will arrange for you to see
another specialist. You may receive services from your current
specialist until we can make arrangements for you to see someone else.

If you have a chronic or disabling condition and lose access to your specialist because we:
terminate our contract with your specialist for other than cause; or
drop out of the Federal Employees Health Benefits (FEHB)
Program and you enroll in another FEHB plan; or 14.
14 Page 15 16
2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 12 Section 3
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, 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 are in the hospital when your enrollment in our Plan begins, call
our Member Services department immediately at 301/ 468-6000 inside the Washington, DC metropolitan area or at 800/ 777-7902 outside the

Washington, DC metropolitan area. Our TTY telephone number is
301/ 879-6380.

If you are new to the FEHB Program, we will arrange for you to receive
care. If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:

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

whichever happens first.
These provisions apply only to the benefits of the hospitalized person.
Circumstances beyond our control Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them.
In that case, we will make all reasonable efforts to provide you with the necessary care.

Services requiring our prior approval Your primary care physician has authority to refer you for most services. For certain services, however, your physician must obtain
approval from us. Before giving approval, we consider if the service is covered, medically necessary, and follows generally accepted medical

practice.
We call this review and approval process precertification. Your physician must obtain precertification for the following services:

Acupuncture
All inpatient services, except maternity
Adenoids or tonsil removal
Breast surgery not associated with cancer
Carpal tunnel surgery
Chiropractic services
Clinical trials
Durable medical equipment
Gastric bypass surgery
Home health care
Hospice care 15.
15 Page 16 17
2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 13 Section 3
Hysterectomy
Infertility treatment
Infusion therapy
Injectable medications
MRI
Nasal surgery
Occupational therapy
Oral surgery
Organ transplants
Pain clinics
Physical therapy
Pulmonary therapy
Prosthetics
Reconstructive surgery
Sclerotherapy for varicose veins
Speech therapy
Spinal surgery not associated with cancer
Sleep studies
Surgical procedures
Temporomandibular Joint surgery
Tubes in the ears

Requests for these services are made to your primary care physician just like any other referral. Your primary care physician submits the
request, with supporting documentation. It takes an average of 2 working days to process the request. You should call your primary care
physician's office if you have not been notified of the outcome of the
review within 5 working days. If your request is not approved, you have a right to appeal by calling inside the Washington, DC

Metropolitan area at 301/ 468-6000 or toll free at 800/ 777-7902. Our
TTY is 301/ 879-6380. After business hours, for urgent situations, you may call Appointments/ Advice to request an appeal at 703/ 359-7878,

800/ 777-7904, TTY is 301/ 879-7616 or 800/ 700-4901. If you wish
additional services, you must make the request to your primary care physician.

Emergency services do not require precertification. However, you or your family member must notify the Plan within 48 hours, or as soon as
reasonably possible. 16.
16 Page 17 18
2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 14 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay to the provider, facility,
pharmacy, etc., when you receive services. Example: When you see your primary care physician, you pay a copayment of $10 per office visit.

Deductible We do not have a deductible.
Coinsurance Coinsurance is the percentage of our allowance that you must pay for certain services you receive. Example: In our Plan, you pay 50% of our
allowance for infertility services, ovulation stimulants, weight management
drugs, smoking cessation drugs, and oxygen and equipment for home use after the first three months.

Fees when you fail to If you do not pay your copayment or coinsurance at the time you receive make your copayment services, we will bill you. You will be required to pay a $10 charge for
or coinsurance each bill sent for unpaid services.

Your catastrophic protection After your copayments and coinsurance total $1,500 per person or $3,000 out-of-pocket maximum for per family enrollment in any calendar year, you do not have to pay any
copayments and coinsurance more for covered services. However, copayments for the following services do not count toward your catastrophic protection out-of-pocket
maximum, and you must continue to pay copayments and coinsurance for these services:

Prescription drugs
Chiropractic and acupuncture services
Dental services
Follow-up and continuing care outside the service area
Infertility services
Any non-FEHB benefits

Be sure to keep accurate records of your copayments and coinsurance since you are responsible for informing us when you reach the maximum. 17.
17 Page 18 19
2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 15 Section 5
Section 5. Benefits OVERVIEW
(See page 9 for how our benefits changed this year and page 76 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, claim filing advice, or more information about our benefits, contact us at
301/ 468-6000 inside the Washington, DC metropolitan area or at 800/ 777-7902 outside the Washington, DC metropolitan area. Our TTY telephone number is 301/ 879-6380. You can also visit our website at

www. kaiserpermanente. org.
(a) Medical services and supplies provided by physicians and other health care professionals ............................... 16-27

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 ........................... 28-31

Surgical procedures
Reconstructive surgery
Oral and maxillofacial surgery
Organ/ tissue transplants
Anesthesia

(c) Services provided by a hospital or other facility, and ambulance services ............................................................ 32-35
Inpatient hospital
Outpatient hospital or ambulatory surgical center
Extended care benefits/ skilled nursing care facility benefits

Hospice care
Ambulance (d) Emergency services/ accidents ..................................................................................................... 36-37

Emergency within our service area
Emergency outside our service area
Ambulance

(e) Mental health and substance abuse benefits ................................................................................................................ 38-40
(f) Prescription drug benefits ............................................................................................................................................... 41-44
(g) Special features ................................................................................................................................................................. 45-47

Flexible benefits option
24 hour nurse line
Services for the deaf and hearing impaired

Centers of Excellence
Travel benefit
Services from other Kaiser Permanente Plans

(h) Dental benefits .................................................................................................................................................................. 48-56

(i) Non-FEHB benefits available to Plan members................................................................................................................ 57

Summary of benefits ...................................................................................................................................................................... 76 18.
18 Page 19 20
2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 16 Section 5( a)
Section 5 (a). Medical services and supplies provided by physicians and other health care professionals
I M
P O
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A N
T

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

Plan physicians must provide or arrange your care.
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. Different copayments apply for primary care visits
and specialty care visits. Please refer to Section 10, Definitions, to learn more about when your primary and specialty care copayments will apply.

We have no calendar year deductible.

I M
P O
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A N
T

Benefit Description You Pay
Diagnostic and treatment services
Professional services of physicians and other health care professionals
In a physician's office
In an urgent care center
Second surgical opinion

$10 per visit to your primary care
provider (except nothing for children from infancy through age 4)

$20 per visit to a specialist

During a hospital stay
In a skilled nursing facility
Note: See Section 5 (c) for facility charges.

Nothing

At home (in the service area) Nothing
Lab, X-ray, and other diagnostic tests
Tests, such as:
Blood tests
Urinalysis
Non-routine pap smears
Pathology
X-rays
Non-routine mammograms
CAT scans/ MRI
Ultrasound
Electrocardiogram and EEG

Nothing 19.
19 Page 20 21
2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 17 Section 5( a)
Preventive care, adult You Pay
Routine screenings, such as:
Total blood cholesterol
Colorectal cancer screening, including
Fecal occult blood test
Sigmoidoscopy -every five years starting at age 50

$10 per visit to your primary care provider
$20 per visit to a specialist

Bone mass measurement for prevention, diagnosis and treatment of
osteoporosis

Routine Prostate Specific Antigen (PSA) test-one annually for men age 40 and older

Chlamydia screenings women under age 20 who are sexually active and women over age 20 with multiple risk factors
Routine pap smear
Travel Consultations
Note: You should consult with your physician to determine what is appropriate for you.

Routine immunizations, limited to:
Tetanus-diphtheria (Td) booster -once every 10 years, ages 19 and over (except as provided for under Childhood immunizations)

Influenza/ Pneumococcal vaccines, annually, age 65 and over
Travel immunizations and vaccines
Note: You pay only one copayment if you receive your routine screening or immunization on the same day as your office visit.

Routine mammogram Covered for women age 35 and older, as follows:
From age 35 to 39, one during this five-year period
From age 40 to 64, one every calendar year
At age 65 and older, one every two consecutive calendar years

Nothing

Not covered:
Physical exams required for:
Obtaining or continuing employment
Participating in employee programs
Insurance or licensing
Court ordered for parole or probation
Attending schools

All charges 20.
20 Page 21 22
2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 18 Section 5( a)
Preventive care, children You Pay
Childhood immunizations recommended by the American Academy of Pediatrics

Examinations, such as:
Eye exams to determine the need for vision correction
Ear exams to determine the need for hearing correction

Travel Consultations
Travel immunizations and vaccines

Nothing for primary care office visits for infancy through age 4
$10 per visit to your primary care provider from age 5 up to age 22

Not covered:
Physical exams required for:
Obtaining or continuing employment
Participating in employee programs
Insurance or licensing
Court ordered for parole or probation
Attending schools

All charges

Maternity care
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Note: Here are some things to keep in mind:
You do not need to precertify your normal delivery.
You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. Your inpatient stay

will be extended if medically necessary.
We cover routine nursery care of the newborn child during the covered portion of the mother's maternity stay. We cover other care

of an infant who requires non-routine treatment only if the infant is covered under a Self and Family enrollment.

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

$10 for the first office visit to confirm pregnancy
Nothing once pregnancy is
confirmed through the post-partum office visit

Not covered:
Routine sonograms to determine fetal age, size, or sex
All charges 21.
21 Page 22 23
2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 19 Section 5( a)
Family planning You Pay
Family planning services, including counseling
Voluntary sterilization (See Surgical procedures Section 5 (b))
Information on birth control
Genetic counseling
Note: We cover surgically implanted time-release contraceptive drugs, injectable contraceptive drugs, intrauterine devices (IUDs), and

diaphragms under the prescription drug benefit.

$10 per visit to your primary care provider
$20 per visit to a specialist

Not covered:
Reversal of voluntary surgical sterilization
All charges

Infertility services
Diagnosis and treatment of involuntary infertility
Artificial insemination
intravaginal insemination (IVI)
intra-cervical insemination (ICI)
intrauterine insemination (IUI)

Fertility Drugs
Note: We cover injectable fertility drugs under the prescription drug benefit.

50% of our allowance

In vitro fertilization, (limited to three (3) attempts per live birth) if:
your oocytes are fertilized with your spouse's sperm;
you and your spouse have a history of infertility of at least 2 years duration; or

the infertility is associated with endometriosis, exposure in utero to diethylstilbestrol, commonly known as DES, blockage
of, or surgical removal of, one or both fallopian tubes (lateral or bilateral salpingectomy, or abnormal male factors, including
oligospermia, contributing to the infertility;
you have been unable to become pregnant through a less costly
infertility treatment for which coverage is available under the Plan

50% of our allowance; Plan pays up to $100,000 in a Member's lifetime

Infertility services continued on next page 22.
22 Page 23 24
2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 20 Section 5( a)
Infertility services (continued) You Pay
Not covered:
These exclusions apply to fertile as well as infertile individuals or couples:

Assisted reproductive technology (ART) procedures, such as:
gamete intrafallopian transfer (GIFT)
zygote intrafallopian transfer (ZIFT)
Donor semen and donor eggs, including retrieval of eggs
Storage and freezing of eggs
Note: Infertility services are not available when either member of the family has been voluntarily surgically sterilized.

All charges

Allergy care
Testing and treatment
Allergy injection
Note: Allergy serum is covered in full as a part of the office visit copayment.

$10 per visit to your primary care
provider

$20 per visit to a specialist

Not covered:
Provocative food testing
Sublingual allergy desensitization

All charges

Treatment therapies
Respiratory and inhalation therapy
Intravenous/ Infusion Therapy
Note: We cover growth hormone therapy (GHT) under the prescription drug benefit.

Qualified medical clinical trials that provide treatment for life-threatening conditions or for preventive, early detection, or treatment
studies of cancer for Phases I, II, III and IV
Dialysis Hemodialysis and peritoneal dialysis
Chemotherapy and radiation therapy

Note: We limit high dose chemotherapy in association with autologous
bone marrow transplants to those transplants listed under Organ/ tissue transplants.

$10 per visit to your primary care provider
$20 per visit to a specialist

Treatment therapies continued on next page 23.
23 Page 24 25
2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 21 Section 5( a)
Treatment therapies (continued) You Pay
Not covered:
Long term rehabilitative therapy
Cognitive therapy
Chemotherapy supported by a bone marrow transplant or with stem cell support, for any diagnosis not listed as covered

Sleep therapy
Thermography and related services

All charges

Physical and occupational therapies
Inpatient Services up to 2 consecutive months of therapy per condition:

Physical therapy by a qualified Plan therapist in consultation with a Plan physician to restore bodily function when you have a total or
partial loss of bodily function due to illness or injury
Occupational therapy by a Plan therapist in consultation with a Plan physician to assist you in achieving and maintaining self-care and

improved functioning in other activities of daily life
We provide inpatient multidisciplinary rehabilitation in a prescribed,
organized program in a plan facility or skilled nursing facility for up to two consecutive months for all covered rehabilitation services and

supplies you may receive at different sites for the same condition
Note: This $100 charge is waived if you have been admitted directly
from a hospital inpatient stay.

$100 per admission

Outpatient physical and occupational therapy
We cover up to 30 office visits or 60 days (whichever is greater) per condition of out-patient physical therapy services

We cover up to 90 days per condition of out-patient occupational therapy services
Habilitative services for children from birth to age 19 for the treatment of congenital and generic birth defects
We cover services to help a child function age-appropriately within
his or her environment and enhance his or her functional ability without an effective cure

$10 per visit to your primary care provider
$20 per visit to a specialist

Not covered:
Long-term rehabilitative therapy
Exercise programs
Cognitive rehabilitation programs
Vocational rehabilitation programs
Therapies done primarily for education purposes, except as may otherwise be covered above

Cardiac rehabilitation

All charges 24.
24 Page 25 26
2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 22 Section 5( a)
Speech therapy You pay
Inpatient Services up to 2 consecutive months of therapy per condition:

Speech therapy by a Plan therapist in consultation with a Plan physician when medically necessary
Note: This $100 charge is waived if you have been admitted directly from a hospital inpatient stay.

$100 per admission

Outpatient Services up to 90 days per condition per year of outpatient
speech therapy

Habilitative services for children from birth to age 19 for the treatment of congenital and generic birth defects

We cover services to help a child function age-appropriately within his or her environment and enhance his or her functional ability
without an effective cure

$10 per visit to your primary care provider
$20 per visit to a specialist

Not covered:
Speech therapy that is not medically necessary such as:
Therapy for educational placement or other educational purposes
Training or therapy to improve articulation in the absence of injury, illness, or medical condition affecting articulation

Therapy for tongue thrust in the absence of swallowing problems
Voice therapy for occupation or performing arts

All charges

Hearing services (testing, treatment, and supplies)
Hearing tests to determine the need for hearing correction $10 per visit to your primary care provider

$20 per visit to a specialist
Hearing aids for children under age 18 All charges in excess of $1400 for each hearing impaired ear every 36
months

Not covered:
Hearing aids, tests to determine their effectiveness, and examinations for them for all persons age 18 and over

All other hearing testing

All charges

Vision services (testing, treatment, and supplies)
Eye exam to determine the need for vision correction
Eye refractions
Diagnosis and treatment of diseases of the eye

$10 per visit to your primary care
provider

$20 per visit to a specialist

Vision services (testing, treatment, and supplies) continued on next page 25.
25 Page 26 27
2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 23 Section 5( a)
Vision services (testing, treatment, and supplies) (continued) You Pay
Eyeglass frames purchased at Plan Optical Shops
Eyeglass lenses purchased at Plan Optical Shops
75% of our allowance

Initial fitting for contact lenses at a Plan facility
Insertion and removal of contact lens training
Three months of follow-up office visits
Note: These services are provided only in conjunction with obtaining
your first set of contact lenses at a Plan Optical Shop.

85% of our allowance

Not covered:
Eye exercises and orthoptics
Radial keratotomy and other refractive surgery
Eye surgery solely for the purpose of correcting refractive defects of the eye, such as near-sightedness (myopia), far-sightedness

(hyperopia), and astigmatism
Cosmetic contact lenses
Cost of eyewear not purchased at Plan facilities
Sunglasses without corrective lenses

All charges

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

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

$10 per visit to your primary care
provider

$20 per visit to a specialist

Not covered:
Cutting, trimming, or removal of corns, calluses, or the free edge of
toenails, and similar routine treatment for 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
Externally worn breast prostheses and surgical bras including necessary replacements following a mastectomy

Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implants
following mastectomy. Note: See Section 5( b) for coverage of the
surgery to insert the device.

20% of our allowance

Orthopedic and prosthetic devices continued on next page 26.
26 Page 27 28
2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 24 Section 5( a)
Orthopedic and prosthetic devices (continued) You Pay
One hair prosthesis if your hair loss results from chemotherapy or radiation treatment for cancer All charges in excess of $350

Not covered:
Comfort, convenience, or luxury equipment or features
External prosthetics and orthotics, such as braces, foot orthotics, artificial limbs, and lenses following cataract removal

Devices, equipment, supplies, and prosthetics related to sexual dysfunction
Orthopedic and corrective shoes
Arch supports
Foot orthotics
Heel pads and heel cups
Lumbosacral supports
Corsets, trusses, elastic stockings, support hose and other supportive devices

All charges

Durable medical equipment (DME)
We cover prescribed DME for home use for up to three months from the date of discharge following:

An authorized hospital admission
An authorized skilled nursing facility admission
An authorized rehabilitation facility admission
An authorized outpatient surgical procedure
Covered items include:
Hospital beds
Wheelchairs
Canes
Walkers
Portable commodes
Crutches
Insulin pumps and supplies

Bilirubin lights and apnea monitors for infants up to age 3 for a period not to exceed 6 months

20% of our allowance

Durable medical equipment (DME) continued on next page 27.
27 Page 28 29
2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 25 Section 5( a)
Durable medical equipment (DME) (continued) You Pay
Continuous Positive Airway Pressure (CPAP) equipment
Oxygen and equipment for home use
Note: Your Plan physician must recertify your medical need for oxygen and equipment every 30 days.

20% of our allowance for the first three months; 50% of our allowance
for every 30 days thereafter

Asthmatic equipment (spacers, peak-flow meters, and nebulizers) for adults and children, when purchased at a Plan pharmacy.
Note: We decide whether to rent or purchase the equipment, and we
select the vendor. We will repair the equipment without charge, unless the repair is due to loss or misuse. You must return the equipment to us

or pay us the fair market price of the equipment when it is no longer
prescribed.

Spacers: $5 per spacer
Peak-Flow Meters: $10 per meter
Nebulizers: $30 per nebulizer

Not covered:
Oxygen tents
Motorized wheelchairs
Comfort, convenience, or luxury equipment or features
Exercise or hygiene equipment
Non-medical items such as sauna baths or elevators
Modifications to your home or car
Devices for testing blood or other body substances (glucose test strips are covered under your prescription drug benefits)

Electronic monitors of bodily functions, except apnea monitors and blood glucose monitors
Disposable supplies
Replacement of lost equipment
Repairs, adjustments, or replacements necessitated by misuse
More than one piece of durable medical equipment serving
essentially the same function, except for replacements other than those necessitated by misuse or loss

Devices, equipment, supplies, and prosthetics for the treatment of sexual dysfunction disorders
External and internally implanted hearing aids for all persons age 18 and over
Experimental or research equipment
Dental appliances

All charges 28.
28 Page 29 30
2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 26 Section 5( a)
Home health services You Pay
If you are homebound and reside in the service area, we cover home health care ordered by a Plan physician and provided by a registered
nurse, licensed practical nurse, licensed vocational nurse, physical therapist, occupational therapist, speech and language pathologist, or
home health aide
Services include oxygen therapy, intravenous therapy, and medications

Note: Your Plan physician will periodically review the home health program for continuing appropriateness and medical need.

Nothing

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

Custodial care
Homemaker services
Services outside the service area
Home care primarily for personal assistance that does not include a
medical component and is not diagnostic, therapeutic, or rehabilitative

General maintenance care of colostomy, ileostomy, and ureterostomy
Medical supplies or dressings applied by you or a family caregiver
Care that a Plan physician determines may be provided in a Plan
facility or skilled nursing facility if we provide or offer to provide that care in one of those facilities

Transportation and delivery service costs of durable medical equipment, medications, drugs, medical supplies, and supplements to
the home
Personal care items

All charges

Chiropractic
Chiropractic services, including spinal manipulation of the neck and back, up to 20 visits per calendar year, for the following services:

Evaluation and management
Routine chiropractic x-rays provided in the chiropractor's office
Chiropractic adjustments
Adjunctive therapies (e. g., hot and cold packs)
Educational materials
Note: You receive these services when your Plan physician, in consultation
with the Complementary and Alternative Medicine Department, determines that such care will result in improvement in your condition.

$15 per office visit

Chiropractic continued on next page 29.
29 Page 30 31
2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 27 Section 5( a)
Chiropractic (continued) You Pay
Not covered:
Structural supports
Nutritional supplements

All charges

Alternative treatments
Acupuncture services up to 20 visits per calendar year, for the following services:

Evaluation and management
Note: You receive these services when your Plan physician, in
consultation with the Complementary and Alternative Medicine Department, determines that such care will result in improvement in

your condition.

$15 per office visit

Not covered:
Herbal and nutritional supplements
All charges

Educational classes and programs
Health education for conditions such as diabetes, post-coronary, and nutritional counseling $10 per visit to your primary care provider

$20 per visit to a specialist
General health education classes such as Lamaze, weight control, smoking cessation, and stress management. Nominal fees ranging from $10 to $50 per class

Not covered:
Educational classes and programs not offered through this Plan
All charges 30.
30 Page 31 32
2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 28 Section 5( b)
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
I M
P O
R T
A N
T

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

necessary.
Plan physicians must provide or arrange your care.
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.
We have no calendar year deductible.
The amounts listed below are for the charges billed by a physician or other health care
professional for your surgical care. Look in Section 5( c) for charges associated with the facility (i. e. hospital, surgical center, etc.).

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

precertification.

I M
P O
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A N
T

Benefit Description You Pay
Surgical procedures
A comprehensive range of services, such as:
Operative procedures
Treatment of fractures, including casting
Normal pre-and post-operative care by the surgeon
Pre-surgical testing
Correction of amblyopia and strabismus
Endoscopy procedures
Biopsy procedures
Removal of tumors and cysts
Correction of congenital anomalies (see reconstructive surgery)
Surgical treatment of morbid obesity --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.

Voluntary sterilization (e. g., Tubal ligation, Vasectomy)
Treatment of burns
Insertion of surgically implanted time-release contraceptive drugs and intrauterine devices (IUDs). Note: We cover the cost of these devices

under the prescription drug benefit (see Section 5( f))
Insertion of other implanted time-release drugs. Note: We cover the cost of these devices under the prescription drug benefit (see Section
5( f)).

$20 per visit to a specialist,
$50 per outpatient surgery, or
$100 per inpatient admission

Surgical procedures continued on next page 31.
31 Page 32 33
2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 29 Section 5( b)
Surgical procedures (continued) You Pay
Not covered:
Reversal of voluntary sterilization
Routine foot care; see Foot care

All charges

Reconstructive surgery
Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if:
it 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, web fingers, and toes.

All stages of breast reconstruction surgery following a mastectomy, such as:
surgery to produce a symmetrical appearance on the other breast;
treatment of any physical complications, such as lymphedemas; and
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.

$20 per visit to a specialist,
$50 per outpatient surgery, or
$100 per inpatient admission

Not covered:
Cosmetic surgery any surgical procedure (or any portion of a
procedure) performed primarily to improve physical appearance and/ or treat a mental condition through change in bodily form

Surgeries related to sex transformation

All charges 32.
32 Page 33 34
2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 30 Section 5( b)
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, cleft palate, or severe functional malocclusion

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

$20 per visit to a specialist,
$50 per outpatient surgery, or

$100 per inpatient admission

Not covered:
Oral implants and transplants
Procedures that involve the teeth or their supporting structures
(such as the periodontal membrane, gingiva, and alveolar bone) except as covered under the accidental dental benefit.

Shortening of the mandible or maxillae for cosmetic purposes and correction of malocclusion.

All charges

Organ/ tissue transplants
Limited to:
Cornea
Heart
Heart/ Lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single -Double
Pancreas
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, testicular, mediastinal, retroperitoneal and ovarian germ cell tumors, breast cancer, multiple myeloma and epithelial

ovarian cancer

$20 per visit to a specialist,
$50 per outpatient surgery, or
$100 per inpatient admission

Organ/ tissue transplants continued on next page 33.
33 Page 34 35
2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 31 Section 5( b)
Organ/ tissue transplants (continued) You Pay
Intestinal transplants (small intestine) and the small intestine with the liver or small intestine with multiple organs such as the liver,
stomach, and pancreas
After referral to a transplant facility, the following apply: unless otherwise
authorized by your physician, transplants are covered only at institutions that we designate as "Centers of Excellence" for that specific transplant. If

your physician or the transplant facility determines that you do not satisfy
the criteria for receiving the transplant, we will pay only for the covered services and supplies you receive before you are notified of that

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

medical director in accordance with the Plan's protocols.
Note: We cover related medical and hospital expenses for a living donor
when those expenses are directly related to your covered transplant.

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

Implants of non-human or artificial organs
Transplants not listed as covered

All charges

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

Nothing 34.
34 Page 35 36
2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 32 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
I M
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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.

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

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about

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

associated with the professional charge (i. e., physicians, etc.) are covered in Sections 5( a) or (b).

YOUR PHYSICIAN MUST GET PRECERTIFICATION OF HOSPITAL
STAYS (except for Maternity stays). Please refer to Section 3 to be sure which services require precertification.

I M
P O
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A N
T

Benefit Description You Pay
Inpatient hospital
Room and board, such as:
Ward, semiprivate, or intensive care accommodations
General nursing care
Medically necessary special duty nursing
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.

$100 per admission

Inpatient hospital continued on next page 35.
35 Page 36 37
2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 33 Section 5( c)
Inpatient hospital (continued) You Pay
Other hospital services and supplies, such as:
Operating, recovery, maternity, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology services
Procurement and storage for approved medically necessary cord blood for a designated recipient

Administration of blood and blood products
Blood or blood plasma, if donated or replaced
Dressings, splints, plaster casts, and sterile tray services
Medical supplies and equipment, including oxygen
Anesthetics and anesthesia services
Take home items
Hospitalization for inpatient foot treatment
Note: You may receive covered medical hospital services for certain dental procedures if a Plan physician determines that you need to be

hospitalized for reasons unrelated to the dental procedure. The conditions for which we will provide hospitalization include hemophilia
and heart disease. The need for anesthesia, by itself, is not such a condition.

$100 per admission

Not covered:
Custodial care
Non-covered facilities
Personal comfort items, such as telephone, television, barber services, guest meals, and beds

Private nursing care
Whole blood and packed red blood cells not replaced by member
Procurement and storage for possible future need or for yet to be determined Member recipient

Any inpatient dental procedures

All charges

Outpatient hospital or ambulatory surgical center
Operating, recovery, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology services
Procurement and storage of cord blood for approved medically necessary procedures requiring cord blood for a designated recipient

Administration of blood and blood products
Blood and blood plasma, if donated or replaced
Pre-surgical testing
Dressings, casts, and sterile tray services
Medical supplies, including oxygen
Anesthetics and anesthesia service

$50 per outpatient surgery

Outpatient hospital or ambulatory surgical center continued on next page 36.
36 Page 37 38
2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 34 Section 5( c)
Outpatient hospital or ambulatory surgical center (continued) You Pay
Not covered:
Whole blood and packed red blood cells not replaced by the member
Procurement and storage for possible future need or for yet to be determined Member recipient

All charges

Extended care benefits/ skilled nursing care facility benefits
Up to 100 days per calendar year when full-time skilled nursing care is necessary and confinement in a skilled nursing facility is medically
appropriate. We cover the following:
Physician and nursing services
Room and board
Medical social services
Administration of blood, blood products, and derivatives
Durable medical equipment ordinarily furnished by a skilled nursing facility, including oxygen-dispensing equipment and oxygen

Respiratory therapy
Biological supplies
Medical supplies

Note: We waive the additional $100 charge if you are admitted to an extended care or skilled nursing facility directly from a hospital inpatient
stay.

$100 per admission

Not covered:
Custodial care
Care in an intermediate facility

All charges 37.
37 Page 38 39
2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 35 Section 5( c)
Hospice care You Pay
Supportive and palliative care for a terminally ill member
You must reside in the service area
Services are provided in your home, or
Services are provided in a Plan approved hospice facility
Services include inpatient care, outpatient care, and family counseling. A
Plan physician must certify that you have a terminal illness, with a life expectancy of approximately six months or less.

Note: Hospice is a program for caring for the terminally ill that emphasizes supportive services, such as home care and pain
control, rather than curative care of the terminal illness. A person who is terminally ill may elect to receive hospice benefits. These
palliative and supportive services include nursing care, medical
social services, physician services, and short-term inpatient care
for pain control and acute and chronic symptom management. We also provide counseling and bereavement services for the

individual and family members, and therapy for purposes of symptom control to enable the person to continue life with as little
disruption as possible. If you make a hospice election, you are not
entitled to receive other health care services that are related to the terminal illness. If you have made a hospice election, you may

revoke that election at any time, and your standard health benefits
will be covered.

Nothing

Not covered
Independent nursing

Homemaker services

All charges

Ambulance
Local professional ambulance service when medically appropriate Nothing 38.
38 Page 39 40
2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 36 Section 5( d)
Section 5 (d). Emergency services/ accidents
I M
P O
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A N
T

Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and we cover them 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
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A N
T

What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your
life or could result in serious injury or disability, and requires immediate medical or surgical care. Some 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:
In a life threatening emergency-call the local emergency system (e. g., the local 911 telephone system). When the operator answers, stay on the phone and answer all questions. If you are not sure whether you are experiencing a

medical emergency, please contact our Emergency Line at 800/ 677-1112.
Emergencies within our service area:
Emergency care is provided at Plan Hospitals 24 hours a day, seven days a week.

If you think you have a medical emergency condition and you cannot safely go to a Plan Hospital, call 911 or go to
the nearest hospital. Be sure to tell the emergency room personnel that you are a Plan member so they can notify the Plan. You or a family member must notify us within 48 hours, or as soon as is reasonably possible, by calling

703/ 359-7878 inside the Washington, DC metropolitan area or toll free 800/ 777-7904. Our TTY is 800/ 700-4901.
If you need to be hospitalized, the Plan must be notified within 48 hours or on the first working day following your admission, unless it was not reasonably possible to notify us within that time. If you are hospitalized in non-Plan

facilities and Plan physicians believe care can be better provided in a Plan Hospital, we will transfer you when
medically feasible, with any ambulance charges covered in full.

Benefits are available for care from non-Plan providers in a medical emergency only if delay in reaching a Plan provider would result in death, disability or significant jeopardy to your condition.

Emergencies outside our service area:
Benefits are available for any medically necessary health service that is immediately required because of injury or unforeseen illness.

If you need to be hospitalized, the Plan must be notified within 48 hours or as soon as is reasonably possible. If a Plan physician believes care can be better provided in a Plan Hospital, we will transfer you when medically feasible, with any
ambulance charges covered in full.
You may obtain emergency and urgent care services from Kaiser Permanente medical facilities and providers when
you are in the service area of another Kaiser Permanente plan. The facilities will be listed in the local telephone book under Kaiser Permanente. These numbers are available 24 hours a day, seven days a week. You may also

obtain information about the location of facilities by calling the Membership Services department at 301/ 468-6000
inside the Washington, DC metropolitan area or at 800/ 777-7902 outside the Washington, DC metropolitan area. Our TTY telephone number is 301/ 879-6380. 39.
39 Page 40 41
2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 37 Section 5( d)
Benefit Description You Pay
Emergency within our service area
Emergency care at a physician's office
Emergency care at a Plan urgent care center
$10 per visit to your primary care provider

$20 per visit to a specialist
Emergency care in a hospital emergency room
Note: Your hospital emergency room visit copayment is waived if you are admitted to a Plan Hospital. Your $100 inpatient copayment will

apply.

$50 per visit

Not covered:
Elective care or non-emergency care
All charges

Emergency outside our service area
Emergency care at a physician's office
Emergency care at an urgent care center
$10 per visit to your primary care provider

$20 per visit to a specialist
Emergency care in a Kaiser Foundation hospital in another Kaiser Foundation Health Plan service area

Emergency care in a non-Plan hospital emergency room
Note: We waive your hospital emergency room visit copayment if you are admitted to a Plan Hospital. Your $100 inpatient copayment will

apply. See the Travel Benefit for coverage of continuing or follow-up care.

$50 per visit

Not covered:
Elective care or non-emergency care
Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area

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

All charges

Ambulance
Professional ambulance service, including air ambulance, when approved by the Plan.

Note: See Section 5( c) for non-emergency ambulance service.
Nothing 40.
40 Page 41 42
2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 38 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
I M
P O
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A N
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 clinically appropriate to treat your condition.

Plan physicians must provide or arrange your care.
We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other

coverage, including with Medicare.

I M
P O
R T
A N
T

Benefit Description You Pay
Mental health and substance abuse benefits
We cover all diagnostic and treatment services recommended by a Plan provider and contained in a treatment plan. The treatment plan may
include services, drugs, and supplies described elsewhere in this brochure.

Note: We cover the services only when we determine that the care is clinically appropriate to treat your condition, and only when you receive
the care as part of a treatment plan developed by a Plan provider.
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 in favor of

another.

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

Mental health and substance abuse benefits continued on next page 41.
41 Page 42 43
2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 39 Section 5( e)
Mental health and substance abuse benefits (continued) You pay
Diagnosis and treatment of psychiatric conditions, mental illness, or disorders of children, adolescents, and adults. Outpatient services
include:
Diagnostic evaluation
Crisis intervention and stabilization for acute episodes
Psychological testing necessary to determine the appropriate psychiatric treatment

Outpatient psychiatric treatment (including individual and group therapy visits)
Medication evaluation and management

Diagnosis and treatment of alcoholism and drug abuse. Services include:
Detoxification (medical management of withdrawal from the substance)

Treatment and counseling (including individual and group therapy visits) as part of intensive outpatient programs
Intensive day treatment
Methadone treatment
Note: You may see a Plan provider for outpatient treatment without a referral from your primary care physician.

Note: Your Plan provider will develop a treatment plan to assist you in improving or maintaining your condition and functional level, or to
prevent relapse and will determine which diagnostic and treatment services are appropriate for you.

$10 per visit to your primary care provider
$20 per visit to a specialist

Inpatient psychiatric care
Inpatient detoxification
Acute inpatient substance abuse rehabilitation
Note: All inpatient admissions and hospital alternative services treatment programs require approval by a Plan physician. Inpatient services will only

be part of a treatment plan when services cannot be provided safely on an outpatient basis or in a less intensive setting than an acute care hospital.

$100 per admission

Hospital alternative services: partial hospitalization, intensive outpatient
psychiatric treatment programs and residential crisis services
$20 per visit or $100 per
admission if your treatment is more than 24 continuous

hours
Mental health and substance abuse benefits continued on next page 42.
42 Page 43 44
2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 40 Section 5( e)
Mental health and substance abuse benefits (continued) You pay
Not covered:
Care that is not clinically appropriate for the treatment of your condition

Services we have not approved
Intelligence, IQ, aptitude ability, learning disabilities, or interest testing not necessary to determine the appropriate treatment of a psychiatric

condition
Evaluation or therapy on court order or as a condition of parole or probation, or otherwise required by the criminal justice system, unless

determined by a Plan physician to be medically necessary and appropriate

Services that are custodial in nature
Marital, family, or educational services
Services rendered or billed by a school or a member of its staff
Services provided under a federal, state, or local government program
Psychoanalysis or psychotherapy credited toward earning a degree or furtherance of education or training regardless of diagnosis or

symptoms that may be present

All charges

Limitation We may limit your benefits if you do not obtain a treatment plan. 43.
43 Page 44 45
2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 41 Section 5( f)
Section 5 (f). Prescription drug benefits
I M
P O
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A N
T

Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart beginning on page 43.

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

There are important features you should be aware of. These include:
Who can write your prescription. A Plan physician, authorized provider or licensed contracted dentist must write the prescription.

Where you can obtain them. You must fill the prescription at a Plan pharmacy, an affiliated network pharmacy, or by the Plan mail order delivery service for a maintenance medication. We will pay for prescriptions written by
a non-Plan physician and filled at a non-Plan pharmacy only when the prescription was given during a hospital
emergency room visit or an urgent care visit outside the service area.

We use a formulary. Our drug formulary is a list of prescribed drugs and accessories that have been approved by
our Pharmacy and Therapeutics Committee for our Members. Unless otherwise specified by your Plan physician or dentist, generic drugs may be used to fill prescriptions.

Our Pharmacy and Therapeutics Committee, which is comprised of Plan physicians, Plan providers, and our pharmacists, selects prescription drugs and accessories for the drug formulary based on a number of factors,
including safety and effectiveness as determined from a review of medical literature and research. In addition, the
Committee sets dispensing limitations in accord with therapeutic guidelines based on the medical literature and research. The Pharmacy and Therapeutics' Committee meets periodically to consider adding and removing

prescribed drugs and accessories on the formulary.
If you request a non-formulary drug when your physician feels there is an acceptable formulary alternative you will be responsible for the full cost of that drug.

However, if your Plan physician believes that a non-formulary drug best treats your medical condition; a formulary drug has been ineffective in the treatment of your medical condition; or a formulary drug causes or is
reasonably expected to cause a harmful reaction, then an exception process is available to your Plan physician. In that case, your standard brand or generic prescription drug copayment would apply.

If you would like information about whether a particular drug or accessory is included in our drug formulary, please visit us on line at www. kaiserpermanente. org, or call our Member Services Department at 301/ 468-6000
inside the Washington, DC metropolitan area or at 800/ 777-7902 outside the Washington, DC metropolitan area.
Our TTY telephone number is 301/ 879-6380.

These are the dispensing limitations. We provide up to a 60-day supply for one brand or generic copayment at a Plan or affiliated network pharmacy based upon (a) the prescribed quantity, (b) the standard manufacturer's
package size, and (c) specified dispensing limits. Maintenance medications may be obtained for up to a 90-day
supply for one brand or generic copayment when ordered through our Plan's mail order program. Injectable drugs that are self-administered and dispensed from the pharmacy are limited to a 30 day supply. 44.
44 Page 45 46
2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 42 Section 5( f)
Why use generic drugs? Kaiser Permanente providers have successfully included the use of generic drugs as part of patient care without compromising quality. Generic drugs offer a safe and economic way to meet your
medication needs. They are less expensive than brand name drugs -therefore you may reduce your out-of-pocket costs by choosing to use a generic drug. Generic drugs must contain the same active ingredients and be equivalent
in strength and dosage to the original brand name product. The U. S. Food and Drug Administration and also
Kaiser Permanente set criteria for the use of generic drugs to ensure that they meet the same standards of purity, strength and quality as brand-name drugs. They are expected to have the same therapeutic effect as the brand

name product. Not all drugs have a generic equivalent. If a generic drug is unavailable, the standard brand
copayment will apply.

When you have to file a claim. When you receive drugs from a Plan pharmacy, you do not have to file a claim.
For a covered out-of-area emergency, you will need to file a claim when you receive drugs from a non-Plan pharmacy. To file a claim, you should contact the Plan's Member Services Department at 301/ 468-6000 inside

the Washington, DC metropolitan area or at 800/ 777-7902 outside the Washington, DC metropolitan area and
obtain a claim form. Our TTY is 301/ 879-6380. A claim for reimbursement must be submitted to the Plan within 12 months after you purchased the prescribed drugs.

Prescription drug benefits begin on the next page 45.
45 Page 46 47
2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 43 Section 5( f)
Benefit Description You Pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan physician and obtained from a Plan pharmacy, an affiliated network
pharmacy or through our mail order program:
Drugs for which a physician's prescription is required by law
Insulin (up to six (6) vials)
Disposable needles and syringes for the administration of covered
medications

Contraceptive drugs
Intrauterine devices (IUDs) and diaphragms
Implanted time-release contraceptive drugs
Other implanted time-release drugs
Injectable contraceptive drugs
Self-injectable drugs, other than ovulation stimulants
Self-administered chemotherapeutic drugs and oral chemotherapeutic agents

Growth hormone therapy (GHT) -for treatment of children with
growth hormone deficiency

Note: Compounded preparations must contain at least one ingredient
requiring a prescription.

$10 per prescription or refill for generic drugs or $20 per
prescription or refill for brand-name
drugs if you get your prescription filled at a Plan

medical center pharmacy

$8 per prescription or refill for generic drugs or $18 per
prescription or refill for brand-name drugs if you get your prescription
filled through our mail order
delivery system

$20 per prescription or refill for
generic drugs or $40 per prescription or refill for brand-name

drugs if you get your prescription
filled at an affiliated network pharmacy

Post-surgical immunosuppressant outpatient drugs required as a result of a covered transplant
Intravenous fluids and medications for home use
Clinically administered chemotherapy drugs

Nothing

Amino acid modified products used to treat congenital errors of amino acid metabolism (PKU) 25% of our allowance
Diabetic supplies when purchased at a Plan pharmacy
Glucose meter $10 per meter
Replacement batteries
Control solutions
Lancets
Disposable needles and syringes (up to 3 boxes)
Glucose test strips (up to six (6) boxes of 50 count)

Note: Lancets, disposable needles and syringes, and glucose test strips are available by mail order or through Plan Pharmacies. Other diabetic

supplies in this section are available only at Plan pharmacies.

$5 per package
$8 per package
$8 per package
20% of our allowance
20% of our allowance

Covered medications and supplies continued on next page 46.
46 Page 47 48
2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 44 Section 5( f)
Covered medications and supplies (continued) You pay
Smoking cessation products are provided for one course of therapy per calendar year, when:

prescribed by Plan provider
you are in a formal smoking cessation program
Weight management drugs for morbid obesity
Drugs for covered infertility treatments
Drugs for sexual dysfunction
Note: Drugs to treat sexual dysfunction have dispensing limitations. Please contact the Plan for details.

50% of our allowance

Not covered:
Drugs obtained at either a non-Plan pharmacy or non-affiliated network pharmacy except for emergencies inside and outside the

service area
Drugs or supplies for cosmetic purposes
Vitamins and nutritional supplements that can be purchased without a prescription

Nonprescription drugs
Prescription drugs for which there is a nonprescription equivalent available

Medical supplies such as dressings and antiseptics
Drugs to enhance athletic performance
Drugs related to non-covered infertility services
Drugs for non-covered services
Dental prescriptions other than those prescribed for pain relief or antibiotics

Replacement prescriptions necessitated by theft, loss, or damage

All charges 47.
47 Page 48 49
2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 45 Section 5( g)
Section 5 (g). Special features
Feature Description

Flexible benefits option Under the flexible benefits option, we determine the most effective way to provide services.
We may identify medically appropriate alternatives to traditional care and coordinate other benefits as a less costly alternative benefit.

Alternative benefits are subject to our ongoing review.
By approving an alternative benefit, we cannot guarantee you will get it in the future.

The decision to offer an alternative benefit is solely ours, and we may withdraw it at any time and resume regular contract benefits.
Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process.

24 hour nurse line For any of your health concerns, 24 hours a day, 7 days a week, you may call 703/ 359/ 7878 inside the Washington, DC metropolitan area or
800/ 777-7904 outside the Washington, DC metropolitan area or call our TTY at 703/ 359-7616 or 800/ 700-4901 and talk with a registered nurse who

will discuss treatment options and answer your health questions.

Services for deaf and hearing impaired For any of your health concerns, 24 hours a day, 7 days a week, you may call 703/ 359-7616 inside the Washington, DC metropolitan area or 800/ 700-4901 outside the Washington, DC metropolitan area and talk with
a registered nurse who will discuss treatment options and answer your health questions.

During regular business hours Monday through Friday, you may contact our
Member Services Department with any questions concerning the Plan and how to obtain services by calling 301/ 879-6380.

Centers of Excellence The Centers of Excellence program began in Fall 1987. As new technologies proliferate and become the standard of care, Kaiser Permanente refers members to contracted "Centers of Excellence" for
certain specialized medical procedures.
We have developed a national contract network of Centers of Excellence for organ transplantation, which consists of medical facilities that have met
stringent criteria for quality care in specific procedures. A national clinical
and administrative team has developed guidelines for site selection, site visit protocol, volume and survival criteria for evaluation and selection of

facilities. The institutions have a record of positive outcomes and
exceptional standards of quality. 48.
48 Page 49 50
2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 46 Section 5( g)
Travel benefit Kaiser Permanente's travel benefits for Federal employees provide you with outpatient follow-up or continuing medical care when you are temporarily outside your home service area by more than 100 miles or
outside of any other Kaiser Permanente service area. These benefits are in addition to your emergency and urgent care benefits and include:

Outpatient follow-up care necessary to complete a course of treatment after a covered emergency. Services include removal of stitches, a
catheter, or a cast.
Outpatient continuing care for covered services for conditions diagnosed
and treated within the previous 90 days by a Kaiser Permanente health care provider or affiliated Plan provider. Services include dialysis and

prescription drug monitoring.
You pay $25 for each follow-up or continuing care office visit. This amount will be deducted from the payment we make to you.

Your benefit is limited to $1200 each calendar year.
For more information about this benefit you should contact the Plan's Member Services Department at 301/ 468-6000 inside the

Washington, DC metropolitan area or at 800/ 777-7902 outside the Washington, DC metropolitan area. Our TTY is 301/ 879-6380.

File claims as shown on page 59.
The following are not included in your travel benefits coverage:
Non-emergency hospitalization
Infertility treatments
Medical and hospital costs resulting from a normal full-term delivery of a baby outside the service area

Transplants
DME
Prescription drugs
Home health services 49.
49 Page 50 51
2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 47 Section 5( g)
Services from other Kaiser Permanente
plans

When you are visiting in the service area of another Kaiser Permanente plan, you are entitled to receive virtually all the benefits described in this
brochure (including our mail order prescription program) at any Kaiser
Permanente medical office or medical center. You must pay the charges or copayments imposed by the Kaiser Permanente Plan you are visiting, with

the exception of mail order prescriptions which are administered by your
home Plan. You will have to pay the charges imposed by the Plan you are visiting. If the Plan you are visiting has a benefit that is different from the

benefits of this Plan, you are not entitled to receive that benefit.

Some services covered by this Plan, such as artificial reproductive services and the services of specialized rehabilitation facilities, will not be available
in other Kaiser Permanente service areas. If a benefit is limited to a
specific number of visits or days, you are entitled to receive only the number of visits or days covered by the Plan in which you are enrolled.

If you are seeking routine, non-emergent, or non-urgent services, you
should call the Kaiser Permanente Membership Services Department in that service area and request an appointment. You may obtain routine follow-up

or continuing care from these Plans, even when you have obtained the
original services in the service area of this Plan. If you require emergency services as the result of unexpected or unforeseen illness that requires

immediate attention, you should go directly to the nearest Kaiser
Permanente facility to receive care.

At the time you register for services, you will be asked to pay the charges required by the local Plan.

If you plan to travel to an area with another Kaiser Permanente plan, and wish to obtain more information about the benefits available to you from
the Kaiser Permanente plan, please call Membership Services at 301/ 468-6000 inside the Washington, DC metropolitan area or at 800/ 777-7902
outside the Washington, DC metropolitan area. Our TTY is 301/ 879-6380. 50.
50 Page 51 52
2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 48 Section 5( h)
Section 5 (h). Dental benefits
I M
P O
R T
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T

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

Plan dentists must provide or arrange your care.
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 except as

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

coverage, including with Medicare.

I M
P O
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T

Dental Benefits You pay
Accidental injury benefit
We cover restorative services and supplies necessary to promptly repair (but not replace) your sound
natural teeth that you have injured as the result of an
external force (not chewing). A sound natural tooth is one that has not been weakened by existing dental

pathology such as, decay or periodontal disease, or
previously restored with a crown, inlay, onlay or porcelain restoration, or treatment by endodontics.

Note: You must start to receive services within 60
days of your accident and complete them within 12 months of your accident. You are only covered for the

most cost effective procedure that will produce a
satisfactory result.

$10 per visit to your primary care provider
$20 per visit to a specialist
All charges in excess of $2,000 per member per
accident

Not covered:
Injuries to non-sound natural teeth
Services required after the 12-month period

Services that are needed, but did not start until later than 60 days after the accident

Services for teeth that have been so severely damaged that restoration is impossible, in the
opinion of the Plan dental provider
Services for teeth that have been knocked-out

All charges 51.
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2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 49 Section 5( h)
Other dental benefits You pay
We cover general anesthesia and associated hospital or ambulatory surgery facility charges in conjunction with
dental care provided by a fully accredited specialist in pediatric dentistry, fully accredited specialist in oral and
maxillofacial surgery, or a dentist for whom hospital privileges has been granted, for the following members:

Children, 7 years of age or younger, who are developmentally disabled, for whom a successful
result cannot be expected from dental care provided
under local anesthesia because of a physical, intellectual, or other medically compromising

condition, for whom a superior result can be expected from dental care provided under general anesthesia

Children, 17 years of age or younger, and extremely
uncooperative, fearful, or uncommunicative with dental needs of such magnitude that treatment should

not be delayed or deferred; and whom a lack of
treatment can be expected to result in oral pain, infection, loss of teeth, or other increased oral or

dental morbidity
Adults, age 17 and older, whose medical condition
requires that dental service be performed in a hospital or ambulatory surgical center for their

safety (e. g., heart disease and hemophilia)

$100 per inpatient admission
$10 per visit to your primary care provider
$20 per visit to a specialist
$50 per outpatient surgery

Not covered:
The dentist's or specialist's professional services
Dental care for temporal mandibular joint (TMJ) disorders

All charges 52.
52 Page 53 54
2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 50 Section 5( h)
Discounted Fee -Dental Benefits
Kaiser Permanente has entered into an Agreement with Dental Benefit Providers, Inc. (" DBP"), under which DBP will provide or arrange for the administration of covered dental services to you through Participating Dental Providers.

All procedures listed in the following schedule of dental services and fees are covered dental services. When you
receive any of the listed procedures from a Participating Dental Provider, you will pay the fee listed next to the procedure description for that service. The Participating Dental Provider has agreed to accept that fee as payment in

full for that procedure. Neither Kaiser Permanente nor DBP are liable for payment of these fees or for any fees incurred as the result of receipt of non-covered dental services.

You will pay a fixed rate of $30 per office visit for procedures with an "FC30" fee indication in the schedule below. We waive the $5 sterilization fee for any office visit in which FC30 applies. "NB" indicates there is no benefit
available and you must pay the full cost of these services.
You may select a Participating Dental Provider, who is a "general dentist," from whom you will receive covered dental services. With a large network of general dentists in our service area, you may select a general dentist from our

Dental Provider Directory for yourself and your family. You can obtain a Dental Provider Directory by calling our Member Services Department at 301/ 468-6000 inside the Washington, DC metropolitan area or at 800/ 777-7902
outside the Washington, DC metropolitan area. Our TTY is 301/ 879-6380.
Specialty care is also available should further covered services be necessary; however, you must be referred to a
Participating Dental Provider who is a specialist by your general dentist. Your discounted fees are slightly higher for care received by a Participating Dental Provider who is a specialist. Please refer to the following schedule of dental

services and fees for those discounted fees.
When a dental emergency occurs outside our service area, Kaiser Permanente will reimburse you for the reasonable
charges, less any discounted fee, upon proof of payment, not to exceed $50 per incident. We cover emergency dental treatment required to alleviate pain, bleeding, or swelling. If post-emergency care is required, you must receive all

post-emergency care from your Participating Dental Provider.

The schedule for dental services and fees are:
Dental Benefits You Pay
ADA
CODE PROCEDURE NAME
TO
DENTIST
TO
SPECIALIST
Diagnostic Services
00120 Periodic Oral Exam (every 6 months) FC30 NB
00140 Ltd Oral Evaluation Problem Focused FC30 NB
00150 Comprehensive Oral Examination FC30 NB
00210 Intraoral-Complete Series Including Bitewings 34 37
00220 Intraoral-Periapical-First Film FC30 9
00230 Intraoral-Periapical-Each Additional Film FC30 9
00240 Intraoral Occlusal Film FC30 9
00270 Bitewing-Single Film FC30 9
00272 Bitewing-Two Films FC30 9
00273 Bitewing Three Films FC30 16
00274 Bitewing Four Films FC30 25
00330 Panoramic Film 28 31
00460 Pulp Vitality Tests FC30 16
00470 Diagnostic Casts FC30 NB
Preventive Services
01110 Prophylaxis Adults (Every six months) FC30 NB
01120 Prophylaxis Child (Every six months) FC30 NB
01201 Topical Fluoride Incl Proph <16 yrs every 6 mos FC30 NB
01203 Topical Fluoride Excl Proph <16 yrs every 6 mos FC30 NB 53.
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2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 51 Section 5( h)
Dental Benefits You Pay
ADA CODE PROCEDURE NAME TO DENTIST TO SPECIALIST

01330 Oral Hygiene Instruction FC30 NB
01351 Sealant Per Tooth To age 16 17 NB
01510 Space Maintainer Fixed Unilateral 184 NB
01515 Space Maintainer Fixed Bilateral 184 NB
01520 Space Maintainer Removable Unilateral 226 NB
01525 Space Maintainer Removable Bilateral 141 NB
01550 Recementation of Space Maintainer 21 NB
Restorative Services
02110 Amalgam One Surface Primary 27 NB
02120 Amalgam Two Surfaces Primary 35 NB
02130 Amalgam Three Surfaces Primary 39 NB
02131 Amalgam Four or More Surfaces Primary 50 NB
02140 Amalgam One Surface Permanent 30 NB
02150 Amalgam Two Surfaces Permanent 41 NB
02160 Amalgam Three Surface Permanent 51 NB
02161 Amalgam Four or More Surfaces Permanent 60 NB
02330 Resin One Surface Anterior 37 NB
02331 Resin Two Surfaces Anterior 51 NB
02332 Resin Three Surfaces Anterior 52 NB
02335 Resin >3 Sur or Inv Incisal Angle Ant 66 NB
02385 Resin -One Surface, Posterior Permanent 35 NB
02386 Resin -Two Surfaces, Posterior Permanent 56 NB
02387 Resin -3 or More Surfaces, Posterior Permanent 70 NB
02510 Inlay-Metallic-One Surface 307 NB
02520 Inlay-Metallic-Two Surfaces 334 NB
02530 Inlay-Metallic-Three Surfaces 371 NB
02540 Onlay-Metallic-Per T In Add to Inlay 408 NB
02610 Inlay-Porcelain/ Ceramic-One Surface 498 NB
02620 Inlay-Porcelain/ Ceramic Two Surfaces 498 NB
02630 Inlay-Porcelain/ Ceramic Three Surfaces 498 NB
02640 Onlay-Porc/ Ceramic-Per Tooth + Inlay 498 NB
02650 Inlay-Compos/ Resin-1 Surf (Lab Proc) 498 NB
02651 Inlay-Compos/ Resin-2 Surf (Lab Proc) 498 NB
02652 Inlay-Compos/ Resin-3 or More Surf (Lab) 498 NB
02710 Crown-Resin-Laboratory 235 NB
02740 Crown-Porcelain/ Ceramic Substrate 526 NB
02750 Crown-Porcelain Fused to Hi Noble Metal 531 NB
02751 Crown-Porcelain Fused to Predom Base Mental 472 NB
02752 Crown-Porcelain Fused to Noble Metal 502 NB
02790 Crown-Full Cast High Noble Metal 510 NB
02791 Crown-Full Cast Predom Base Metal 442 NB
02792 Crown-Full Cast Noble Metal 465 NB
02810 Crown-3/ 4 Cast Metallic 521 NB
02910 Recement Inlay 34 NB
02920 Recement Crown 34 NB
02930 Prefab Stainl Stl Crown-Prim Tooth 101 NB
02931 Prefab Stainl Stl Crown-Perm Tooth 106 NB
02932 Prefabricated Resin Crown 157 NB
02940 Sedative Fillings 34 NB
02950 Crown Buildup (Substructure) w/ pins 101 NB
02951 Pin Reten-Per Tooth in Add to Rest 22 NB
02952 Cast Post & Core In Add to Crown 146 NB
02954 Prefab Post & Core in Add to Crown 129 NB 54.
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2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 52 Section 5( h)
Dental Benefits You Pay
ADA CODE PROCEDURE NAME TO DENTIST TO SPECIALIST

02970 Temporary Crown (Fractured Tooth) 84 NB
02980 Crown Repair 84 NB
Endodontic Services
03110 Pulp Cap-Direct Excl Final Rest 22 NB
03120 Pulp Cap-Indirect Excl Final Rest 22 NB
03220 Therapeutic Pulpotomy Exc Fin Rest 62 67
03310 RC Ther Ant Exc Final Restoration 253 319
03320 RC Ther-Bicuspid Exc Final Restoration 294 496
03330 RC Ther Molar Exc Final Restoration 313 614
03346 Retreatment of Prev RC Ther -Anterior NB 378
03347 Retreatment of Prev RC Ther -Bicuspid NB 584
03348 Retreatment of Prev RC Ther -Molar NB 732
03350 Apexification/ Recalc Per Trmt Visit 118 164
03410 Apicoectomy/ Periradicular Surg-Ant 148 381
03421 Apico/ perirad Surg-Bicus First Root 148 465
03425 Apico/ Perirad Srg-Molar First Root 148 487
03426 Apico/ Perirad Srg-Molar Ea Add Root 49 185
06430 Retrograde Filling Per Root 104 196
03450 Root Amputation-Per Root 104 252
03920 Hemisect W Rt Rem-Wo Root Canal Therapy 125 224
Periodontic Services
04210 Gingivectomy/ Gingivoplasty-Per Quad 222 297
04211 Gingivectomy/ Gingivoplasty-Per Tooth 59 90
04220 Ging Curettage Surg/ Quad-By Report 67 140
04240 Gingival Flap Incl Rt Health Plan-Per Quad 222 381
04249 Crn Lengthn-Hard/ Soft Tissue by Rep 260 358
04250 Muco-Gingival Surgery-Per Qdrant 260 370
04260 Oss Surg Inc Flap Ent, Grafts & Clos 371 661
04261 Osseous Graft 185 330
04262 Osseous Graft Multiple 185 330
04268 Guid Tis Rgen Inc Sur Re-Ent by Rep 358 358
04270 Pedicle Soft Tissue Graft Procedure 178 420
04271 Free Soft Tissue Graft & Donor Site 260 510
04320 Provisional Splinting Intracoronal 106 130
04321 Provisional Splinting Extracoronal 74 134
04341 Perio Scaling/ Root Health Planing-Per Quad 71 140
04355 FM Debridmt before Comp Trmt 67 140
04910 Perio Maint After Active Ther 45 67
Prosthetics -Removable
05110 Complete Denture Upper 525 NB
05120 Complete Denture Lower 525 NB
05130 Immediate Denture Upper 525 NB
05140 Immediate Denture Lower 525 NB
05211 Upper Part Dent-Resin Base Incl Clsp 381 NB
05212 Lower Part Dent-Resin Base Incl Clsp 470 NB
05213 Up Part Dent-Met Base, Res SDL Incl Clsp 567 NB
05214 Lo Part Dent-Met Base, Res SDL Incl Clsp 567 NB
05281 Uni Part Dent-Met Base, Cast Clsp 269 NB
05410 Adjust Dent-Comp or Part, Upr or Lwr 73 NB
05510 Repair Broken Complete Denture Base 56 NB
05520 Repl Miss/ Brkn T-Compl Den-Ea T 45 NB
05610 Repair Acrylic Saddle or Base 56 NB
05620 Repair Cast Framework 62 NB 55.
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2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 53 Section 5( h)
Dental Benefits You Pay
ADA CODE PROCEDURE NAME TO DENTIST TO SPECIALIST

05630 Repair or Replace Broken Clasp 50 NB
05640 Replace Broken Teeth-Per Tooth 50 NB
05650 Add Tooth to Existing Part Denture 73 NB
05660 Add Clasp to Existing Part Denture 101 NB
05710 Rebase Dnt-Comp or Par, Upr or Lower 196 NB
05730 Reline Dnt-Comp or Part, Chair 134 NB
05750 Reline Dent-Comp or Part, Lab 148 NB
05820 Temp Part Stayplate-Upper or Lower 207 NB
05850 Tissue Conditioning Upper Denture 50 NB
05851 Tissue Conditioning Lower Denture 56 NB
Prosthetics -Fixed
06210 Pontic-Cast High Noble Metal 525 NB
06211 Pontic-Cast Predom Base Metal 484 NB
06212 Pontic-Cast Noble Metal 459 NB
06240 Pontic-Porc Fused to Hi Noble Metal 493 NB
06241 Pontic-Porc Fused to Predom Base Metal 431 NB
06242 Pontic-Porc Fused to Noble Metal 465 NB
06520 Inlay-Metallic-Two Surfaces 353 NB
06530 Inlay-Metallic 3 or More Surfaces 392 NB
06540 Only Metallic Per Tooth + Inlay 431 NB
06545 Rtain-Cast Mtl For Acide Etch Brdg 224 NB
06750 Crown-Porc Fused to Hi Noble Metal 504 NB
06751 Crown-Porc Fused to Predom Bse Metal 420 NB
06752 Crown-Porc Fused to Nobel Metal 454 NB
06780 Crown-3/ 4 Cast High Noble Metal 476 NB
06790 Crown-Full Cast High Noble Metal 537 NB
06791 Crown-Full Cast Predom Base Metal 478 NB
06792 Crown-Full Cast Noble Metal0 465 NB
06930 Recement Bridge 39 NB
Oral Surgery

07110 Single Tooth 47 53
07120 Each Additional Tooth 41 47
07130 Root Removal Exposed Roots 28 39
07210 Surgical Removal of Erupted Tooth 59 106
07220 Rem Impacted Tooth-Soft Tissue 52 129
07230 Rem Impacted Tooth-Part Bony 67 162
07240 Rem Impacted Tooth Compl Bony 111 190
07250 Surg Rem Resid T Roots-Cutting Proc 59 106
07260 Oroantral Fistula Closure 170 213
07270 Tooth Reimplantation 104 241
07280 Surg Expos Imp/ Unerup T-Ortho 125 207
07281 Surg Expos Imp/ Unerup T-Aid Erup 88 168
07285 Biopsy of Oral Tissue-Hard** 74 129
07286 Biopsy of Oral Tissue-Soft** 74 112
07291 Transseptal Fiberotomy 34 34
07310 Alveolopl In Conj w Extrac-Per Quad 59 118
07320 Alveolopl No Extract-Per Quad 74 134
07410 Rad Exc-Lesion to 1.25cm** 88 168
07420 Rad Exc-Lesion over 1.25cm** 141 286
07430 Exc Benign Tumor-Lesion to 1.25cm** 111 179
07431 Exc Benign Tumor-Lesion over 1.25cm** 140 281
07450 Rem Odont Cyc/ Tum-Les to 1.25cm 105 170
07451 Rem Odont Cyst/ Tum-Les over 1.25cm 140 281 56.
56 Page 57 58
2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 54 Section 5( h)
Dental Benefits You Pay
ADA CODE PROCEDURE NAME TO DENTIST TO SPECIALIST

07460 Rem NonOdont Cyst/ Tum-Les to 1.25cm 111 179
07461 Rem NonOdont Cyst/ Tum-Les over 1.25cm 148 297
07470 Rem Exostosis-Maxilla or Mandible 193 280
07480 Part Ostectomy Gutter or Sauceriz 281 281
07510 I& D Abscess-Intraoral Soft Tissue 59 78
07520 I& D Abscess-Extraoral Soft-Tissue 59 78
07530 Rem Foreign Body/ Skn/ Subcut Areo Tissue 120 179
07550 Sequestrectomy for Osteomyelitis 162 162
07910 Suture Simple Wounds up to 5cm 39 39
07911 Suture of Complex Wounds up to 5cm 78 78
07960 Frenectomy Frenec/ Frenot-Sep Proc 91 196
07970 Exc of Hyperplastic Tissue-Per Arch 56 148
07971 Excision of Periocoronal Gingiva 67 95
Additional Procedures
09110 Palliative Treatment 28 NB
09210 Local Anesthesia 0 NB
09220 General Anesthesia-First 30 Minutes 74 185
09221 General Anesthesia-Each Add'l 15 Minutes 37 123
09230 Analgesia (per 30 Minutes) 17 22
09240 IV Sedation (per hour) 111 179
09310 Consult (No Add'l Procs Indicated) 45 49
09910 Appl Of Desensitizing Med 28 28
09940 Occlusal Guards by Report 162 269
09951 Occlusal Adjustment Limited 37 57
09952 Occlusal Adjustment-Complete 148 244
09980 Sterilization Surcharge (per visit) 5 5
09990 After Hours Surcharge 25 25
09999 Broken Appointment Fee Per Hour 15 15
Orthodontics Per Case
08070 Orthodontic Fully Banded 2 Yr. Case -Transitional NB 2375
08080 Orthodontic Fully Banded 2 Yr. Case -Adolescent NB 2375

Limitations to dental services:
Full mouth X-rays and panoramic X-rays are covered once every thirty-six (36) months, except when taken for diagnosis of third molars, cysts, or neoplasms

Full mouth debridement (ADA Code 4355) is limited to once every thirty-six (36) months
Perio Maintenance After Active Therapy (ADA Code 04910) is limited to twice within twelve (12) months after Osseous Surgery

Denture relines for complete or partial conventional dentures are included in the denture fee for the six (6)
month period following insertion. Thereafter relines are covered once every twelve (12) months.

Sealants (ADA Code 01351) are limited to the first and second permanent molars. Additionally, coverage is limited to members under age 16.

Root canal retreatment within one (1) year following the initial therapy is the responsibility of the original treating Participating Dental Provider (ADA Codes 3346, 3347, 3348)
Orthodontics coverage is limited to treatment for a handicapping malocclusion, which is defined as an
occlusion causing difficulty in chewing, speech or overall dental functioning. Coverage is limited to two (2) years of active treatment per eligible member per lifetime. Patients must be banded by age 19. If Dental

Plan pays for interceptive therapy, minor tooth movement or other orthodontic treatment prior to fully banded care, the Dental Plan payment for inceptive therapy, minor tooth movement or other orthodontic
treatment will be deducted from dental Plan's payment for fully banded care. 57.
57 Page 58 59
2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 55 Section 5( h)
Root planing or scaling (ADA Code 4341) is covered once every six (6) months per quadrant.
Periodontal surgery of any type, including gingivectomy, gingivoplasty, gingival curettage, gingival flap procedure, mucogingival surgery, osseous surgery, pedicle graft, or free tissue graft is covered once every

thirty-six (36) months per quadrant.
Osseous grafts are covered once every thirty-six (36) months per quadrant or surgical site.
Replacement of crowns, bridges and fixed or removable prosthetic appliances inserted prior to Dental Plan coverage is not covered until twelve (12) months of continuous Dental Plan coverage have been achieved. If

loss of a tooth requires the addition of a clasp, pontic, and/ or abutment( s) within this twelve-(12) month period, the plan will cover only the procedures associated with the addition.

Not covered:
Services of dentists or other practitioners of healing arts not associated with Kaiser Permanente and DBP
except upon referral arranged by a Participating Dental Provider and authorized by us, or when required in a covered emergency. Such excluded services mean any kind of dental care and anything prescribed in

connection therewith.
Hospitalization for any dental procedure, except as may otherwise be covered by the Plan
Any cosmetic, beautifying, or elective procedure
Any procedure not performed in a dental office setting
Experimental procedures, implantations, or pharmacological regiments
Services for injuries or conditions which are covered under Workers' Compensation or Employer's Liability laws; services which are provided without cost to the Member by any municipality, county, or

other political subdivision. This exclusion does not apply to any services that are covered by Medicaid.
Replacement of denture, bridgework, and/ or dental appliances previously supplied under this benefit, due to loss or theft, or for any reason within sixty (60) months of initial insertion

Services which, in the opinion of the attending Participating Dental Provider, are not necessary for the
member's dental health

Dental services pertaining, or related, to the Temporomandibular Joint (TMJ), except when those services are included on the attached dental fee schedule and are performed by the member's Participating Dental

Provider in that provider's office
Charges for failure to keep a scheduled dental appointment. The charges are listed in the attached dental fee schedule, and are charged by the general dentist and/ or specialist, for each missed hour appointment

without twenty-four (24) hours notice.
Services of Pedodontists and/ or Prosthodontists
Charges for second opinions, unless previously authorized by the Plan
Occlusal guards are excluded for any purpose other than habitual grinding
Procedures requiring fixed prosthodontic restoration, which are necessary for complete oral rehabilitation or reconstruction

Procedures relating to the change and maintenance of vertical dimension or the restoration of occlusion
Dental lab fees for excisions and biopsies. Procedures requiring lab fees are shown with asterisks ("**").
Drugs obtainable with or without a prescription (see your prescription drug benefit as described in Section 5( f) for coverage of dental prescriptions)

The setting of fractures or dislocations (see your medical and surgical benefits as described in Sections 5( a) and 5( b) for coverage of these services)
Treatment of malignancies, cysts or neoplasm or congenital malformations. (see your medical and surgical benefits as described in Sections 5( a) and 5( b) for coverage of these services) 58.
58 Page 59 60
2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 56 Section 5( h)
Dental expenses incurred in connection with any dental procedure started prior to member's eligibility with
Dental Plan. Examples: orthodontic work in progress, teeth prepared for crowns, root canal therapy in progress.

Clinical situations that can be effectively treated by a less costly, clinically acceptable alternative procedure
will be assigned a benefit based on the less costly procedure, in accordance with the "Standards of Care" established by DBP for its participating providers.

Placement of dental implants, implant-supported abutments and prostheses.
Billing for incision and drainage (ADA Code 7510) is excluded if the involved abscessed tooth is removed on the same date of service.

Placement of fixed bridgework solely for the purpose of achieving periodontal stability.
Procedures not shown on the dental service and fees listing 59.
59 Page 60 61
2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 57 Section 5( i)
Section 5 (i). Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed claim about them. Fees you pay for these services do not count toward FEHB deductibles or catastrophic
protection out-of-pocket maximums.
Medicare Prepaid Plan Enrollment We offer Medicare recipients the opportunity to enroll in our Plan through Medicare. Annuitants and former spouses

with FEHB coverage and Medicare Parts A and B or Part B only may elect to either drop their FEHB coverage and
enroll in a Medicare prepaid plan or remain enrolled in the FEHB Program and simultaneously enroll in the Medicare prepaid plan when one is available in their area. If you choose to disenroll from the FEHB Program you may then later

re-enroll in the FEHB Program.

Most federal annuitants have Medicare Part A (hospital coverage). Those without Medicare Part A may join this Medicare prepaid plan after they have elected to purchase Medicare Part A in addition to continuing to pay for their
Part B premium. Before you drop your FEHB coverage and apply for coverage in the Medicare prepaid plan, please
contact us at 301/ 816-5690 or 301/ 816-6143.

Expanded Dental Benefits We are pleased to offer you an additional choice of dental coverage to supplement what is currently available to you
through the FEHB program. This dental program is designed to enhance the level of dental benefits that you currently receive. Your basic discounted dental coverage through the Plan is not affected by this enhanced product offering.
This supplemental coverage is through Delta Dental, a national dental provider, and is only available to members of
Kaiser Permanente.

Delta Premier, a table of allowances program, allows you to choose any licensed dentist; however, discounted pricing is available only through Delta's provider network. After you satisfy a deductible, Delta will pay a predetermined
amount toward each covered service. You will not need to satisfy a deductible toward covered preventive services you receive. Delta Premier offers a full range of covered services: diagnostic, preventive, restorative, endodontics,
periodontics, oral surgery, and both fixed and removable prosthodontics. Orthodontic coverage is not available.
Covered services will be phased in over a three (3) year period.

Delta Premier is only available to you if you are enrolled in Kaiser Permanente's Plan for the FEHB. You do not need to purchase this program to receive the basic dental coverage included in the Plan. Premium payments should be
made directly to Delta Dental. Payroll deduction is not available for this program.
How to Enroll: An enrollment form for Delta Premier is included in your Kaiser Permanente enrollment kit. If you would wish more information on Delta Premier, please call Delta Dental at 800/ 932-0783.

Monthly Premiums: Self $18.45
Self and One Party $33.45
Family $52.45 60.
60 Page 61 62
2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 58 Section 6
Section 6. General exclusions --things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we
will not cover it unless your Plan physician determines it is medically necessary to prevent, diagnose, or treat your illness, disease, injury, or condition.

We do not cover the following:
Care by non-Plan providers except for authorized referrals or emergencies (see Section 5( d)), services under the Travel Benefit (see Section 5( g)), and services received from other Kaiser Permanente plans

(see Section 5( g));
Services, drugs, or supplies you receive while you are not enrolled in this Plan;
Services, drugs, or supplies that are not medically necessary;
Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice;

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

incest;
Services, drugs, or supplies you receive without charge while in active military service;
Services, drugs, or supplies related to sex transformations; or
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program. 61.
61 Page 62 63
2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 59 Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or fill your prescription drugs at Plan
pharmacies, you will not have to file claims. Just present your identification card and pay your copayment or coinsurance.

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

Medical, hospital, and drug In most cases, providers and facilities file claims for you. Physicians benefits must file on the form HCFA-1500, Health Insurance Claim Form.
Facilities will file on the UB-92 form. For claims questions and assistance, call us at 301/ 468-6000 inside the Washington, DC
metropolitan area or at 800/ 777-7902 outside the Washington, DC
metropolitan area. Our TTY telephone number is 301/ 879-6380.

When you must file a claim such as for services you receive outside of the Plan's service area submit it on the HCFA-1500 or a claim form

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

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

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

Receipts, if you paid for your services.
Submit your claims to:
Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.
Attention: Claims Department P. O. Box 6233

Rockville, Maryland 20849-6233

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

When we need more information Please reply promptly when we ask for additional information. We may delay processing or deny your claim if you do not respond. 62.
62 Page 63 64
2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 60 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: Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc., 2101 East Jefferson Street, Rockville, MD 20852, Attn: Member Services Appeals Unit; and

(c) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure; and
(d) Include copies of documents that support your claim, such as physicians' letters, operative reports,
bills, medical records, and explanation of benefits (EOB) forms.

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

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

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

Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Contracts Division 3, 1900 E Street, NW, Washington, DC 20415-3630.

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. 63.
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2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 61 Section 8
Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representative, such as medical providers, must include a copy of your specific written consent with the
review request.
Note: The above deadlines may be extended if you show that you were unable to meet the deadline because of reasons beyond your control.

5 OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct. OPM will send you a final decision within 60 days. There are no other administrative appeals.

If you do not agree with OPM's decision, your only recourse is to sue. If you decide to sue, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received
the disputed services, drugs, or supplies or from the year in which you were denied precertification or prior approval. This is the only deadline that may not be extended.

OPM may disclose the information it collects during the review process to support their disputed claim
decision. This information will become part of the court record.

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

NOTE: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and
(a) We haven't responded yet to your initial request for care or preauthorization/ prior approval, then call us
Monday through Friday at 301/ 468-6000 inside the Washington, DC metropolitan area or 800/ 777-7902 outside the Washington, DC metropolitan area. Our TTY is 301/ 879-6380. Weekends and holidays, please

call 703/ 359-7878 inside the Washington, DC metropolitan area or 800/ 777-7904 outside the Washington, DC metropolitan area. Our weekend TDD numbers are 703/ 359-7616 or toll free at 800/ 700-4901. We will
expedite our review; or
(b) We denied your initial request for care or pre-authorization/ 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 3 at 202/ 606-0755 between 8 a. m. and 5 p. m. eastern time. 64.
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2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 62 Section 9
Section 9. Coordinating benefits with other coverage
When you have other health You must tell us if you or a covered family member have coverage 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 is the primary payer; it pays
benefits first. The other plan pays a reduced benefit as the secondary payer. We, like other insurers, determine which coverage is primary

according to the National Association of Insurance Commissioners'
Guidelines.

When we are the primary payer, we will pay the benefits described in this
brochure.

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

are the secondary payer, and you received your services from Plan
providers, we may bill the primary carrier.

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

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

employment, you should be able to qualify for premium-free Part A insurance. (Someone who was a Federal employee on January
1, 1983 or since automatically qualifies.) Otherwise, if you are age 65
or older, you may be able to buy it. Contact 1-800-MEDICARE for more information.

Part B (Medical Insurance). Most people pay monthly for Part B. Generally, Part B premiums are withheld from your monthly Social
Security check or your retirement check.
If you are eligible for Medicare, you may have choices in how you get your health care. The information in the next few pages shows how we
coordinate benefits with Medicare, depending on the type of Medicare managed care plan you have.

The Original Medicare Plan The Original Medicare Plan (Original Medicare) is available everywhere (Part A or Part B) in the United States. It is the way everyone used to get Medicare benefits
and is the way most people get their Medicare Part A and Part B benefits
now. You may go to any doctor, specialist, or hospital that accepts Medicare. The Original Medicare Plan pays its share and you pay your

share. Some things are not covered under Original Medicare, like
prescription drugs. 65.
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2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 63 Section 9
When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care.
We will not waive any of our copayments.
Claims process when you have the Original Medicare Plan --You probably will never have to file a claim form when you have both our
Plan and the Original Medicare Plan.
When we are the primary payer, we process the claim first.
When Original Medicare is the primary payer, Medicare processes your claim first. In most cases, your claim will be coordinated
automatically and we will then provide secondary benefits for
covered charges. You will not need to do anything. To find out if you need to do something to file your claim, please call 301/ 468-

6000 or 800/ 777-7902 or TTY 301/ 879-6380.
(Primary payer chart begins on next page.) 66.
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2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 64 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 67.
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2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 65 Section 9
Medicare managed care plan If you are eligible for Medicare, you may choose to enroll in and get your
Medicare benefits from another plan --a Medicare managed care plan. This is a health care choice (like HMOs) in some areas of the country. In

most Medicare managed care plans, you can only go to doctors,
specialists, or hospitals that are part of the plan. Medicare managed care plans provide all the benefits that Original Medicare covers. Some cover

extras, like prescription drugs. To learn more about enrolling in a
Medicare managed care plan, contact Medicare at 1-800-MEDICARE (1-800-633-4227) or at www. medicare. gov.

If you enroll in a Medicare managed care plan, the following options are available to you:
This Plan and our Medicare managed care plan: You may enroll in our Medicare managed care plan, known as Kaiser Permanente Medicare
Plus (an 1876 Medicare Cost plan), and also remain enrolled in our
FEHB Plan. To be eligible for Kaiser Permanente Medicare Plus, you must have Medicare Parts A and B or Medicare Part B only.

You may enroll in Medicare Plus at no additional monthly premium cost to you. This plan offers you enhanced benefits and additional flexibility
in how you receive your medical care. If you enroll in Medicare Plus,
you still receive all of your in-network care through Kaiser Permanente contracted Plan Providers. When you use Plan Providers, some of your

copayments and coinsurance will be lowered.
Under the Kaiser Permanente Medicare Plus plan, you may also choose to receive care from providers outside our network. If you receive
medical care from Medicare participating providers outside our network, Medicare will pay its share of approved charges. You will be responsible
for the Medicare coinsurance and deductible amounts.
Under Kaiser Permanente Medicare Plus, when you receive your medical care through Plan Providers, the following copayments or coinsurance
have been lowered:
Physician Office Visits (preventive and non-preventive): $5
Dialysis: $0
Voluntary sterilizations and family planning: $5
Rehabilitative and Other Therapies: $5; unlimited number of visits as medically necessary

Cardiac Rehabilitation: $5
Comprehensive Outpatient Rehabilitation Facility Services: $5
Chiropractic Services and Acupuncture beyond what is covered by Medicare: $5 up to 20 visits per modality per calendar year

Urgent Care Services: $5
Outpatient Substance Abuse Rehabilitation: $5
Outpatient Mental Health Services: $5
Vision Services: $5 for eye examinations and refractions; covered up to the Medicare-allowable amount for glasses after cataract

surgery; 25% discount on eyeglass lenses and frames; 15% discount
on initial purchase of contact lenses

Hearing exams: $5 for routine and Medicare-covered hearing tests
Podiatry (medically necessary): $5
Blood transfusions: $5 68.
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2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 66 Section 9
Blood and blood components: $0 if the blood is replaced;
otherwise you must replace the first three (3) pints or pay non-replacement fees for whole blood; $0 for all blood products, except

for hemophiliac factors that are covered under the Prescription Drug
benefit

Health Education Classes: $10-$ 20 for health education classes

If you would like information about Kaiser Permanente Medicare Plus, please call 301/ 468-6000 or 800/ 777-7902 or TTY 301/ 879-6380.

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 if you use our Plan providers, but we will not waive any of our copayments or coinsurance. If you enroll in

a Medicare managed care plan, tell us. We will need to know whether
you are in the Original Medicare Plan or in a Medicare managed care plan so we can correctly coordinate benefits with Medicare.

Suspended FEHB coverage to enroll in a Medicare managed care plan: If you are an annuitant or former spouse, you can suspend your
FEHB coverage to enroll in a Medicare managed care plan, eliminating
your FEHB premium. (OPM does not contribute to your Medicare managed care plan premium.) For information on suspending your

FEHB enrollment, contact your retirement office. If you later want to re-enroll
in the FEHB Program, generally you may do so only at the next open season unless you involuntarily lose coverage or move out of the

Medicare managed care service area.

If you do enroll in If you enroll in Medicare Part B, we require you to assign your Medicare Medicare Part B Part B benefits to the Plan for its services.

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

TRICARE and CHAMPVA TRICARE is the health care program for eligible dependents of military persons and retirees of the military. TRICARE includes the CHAMPUS
program. CHAMPVA provides health coverage to disabled Veterans and
their eligible dependents. If TRICARE or CHAMPVA and this Plan cover you, we pay first. See your TRICARE or CHAMPVA Health

Benefits Advisor if you have questions about these programs.
Suspended FEHB coverage to enroll in TRICARE OR CHAMPVA: If you are an annuitant or former spouse, you can suspend your FEHB
coverage to enroll in one of these programs, eliminating your FEHB premium. (OPM does not contribute to any applicable plan premiums.)
For information on suspending your FEHB enrollment, contact your
retirement office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you

involuntarily lose coverage under the program. 69.
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2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 67 Section 9
Workers' Compensation We do not cover services that: you need because of a workplace-related illness or injury that the
Office of Workers' Compensation Programs (OWCP) or a similar Federal or State agency determines they must provide; or
OWCP or a similar agency pays for through a third party injury
settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws.

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

Medicaid When you have this Plan and Medicaid, we pay first.
Suspended FEHB coverage to enroll in Medicaid or a similar State-sponsored
program of medical assistance: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of

these State programs, eliminating your FEHB premium. For information
on suspending your FEHB enrollment, contact your retirement office. If you later want to re-enroll in the FEHB Program, generally you may do

so only at the next Open Season unless you involuntarily lose coverage
under the State program.

When other Government agencies We do not cover services and supplies when a local, State, are responsible for your care or Federal Government agency directly or indirectly pays for them.

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

If you do not seek damages you must agree to let us try. This is called
subrogation. If you need more information, contact us for our subrogation procedures. 70.
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2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 68 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.

Copayment A copayment is a fixed amount of money you pay when you receive covered services.

Covered services Care we provide benefits for, as described in this brochure.
Custodial care (1) Assistance with activities of daily living, for example, walking, getting in and out of bed, dressing, feeding, toileting, and taking
medicine. (2) Care that can be performed safely and effectively by people who, in order to provide the care, do not require medical licenses
or certificates or the presence of a supervising licensed nurse. Custodial
care that lasts 90 days or more is sometimes known as Long term care.

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

Durable medical equipment Durable medical equipment (DME) is equipment that is intended for repeated use, medically necessary, primarily and customarily used to
serve a medical purpose, generally not useful to a person who is not ill or
injured, designed for prolonged use, appropriate for use in the home, and serving a specific therapeutic purpose in the treatment of an illness or

injury.

Experimental or investigational services A service, supply, item or drug that: (1) has not been approved by the FDA; or
(2) is the subject of a new drug or new device application on file with the FDA; or

(3) is available as the result of a written protocol that evaluates the
service's safety, toxicity, or efficacy; or (4) is subject to the approval or review of an Institutional Review Board;

or
(5) requires an informed consent that describes the service as experimental or investigational.

Group health coverage Health care benefits that are available as a result of your employment, or the employment of your spouse, and that are offered by an employer or
through membership in an employee organization. Health care coverage may be insured or indemnity coverage, self-insured or self-funded
coverage, or coverage through health maintenance organizations or other
managed care plans. Health care coverage purchased through membership in an organization is also "group health coverage." 71.
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2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 69 Section 10
Medically necessary All benefits need to be medically necessary in order for them to be covered benefits. Generally, if your Plan physician provides the service
in accord with the terms of this brochure, it will be considered medically
necessary. However, some services are reviewed in advance of your receiving them to determine if they are medically necessary. When we

review a service to determine if it is medically necessary, a Plan
physician will evaluate what would happen to you if you do not receive the service. If not receiving the service would adversely affect your

health, it will be considered medically necessary. The services must be a
medically appropriate course of treatment for your condition. If they are not medically necessary, we will not cover the services. In case of

emergency services, the services that you received will be evaluated to
determine if they were medically necessary.

Our allowance The amount we use to determine your coinsurance. When you receive services or supplies from Plan providers, it is the amount that we set for
the services or supplies if we were to charge for them. When you receive services from non-Plan providers, we determine the amount that we
believe is usual and customary for the service or supply, and compare it to the charges. Our allowance is based upon the reasonableness of the
charges. If the charges exceed what we believe is reasonable, you may
be responsible for the excess over our allowance in addition to your coinsurance.

Your Primary care copayment The copayment for your primary care visit is $10 for the following services: internal medicine, obstetrics and gynecology, pediatrics and,
family practice services.
Your Specialty care copayment The copayment for your specialty care visit is $20. This copayment applies when you receive services from medical providers who are not
primary care physicians (as defined above).

Us/ We Us and we refer to Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.

You You refers to the enrollee and each covered family member. 72.
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2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 70 Section 11
Section 11. FEHB facts
No pre-existing condition We will not refuse to cover the treatment of a condition that you had limitation before you enrolled in this Plan solely because you had the condition
before you enrolled.
Where you can get information See www. opm. gov/ insure. Also, your employing or retirement office about enrolling in the can answer your questions, and give you a Guide to Federal Employees

FEHB Program Health Benefits Plans, brochures for other plans, and other materials you need to make an informed decision about your FEHB coverage. These
materials tell you:

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

When your enrollment ends; and
When the next open season for enrollment begins.
We don't determine who is eligible for coverage and, in most cases, cannot change your enrollment status without information from your

employing or retirement office.
Types of coverage available Self Only coverage is for you alone. Self and Family coverage is for for you and your family you, your spouse, and your unmarried dependent children under age 22,

including any foster children or stepchildren your employing or retirement office authorizes coverage for. Under certain circumstances,
you may also continue coverage for a disabled child 22 years of age or older who is incapable of self-support.

If you have a Self Only enrollment, you may change to a Self and Family enrollment if you marry, give birth, or add a child to your family. You
may change your enrollment 31 days before to 60 days after that event.
The Self and Family enrollment begins on the first day of the pay period in which the child is born or becomes an eligible family member. When

you change to Self and Family because you marry, the change is effective
on the first day of the pay period that begins after your employing office receives your enrollment form; benefits will not be available to your

spouse until you marry.
Your employing or retirement office will not notify you when a family member is no longer eligible to receive health benefits, nor will we.
Please tell us immediately when you add or remove family members from your coverage for any reason, including divorce, or when your child
under age 22 marries or turns 22.
If you or one of your family members is enrolled in one FEHB plan, that person may not be enrolled in or covered as a family member by another
FEHB plan. 73.
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2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 71 Section 11
Children's Equity Act OPM has implemented the Federal Employees Health Benefits Children's Equity Act of 2000. This law mandates that you be enrolled for Self and
Family coverage in the Federal Employees Health Benefits (FEHB)
Program, if you are an employee subject to a court or administrative order requiring you to provide health benefits for your child( ren).

If this law applies to you, you must enroll for Self and Family coverage in a health plan that provides full benefits in the area where your children
live or provide documentation to your employing office that you have
obtained other health benefits coverage for your children. If you do not do so, your employing office will enroll you involuntarily as follows:

If you have no FEHB coverage, your employing office will enroll you for Self and Family coverage in the Blue Cross and Blue Shield
Service Benefit Plan's Basic Option,
If you have a Self Only enrollment in a fee-for-service plan or in an
HMO that serves the area where your children live, your employing office will change your enrollment to Self and Family in the same

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

Self and Family in the Blue Cross and Blue Shield Service Benefit
Plan's Basic Option.

As long as the court/ administrative order is in effect, and you have at
least one child identified in the order who is still eligible under the FEHB Program, you cannot cancel your enrollment, change to Self Only, or

change to a plan that doesn't serve the area in which your children live,
unless you provide documentation that you have other coverage for the children. If the court/ administrative order is still in effect when you

retire, and you have at least one child still eligible for FEHB coverage,
you must continue your FEHB coverage into retirement (if eligible) and cannot make any changes after retirement. Contact you employing office

for further information.

When benefits and The benefits in this brochure are effective on January 1. If you joined premiums start 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. 74.
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2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 72 Section 11
You may be eligible for spouse equity coverage or Temporary Continuation of Coverage.
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 download the
guide from OPM's website, www. opm. gov/ insure.

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

you are not able to continue your FEHB enrollment after you retire, if
you lose your job, if you are a covered dependent child and you turn 22 or marry, etc.

You may not elect TCC if you are fired from your Federal job due to gross misconduct.
Enrolling in TCC. Get the RI 79-27, which describes TCC, and the RI 70-5, the Guide to Federal Employees Health Benefits Plans for
Temporary Continuation of Coverage and Former Spouse Enrollees,
from your employing or retirement office or from www. opm. gov/ insure. It explains what you have to do to enroll.

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

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

is losing coverage, the employing or retirement office will not notify
you. You must apply in writing to us within 31 days after you are no longer eligible for coverage.

Your benefits and rates will differ from those under the FEHB Program; however, you will not have to answer questions about your health, and
we will not impose a waiting period or limit your coverage due to pre-existing
conditions.

Getting a Certificate of The Health Insurance Portability and Accountability Act of 1996
Group Health Plan Coverage (HIPAA) is a Federal law that offers limited Federal protections for health coverage availability and continuity to people who lose employer group

coverage. If you leave the FEHB Program, we will give you a Certificate
of Group Health Plan Coverage that indicates how long you have been 75.
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2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 73 Section 11
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. 76.
76 Page 77 78
2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 74 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 800/ LTC-FEDS (800/ 582-3337) (TDD for the hearing
impaired: 800/ 843-3557) or visiting www. ltcfeds. com to get more information and to request an application. 77.
77 Page 78 79
2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 75 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 48 Allergy tests 20
Alternative treatment 27 Ambulance 35
Anesthesia 31 Autologous bone marrow
transplant 30 Biopsies 28
Blood and blood plasma 33 Breast cancer screening 17
Casts 33 Centers of Excellence 45
Changes for 2003 9 Chemotherapy 20
Chiropractic 26 Cholesterol tests 17
Coinsurance 68 Colorectal cancer screening 17
Congenital anomalies 28 Contraceptive devices and drugs 19
Coordination of benefits 62 Covered providers 10
Crutches 24 Deaf and hearing impaired
service 45 Deductible 68
Dental care 48 Diagnostic services 50
Disputed claims review 60 Donor expenses (transplants ) 30
Dressings 33 Durable medical equipment
(DME) 24 Educational classes and programs 27
Effective date of enrollment 68 Emergency 36
Experimental or investigational 58 Eyeglasses 23
Family planning 19 Fecal occult blood test 17
Flexible benefits options 45 General Exclusions 58

Hearing services 22 Home health services 26
Hospice care 35 Hospital 12
Immunizations 18 Infertility 19
Inpatient Hospital Benefits 32 Insulin 43

Laboratory and pathological services 16
Magnetic Resonance Imagings (MRIs) 16
Mail Order Prescription Drugs 43 Mammograms 17
Maternity Benefits 18 Medicaid 67
Medically necessary 69 Medicare 62
Mental Conditions/ Substance Abuse Benefits 38
Neurological testing 16 Newborn care 18
Non-FEHB Benefits 57 Nurse 10
Licensed Practical Nurse 26 Nurse Anesthetist 28
Nurse Practitioner 26 Registered Nurse 45
Nursery charges 18 Obstetrical care 18
Ocular Injury 22 Occupational therapy 21
Oral and maxillofacial surgery 30 Orthopedic devices 23
Ostomy and catheter supplies 46 Out-of-pocket expenses 14
Oxygen 25 Pap test 17
Physical examination 17 Physical therapy 21
Precertification 12

Preventive care, adult 17 Preventive care, children 18
Preventive services 50 Primary care 10
Prior approval 12 Prostate cancer screening 17
Prosthetic devices 23 Psychotherapy 40
Radiation therapy 20 Renal dialysis 20
Room and board 32 Second surgical opinion 16
Services from other Kaiser Permanente Plans 47
Skilled nursing facility care 34 Smoking cessation 44
Specialty care 10 Speech therapy 22
Splints 33 Sterilization procedures 19
Subrogation 67 Substance abuse 38
Surgery 28 Anesthesia 31
Oral 13 Outpatient 28
Reconstructive 29 Syringes 43
Temporary continuation of coverage 72
Transplants 30 Travel benefit 46
Treatment therapies 20 Vision services 22
Well child care 7 Wheelchairs 24
Workers' compensation 67 X-rays 16
24 hour nurse line 45 78.
78 Page 79 80
2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 76 Summary
Summary of benefits for Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 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.

We only cover services provided or arranged by Plan physicians, except in emergencies.
Benefits You Pay Page
Medical services provided by physicians:
Diagnostic and treatment services provided in the office ................... $10 per visit to your primary care
provider

$20 per visit to a specialist

16

Services provided by a hospital:
Inpatient.......................................................................................................
Outpatient....................................................................................................
$100 per admission
$ 50 per outpatient surgery
32
33

Emergency benefits:
In-area .........................................................................................................
Out-of-area .................................................................................................
$50 per visit
$50 per visit
37
37

Mental health and substance abuse treatment: ...................................... Regular cost sharing 38
Prescription drugs........................................................................................... $10 per prescription or refill for generic drugs or $20 per
prescription or refill for brand-name drugs if you get your
prescription filled at a Plan
medical center pharmacy

$8 per prescription or refill for generic drugs or $18 per

prescription or refill for brand-name drugs if you get your
prescription filled through our
mail order delivery system

$20 per prescription or refill for generic drugs or $40 per
prescription or refill for brand-name drugs if you get your
prescription filled at an affiliated
network pharmacy

41

Dental Care................................................................................................... Various copayments based on procedure rendered 48
Vision Care................................................................................................... Refractions; $10 per office visit 22 79.
79 Page 80 81
2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 77 Summary
Special features: Flexible benefits option; 24 hour nurse line; Services for deaf and hearing impaired; Centers of Excellence; Travel benefit; Services from other Kaiser Permanente Plans. 45
Protection against catastrophic costs (your catastrophic protection out-of-pocket maximum)....................... Nothing after $1,500/ Self Only or $3,000/ Family enrollment per
year
Some costs do not count toward this protection

14 80.
80 Page 81 82
2003 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 78 Notes
Notes 81.
81 Page 82
2003 Rate Information for
Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.

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

Self Only E31 $92.42 $30.81 $200.25 $66.75 $109.37 $13.86
Self and Family E32 $219.97 $73.32 $476.60 $158.86 $260.29 $33.00 82.

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