Fallon Community Health Plan

Federal Employees Health Benefits Program
2003 Plan Brochure
Accessible Version

Pages 1--71

Page 1


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

2003
Serving: Central and Eastern Massachusetts, including the Worcester metropolitan area
Enrollment in this Plan is limited. You must live in or work in our Geographic service area to enroll. See page 6 for requirements.

Enrollment codes for this Plan:
JV1 Self Only JV2 Self and Family

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

RI 73-090

For changes
in benefits
see page 9.

A Health Maintenance Organization
http://www.fchp.org 1.
1 Page 2 3
2.
2 Page 3 4
Notice of the Office of Personnel Managements
Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT
CAREFULLY.

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

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

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

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

By law, you have the right to:
See and get a copy of your personal medical information held by OPM. Amend any of your personal medical information created by OPM if you believe that it is wrong or if information is missing,
and OPM agrees. If OPM disagrees, you may have a statement of your disagreement added to your personal medical
information.
Get a listing of those getting your personal medical information from OPM in the past 6 years. The listing will not cover your personal medical information that was given to you or your personal representative, any information that you authorized

OPM to release, or that was given out for law enforcement purposes or to pay for your health care or a disputed claim.
Ask OPM to communicate with you in a different manner or at a different place (for example, by sending materials to a P.O. Box instead of your home address). 3.
3 Page 4 5
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 OPMs 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

Fallon Community Health Plan
10 Chestnut St.
Worcester, MA 01608

This brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations, and
exclusions of this brochure. It is your responsibility to be informed about your health benefits.

If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in Self and Family
coverage, each eligible family member is also entitled to these benefits. You do not have a right to benefits that were available
before January 1, 2003, unless those benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2003, and changes are
summarized on page 9. Rates are shown at the end of this brochure.

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

Except for necessary technical terms, we use common words. For instance, you means the enrollee or family member;
"we" means Fallon Community Health Plan.

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

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

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

Protect Yourself From Fraud -Here are some things you can do to prevent fraud:
Be wary of giving your plan identification (ID) number over the telephone or to people you do not know, except to your doctor, other provider, or authorized plan or OPM representative.
Let only the appropriate medical professionals review your medical record or recommend services. 7.
7 Page 8 9
2003 Fallon Community Health Plan 5 Introduction/Plain Language/Advisory
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 provider has charged you for services you did not receive, billed you twice for the same service, or misrepresented any information, do the following:
Call the provider and ask for an explanation. There may be an error. If the provider does not resolve the matter, call us at 1-800-868-5200 (TDD/TTY: 1-877-608-7677) and explain the
situation.
If we do not resolve the issue:

Do not maintain as a family member on your policy:
your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise); or your child over age 22 (unless he/she is disabled and incapable of self support).

If you have any questions about the eligibility of a dependent, check with your personnel office if you are employed or with OPM if you are retired.
You can be prosecuted for fraud and your agency may take action against you if you falsify a claim to obtain FEHB benefits or try to obtain services for someone who is not an eligible family member or who is no longer enrolled in the Plan.

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

OR WRITE TO: The United States Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street, NW, Room 6400
Washington, DC 20415 8.
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2003 Fallon Community Health Plan 6 Section 1
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and other providers that
contract with us. These Plan providers coordinate your health care services. The Plan is solely responsible for the selection of these
providers in your area. Contact the Plan for a copy of their most recent provider directory.

HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in addition to
treatment for illness and injury. Our providers follow generally accepted medical practice when prescribing any course of treatment.

When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You only pay the copayments,
coinsurance, and deductibles described in this brochure. When you receive emergency services from non-Plan providers, you may
have to submit claim forms.

You should join an HMO because you prefer the plans 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 contract with individual physicians, medical groups and hospitals to provide care to our members. We negotiate with providers to
agree upon a contracted rate. The Plan pays its providers using various payment methods including capitation, per diem, incentive,
and discounted fee-for-service arrangements. Capitation means paying a fixed dollar amount per month for each member assigned to
the provider. Per diem means paying a fixed dollar amount per day for all services rendered. Incentive means a payment that is based
on appropriate medical management by the provider. Discounted fee-for-service means paying the providers usual, customary and
regular fee discounted by a negotiated percentage. When you receive a covered service, the only payment that a provider will collect
from you is the copayment amount shown in this brochure.

We cannot guarantee that any one physician, hospital or other provider will be available or remain under contract with us. We reserve
the right at any time to end our contract with your primary care physician or with any other plan provider. If this occurs, we will
generally no longer pay for services provided to you by that provider.

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. OPMs 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.

Fallon Community Health Plan is licensed in the Commonwealth of Massachusetts as an HMO, we also qualify under federal law as an HMO.

We have been in operation since 1977.
FCHP is a not-for-profit organization.
If you want more information about us, call 1-800-868-5200 (TDD/TTY: 1-877-608-7677, or write to Fallon Community Health Plan,
10 Chestnut St., Worcester, MA 01608. You may also contact us by fax at 1-508-831-0912 or visit our website at www.fchp.org.

Service Area
To enroll in this Plan, you must live in or work in our Select Care Service Area. This is where our providers practice. Our service area
is in the following Massachusetts counties: all of Essex, Middlesex, Norfolk, Suffolk and Worcester Counties, and parts of Bristol,
Franklin, Hampden, Hampshire and Plymouth Counties. This includes the communities listed below.

Abington Acton
Amesbury Andover
Arlington Ashburnham
Ashby Ashland
Assonet Athol
Attleboro Auburn
Avon Ayer
Barre Bedford 9.
9 Page 10 11
2003 Fallon Community Health Plan 7 Section 1
Bellingham Belmont
Berkley Berlin
Beverly Billerica
Blackstone Bolton
Boston Boxborough
Boxford Boylston
Braintree Bridgewater
Brimfield Brockton
Brookfield Brookline
Burlington Cambridge
Canton Carlisle
Charlton Chelmsford
Chelsea Clinton
Cohasset Concord
Danvers Dedham
Dighton Douglas
Dover Dracut
Dudley Dunstable
Duxbury East Bridgewater
East Brookfield East Walpole
Easton Erving
Essex Everett
Fall River Fitchburg
Foxborough Framingham
Franklin Freetown
Gardner Georgetown
Gloucester Grafton
Groton Groveland
Halifax

Hamilton Hanover
Hanscom AFB Hanson
Hardwick Harvard
Hathorne Haverhill
Hingham Holbrook
Holden Holland
Holliston Hopedale
Hopkinton Hubbardston
Hudson Hull
Ipswich Kingston
Lakeville Lancaster
Lawrence Leicester
Leominster Lexington
Lincoln Littleton
Lowell Lunenburg
Lynn Lynnfield
Malden Manchester
Mansfield Marblehead
Marlborough Marshfield
Mattapan Maynard
Medfield Medford
Medway Melrose
Mendon Merrimac
Methuen Middleborough
Middleton Milford
Millbury Millis
Millville Milton
Monson Nahant
Natick

Needham New Braintree
New Salem Newbury
Newburyport Newton
Norfolk North Andover
North Attleborough
North Billerica North Brookfield
North Chelmsford
North Reading Northborough
Northbridge Norton
Norwell Norwood
Oakham Orange
Oxford Palmer
Paxton Peabody
Pembroke Pepperell
Petersham Phillipston
Plainville Plympton
Princeton Quincy
Randolph Raynham
Reading Rehoboth
Revere Rockland
Rockport Rowley
Royalston Rutland
Salem Salisbury
Saugus Scituate
Seekonk Sharon
Sherborn Shirley
Shrewsbury Somerset
Somerville South Hamilton
South Walpole

Southborough Southbridge
Spencer Sterling
Stoneham Stoughton
Stow Sturbridge
Sudbury Sutton
Swampscott Swansea
Taunton Templeton
Tewksbury Three Rivers
Topsfield Townsend
Tyngsborough Upton
Uxbridge Village of Nagog
Woods Waban
Wales Walpole
Waltham Ware
Warren Warwick
Watertown Waverly
Wayland Webster
Wellesley Wendell
Wenham West Boylston
West Bridgewater
West Brookfield
West Newbury Westborough
Westford Westminster
Weston Westwood
Weymouth Whitman
Wilmington Winchendon
Winchester Winthrop
Woburn Worcester
Wrentham 10.
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2003 Fallon Community Health Plan 8 Section 1
Ordinarily, you must get your care from providers who contract with us. If you receive care outside our service area, we will pay only
for emergency care benefits. Some benefits are available for out-of-area students (see page 44). We will not pay for any other health
care services out of our service area unless the services have prior plan approval.

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 Fallon Community Health Plan 9 Section 3
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 Managements Privacy Practices is included.
A section on the Childrens 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 decrease by 13.5% for self only and increase by 42.7% for self and family.
We now have a 3-tier prescription drug copayment structure. See page 41.
Emergency room visit copays are now $50.
The Plan will provide coverage for autologous tandem transplants for testicular and other germ cell tumors. See page 31.
You no longer need to pick between Fallon Plus and Fallon Affiliates. 12.
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2003 Fallon Community Health Plan 10 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services from a Plan
provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use
your copy of the Health Benefits Election Form, SF-2809, your health benefits
enrollment confirmation (for annuitants), or your Employee Express confirmation letter.

If you do not receive your ID card within 30 days after the effective date of your
enrollment, or if you need replacement cards, call us at 1-800-868-5200 (TDD/TTY: 1-
877-608-7677) or write us at Fallon Community Health Plan, Customer Service
Department, 10 Chestnut St., Worcester, MA 01608. You may also request replacement
cards through our website at www.fchp.org.

Where you get covered care You get care from Plan providers and Plan facilities. You will only pay copayments, and you will not have to file claims.

Plan providers Plan providers are licensed physicians and other health care professionals in our service area that we contract with to provide covered services to our members.
We list Plan providers in the Provider Directory, which we update periodically. The
Provider Directory is also available on our website, www.fchp.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. We list these in the Provider Directory, which
we update periodically. The Provider Directory is also available on our website.
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.

Primary care Your primary care physician can be a family practitioner, internist, or pediatrician (or in some cases, a physician assistant or nurse practitioner who works under the supervision
of a plan 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, call Customer Service at 1-800-868-5200
(TDD/TTY: 1-877-608-7677). You can also change your primary care physician at our
web site at www.fchp.org.

If our contract with your primary care physician ends, we will notify you in writing either
30 days prior to the date the contract ends or as soon as we are notified of the
termination, whichever is later (except where the contract has been ended for reasons
involving fraud, patient safety or quality of care). You may continue to receive treatment
from your primary care physician for 30 days beyond the end of the contract.
If our contract with your primary care physician ends, you will be required to choose a
new primary care physician.

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.

What you must do
to get covered care 13.
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2003 Fallon Community Health Plan 11 Section 3
In some instances you can self-refer to a plan specialist. This means that you can call the
specialist and make the appointment yourself. You do not need to have a referral from
your primary care physician but you must see a Plan provider. You can self-refer for:

Services with a Fallon Clinic specialist (physician, physician assistant, nurse midwife, or nurse practitioner only) if you have a Fallon Clinic primary care
physician.
Obstetrical and gynecology services. This includes an annual exam, Pap smear, routine mammogram, and maternity care. It does not include infertility treatment or

inpatient admissions. If you are admitted to a hospital as an inpatient (for childbirth,
for example), you must notify the Plan of your admission.
Routine dental care by a Plan dentist. See section 5(h) for a description of covered dental services.

Visits to an oral surgeon for extraction of impacted teeth. Visits to an oral surgeon for any other procedure require a referral and Plan authorization.
Routine eye examinations with a Plan ophthalmologist or optometrist. Outpatient mental health and substance abuse services with Plan providers. Call 1-
888-421-8861 (TDD/TTY: 1-781-994-7660) to locate a Plan provider.
Authorization may be required for follow-up visits with these providers if they are
beyond the scope of what is described above. Authorization may also be required if a
provider to whom you have self-referred wishes to refer you elsewhere.

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 issue a standing referral to a
Plan specialist that allows you to see your specialist for a certain number of visits
without additional referrals. For standing referrals, your primary care physician and
specialist will work together to develop a treatment plan and the specialist must keep
your primary care physician up-to-date on your treatment.

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.

We will make pediatric specialty care available, including mental health care, provided by persons with recognized expertise in specialty pediatrics.

If you have a chronic or disabling condition and lose access to your specialist because we:
terminate our contract with your specialist for other than cause; or
drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB Plan; or

reduce our service area and you enroll in another FEHB Plan 14.
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2003 Fallon Community Health Plan 12 Section 3
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.

We will continue to pay for services of a specialist after our contract with the specialist
ends in the following circumstances:

If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can continue to see your specialist
until the end of your postpartum care, even if it is beyond the 90 days.

If you are terminally ill and our contract with a provider from who you are receiving treatment related to that illness ends, you may continue to receive treatment from that
provider.

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 customer
service department immediately at 1-800-868-5200 (TDD/TTY: 1-877-608-7677). 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.
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.

In most cases, your primary care physician can refer you to a specialist without prior
authorization from the Plan. Your primary care physician will provide you with a copy
of the referral form and then you can make an appointment with the specialist.

Examples of services that do not require Plan authorization:
Most specialty medical or surgical consultations with plan providers. In some cases, the specialist may need to obtain an additional referral from your primary care

physician and or authorization from the Plan to continue treatment.
Initial evaluations for chiropractic services, physical therapy, speech therapy, or occupational therapy. Plan authorization is required for additional visits.

Allergy injections for up to 12 months. Chemotherapy for up to 12 months.
Outpatient radiation therapy for up to 12 months. Many outpatient diagnostic tests.

Services requiring our
prior approval 15.
15 Page 16 17
2003 Fallon Community Health Plan 13 Section 3
In some instances your primary care physician will need to get prior authorization for a
specialty referral. An authorization is an assurance by the Plan that we have approved a
referral to a specialist. When your primary care physician needs prior authorization, he
or she will send a Request for Authorization to the Plan. We will review the request
and make an authorization decision within two working days of receipt of medical
information. We will inform your primary care physician of our decision within 24 hours
of the time that we make our decision.

If we authorize the service, we will send you and your primary care physician an
authorization letter within two working days of the decision. When you get your letter
with the authorization number, you can call the specialist to make your appointment. The
authorization letter will state the services that the Plan has approved for coverage. If the
specialist feels you need services beyond those authorized, the specialist will ask for
authorization from the Plan. If we approve the request for additional services, we will
send both you and your primary care physician an authorization letter.

If we do not authorize the specialty service, we will send you and your primary care
physician a denial letter within one working day of the decision. The letter will explain
our reasons for the decision and will describe your right to file a grievance.

Examples of services that do require prior authorization from the Plan:
Inpatient admissions to a hospital or other facility Services with non-Plan provider

Transplant evaluation services Podiatry consultations
Neuropsychological testing Pain clinic
Durable medical equipment
Plan physicians are freely able to recommend treatment options without restraint from the
Plan. As such, a referral or treatment recommendation does not guarantee that the service
is a covered benefit. It does not guarantee that the specialist is a Plan provider.
Therefore, if your primary care physician refers you to a specialist who is not a Plan
provider, you will be financially responsible unless a Plan authorization is issued.

Coverage of non-Plan providers Once you become a Plan member, we will generally only pay for services that you receive from Plan providers. However, there are some circumstances in which we will
temporarily pay for services that you receive from a non-plan provider, if you had been
receiving care from that provider prior to becoming a member:
If your prior primary care physician is not a participating provider in any health insurance plan that FEHB offers to you, we will pay for services from that provider

for 30 days from your effective date.
If you are receiving an ongoing course of treatment from a provider who is not a participating provider in any health insurance plan that FEHB offers to you, we will

pay for services from that provider for 30 days from your effective date.
If you are in the second or third trimester of pregnancy, and you are receiving services related to your pregnancy from a provider who is not a participating

provider in any health insurance plan that FEHB offers, we will pay for services
from that provider through your post-partum period.
If you are terminally ill, and you are receiving ongoing treatment from a provider who is not a participating provided in any health insurance plan that FEHB offers to

you, we will pay for your services from that provider until your death.
In all cases, the provider must agree to accept reimbursement for services at our rates and
adhere to our quality assurance standards, and other policies and procedures such as
obtaining appropriate referrals and prior authorizations. 16.
16 Page 17 18
2003 Fallon Community Health Plan 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 We do not have coinsurance.

out-of-pocket maximum We do not have a catastrophic protection out-of-pocket maximum.
Your catastrophic protection
out-of-pocket maximum 17.
17 Page 18 19
2003 Fallon Community Health Plan 15 Section 5
Section 5. Benefits --OVERVIEW
(See page 9 for how our benefits changed this year and page 64 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
claims forms, claims filing advice, or more information about our benefits, contact us at 1-800-868-5200 (TDD/TTY 1-877-608-7677)
or at our website at www.fchp.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......................................................28-33
Surgical procedures Reconstructive surgery Oral and maxillofacial surgery Organ/tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services.....................................................................................34-36
Inpatient hospital Outpatient hospital or ambulatory surgical center Extended care benefits/skilled nursing care facility benefits Hospice care
Ambulance
(d) Emergency services/accidents ..........................................................................................................................................................37-38
Medical emergency Ambulance

(e) Mental health and substance abuse benefits.....................................................................................................................................39-40
(f) Prescription drug benefits .................................................................................................................................................................41-43
(g) Special features ................................................................................................................................................................................ 44-45
Flexible benefits option

Services for the hearing impaired
Interpreter services
Peace of Mind Program
Out-of-area student coverage
(h) Dental benefits...................................................................................................................................................................................46-47
(i) Non-FEHB benefits available to Plan members ................................................................................................................................... 48
Summary of benefits...................................................................................................................................................................................... 64 18.
18 Page 19 20
2003 Fallon Community Health Plan 16 Section 5(a)
Section 5 (a). Medical services and supplies provided by physicians
and other health care professionals

I M
P O
R T
A N
T

Here are some important things 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, or valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

I M
P O
R T
A N
T

Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians and other health care professionals
In physicians office
Office medical consultation
Second surgical opinion
In an urgent care center

$10 per office visit

Professional services of physicians
During a hospital stay
In a skilled nursing facility

Nothing

Professional services of physicians
At home
$10 per visit 19.
19 Page 20 21
2003 Fallon Community Health Plan 17 Section 5(a)
Lab, X-ray and other diagnostic tests
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
Cat Scans/MRI
Ultrasound
Electrocardiogram and EEG

Nothing
(If you receive these services during an
office visit, the $10 copay applies to the
office visit only)

Preventive care, adult
Routine screenings, such as:
Total Blood Cholesterol once every three years
Fasting lipoprotein profile (total cholesterol, LDL, HDL and triglycerides) once every five years for adults age 20 and over

Nothing
(If you receive these services during an
office visit, the $10 copay applies to the
office visit only)

Routine Prostate Specific Antigen (PSA) test one annually for men age 40
and older
Nothing

(If you receive these services during an
office visit, the $10 copay applies to the
office visit only)

Colorectal Cancer Screening, including
Fecal occult blood test
Sigmoidoscopy once every five years starting at age 50; or
Colonoscopy once every 10 years starting at age 50; or
Double contrast barium enema once every 5 to 10 years starting at age 50.

Nothing
(If you receive these services during an
office visit, the $10 copay applies to the
office visit only)

Routine Pap test Nothing
(If you receive these services during an
office visit, the $10 copay applies to the
office visit only)

Preventive Care -Adult --continued on next page 20.
20 Page 21 22
2003 Fallon Community Health Plan 18 Section 5(a)
Preventive care, adult (continued) You pay
Routine mammogramcovered for women age 35 and older, as follows:
From age 35 through 39, one during this five year period
From age 40 and up, one every calendar year

Nothing

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

Routine immunizations, limited to:
Tetanus-diphtheria (Td) booster once every 10 years, ages19 and over (except as provided for under Childhood immunizations)

Influenza vaccine, annually, age 65 and over
Pneumococcal vaccine, age 65 and over

Nothing
(If you receive these services during an
office visit, the $10 copay applies to the
office visit only)

Preventive care, children
Childhood immunizations recommended by the American Academy of Pediatrics Nothing
(If you receive these services during an
office visit, the $10 copay applies to the
office visit only)

Well-child care, routine examinations and immunizations from birth to age 22

Screening of all children under six years of age for the presence of lead poisoning
Eye and ear examinations for children through age 17, to determine the need for vision and hearing correction
Physical examination, history, measurements, sensory screening, neuropsychiatric evaluation and development screening six times
during the childs first year after birth, three times during the next
year, annually until age six

Tuberculin tests, hematocrit, hemoglobin or other appropriate blood tests, and urinalysis as recommended by the physician

$10 per office visit 21.
21 Page 22 23
2003 Fallon Community Health Plan 19 Section 5(a)
Maternity care You pay
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Note: Here are some things to keep in mind:

You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will extend

your inpatient stay if medically necessary.
We cover routine nursery care of the newborn child during the covered portion of the mothers maternity stay, such as nursery

charges, circumcision, routine examination, heredity and metabolic
screening, newborn hearing screening and medically necessary
treatments of congenital defects, birth abnormalities or premature
birth.

We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self and Family

enrollment.
We 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 for prenatal
care; all other prenatal visits covered-in-full

$10 for each office visit for post natal care

Not covered: Routine sonograms to determine fetal age, size or sex All charges.
Family planning
A broad range of voluntary family planning services, limited to:
Consultations, examinations, procedures and medical services related to the use of all contraceptive methods

Oral contraceptives
Voluntary sterilization (See Surgical procedures Section 5 (b)
Injectable contraceptive drugs (such as Depo Provera)
Diaphragms
Intrauterine devices (IUDs)
Surgically implanted contraceptives (such as Norplant)
NOTE: Contraceptive drugs and devices dispensed at a Plan pharmacy
are subject to the to the appropriate prescription medication copayment.
Contraceptive drugs and devices supplied by a Plan provider during an
office visit are covered under the Plan medical benefit.

$10 per office visit

Not covered: reversal of voluntary surgical sterilization, genetic
counseling, over-the-counter birth control preparations or devices
All charges. 22.
22 Page 23 24
2003 Fallon Community Health Plan 20 Section 5(a)
Infertility services You pay
Diagnosis and treatment of infertility, such as:
Office visits for the evaluation and diagnosis of infertility
Diagnostic laboratory and x-ray services
Fertility drugs
Artificial insemination
In vitro fertilization (IVF)
Gamete Intrafallopian transfer (GIFT)
Zygote intrafallopian transfer (ZIFT)
Intracytoplasmic sperm injection
Sperm, egg and/or inseminated egg procurement and processing, and banking of sperm or inseminated eggs

To be eligible, you must be an individual who:
(1) is unable to conceive or produce conception during a period of one
year; and
(2) should expect fertility as a natural state; or
(3) is a pre-menopausal female or a female who is experiencing
menopause at a premature age.

Approval for Assisted Reproductive Technology (ART) is contingent
upon review of your medical history by the Plan Medical Director. Initial
approval covers 4 ART cycles, if you wish to continue beyond 4 cycles,
further medical review by the Plan Medical Director is required.

A benefits pamphlet is available by contacting our Customer Service
Department at 1-800-868-5200 (TDD/TTY: 1-877-608-7677).

Note: We cover injectable fertility drugs under the medical benefit and
oral fertility drugs under the prescription drug benefit.

$10 per office visit

Not covered:
Treatments, services and supplies which have not been determined to be medically necessary

Donor egg transfer for women who are menopausal, except as stated above
Chromosome studies of a donor (sperm or egg) Charges for the storage of donor sperm, eggs, or embryo that remain
in storage after the completion of an approved treatment cycle
Compensation to a donor (this does not include charges related to the procurement and processing of sperm, egg, and inseminated egg, to

the extent that the donors insurance does not cover these costs)
Supplies that may be purchased without a physicians written order, such as ovulation test kits

Services which are necessary due to a voluntary sterilization, of for which there is no diagnosis of infertility
Surrogacy or gestational carrier services Transportation costs to or from the medical facility

All charges. 23.
23 Page 24 25
2003 Fallon Community Health Plan 21 Section 5(a)
Allergy care
Testing and treatment
Allergy injection
$10 per office visit

Allergy serum Nothing
Not covered: provocative food testing and sublingual allergy
desensitization
All charges.

Treatment therapies You pay
Chemotherapy
Note: High dose chemotherapy in association with autologous bone
marrow transplants is limited to those transplants listed under
Organ/Tissue Transplants on page 31.

Radiation therapy
Respiratory and inhalation therapy
Note: Drug therapies for the treatments of respiratory diseases are
covered under the prescription drug benefit.

Dialysis hemodialysis and peritoneal dialysis
Intravenous (IV)/Infusion Therapy home IV and antibiotic therapy
Growth hormone therapy (GHT)
Note: We will only provide coverage for the use of growth hormone
therapy when it has been pre-approved by the Plan. Your Plan
physician will ask us to authorize GHT before you begin treatment;
otherwise, we will only cover GHT services from the date you submit
the information. If you do not ask or if we determine GHT is not
medically necessary, we will not cover the GHT or related services and
supplies. See Services requiring our prior approval in Section 3.

Nothing except where noted. (Treatment
therapies are covered in full when ordered,
supplied and administered by a Plan
physician.) 24.
24 Page 25 26
2003 Fallon Community Health Plan 22 Section 5(a)
Physical and occupational therapies
Up to 60 consecutive days or 20 nonconsecutive visits (whichever is greater) per condition per calendar year for:

Physical therapy Occupational therapy

Note: We only cover therapy to restore bodily function when there has
been a total or partial loss of bodily function due to illness or injury.

Cardiac rehabilitation for persons with documented cardiovascular
disease.

$10 per office visit
Nothing per visit during covered inpatient
admission

Early intervention services provided by certified early intervention
specialists as defined in the early intervention operational standards
developed by the Department of Public Health for children through
age 3. Benefits are limited to a maximum of $3,200 per year per child
and an aggregate of $9,600 over the term of the childs Plan
membership.

Nothing

Not covered:
long-term rehabilitative therapy exercise programs

massage therapy

All charges.

Speech therapy
Services for the diagnosis and treatment of speech, hearing and
language disorders by licensed, plan-affiliated speech-language
pathologists or audiologists.

Note: Coverage shall not extend to the diagnosis or treatment of
speech, hearing and language disorders in a school-based setting.

$10 per office visit
Nothing per visit during covered inpatient
admission 25.
25 Page 26 27
2003 Fallon Community Health Plan 23 Section 5(a)
Hearing services (testing, treatment, and supplies) You pay
Hearing testing for children through age 17 (see Preventive care, children) $10 per office visit

Not covered:
all other hearing testing hearing aids, testing and examinations for them All charges.

Vision services (testing, treatment, and supplies)
Diagnosis and treatment of diseases of the eye $10 per office visit

Routine eye exam to determine the need for vision correction, once per 12-month period (including written prescriptions for eyeglasses)
Note: See Preventive care, children for eye exams for children
$10 per office visit

Not covered:
Eyeglasses or contact lenses Eye examinations for contact lenses

Eye exercises and orthoptics Radial keratotomy and other refractive surgery

All charges. 26.
26 Page 27 28
2003 Fallon Community Health Plan 24 Section 5(a)
Foot care You pay
Routine foot care when you are under active treatment for a metabolic
or peripheral vascular disease, such as diabetes.

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

$10 per office visit

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

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

treatment is by open cutting surgery)

All charges.

Orthopedic and prosthetic devices
Orthopedic devices (devices that support part of the body and/or
eliminate motion) such as neck collars for cervical support, molded
body jacket for curvature of the spine, and braces with rigid support

Prosthetic devices (devices that replace all or part of an organ or body
part, not including dental) such as artificial limbs and eyes, implanted
corrective lenses following cataract surgery, and electric speech aids

Note: All orthopedic and prosthetic devices must be ordered by a Plan
physician and authorized by the Plan

Nothing up to the benefit limit of $1500 per
calendar year. You pay all charges beyond
the benefit limit.

Orthopedic and prosthetic devices and
durable medical equipment are subject to a
combined benefit limit.

Scalp hair prosthesis (wigs) for individuals who have suffered hair loss
as a result of the treatment of any form of cancer or leukemia
Nothing up to the benefit limit of $350 per
calendar year. You pay all charges beyond
the benefit limit.

Externally worn breast prostheses and surgical bras, including
necessary replacements, following a mastectomy

Internal prosthetic devices, such as artificial joints, pacemakers,
cochlear implants, and surgically implanted breast implant following
mastectomy. Note: We pay internal prosthetic devices as hospital
benefits; see Section 5(c) for payment information. See 5(b) for
coverage of the surgery to insert the device.

Corrective orthopedic appliances for non-dental treatment of
temporomandibular joint (TMJ) pain dysfunction syndrome.

Nothing

Orthopedic and prosthetic devices-Continued on next page 27.
27 Page 28 29
2003 Fallon Community Health Plan 25 Section 5(a)
Orthopedic and prosthetic devices (Continued) You pay
Not covered:
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)
Rental or purchase, at our option, including repair and adjustment, of
durable medical equipment prescribed by your Plan physician and
authorized by the Plan, such as

crutches
wheelchairs
walkers
hospital beds
blood glucose monitors
insulin pumps therapeutic/molded shoes and shoe inserts for the treatment of severe

diabetic foot disease
visual magnifying aids and voice synthesizers for blood glucose monitors for use by the legally blind

Nothing up to the benefit limit of $1500 per
calendar year. You pay all costs over and
above the benefit limit.

Orthopedic and prosthetic devices and
durable medical equipment are subject to a
combined benefit limit.

oxygen and oxygen equipment Nothing
Not covered:
Items that are not covered include, but are not limited to air conditioners, air purifiers, arch supports, ear plugs (to prevent fluid

from entering the ear canal during water activities), foot orthotics,
orthopedic shoes (except when part of a brace) or other supportive
devices for the feet, articles of special clothing, Jobst stockings,
bed-pans, raised toilet seats, dehumidifiers, dentures, elevators,
safety grab bars, car seats, seizure helmets, hearing aids, heating
pads, hot water bottles, exercise equipment or similar equipment.
Oxygen and related equipment when received from a non-plan provider. This includes oxygen and related equipment that you are

supplied with while you are out of our service area.

All charges. 28.
28 Page 29 30
2003 Fallon Community Health Plan 26 Section 5(a)
Home health services You pay
Home health care ordered by a Plan physician and authorized by the Plan.
Services include:

skilled nursing care
physical, occupational and speech therapy
oxygen and intravenous therapy
medical social services
home health aide services
medical and surgical supplies and durable medical equipment
nutritional consultation
medication visits to monitor, evaluate or adjust the prescription medication dosage that is being prescribed for a medical or

psychological condition
Note: Durable medical equipment provided as part of your home health
care services is not counted toward the annual limit

Nothing

Not covered:
nursing care requested by, or for the convenience of, the patient or the patients family;

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

All charges.

Chiropractic
Chiropractic services for acute musculoskeletal conditions. The condition
must be new or an exacerbation of a previous condition. Treatment must
be provided by a Plan chiropractor and requires a referral from your
primary care physician. Coverage is provided for up to 20 visits in each
calendar year.

$10 per office visit (visits 1-10)
$25 per office visit (visits 11-20) 29.
29 Page 30 31
2003 Fallon Community Health Plan 27 Section 5(a)
Alternative treatments You pay
Not covered:
naturopathic services aquatic therapy

hypnotherapy biofeedback

All charges.

Educational classes and programs
Diabetes self-management training and education, including medical nutrition therapy, provided by a certified diabetes health care provider $10 per office visit

Smoking Cessation Program
Up to $100 for one smoking cessation program per member per
lifetime, including all related expenses such as drugs.

Nothing

Health education and nutrition services, such as library services, nutrition classes and programs, behavioral medicine and womens
wellness.

The Fallon Foundation offers many health education programs and
classes at the Lifetime Center for Family Health, 630A Plantation St.,
Worcester, for those who want to take a more active role in their
healthcare. (Similar classes and programs may be available in other
locations through Plan-affiliated hospitals.) In addition, the Lifetime
Center offers a variety of free brochures and booklets that provide
information about wellness, prevention and coping with various
illnesses.

Copayments vary, call Customer Service (1-
800-868-5200) or the Lifetime Center for
Family Health (1-800-891-233) for details 30.
30 Page 31 32
2003 Fallon Community Health Plan 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

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.

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 PRIOR AUTHORIZATION FOR SOME SURGICAL PROCEDURES. Please refer to the prior authorization information shown in Section 3 to be sure which services require
authorization and identify which surgeries require prior authorization.

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 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 5(a) Orthopedic and prosthetic devices for device coverage information.

Voluntary sterilization (e.g., Tubal ligation, Vasectomy) Treatment of burns
Note: Generally, we pay for internal prostheses (devices) according to
where the procedure is done. For example, we pay hospital benefits for
a pacemaker and Surgery benefits for insertion of the pacemaker.

$10 per office visit
Nothing for services in a hospital
outpatient or ambulatory surgical center

Nothing for inpatient hospital visits

Not covered:
Reversal of voluntary sterilization Routine treatment of conditions of the foot; see Foot care. All charges. 31.
31 Page 32 33
2003 Fallon Community Health Plan 29 Section 5(b)
Reconstructive surgery
Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if: the condition produced a major effect on the members

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

Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of
congenital anomalies are: protruding ear deformities; cleft lip; cleft
palate; birth marks; webbed fingers; and webbed toes.

$10 per office visit
Nothing for services in a hospital
outpatient or ambulatory surgical center

Nothing for hospital visits

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

Note: 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.

$10 per office visit
Nothing for services in a hospital outpatient
or ambulatory surgical center

Nothing for hospital visits

Breast prostheses and surgical bras and replacements (see Prosthetic
devices, Section 5(a))

Nothing

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

through change in bodily form, except repair of accidental injury
Surgeries related to sex transformation

All charges. 32.
32 Page 33 34
2003 Fallon Community Health Plan 30 Section 5(b)
Oral and maxillofacial surgery
Oral surgical procedures, limited to:
Evaluation and treatment of temporomandibular joint disorder when a medical condition is diagnosed;

Removal or exposure of impacted teeth; 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; and
Other surgical procedures that do not involve the teeth or their supporting structures.

$10 per office visit

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

the periodontal membrane, gingival, and alveolar bone)

All charges. 33.
33 Page 34 35
2003 Fallon Community Health Plan 31 Section 5(b)
Organ/tissue transplants You pay
Services must be provided at a Plan-affiliated facility, subject to your
acceptance into the facilitys program. The transplant facility makes the
final determination on eligibility for transplant coverage. The plan may
require that members receive their transplant at a specified facility.

If a covered bone marrow transplant is not available from Plan provider,
benefits will be paid at the same benefit level for services rendered by a
non-Plan provider.

Limited to:
Cornea
Heart Heart/lung transplant for patients under age 60 with end-stage

primary or secondary pulmonary hypertension
Intestinal transplants (small intestine) and the small intestine with the liver or small intestine with multiple organs such as the liver, stomach,

and pancreas
Kidney
Liver Lung transplant for patients under age 60 with end-stage obstructive

or restrictive pulmonary disease
Allogeneic (donor) bone marrow transplants for leukemia, aplastic anemia, severe combined immunodeficiency disease, Wiskott-

Aldrich syndrome, or for patients with high-risk lymphoblastic
lymphoma in remission, or patients under 60 with myelodysplasia.
Autologous bone marrow transplants (autologous stem cell and peripheral cell cell support) for acute lymphocytic or non-

lymphocytic leukemia, resistant non-Hodgkins disease or advanced
Hodgkins disease, recurrent or refractory neuroblastoma, or for
persons diagnosed with breast cancer that has progressed to
metastatic disease, or for persons under age 65 with chemo-
responsive multiple myeloma.
Autologous tandem transplants for testicular, mediastinal, retroperitoneal and ovarian germ cell tumors

Human Leukocyte (HLA) or histocompatibility locus antigen testing for A, B, or DR antigens, or any combination thereof, necessary to
establish bone marrow transplant donor suitability
Autologous tandem transplants for testicular, mediastinal, retroperitoneal, and ovarian germ cell tumors

Limited Benefits -Treatment for 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 Plans medical director in
accordance with the Plans protocols.

Note: We cover related medical and hospital expenses of the donor
when we cover the recipient.

Nothing

Not covered:
Implants of artificial organs Transplants not listed as covered

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

All charges. 34.
34 Page 35 36
2003 Fallon Community Health Plan 32 Section 5(b)
Not covered continued
Services for the organ donor that are covered by another insurance plan

Services for the organ donor if the recipient is not a member of this Plan
Transportation, housing or home cleaning services incurred by either the donor or the recipient 35.
35 Page 36 37
2003 Fallon Community Health Plan 33 Section 5(b)
Anesthesia You pay
Professional services provided in:
Hospital (inpatient) Hospital outpatient department

Skilled nursing facility Ambulatory surgical center

Nothing

Professional services provided in:
Physicians Office
$10 per office visit 36.
36 Page 37 38
2003 Fallon Community Health Plan 34 Section 5(c)
Section 5 (c). Services provided by a hospital or other facility,
and ambulance services

I M
P O
R T
A N
T

Here are some important things 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 PRIOR AUTHORIZATION FOR HOSPITAL STAYS. Please refer to Section 3 to be sure which services require PRIOR AUTHORIZATION.

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; and

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.

Nothing

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

Diagnostic laboratory tests and X-rays Administration of blood and blood products
Blood or blood plasma Dressings, splints, casts, and sterile tray services
Medical supplies and equipment, including oxygen Anesthetics, including nurse anesthetist services
Take-home items Medical supplies, appliances, medical equipment, and any covered
items billed by a hospital for use at home

Nothing

Not covered:
Custodial care Non-covered facilities, such as nursing homes, schools

Personal comfort items, such as telephone, television, barber services, guest meals and beds
Private nursing care

All charges 37.
37 Page 38 39
2003 Fallon Community Health Plan 35 Section 5(c)
Outpatient hospital or ambulatory surgical center You pay
Operating, recovery, and other treatment rooms Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology services Administration of blood, blood plasma, and other biologicals
Blood and blood plasma Pre-surgical testing
Dressings, casts, and sterile tray services Medical supplies, including oxygen
Anesthetics and anesthesia service
NOTE: We cover hospital services and supplies related to dental
procedures when necessitated by a non-dental physical impairment. We
do not cover the dental procedures.

Nothing

Extended care benefits/skilled nursing care facility benefits
The Plan covers inpatient services in a skilled nursing facility for up to
100 days in each calendar year.

You may be admitted to a skilled nursing facility if, based on your
medical condition, you need daily skilled nursing care, skilled
rehabilitation services or other medical services that may require access
to 24-hour medical care but does not require the specialized care of an
acute care hospital.

Services provided are:
Room and board in a semiprivate room (or private room if medically necessary)

The services and supplies that would ordinarily be furnished to you while you are an inpatient. These include, but are not limited to,
nursing services, physical, speech and occupational therapy,
medical supplies and equipment.

Drugs, biologicals, equipment and supplies ordinarily provided or arranged by the skilled nursing facility, when prescribed by a Plan

physician.

Nothing

Not covered: custodial care, or personal comfort items such as
telephone, radio or television
All charges. 38.
38 Page 39 40
2003 Fallon Community Health Plan 36 Section 5(c)
Hospice care You pay
The Plan provides coverage for hospice care services. Hospice care is a
method of caring for the terminally ill that helps those individuals
continue their lives with as little disruption as possible. This type of
care emphasizes supportive services, such as home care and pain
control, rather than the cure-oriented services that are provided in
hospitals. To be eligible for hospice care you must be terminally ill
with a life expectancy of less than six months.

Services are provided, as necessary, to maintain the terminally ill
individual at home such as:
Physicians services, nursing care and medical social services Medical appliances and supplies including drugs and biologicals

(prescription copayments may apply)
Inpatient respite care in a Plan affiliated facility (hospice or skilled nursing) for up to five consecutive days

Nothing

Not covered: Independent nursing, homemaker services All charges.
Ambulance
Ambulance transportation when medically appropriate Nothing 39.
39 Page 40 41
2003 Fallon Community Health Plan 37 Section 5(d)
Section 5 (d). Emergency services/accidents
I M
P O
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Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

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

What to do in case of emergency:
Emergency Care
The plan covers emergency care worldwide. When you have a medical emergency (as described above) you should go to the
nearest emergency room for care or call your local emergency communications system (e.g., police or fire department, or
911) to request ambulance transportation.

Emergency services do not require referral or authorization, but you or someone on your behalf must notify the Plan of any
emergency services that you receive within 48 hours or as soon as is medically possible. You should also notify your
primary care physician. Your primary care physician will work with the Plan to assure that any follow-up or continuing care
that is medically necessary will be arranged for you.

If you need to be hospitalized the Plan must be notified as soon as reasonably possible. If you are hospitalized in a non-Plan
facility and Plan doctors believe care can be better provided in a Plan hospital, you would be transferred when medically
appropriate.

Urgent Care within our service area:
Sometimes you may need care for minor medical emergencies such as cuts that require stitches or a sprained ankle. If you
are within the Plan service area, call your primary care physicians office for information on how and where to seek
treatment. If your doctor is not available, a doctor on call will make arrangements for your care. Doctors telephones are
answered 24 hours a day, seven days a week. Explain the medical situation to the doctor and state where you are calling
from so that the doctor can refer you to the most appropriate facility.

Urgent Care outside our service area:
If you have a minor medical emergency and you are outside our service area, go to the nearest medical facility for care. You
or someone on your behalf must notify the Plan within 48 hours or as soon as is medically possible. You should also notify
your primary care physician if you need follow-up care. 40.
40 Page 41 42
2003 Fallon Community Health Plan 38 Section 5(d)
Benefit Description You pay
Emergency within our service area
Emergency care at a doctor's office Emergency care at an urgent care center $10 per visit

Emergency care as an outpatient or inpatient at a hospital, including doctors' services $50 copay (waived if admitted or held in an observation room)

Not covered: Elective care or non-emergency care All charges.
Emergency outside our service area
Emergency care at a doctor's office Emergency care at an urgent care center S10 per visit

Emergency care as an outpatient or inpatient at a hospital, including doctors services $50 copay (waived if admitted or held in an observation room)
Not covered:
Elective 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 when medically appropriate (See
Section 5(c) for non-emergency ambulance services).
Nothing

Not covered:
Air ambulance when not appropriate to medical or geographic condition

Transfers between hospitals when the patients medical condition does not warrant that he/she be transported to another facility

All charges. 41.
41 Page 42 43
2003 {Insert HMO Plan name} 39 Section 5(e)
Section 5 (e). Mental health and substance abuse benefits
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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.

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.
YOU MUST GET PRIOR AUTHORIZATION FOR SOME OF THESE SERVICES. See the instructions after the benefits description below.

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Benefit Description You pay
Mental health and substance abuse benefits
All diagnostic and treatment services recommended by a Plan provider
and contained in a treatment plan that we approve. The treatment plan
may include services, drugs, and supplies described elsewhere in this
brochure.

Note: Plan benefits are payable only when we determine the care is
medically necessary to treat your condition and only when you receive
the care as part of a treatment plan that we approve.

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

Professional services, including individual or group therapy by
providers such as psychiatrists, psychologists, or clinical social
workers

Medication management

$10 per visit

Mental health and substance abuse benefits -continued on next page 42.
42 Page 43 44
2003 {Insert HMO Plan name} 40 Section 5(e)
Mental health and substance abuse benefits (continued) You pay
Diagnostic tests Nothing

Services provided by a hospital or other facility
Services in approved alternative care settings such as partial
hospitalization, residential treatment, full-day hospitalization, facility
based intensive outpatient treatment

Nothing

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

All charges.

Prior authorization To be eligible to receive these benefits you must follow the following authorization processes:
You may self-refer for outpatient mental health or substance abuse services with a Plan
provider. Read Section 3, Specialty care, for information about self-referral. For
assistance in finding a contracted provider, call 1-888-421-8861 (TDD/TTY: 781-994-
7660).

Inpatient services require prior authorization. To access inpatient mental health or
substance abuse services, call 1-888-421-8861 (TDD/TTY: 781-994-7660).

Limitation We may limit your benefits if you do not obtain a treatment plan. 43.
43 Page 44 45
2003 Fallon Community Health Plan 41 Section 5(f)
Section 5 (f). Prescription drug benefits
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Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart beginning on the next page.
All benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.

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There are important features you should be aware of. These include:
Who can write your prescription. A licensed Plan provider or a provider who you have seen on an authorized referral can write your prescription.

Where you can obtain them. You must fill the prescription at a Plan pharmacy, or through a Plan-affiliated mail order pharmacy supplier. See your Provider Directory for a list of plan pharmacies.
We use a formulary. Our formulary is a list of medications that shows the copayment tier and prior authorization requirements for each medication. We have selected the tiers and determined the criteria for
prior authorization based on efficacy and cost effectiveness. Coverage of certain drugs is based on medical
necessity. They are shown on the formulary as MN. Your physician must get prior authorization from the
Plan before writing a prescription for these drugs.

The formulary has a three-tiered copayment structure. There is a different copayment for each tier. Tier 1
drugs have the lowest copayment. Tier 2 drugs have the next lowest copayment, and Tier 3 drugs have the
highest copayment. All drugs on the formulary have been approved for sale and distribution by the U. S.
Food and Drug Administration (FDA).

Any drug not shown on the formulary will be considered a Tier 3 drug. Your physician must get prior
approval from the Plan before writing a prescription for these drugs.

These are the dispensing limitations. Prescription drugs are generally dispensed for up to a 30-day supply. Occasionally, for safety reasons or as directed by your physician, the length of therapy will be less than 30

days. For maintenance medications, your prescription may be for a 90-day supply. We follow FDA
dispensing guidelines. You generally cannot obtain a refill until most or all of the previous supply has been
used.

A generic drug is a drug product that meets the approval of the FDA and is equivalent to a brand name
product in terms of quality and performance. You will generally receive a generic drug from plan pharmacies
anytime one is available, unless your doctor has directed the pharmacist to only dispense a specific brand
name drug. However, some drugs do not have a generic equivalent. In both of these cases you will receive
the brand name drug and you will be responsible for the copayment for that drug. 44.
44 Page 45 46
2003 Fallon Community Health Plan 42 Section 5(f)
Why use generic drugs? Generic drugs offer a safe and economic way to meet your prescription drug needs. The generic name of a drug is its chemical name; the name brand is the name under which the manufacturer
advertises and sells a drug. Under Federal law, generic and brand name drugs must meet the same standards
for safety, purity, strength and effectiveness. A generic prescription costs you and us less than a brand
name prescription.

When you have to file a claim. If you need an emergency prescription as part of an approved emergency treatment while you are out of the Plan service area, the Plan will reimburse you (less the appropriate
copayment) for up to a 14-day supply of medication. Claims can be submitted to Fallon Community Health
Plan, Claims Department, P. O. Box 15121., Worcester, MA 01615-0121.

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 or through our mail order
program:

Drugs and medicines that by Federal law of the United States require a physicians prescription for their purchase, except those
listed as Not covered.
Diabetic supplies and medications, including insulin, insulin syringes, blood glucose monitoring strips, urine glucose strips,

ketone strips, lancets, insulin pumps, insulin pump supplies and
insulin pens.
Disposable needles and syringes for the administration of covered medications

Fertility drugs Drugs for sexual dysfunction (requires prior authorization from the
Plan)
Contraceptive drugs

Emergency prescriptions (up to a 14-day supply) provided out of the service area as part of an approved emergency treatment

Off-label use of covered drugs in the treatment of HIV, AIDS or cancer

Note: Injectables administered in a doctors office or under professional
supervision are generally covered under the medical benefit.

At a Plan pharmacy:
Tier 1: $5 copay for up to a 30-day supply
Tier 2: $15 copay for up to a 30-day supply
Tier 3: $35 copay for up to a 30-day supply

Mail Order:
Tier 1: $3 copay for up to a 30-day supply
Tier 2: $13 copay for up to a 30-day supply
Tier 3: $33 copay for up to a 30-day supply

Covered medications and supplies --continued on next page 45.
45 Page 46 47
2003 Fallon Community Health Plan 43 Section 5(f)
Covered medications and supplies (continued) You pay
The Plan covers the special medical formulas and food products limited to
those listed below. Prior authorization is required.

Special medical formulas for the treatment of phenylketonuria, tyrosinemia, homcystinuria, maple syrup disease, propionic acidemia,

or methylmalonic acidemis in infants and children or to protect the
unborn fetuses of pregnant women with phenylketonuria.

Enteral formulas for home use for which a physician has issued a written order and which are necessary for the treatment of

malabsorption caused by Crohns disease, ulcerative colitis,
gastroesophageal reflux, gastrointestinal motility, chronic intestinal
pseudo-obstruction, and inherited diseases of amino acids and organic
acids.

Nothing

Food products modified to be low in protein for individuals that have been diagnosed with phenylketonuria and other inherited
diseases of amino acids and organic acids.
Nothing up to a maximum of $2500 per
calendar year

Not covered:
Drugs and supplies for cosmetic purposes
Drugs to enhance athletic performance
Drugs obtained at a non-Plan pharmacy; except for out-of-area emergencies

Vitamins, nutrients and food supplements even if a physician prescribes or administers them
Nonprescription medicines, over-the-counter preparations and devices, and medical supplies such as dressings and antiseptics

Drugs that are investigational or that have not been approved for general sale and distribution by the U.S. Food and Drug
Administration

Nicotine patches, and gum or other smoking cessation products unless supplied to you as part of an approved smoking cessation
program.

All charges. 46.
46 Page 47 48
2003 Fallon Community Health Plan 44 Section 5(h)
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.

Out-of-area student
coverage

Students attending school outside the plan service area may not have easy access to the Plan provider network. They are covered for a limited number of services while out-of-
area, if authorized in advance by the Plan. These services include:
Nonroutine medical office visits
Diagnostic lab and X-ray connected with a nonroutine office visits
Non-elective inpatient services if the plan is notified within 48 hours of admission
Outpatient services to treat the abuse of or addiction to alcohol or drugs, up to 20 office visits in each calendar year while out of the plan service area

Outpatient services to diagnose and/or treat mental conditions
Short-term rehabilitation services, including physical, occupational and speech therapy. Coverage for physical and occupational therapy is provided for up to 20

office visits in each calendar year per illness or injury (combined with any in-area visits). Coverage for speech therapy is determined by medical necessity

Aside from emergency care, the services listed above are the only services that are
covered for students on an out-of-network basis. To be covered, all other services must be
obtained when they return to the Plan service area.

Services that are not covered for students while out of the Plan service area include:
Routine physical, gynecological exams, vision screening and hearing screening Routine preventive care

Nonemergency prescription medication. You may use the prescription medication mail order program to fill medication refills. (See pages 41-42.)
Second opinion Preventive dental care or minor restorative care (e.g., fillings)
Chiropractic care services Home health care
Outpatient surgical procedures that could be delayed until return to the plan service area
Maternity care or delivery Durable medical equipment (e.g., wheelchairs), including maintenance or
replacement 47.
47 Page 48 49
2003 Fallon Community Health Plan 45 Section 5(h)
Section 5 (g). Special features
Interpreter Services We will, upon request, provide members with interpreters and translation services related to our administrative procedures.

Services for the hearing
impaired

You may access our TDD/TTY equipment at 1-877-608-7677

Peace of Mind Program Our Peace of Mind Program provides access to specialty services at specified Boston area medical centers. You may access Peace of Mind Program providers if you meet the following conditions;
Care is for covered services as described in this brochure. The same copayments and benefit limits apply
You have seen a Plan specialist for this condition within the past three months
A referral to a specific Peace of Mind Program physician is made by your primary care physician and notification is given to the plan that you are accessing that

specialist through the Peace of Mind Program
The physician to whom you are referred is on staff at one of the six medical centers listed below:

Massachusetts General Hospital
Brigham and Womens Hospital
Childrens Hospital (Boston)
Dana-Farber Cancer Institute
New England Medical Center
Boston IVF (for infertility services only)
Once the plan has been notified of the Peace of Mind Program referral to a specific
physician, you may arrange an appointment to see this specialist for a consultation. You
may continue treatment with this specialist or you may return to a Plan provider for care
at any time, so long as you obtain appropriate authorization. If you wish to see any other
Peace of Mind Program provider, you must request a separate referral from your
primary care physician and the plan must be notified of your request, and the request
must meet the conditions listed above.

You should advise your Peace of Mind Program provider that all laboratory, x-ray services and tests must be authorized in advance by the Plan. To ensure coverage, the
Peace of Mind Program provider should work with the Plans Peace of Mind Program Coordinator to make arrangements for these services. Whenever practical,
arrangements will be made for these services to be performed by Plan providers. Unauthorized services will not be covered. You should not rely on an assurance from the
Peace of Mind Program provider that a service will be covered by the Plan. Services must be authorized by the Plan to be covered.

You may use the Peace of Mind Program for all specialty care except mental health, substance abuse, chiropractic services, obstetrics or dental care. You may not use the
Peace of Mind Program for any primary care services, including internal medicine, family practice or pediatrics. If you have not met the conditions listed above, or if you or
your physician has not obtained Plan authorization for a Peace of Mind Program service, the service will not be covered by the Plan and the Peace of Mind Program
provider may hold you financially responsible. 48.
48 Page 49 50
2003 Fallon Community Health Plan 46 Section 5(h)
Section 5 (h). Dental benefits
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Plan dentists must provide or arrange your care.
We cover hospitalization for dental procedures only when a nondental physical impairment exists which makes hospitalization necessary to safeguard the health of the patient; we do not cover the dental procedure unless it is

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

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Accidental injury benefit You pay

We cover emergency medical care such as to relieve pain and stop
bleeding as a result of an accidental injury to sound natural teeth or
tissues, when provided as soon as medically possible after the injury.
You do not need authorization for emergency care needed as a result of
dental trauma. Go to the closest dentist and notify us within 48 hours of
receiving care.

Note: This accidental injury benefit does not include restorative or other
dental services.

$10 per office visit

Out-of-Area care
While you are out of the plan service area, we will cover some limited
urgent dental care services for minor ailments such as a toothache or
loose filling. Go to the closest provider and notify the plan within 48
hours of receiving urgent dental care.

$10 per office visit
Coverage is provided for up to $50 per
incident

Dental benefits

The Plan covers preventative and minor restorative dental services. Services not listed are not covered. You do not need Plan
authorization for these services, but you must see a Plan dentist. Refer to the Dental Directory for a list of Plan dentists, or
call Customer Services at 1-800-868-5200 and we will help in find a Plan dentist.

Preventative care is covered once every six months. You are responsible for one copayment per visit for any visit in which
exam, cleaning and x-rays (except full mouth series and panoramic) are performed.

The plan covers minor restorative dental care such as metal or composite fillings. Copayments for these services vary from $13 to $35.

Additional dental benefits are available from participating Plan dentists at discounted rates. These discounted services are not to be considered Plan benefits and are not covered under this contract. See Section 5(I) Non-FEHB benefits available to Plan
members for more information about discounted dental services. 49.
49 Page 50 51
2003 Fallon Community Health Plan 47 Section 5(i)
Dental Benefits
Service You pay
110 Initial oral examination
120 Periodic oral examination
130 Emergency oral examination
140 Limited oral evaluation (problem focused)
150 Comprehensive oral evaluation
220 Intraoral: (periapical, first film)
230 Intraoral: (periapical, each additional film)
240 Intraoral: (occlusal film)
241 Bitewing (single film)
272 Bitewings (two films)
273 Bitewings (three films)
274 Bitewings (four films)
460 Pulp vitality tests
461 Diagnostic casts
1110 Prophylaxis (adult, every six months)
1120 Prophylaxis (child, every six months)
1201 Top application fluoride (includes prophylaxischild under age 16)
1203 Top application fluoride (excludes prophylaxischild under age 16)
1205 Top application fluoride (includes prophylaxisadult age 16 and over)
1130 Oral hygiene instruction
2110 Amalgam (one surface, primary)
2120 Amalgam (two surfaces, primary)
2130 Amalgam (three surfaces, primary)
2131 Amalgam (four or more surfaces, primary)
2140 Amalgam (one surface, permanent)
2150 Amalgam (two surfaces, permanent)
2160 Amalgam (three surfaces, permanent)
2161 Amalgam (four or more surfaces, permanent)
2330 Resin (one surface, anterior)
2331 Resin (two surfaces, anterior)
2332 Resin (three surfaces, anterior)
2335 Resin (three surfaces, or involving incisal angle anterior)
2385 Resin (one surface, posterior permanent)
2386 Resin (two surfaces, posterior permanent)
2333 Resin (three or more surfaces, posterior permanent)

$10
$10
$10
$10
$10
$10
$10
$10
$10
$10
$10
$10
$10
$10
$10
$10
$10
$10
$10
$10
$13
$18
$22
$28
$15
$20
$22
$28
$19
$22
$28
$33
$19
$25
$35 50.
50 Page 51 52
2003 Fallon Community Health Plan 48 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.

Discounts on chiropractic visits
For conditions that are not usually covered under the Plans chiropractic benefitand for visits 21 and beyondyou
may see a Plan chiropractor at a discounted rate. For more information on discounted chiropractic services, or to
locate a participating Plan chiropractor, call Customer Service at 1-800-868-5200 (TDD/TTY: 1-877-608-7677).

Discounted dental services
We have arranged for discounts on non-covered dental services at participating plan dentists. For a complete listing of
discounted dental services call the Customer Service Department at 1-800-868-5200 (TDD/TTY: 1-877-608-7677).

Eyewear discounts The Plan has arranged for discounts on eyeglass frames, prescription lenses and contact lenses. For more information,
contact the Customer Service Department at 1-800-868-5200 (TDD/TTY: 1-877-608-7677).
Hearing aid discounts
The Plan has arranged for discounts off the regular price of hearing aids. Contact the Customer Services Department
at 1-800-868-5200 (TDD/TTY: 1-877-608-7677) for a list of providers.

Fitness center discounts
Members of the Plan are entitled to discounted memberships at several area health clubs. Discounts vary from club to
club. For more information call the Customer Service Department at 1-800-868-5200 (TDD/TTY: 1-877-608-7677).

Naturally Well Through our Naturally Well program we offer discounts on alternative health care. Currently we offer discounts on
acupuncture, massage therapy and nutrition counseling. For information on the Naturally Well program, call the
Customer Service Department at 1-800-868-5200 (TDD/TTY: 1-877-608-7677).

Weight Watchers
Plan members are entitled to a 12-week membership to Weight Watchers in each calendar year. The membership
includes the registration fee and weekly fee for a 12-consecutive week series of Weight Watchers. Additional
memberships and food products are not covered. To request coupons call the Customer Service Department at 1-800-
868-5200 (TDD/TTY: 1-877-608-7677).

Medicare prepaid plan enrollment This plan offers Medicare recipients the opportunity to enroll in the plan through Medicare. As indicated on page xx,
annuitants and former spouses with FEHB coverage and Medicare Part B may elect to drop their FEHB coverage and
enroll in a Medicare prepaid plan if one is available in their area. They may then later re-enroll in the FEHB program.
Most federal annuitants have Medicare Part A. Those without Medicare Part A may join this Medicare prepaid
program but will probably have to pay for hospital coverage in addition to the Part B premium. Before you join the
plan, ask whether the plan covers hospital benefits and, if so, what you have to pay. Contact your retirement system
for information on dropping your FEHB enrollment and changing to a Medicare prepaid plan. Contact our Customer
Service Department at 1-800-868-5200 (TDD/TTY: 1-877-608-7677) for information on benefits available under the
Medicare HMO. 51.
51 Page 52 53
2003 Fallon Community Health Plan 49 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 doctor determines it is medically necessary to prevent, diagnose, or treat your illness, disease, injury,
or condition, and we agree, as discussed under, Services requiring our prior approval on page 12.

We do not cover the following:
Care by non-Plan providers except for authorized referrals or emergencies (see Emergency Benefits);
Services, drugs, or supplies you receive while you are not enrolled in this Plan;
Services, drugs, or supplies that are not medically necessary;
Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice;
Experimental or investigational procedures, treatments, drugs or devices;
Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest;

Services, drugs, or supplies related to sex transformations;
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program; or
Services, drugs, or supplies you receive without charge while in active military service. 52.
52 Page 53 54
2003 Fallon Community Health Plan 50 Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at Plan pharmacies,
you will not have to file claims. Just present your identification card and pay your copayment.

You will only need to file a claim when you receive emergency services from non-plan providers. Send all claims for urgent or
emergency care to us within six months of the date of service. You may submit the claim yourself, or the provider may submit them
directly. With your authorization, we will pay benefits directly to the provider. Otherwise, we will send payment to you. All bills
should include a description of the services, the dates of service and the charge for each service. We will pay for the reasonable cost
of services in full, less the appropriate copayment.

Claims for services in a foreign country may be submitted if the services are not provided free of charge by that country. The bills
must be itemized and in English (or translated into English). Payment will be made to you, and you must pay the provider.

Services, drugs or supplies In most cases, providers and facilities file claims for you. Physicians 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 1-800-868-5200 (TDD/TTY: 1-877-608-
7677).

When you must file a claim --such as for services you receive outside of the Plans
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 members name and ID number;
Name and address of the physician or facility that provided the service or supply;
Dates you received the services or supplies;
Diagnosis;
Type of each service or supply;
The charge for each service or supply;
A copy of the explanation of benefits, payments, or denial from any primary payer --such as the Medicare Summary Notice (MSN); and

Receipts, if you paid for your services.
Submit your claims to: Fallon Community Health Plan
Claims Department
P. O. Box 15121
Worcester, MA 01615-0121

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. 53.
53 Page 54 55
2003 Fallon Community Health Plan 51 Section 8
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your claim or
request for services, drugs, or supplies including a request for preauthorization:

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: Fallon Community Health Plan, Consumer Affairs Department, 10 Chestnut St., Worcester,
MA 01608; or fax it to us at 508-755-7393; or make your request by telephone at 1-800-868-5200 (TDD/TTY: 1-877-
608-7677) Monday through Friday, 8:30 a.m. to 5:00 p.m.; or make your request in person at our Consumer Affairs
Department; 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. Also include your name, FCHP identification number, and the name of any
FCHP representative with whom you have spoken.

If you send us a written or electronic grievance, we will acknowledge your request in writing within 15 business days from
the date that we receive the request. If you call us or come in to our offices, we will put your grievance in writing and send a
written statement to you or your authorized representative within 48 hours of the time that we talked to you.

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
Ask you or your provider for more information. If we ask your provider, we will send you a copy of our requestgo 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. Your grievance will be reviewed by FCHP administrators and/or physicians who are knowledgeable about matters at issue in the grievance. As part of certain types of review, we may ask you to participate in a conference.
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. Our response will describe the specific information considered as well as an
explanation for the decision.

You may ask for a reconsideration of a final adverse determination if any relevant information was received too late to
review within the time limits described above, or is expected to become available within a reasonable time period after you
receive our written response. If we agree to reconsider, we will indicate a new time period for review in writing. This would
not be longer than 30 days from the date we agree to the reconsideration.

If we do not complete a review in the time limits specified above, the decision will automatically be in favor of the member.
Time limits include any extensions made by mutual written agreement between you or your authorized representative and the
plan.

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. 54.
54 Page 55 56
2003 Fallon Community Health Plan 52 Section 8
The Disputed Claims process (Continued)
Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Health Benefits 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.

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 OPMs 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 prior approval. This is the only deadline that may not be extended.

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

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

NOTE: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if
not treated as soon as possible), and

(a) We haven't responded yet to your initial request for care or preauthorization/prior approval, then call us at 1-800-868-5200
(TDD/TTY 1-877-608-7677) and we will expedite our review. If you have a terminal illness, and if our review of your
expedited review results in denial of coverage, you may request a conference. We will schedule the conference within 10
business days from the date on which we receive your request; or within five business days if your physician determines,
after consultation with a plan medical director, that based on standard medical practice, the effectiveness of the proposed
treatment, services or supplies or any alternative treatment, services or supplies would be materially reduced if not provided
at the earliest possible date. You may attend the conference, but your attendance is not required; or

(b) We denied your initial request for care or preauthorization/prior approval, then:
If we expedite our review and maintain our denial, we will inform OPM so that they can give your claim expedited treatment too, or

You may call OPM's Health Benefits Contracts Division 3 at 202/606-0737 between 8 a.m. and 5 p.m. eastern time. 55.
55 Page 56 57
2003 Fallon Community Health Plan 53 Section 9
Section 9. Coordinating benefits with other coverage
When you have other health coverage You must tell us if you or a covered family member have coverage under another group health plan or have automobile insurance that pays health care expenses without regard to
fault. This is called double coverage.
When you have double coverage, one plan normally pays its benefits in full as the
primary payer and the other plan pays a reduced benefit as the secondary payer. We, like
other insurers, determine which coverage is primary according to the National
Association of Insurance Commissioners' guidelines.

When we are the primary payer, we will pay the benefits described in this brochure.
When we are the secondary payer, we will 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. We follow the National Association of Insurance
Commissioners guidelines in determining secondary coverage.

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

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

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

Part B (Medical Insurance). Most people pay monthly for Part B. Generally, Part B premiums are withheld from your monthly Social Security check or your retirement

check.
If you are eligible for Medicare, you may have choices in how you get your health care.
Medicare + Choice is the term used to describe the various health plan choices available
to Medicare beneficiaries. The information in the next few pages shows how we
coordinate benefits with Medicare, depending on the type of Medicare managed care plan
you have.

The Original Medicare Plan (Original Medicare) is available everywhere in the United
States. It is the way everyone used to get Medicare benefits and is the way most people
get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist,
or hospital that accepts Medicare. The Original Medicare Plan pays its share and you pay
your share. Some things are not covered under Original Medicare, like prescription
drugs.

When you are enrolled in Original Medicare along with this Plan, you still need to follow
the rules in this brochure for us to cover your care.

Claims process when you have the Original Medicare Plan --You probably will never
have to file a claim form when you have both our Plan and the Original Medicare Plan.

The Original Medicare Plan (Part A or Part B) 56.
56 Page 57 58
2003 Fallon Community Health Plan 54 Section 9
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 about filing your claims, call us at 1-800-868-5200
(TDD/TTY: 1-877-608-7677).

We do not waive any costs when you have Medicare.
(Primary payer chart begins on next page.) 57.
57 Page 58 59
2003 Fallon Community Health Plan 55 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 anactive employee with theFederalgovernment(including whenyou or a
familymember are eligibleforMedicaresolely becauseof adisability), !

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,

!
(exceptfor 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 ! 58.
58 Page 59 60
2003 Fallon Community Health Plan 56 Section 9
Medicare managed care plan If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare managed care plan. These are health care choices (like HMOs)
in some areas of the country. In most Medicare managed care plans, you can only go to
doctors, specialists, or hospitals that are part of the plan. Medicare managed care plans
provide all the benefits that Original Medicare covers. Some cover extras, like
prescription drugs. To learn more about enrolling in a Medicare managed care plan,
contact Medicare at 1-800-MEDICARE (1-800-633-4227) or at www.medicare.gov.

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

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

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

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

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

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

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

If you do not enroll in Medicare Part A or Part B 59.
59 Page 60 61
2003 Fallon Community Health Plan 57 Section 9
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 a one of these State programs, eliminating your
FEHB premium. For information on suspending your FEHB enrollment, contact your
retirement office. If you later want to re-enroll in the FEHB Program, generally you may
do so only at the next Open Season unless you involuntarily lose coverage under the State
program.

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

When others are responsible When you receive money to compensate you for medical or hospital care for injuries or
for injuries 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. 60.
60 Page 61 62
2003 Fallon Community Health Plan 58 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.

Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 14.

Covered services Care we provide benefits for, as described in this brochure.
Custodial care Care furnished to meet non-medically necessary needs such as assistance in mobility, dressing, bathing, eating, preparation of special diets, and taking medication. Custodial
care that lasts 90 days or more is sometimes known as Long term care. Custodial care is
not covered by the Plan.

The Plans Benefits & Technology Assessment Committee determines what procedures,
devices and services are experimental or investigational use FDA guidelines and long-
term clinical studies. Clinical studies are used to ensure that the procedure, device, or
service has proven to be more effective than currently accepted procedures, devices or
services.

Group health coverage Health care coverage through a partnership, association, or corporation that has an agreement to pay the plan, or its agent, the plan premium for a group of subscribers.
FEHB is an example of a group.

Medical necessity A medical or hospital service which is rendered for treatment or diagnosis of an injury or illness, not furnished primarily for the convenience of the member, physician or provider,
and is in accordance with professionally recognized medical standards and plan medical
criteria.

Provider A person, agency or facility that may furnish health care to you under the terms of this contract. This includes doctors of medicine, osteopathy and podiatry; registered nurse
anesthetists; and nurse practitioners.

Us/We Us and we refer to Fallon Community Health Plan
You You refers to the enrollee and each covered family member.

Experimental or
investigational services 61.
61 Page 62 63
2003 Fallon Community Health Plan 59 Section 11
Section 11. FEHB facts
No pre-existing condition We will not refuse to cover the treatment of a condition that you had
limitation before you enrolled in this Plan solely because you had the condition before you enrolled.

Where you can get information See www.opm.gov/insure. Also, your employing or retirement office can answer your
about enrolling in the questions, and give you a Guide to Federal Employees Health Benefits Plans, brochures
FEHB Program for other plans, and other materials you need to make an informed decision about your FEHB coverage. These materials will 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 dont determine who is eligible for coverage and, in most cases, cannot change your
enrollment status without information from your employing or retirement office.

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

circumstances, you may also continue coverage for a disabled child 22 years of age or
older who is incapable of self-support.

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

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

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

Childrens 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: 62.
62 Page 63 64
2003 Fallon Community Health Plan 60 Section 11
If you have no FEHB coverage, your employing office will enroll you for self and family coverage in the option of the Blue Cross and Blue Shield Service Benefit Plan
that provides the lower level of coverage;
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 Plans 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 this Plan
premiums start during Open Season, your coverage begins on the first day of your first pay period that starts on or after January 1. Annuitants coverage and premiums begin on January 1. If

you joined at any other time during the year, your employing office will tell you the
effective date of coverage.

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

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

Spouse equity If you are divorced from a Federal employee or annuitant, you may not continue to get coverage benefits under your former spouses 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-spouses employing or retirement office to get RI 70-5, the Guide to Federal
Employees Health Benefits Plans for Temporary Continuation of Coverage and Former
Spouse Enrollees, or other information about your coverage choices. You can also
download the guide from OPMs website www.opm.gov/insure.

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

You may not elect TCC if you are fired from your Federal job due to gross misconduct. 63.
63 Page 64 65
2003 Fallon Community Health Plan 61 Section 11
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 (HIPAA) is a Federal Group Health Plan Coverage law that offers limited Federal protections for health coverage availability and continuity
to people who lose employer group coverage. If you leave the FEHB Program, we will
give you a Certificate of Group Health Plan Coverage that indicates how long you have
been enrolled with us. You can use this certificate when getting health insurance or other
health care coverage. Your new plan must reduce or eliminate waiting periods,
limitations, or exclusions for health related conditions based on the information in the
certificate, as long as you enroll within 63 days of losing coverage under this Plan. If you
have been enrolled with us for less than 12 months, but were previously enrolled in other
FEHB plans, you may also request a certificate from those plans. For more information,
get OPM pamphlet RI 79-27, Temporary Continuation of Coverage (TCC) under the
FEHB Program. See also the FEHB web site (www.opm.gov/insure/archive/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. 64.
64 Page 65 66
2003 Fallon Community Health Plan 62 Long Term Care Insurance
Long Term Care Insurance Is Still Available!
Open Season The Federal Long Term Care Insurance Programs open season for enrollment ends on December 31, 2002. If youre a Federal employee, this is the chance for you and your spouse to apply by
answering only a few questions about your health.

You Can Also Apply Later You and your qualified relatives can still apply for coverage after open season ends. The difference for employees and their spouses is that they wont have the advantage of open seasons
abbreviated underwriting, so theyll have to answer more health-related questions. For annuitants and other qualified relatives, theres no difference in the underwriting requirements during and
after the open season.

FEHB Doesnt Cover It Its important to keep in mind that neither your FEHB plan nor Medicare covers the cost of long term care. Also called custodial care, its care you receive when you need help performing
activities of daily living --such as bathing or dressing yourself. This need can strike any one at any age and the cost of care can be substantial.

Its Not Too Late! Its not too late to protect yourself against the high cost of long term care by applying for the Federal Long Term Care Insurance Program. Dont delay --if you apply during open season, your
premiums will be based on your age as of July 1, 2002. After open season, your premiums are based on your age at the time your application for enrollment is received by LTC Partners.

Find Out More Call 1-800-LTC-FEDS (1-800-582-3337) or visit www.ltcfeds.com to get more information and to request an application. 65.
65 Page 66 67
2003 Fallon Community Health Plan 63 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 29, 46 Allergy tests 22
Alternative treatment 27, 52 Allogeneic (donor) bone marrow
transplant 31 Ambulance 15, 34, 36-38
Anesthesia 28, 33, 35 Autologous bone marrow transplant 31
Biopsies 28 Blood and blood plasma 34, 35
Breast cancer screening 17, 18 Casts 34, 47
Catastrophic protection out-of-pocket maximum 14
Changes for 2003 9 Chemotherapy 12, 21
Childbirth 11 Chiropractic 13, 26, 44, 45
Cholesterol tests 17 Circumcision 19
Claims 10, 42, 44, 50, 51, 53-55 Colorectal cancer screening 17
Congenital anomalies 19, 28-29 Contraceptive devices and drugs 19, 42
Coordination of benefits 55 Covered charges 54
Crutches 25 Definitions 64
Dental care 11, 24, 29, 35, 44-47 Diagnostic services 12, 16, 17, 20, 34, 35,
39, 40, 44, 47 Disputed claims review 48
Donor expenses (transplants) 31 Dressings 34, 35, 43
Durable medical equipment (DME) 13, 24-26, 44
Educational classes and programs 27 Effective date of enrollment 10, 13, 41,
58-60 Emergency 6, 8, 37, 38, 42, 44, 46, 47, 49,
50 Experimental or investigational 61
Eyeglasses 23
Family planning 19 Fecal occult blood test 17

Fraud 4

General Exclusions 49 Hearing services 18, 19, 23, 44
Home health services 26, 44 Hospice care 36
Hospital 31, 33-38, 40, 48, 50, 56-58
Immunizations 6, 18 Infertility 11, 20, 45
Inpatient Hospital Benefits 20, 23, 29, 30, 34-36, 41, 45, 65
Insulin 25, 42
Laboratory and pathological services 20, 34, 35, 45

Magnetic Resonance Imagings (MRIs) 17
Mail Order Prescription Drugs 41, 42, 44
Mammograms 11, 17, 18 Maternity Benefits 11, 19, 44
Medicaid 57 Medically necessary 12, 16,
19-22, 28, 34, 35, 37, 39, 44, 46, 49, 58
Medicare 55, 56 Members 4-6, 8, 10, 12, 13, 28,
29, 31, 32, 45, 46, 51, 53, 55, 58, 59
Mental Conditions/Substance Abuse Benefits 39, 40
Newborn care 19 Non-FEHB Benefits 48
Nurse Nurse Midwife 11
Nurse Practitioner 10, 11, 58 Registered Nurse 58
Nursery charges 19
Obstetrical care 11, 20 Occupational therapy 12, 22, 35,

44 Office visits 6, 14, 16-24, 26-30,
33, 44, 46, 64 Oral and maxillofacial surgery 30
Orthopedic devices 24 Out-of-pocket expenses 14, 64
Outpatient care 10, 12, 13, 16, 28-30, 34-36, 39, 41, 45, 65

Oxygen 25, 26, 34, 35 Pap test 11
Physical examination 6, 18 Physical therapy 12, 22
Physician 6, 10-13, 16, 18, 20, 21, 25, 26, 28, 34-37,
41-43, 45, 50-52, 58, 64 Preventive care, adult 17, 18
Preventive care, children 18 Prescription drugs 9, 10, 19-21, 36,
41-44, 50, 53, 56, 64 Preventive services 17, 18
Prior approval 12, 41, 52 Prostate cancer screening 17
Prosthetic devices 24, 25, 28, 29 Psychologist 39
Radiation therapy 12, 21 Renal dialysis 21
Room and board 34, 35 Second surgical opinion 16
Skilled nursing facility care 16, 33, 35 Smoking cessation 27, 43
Speech therapy 12, 22, 26, 44 Splints 34
Sterilization procedures 19, 20, 28 Subrogation 57
Substance abuse 11, 39, 40, 45, 64 Surgery 23, 24, 29, 30, 34
Anesthesia 28, 33, 35 Outpatient 28, 29, 35
Reconstructive 28, 29 Syringes 42
Temporary continuation of coverage 60, 61
Transplants 9, 13, 21, 30, 31, 53 Treatment therapies 21
Vision services 23, 64 Well child care 18
Wheelchairs 25, 44 Workers compensation 55, 56
X-rays 17, 20, 34, 35, 44, 45 66.
66 Page 67 68
2003Fallon Community Health Plan 64
Summary of benefits for the Fallon Community Health Plan 2003
Do not rely on this chart alone. All benefits are provided in full unless indicated and are subject to the definitions, limitations,
and exclusions in this brochure. On this page we summarize specific expenses we cover; for more detail, look inside.

If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on your
enrollment form.

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.................... Office visit copay: $10 primary care; $10 specialist 16

Services provided by a hospital:
Inpatient.................................................................................................
Outpatient ..............................................................................................

Nothing
Nothing

35
Emergency benefits:
In-area..................................................................................................
Out-of-area ..........................................................................................

$50 per visit
$50 per visit

38
38
Mental health and substance abuse treatment ........................................ Regular cost sharing. 39

Prescription drugs ..................................................................................... Tier 1: $5 copay for up to a 30-day supply
Tier 2: $15 copay for up to a 30-day supply
Tier 3: $35 copay for up to a 30-day supply

Dental Care ............................................................................................ $10 copay for preventative limited services
$13-$35 copay for minor restorative services
Discounts available for other dental procedures

Vision Care ............................................................................................ $10 per visit 23
Special Features. Flexible benefits option
Services for the hearing impaired
Peace of Mind Program
Out-of-Area Student Coverage
Interpreter Services

Protection against catastrophic costs
(your catastrophic protection out-of-pocket maximum) ......................

We do not have a catastrophic protection out-of-
pocket maximum 14 67.
67 Page 68 69
2003Fallon Community Health Plan 65
2003 Rate Information for
Fallon Community Health Plan

Non-Postal rates apply to most non-Postal enrollees. If you are in a special enrollment category, refer
to the FEHB Guide for that category or contact the agency that maintains your health benefits
enrollment.

Postal rates apply to career Postal Service employees. Most employees should refer to the FEHB Guide for United States Postal Service Employees, RI 70-2. Different postal rates apply and a special FEHB guide is
published for Postal Service Inspectors and Office of Inspector General (OIG) employees (see RI 70-2IN).
Postal rates do not apply to non-career postal employees, postal retirees, or associate members of any postal
employee organization who are not career postal employees. Refer to the applicable FEHB Guide.

Type of
Enrollment Code

Non-Postal Premium
Biweekly Monthly
Gov't Your Gov't Your
Share Share Share Share

Postal Premium
Biweekly

USPS Your
Share Share

Location Information: Central and Eastern Massachusetts, Including the Worcester metropolitan area
High Option Self Only

High Option
Self & Family

JV1
JV2
$105.98 $35.32 $229.61 $76.54
$249.62 $113.53 $540.84 $245.99
$125.40 $15.90
$294.70 $68.45 68.
68 Page 69 70
69.
69 Page 70 71
HMO INSTRUCTIONS PAGE 1 (DO NOT TYPESET THESE PAGES) 70.
70 Page 71
HMO INSTRUCTIONS PAGE 2 (DO NOT TYPESET THESE PAGES) 71.

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