Keystone Health Plan Central

Federal Employees Health Benefits Program
2003 Plan Brochure
Accessible Version

Pages 1--72

Page 1


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

Keystone Health Plan Central 2003 http:// www. khpc. com
A Health Maintenance Organization

Serving: Harrisburg, Lehigh Valley and Northern Tier areas of Pennsylvania
Enrollment in this Plan is limited. You must live or work in our Geographic service area to enroll. See page 7 for requirements.

Enrollment codes for this Plan:
S41 Self Only S42 Self and Family

RI 73-241
RI 73-241

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

For changes
in benefits
see page 8. 1.
1 Page 2 3

2.
2 Page 3 4
Notice of the Office of Personnel Management's
Privacy Practices
(A) 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. 3.
3 Page 4 5

Get a listing of those getting your personal medical information from OPM in the past 6 years. The listing will not cover your personal medical information that was given to you or your personal representative, any
information that you authorized OPM to release, or that was given out for law enforcement purposes or to pay for your health care or a disputed claim.
Ask OPM to communicate with you in a different manner or at a different place (for example, by sending
materials to a P. O. Box instead of your home address).
Ask OPM to limit how your personal medical information is used or given out. However, OPM may not be able to agree to your request if the information is used to conduct operations in the manner described above.

Get a separate paper copy of this notice.
For more information on exercising your rights set out in this notice, look at www. opm. gov/ insure on the web. You
may also call 202-606-0191 and ask for OPM's FEHB Program privacy official for this purpose.

If you believe OPM has violated your privacy rights set out in this notice, you may file a complaint with OPM at the
following address:

Privacy Complaints
Office of Personnel Management P. O. Box 707

Washington, DC 20004-0707
Filing a complaint will not affect your benefits under the FEHB Program. You also may file a complaint with the Secretary of the Department of Health and Human Services.

By law, OPM is required to follow the terms in this privacy notice. OPM has the right to change the way your personal medical information is used and given out. If OPM makes any changes, you will get a new notice by mail
within 60 days of the change. The privacy practices listed in this notice will be effective April 14, 2003. 4.
4 Page 5 6

BlueCard -Urgent Care Out of Area
Away from Home Care -Guest Membership 5.
5 Page 6 7

2003 Keystone Health Plan Central 3 Table of Contents
Keeping Well
HealthLink
www. khpc. com

2003 Keystone Health Plan Central 4 Introduction/ Plain Language/ Advisory
Introduction
This brochure describes the benefits of Keystone Health Plan Central under our contract (CS 2076) with the Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. This Plan is
underwritten by Keystone Health Plan Central. The address for Keystone Health Plan Central administrative offices is:
Keystone Health Plan Central
P. O. Box 898812 Camp Hill, PA 17089-8812

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 8. 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 Keystone Health Plan Central.
We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the Office of Personnel Management. If we use others, we tell you what they mean first.
Our brochure and other FEHB plans' brochures have the same format and similar descriptions to help you compare plans.

If you have comments or suggestions about how to improve the structure of this brochure, let OPM know. Visit OPM's "Rate Us" feedback area at www. opm. gov/ insure or e-mail OPM at fehbwebcomments@ opm. gov. You may
also write to OPM at the Office of Personnel Management, Office of Insurance Planning and Evaluation Division, 1900 E Street, NW, Washington, DC 20415-3650. 7.
7 Page 8 9
2003 Keystone Health Plan Central 5 Introduction/ Plain Language/ Advisory
Stop Health Care Fraud!
Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits (FEHB) Program premium.
OPM's Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program
regardless of the agency that employs you or from which you retired.

Protect Yourself From Fraud -Here are some things you can do to prevent fraud:

Be wary of giving your plan identification (ID) number over the telephone or to people you do not know, except to your doctor, other provider, or authorized plan or OPM representative.
Let only the appropriate medical professionals review your medical record or recommend services.
Avoid using health care providers who say that an item or service is not usually covered, but they know how to bill us to get it paid.

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

If you suspect that a provider has charged you for services you did not receive, billed you twice for the same
service, or misrepresented any information, do the following:
Call the provider and ask for an explanation. There may be an error.
If the provider does not resolve the matter, call us at 1-800-622-2843 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.
8 Page 9 10

2003 Keystone Health Plan Central 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 and coinsurance described in this brochure. When you receive emergency services from non-Plan
providers, you may have to submit claim forms.
You should join an HMO because you prefer the plan's benefits, not because a particular provider is available. You cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician,
hospital, or other provider will be available and/ or remain under contract with us.
How we pay providers
We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure. These Plan providers accept a negotiated payment from us, and you will only be responsible for your copayments or
coinsurance.

Your Rights
OPM requires that all FEHB Plans provide certain information to their FEHB members. You may get information
about us, our networks, providers, and facilities. OPM's FEHB website (www. opm. gov/ insure) lists the specific types of information that we must make available to you. Some of the required information is listed below.

As a Member of KHP Central, you may submit a written request for any of the following written information:
A list of the names, business addresses and official positions of the membership of our board of directors or
officers.
The procedures adopted by us to protect the confidentiality of your medical records and other member information.

A description of the credentialing process for participating providers.
A list of the participating providers affiliated with participating hospitals.
Whether a specifically identified drug is included or excluded from your coverage.
A description of the process by which a participating provider can prescribe specific drugs, drugs used for an off-label purpose, biologicals and medications not included in our drug formulary for prescription drugs or

biologicals when the formulary's equivalent has been ineffective in the treatment of your disease or if the drug
causes or is reasonably expected to cause adverse or harmful reactions in your case, if applicable to your coverage.

A description of the procedures followed by us to make decisions about the experimental nature of individual drugs, medical devices or treatments.
A summary of the methodologies used by us to reimburse providers for covered services. Please note that we will not disclose the terms of individual contracts or the specific details of any financial arrangement between a
participating provider and us.
A description of the procedures used in our Quality Assurance Program. 9.
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2003 Keystone Health Plan Central 7 Section 1
Your request must specifically identify what information is being requested and should be sent to:
Keystone Health Plan Central P. O. Box 898880
Camp Hill, PA 17089-8880
If you want more information about us, call 1-800-622-2843 (TDD 1-800-669-7075), or write to Keystone Health
Plan Central, Attn: Customer Service, P. O. Box 898880, Camp Hill, PA, 17089-8880. You may also contact us by fax at 717-302-0120, visit our website at www. khpc. com, or e-mail us at CustomerService@ khpc. com.

Service Area
To enroll in this Plan, you must live in or work in our Service Area. This is where our providers practice. Our service area is:
Harrisburg: The Pennsylvania counties of Adams, Berks, Cumberland, Dauphin, Lancaster, Lebanon, Perry,
Schuylkill and York.

Lehigh Valley: The Pennsylvania counties of Lehigh and Northampton
Northern Tier: The Pennsylvania counties of Centre, Columbia, Juniata, Mifflin, Montour, Northumberland, Snyder and Union.

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. 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 check with us to see if a Guest Membership can be established or 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.

If you are traveling outside the Plan's service area and require urgent care, you need to use the following procedure:

Contact the 24-hour, toll-free provider locator service at 1-800-810-2583 or log on to www. bcbs. com.
You will receive information regarding three available local providers (names, addresses, phone numbers, and directions) who can meet your medical needs.

You will need to select a provider and schedule your own appointment.
At the appointment, you must present your Plan Medical ID card and pay the applicable copayment while you are at your appointment.

You must contact your Primary Care Physician to advise the office of your need for medical attention and coordinate any necessary follow-up care.

Your away-from-home travel isn't always measured in day trips or week vacations. That's why we also provide care when someone's away a long time, whether it's extended out-of-town business, semesters at school or families living
apart. For anyone away at least 90 days, we offer Guest Membership at an affiliated HMO near your travel
destination. Guest Membership allows you or your family to enjoy the full range of benefits offered by the Host HMO.

For more details, please contact KHP Central at 1-800-622-2843 and ask to speak with the Guest Membership Coordinator. 10.
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2003 Keystone Health Plan Central 8 Section 2
Section 2. How we change for 2003
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5 Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here is a
clarification that does not change benefits.
Program-wide changes
A Notice of the Office of Personnel Management's Privacy Practices is included.
A section on the Children's Equity Act describes when an employee is required to maintain Self and Family coverage.

Program information on TRICARE and CHAMPVA explains how annuitants or former spouses may suspend
their FEHB Program enrollment.
Program information on Medicare is revis ed.
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 0.9 % for Self Only or increase by 0.7 % for Self and Family.

Your Prescription Drug Benefit copayment at a participating pharmacy will change to the following:
-A $10 copayment for generic drugs for up to a 30-day supply or unit of use
-A $25 copayment for preferred name brand drugs for up to a 30-day supply or unit of use
-A $40 copayment for non-preferred name brand drugs for up to a 30-day supply or unit of use
Your Prescription Drug Benefit copayment at the mail service pharmacy will change to the following:
-A $20 copayment for generic drugs for up to a 90-day supply or unit of use
-A $50 copayment for preferred name brand drugs for up to a 90-day supply or unit of use
-A $80 copayment for non-preferred name brand drugs for up to a 90-day supply or unit of use
Your provider must obtain prior approval for Durable Medical Equipment purchases with a cost of $250 or more per item. 11.
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2003 Keystone Health Plan Central 9 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 1-800-622-
2843 (TDD 1-800-669-7075), write to us at P. O. Box 898880; Camp Hill, PA 17089-8880, or e-mail us at CustomerService@ khpc. com. You
may also request replacement cards through our website at
www. khpc. com.

Where you get covered care You get care from "Plan providers" and "Plan facilities." You will only pay copayments or coinsurance and you will not have to file claims,
unless you receive emergency services from a provider who doesn't
contract with us.

Plan providers Plan providers are physicians and other health care professionals in our
service area with whom we contract to provide covered services to our members. We credential Plan providers according to national standards.

We list Plan providers in the provider directory, which we update
periodically. The list is also on our website. You can view our website at www. khpc. com or call our Customer Service Department at 1-800-622-

2843 (TDD 1-800- 669-7075) to request a provider directory.

Plan facilities Plan facilities are hospitals and other facilities in our service area with whom we contract to provide covered services to our members. We list
these in the provider directory, which we update periodically. The list is also on our website. You can view our website at www. khpc. com or call
our Customer Service Department at 1-800-622-2843 (TDD 1-800- 669-7075)
to request a provider directory.

What you must do It depends on the type of care you need. First, you and each family to get covered care 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. You must select a Primary Care Physician (PCP) from our provider directory. You can request a provider directory

from us by calling 1-800-622-2843 (TDD 1-800-669-7075), e-mailing us
at CustomerService@ khpc. com, or search for a PCP on our website at www. khpc. com

Primary care Your primary care physician can be a general or family practitioner, internist or pediatrician. Your primary care physician will provide most
of your health care, or give you a referral to see a specialist.
If you want to change primary care physicians or if your primary care physician leaves the Plan, call us. We will help you select a new one.

If you need medical services after normal office hours, contact your PCP. The PCP's answering service may take your call. If so, the answering 12.
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2003 Keystone Health Plan Central 10 Section 3
service will contact your physician or the physician on call, who will
contact you as soon as possible. Try to keep your phone free in the meantime. Limit after-hours calls to medical problems requiring

immediate attention. Do not postpone calling your PCP's office if you
feel you need medical attention; however, please do not call after scheduled office hours to obtain test results, prescription refills or other

non-urgent matters.

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 referred you for a certain number of visits without
additional referrals. The primary care physician must provide or refer all
follow-up care. Do not go to the specialist for return visits unless your primary care physician gives you a referral. However, you may see

certain specialists to receive services without a referral as described
below. If your PCP determines that you need specialized services, he or she will provide you with a referral to the appropriate Participating

Provider. Some services will also require prior authorization from KHP
Central. If you wish to change the specialist to whom you have been referred, contact your PCP for a new referral.

Your PCP will give you a referral for medically necessary care. The referral form will indicate the services to be performed by the specialist
or facility and any specific timeframe for which the referral is valid. The
specialist or facility must contact the PCP before providing additional services not listed on the form. In some cases, you will be required to

obtain an additional referral form from the PCP for the requested additional services. It is important to note that all laboratory services
must be obtained using the PCP's laboratory arrangement listed on your ID card. Referrals are good only for the provider listed on the referral
form. If you need additional services or if you need to see another
provider, you should call your PCP.

KHP Central also has a telephonic referral system which allows your
PCP's office to issue a specialty care referral by telephone, eliminating the need for a paper referral. With the telephonic process, your referral

will be entered into our system and a copy will be faxed to your PCP and
your specialist. Please note that if your PCP uses the telephonic referral process you will not receive or require a hard copy of the referral.

Certain services require prior authorization by KHP Central's Utilization Management Department. We recommend you consult with your
provider before having services rendered to ensure that he or she has
obtained the proper prior authorization from KHP Central for the listed services.

If you are afflicted with a life-threatening, degenerative or disabling disease or condition, a standing Referral may be given to your specialist
with the appropriate clinical experience in treating the condition, or, in
certain cases, your specialist may be designated to provide and coordinate your primary and specialty care. In order to receive a

standing referral, a referral form must be obtained by your primary care
physician. The referral form allows the specialist to perform the treatment required for a specific episode of illness, for up to ninety (90)

days. The specialist may refer you for additional services, including
laboratory testing, radiology, diagnostic testing or durable medical equipment (DME). Having your specialist designated to provide and 13.
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2003 Keystone Health Plan Central 11 Section 3
coordinate your care requires approval of the Plan. You must submit
your request in writing.

Obstetrical and Gynecological Care. Services provided to you for
obstetrical and gynecological care do not require a referral from your PCP. You are permitted to contact your Plan Obstetrical/ Gynecological

specialist directly and seek treatment. The services permitted are limited
to those encompassed by and unique to the specialty of obstetrics and gynecology, including follow-up care and must be performed by a

participating OB/ GYN Provider. If you have any questions, please
contact the specialist, your PCP or KHP Central to ensure that your treatment is considered to be obstetrical or gynecological. The specialist

is to notify your PCP of all services and treatment you receive. This will
ensure the continuity of your care. Please note that all prior authorization guidelines still apply.

Oral Surgical Care. Services provided to you for the extraction of impacted teeth when partially or totally covered by bone do not require a
referral from your PCP. You are permitted to contact your Plan Oral
Surgeon directly and seek treatment. Please note that all prior authorization guidelines still apply.

Retroactive referrals are not permitted by KHP Central. You must obtain the referral before receiving services other than obstetrical,
gynecological, oral surgical, or emergency services.
Mental Health and Substance Abuse Treatment. Management of mental health and/ or substance abuse treatment is provided through a
subcontract with PacifiCare Behavioral Health, a behavioral health
managed care company that maintains a network of qualified mental health and substance abuse professionals who offer care to KHP Central

Members.
You must contact PacifiCare Behavioral Health (PBH) at 1-800-216-9748, (TDD number at 1-888-877-5378) to notify PBH of the need for
services and to receive names of network providers who will best meet your needs. PacifiCare also offers translator services to its non-English
speaking Members. To access this service, simply contact PacifiCare at
1-800-216-9748. The PBH Provider you choose will be responsible for providing and/ or coordinating your mental health/ substance abuse

treatment.
If you receive outpatient non-emergency services from a non-PBH provider and without prior notification to PBH these services will NOT
be covered. If you are faced with a crisis, contact PBH at 1-800-216-9748 (TDD number at 1-888-877-5378). PacifiCare Behavioral Health
Care Management Team and network providers are available 24 hours a
day, 7 days a week, to offer assistance and coordinate care.

Here are other things you should know about specialty care:
If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician

will work with your specialist to develop a treatment plan that allows
you to see your specialist for a certain number of visits without additional referrals. Your primary care physician will use our criteria

when creating your treatment plan (the physician may have to get an
authorization or approval beforehand). 14.
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2003 Keystone Health Plan Central 12 Section 3
If you are seeing a specialist when you enroll in our Plan, talk to your
primary care physician. Your primary care physician will decide what treatment you need. If he or she decides to refer you to a

specialist, ask if you can see your current specialist. If your current
specialist does not participate with us, you must receive treatment from a specialist who does. Generally, we will not pay for you to see

a specialist who does not participate with our Plan.

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

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

-reduce our service area and you enroll in another FEHB Plan,
you may be able to continue seeing your specialist for up to 90 days after you receive notice of the change. Contact us, or if we drop out of
the Program, contact your new plan.
If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can
continue to see your specialis t until the end of your postpartum care, even if it is beyond the 90 days.

Hospital care Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission
to a skilled nursing or other type of facility. To receive hospital care, we
must authorize all admissions.

If you are in the hospital when your enrollment in our Plan begins, call
our Customer Service department immediately at 1-800-622-2843. 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. 15.
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2003 Keystone Health Plan Central 13 Section 3
Services requiring our Your primary care physician has the authority to refer you for most prior approval services. For certain services, however, your physician must obtain
approval from us. Before giving approval, we consider if the service is
covered, medically necessary, and follows generally accepted medical practice.

We call this review and approval process "prior authorization." Your physician must obtain prior authorization for the following services,
which include, but are not limited to:

Admissions -all inpatient facility admissions, including skilled nursing and rehabilitation
Allergy -all allergy injections (except venom injections) by a specialist beyond the first injection for each new vial
Ambulance -ambulance transport (for other than true emergencies)
Bone mineral density studies
Cancer clinical trials
Cancer therapies (inpatient only)
DME -all eligible rental items and/ or all eligible purchased items
with a cost of $250 or more per item
Drug therapies prior authorized by KHP Central (not a Pharmacy Benefits Manager [PBM]):

--Remicade infusion therapy --Visudyne/ Photodynamic therapy
--Rabies Vaccine & Immunoglobulin
v The following commonly self-administered drugs when given by a health care professional (beyond the first 2

injections):
--Epogen/ Procrit (except when used in the treatment of chronic renal failure)

--Neupogen
--Leukine --Neumega

--Interferons (examples include, but are not limited to,
Roferon-A, Alferon N, Intron A, Betaseron, and Avonex)

--Sandostatin
--Enbrel
Education/ training -diabetic teaching, nutritional counseling, and all other education/ training services

Emergency room non-emergency services received in an emergency room setting
Epidurals -epidural injections performed in an outpatient or office setting
Gastroenterology services -esophagoscopies, gastroscopies, duodenoscopies (and combinations thereof), colonoscopies, and
ERCP's (endoscopic retrograde cholangiopancreatographies)
Genetic testing
Home health services -including home infusion, private duty nursing, and patient monitoring

Hospice care
Imaging procedures -MRI, MRA, CT Scan, PET Scan, SPECT Scan
Infertility -all services, diagnostic testing and treatment
Manipulation therapy -spinal and other body part manipulation therapy (including chiropractic care) not provided by the Primary

Care Physician 16.
16 Page 17 18
2003 Keystone Health Plan Central 14 Section 3
Maternity Care -all prenatal and maternity care (including all diagnostic testing beyond the global maternity policy)
Neuropsychological testing
Non-contracted providers and/ or out of network services
Nuclear medicine
Office surgical procedures -select office surgical procedures when performed outside the physician office setting:

--Arthrocentesis
--Aspiration of a joint --Colposcopy

--Electrodessication condylomata -complex
--Excision of a chalazion --Excision of a nail, partial or complete

--Excision of all types of benign lesions (under
2.0 cm diameter) --External hemorrhoidectomy

--Injection of a ligament or tendon
--Oral surgery --Pain management, including facet joint

injections, trigger point injections, stellate
ganglion blocks, peripheral nerve blocks, SI joint injections, and intercostal nerve blocks

--Proctosigmoidoscopy/ Flexible sigmoidoscopy
--Removal of partial or complete bony impacted teeth

--Suture of uncomplicated wounds
--Vasectomy --Wound care and dressings

Pain Management all pain management procedures when
performed outside the physician office setting
Rehabilitative therapies -all rehabilitative therapies, such as physical, occupational, speech, cardiac, respiratory, vision, and

urinary incontinence
Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
Surgeries -all outpatient facility based surgeries, including hospitals and ambulatory surgical centers (excluding endoscopic procedures

except those listed in bulleted item 12)
Transplant evaluations.

We recommend that you consult with your provider before you receive services to make sure that he or she has obtained the correct prior
authorization from us before treatment begins. 17.
17 Page 18 19
2003 Keystone Health Plan Central Section 4 15
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.

Examples: When you see your primary care physician (PCP) you pay a copayment of $10 per office visit. If you see your PCP for services after
the hours normally scheduled for office services you will pay $20 per visit.

If you use an emergency room for emergency services you will pay $25 per visit. This copayment is waived if you are admitted to the hospital at
that time. If you are sent to the emergency room by your PCP or by us to
receive services the PCP could have performed in his/ her office, you will pay $10 per visit.

Deductible We do not have a deductible.
Coinsurance Coinsurance is the percentage of our negotiated fee that you must pay for your care.

Example: You pay 50% of our allowance for services and medications to treat infertility, and medications for treatment of sexual dysfunction.

Your catastrophic protection We do not have a catastrophic protection out-of-pocket maximum. out-of-pocket maximum 18.
18 Page 19 20

2003 Keystone Health Plan Central 16 Section 5
Section 5. Benefits OVERVIEW
(See page 8 for how our benefits changed this year and page 67 for a benefits summary.)

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

at 1-800-622-2843 (TDD 1-800-669-7075), at our website at www. khpc. com, or e-mail us at
CustomerService@ khpc. com.

(a) Medical services and supplies provided by physicians and other health care professionals...............................17-28
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, Occupational & Rehabilitative 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........................... 29-33
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................................................................................................................................ 37-39
Medical emergency

Ambulance
(e) Mental health and substance abuse benefits........................................................................................................ 40-41
(f) Prescription drug benefits ............................................................................................................................................... 42-46
(g) Special features................................................................................................................................................................. 47-48
BlueCard Urgent Care -Out of Area Services
Away From Home Care Guest Membership
Keeping Well
HealthLink
www. khpc. com

Summary of benefits................................................................................................................................................................ 67-68 19.
19 Page 20 21
2003 Keystone Health Plan Central 17 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.
We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other

coverage, including with Medicare.

I M
P O
R T
A N
T

Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
In physician's office $10 per office visit.

$20 per office visit if you see your Plan PCP for services during hours other
than those regularly scheduled for appointments.

Professional services of physicians
In an urgent care center
During a hospital stay
In a skilled nursing facility
Office medical consultations
Second surgical opinion

$25 per visit.
Nothing.
Nothing.
$10 per office visit.
$10 per office visit.

At home $10 per visit.
$20 per visit if you see your Plan PCP for services during hours other than
those regularly scheduled for appointments. 20.
20 Page 21 22
2003 Keystone Health Plan Central 18 Section 5( a)
Lab, X-ray and other diagnostic tests You pay
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 associated office visit or if we authorize the

service and your provider refers
you.

$10 per office visit if you must
have an office visit to receive these services.

Preventive care, adult
Routine screenings, such as:
Vision or hearing
Total Blood Cholesterol once every three years
Sigmoidoscopy, screening every five years starting at age 50
Colorectal Cancer Screening, including
-Fecal occult blood test
Routine Prostate Specific Antigen (PSA) test one annually for men age 40 and
older

Routine pap test

Nothing if you receive these
services during an associated office visit or if we authorize the

service and your provider refers
you.

$10 per office visit if you must
have an office visit to receive these services.

Note: If you are diabetic you may self-refer for one diabetic retinopathy
screening to a Plan ophthalmologist or optometrist. You will receive a letter and reminder card notifying you of this benefit each year. Take this card

with you to your appointment with the Plan eye specialist.
Nothing.

Routine mammogram covered for women age 35 and older, as follows:
From age 35 through 39, one during this five year period
From age 40 and older, one every calendar year
Female members under age 40 must get a referral from their Plan doctor
for a screening mammogram; female members age 40 and over may self-refer to a participating provider for an annual mammogram, either

screening or diagnostic.

Nothing when this is part of your annual OB/ GYN examination or
when your Plan provider refers
you.

Not covered:
Physical exams and preparation of specialized reports required for obtaining or continuing employment or insurance, attending schools
or camp, or travel.
Vision examinations for refractive corrections

All charges. 21.
21 Page 22 23
2003 Keystone Health Plan Central 19 Section 5( a)
Preventive care, adult (Continued) You pay
Routine Immunizations, including but not limited to:
Tetanus-diphtheria (Td) booster once every 10 years, ages 19 and over (except as provided for under Childhood immunizations)

Influenza vaccine, annually, age 50 and over
Pneumococcal vaccine, one injection, age 65 and over

Nothing if you receive these services during an associated
office visit or if we authorize the
service and your provider refers you.

$10 per office visit if you must
have an office visit to receive these services.

Preventive care, children
Childhood immunizations recommended by KHP Central Health Maintenance guidelines Nothing if you receive these services during an associated
office visit or if we authorize the
service and your provider refers you.

$10 per office visit if you must
have an office visit to receive these services.

Well-child care charges for routine examinations, immunizations and care (up to age 22)
Examinations by your PCP, such as:
-Eye exams through age 17 to determine the need for vision correction

-Ear exams through age 17 to determine the need for hearing
correction

-Examinations done on the day of immunizations (up to age 22)

Nothing if you receive these services during an associated
office visit or if we authorize the service and your provider refers
you.

$10 per office visit if you must
have an office visit to receive these services.

Note: If your child is diabetic she/ he may self-refer for one diabetic retinopathy
screening to a Plan ophthalmologist or optometrist. You will receive a letter and reminder card notifying you of this benefit each year. Take this card with

you to your child's appointment with the Plan eye specialist.

Nothing.

Not covered: Vision examinations for refractive corrections All charges. 22.
22 Page 23 24
2003 Keystone Health Plan Central 20 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:
Your doctor must obtain prior authorization for your normal
delivery; see page 12 for other circumstances, such as extended stays for you or your baby.

You may remain in the hospital up to 48 hours after a regular
delivery and 96 hours after a cesarean delivery. We will extend your inpatient stay if medically necessary. If you are discharged prior to

these times you are eligible to receive one home health care visit
within 48 hours of your discharge.

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

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

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

Nothing when we prior authorize your treatment.

Not covered: Routine sonograms to determine fetal age, size or sex. All charges.
Family planning
A range of voluntary family planning services, such as:
Voluntary sterilization (See Surgical procedures Section 5( b))
Surgically implanted contraceptives
Injectable contraceptive drugs (such as Depo provera)
Intrauterine devices (IUDs)
Diaphragms
Note: We cover oral contraceptives under the prescription drug program.
Note: Your physician cannot dispense the contraceptive form of Depo provera from the office. You must get it at the pharmacy.

$10 per office visit if you must have an office visit to receive these
services

Applicable prescription drug copayment
Applicable 90-day prescription drug copayment

Not covered: reversal of voluntary surgical sterilization, genetic counseling, All charges. 23.
23 Page 24 25
2003 Keystone Health Plan Central 21 Section 5( a)
Infertility services You pay
Diagnosis and treatment of infertility, such as:
Artificial insemination:
-intravaginal insemination (IVI)

-intracervical insemination (ICI)
-intrauterine insemination (IUI)
Fertility drugs

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

50% of the cost of treatment when
authorized by KHP Central.

50% of the cost of the medications. You can receive up to a 90-day
supply at one time.

Not covered:
Assisted reproductive technology (ART) procedures, such as:
-In vitro fertilization
-Embryo transfer, gamete GIFT and zygote ZIFT
-Zygote transfer
Services and supplies related to excluded ART procedures

Cost of donor sperm
Cost of donor egg

All charges. 24.
24 Page 25 26
2003 Keystone Health Plan Central 22 Section 5( a)
Allergy care You Pay
Testing and treatment $10 per office visit.

Allergy serum
Allergy injection
Nothing when we prior authorize your treatment.

Not covered: provocative food testing and sublingual allergy desensitization All charges. 25.
25 Page 26 27
2003 Keystone Health Plan Central 23 Section 5( a)
Treatment therapies You pay
Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone
marrow transplants is limited to those transplants listed under Organ/ Tissue Transplants on page 31. We cover injectable

chemotherapy under the medical benefit and oral chemotherapy under
the prescription drug benefit.

Respiratory and inhalation therapy

Dialysis hemodialysis and peritoneal dialysis
Intravenous (IV)/ Infusion Therapy Home IV and antibiotic therapy

Nothing when we prior authorize your treatment.

Growth hormone therapy (GHT) These are covered under your
prescription drug program and require prior authorization from the Pharmacy Benefit Manager, Express Scripts (ESI)( these drugs are on

the prior authorization list.)
Note: We will only cover GHT when the treatment is prior authorized. You must ask your Plan provider to submit information that establishes

that the GHT is medically necessary. Your Plan provider must ask ESI
to authorize GHT before you begin treatment; otherwise, GHT serviceswill be covered from the date approval is issued by ESI. If you

do not ask or if ESI determines GHT is not medically necessary, GHT or
related services and supplies will not be covered. .

Applicable prescription drug
copayment.

Physical, Occupational, and Rehabilitative therapies
Physical therapy, occupational therapy, respiratory therapy, orthoptic therapy, urinary incontinence therapy and cardiac therapy --

60 visits per condition per calendar year for the services of each of
the following:

-Qualified physical therapists; occupational therapists, respiratory therapists; orthoptic therapists; urinary incontinence therapists

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

injury.

Nothing when we prior authorize your treatment and you are
referred by your Plan provider.

Not covered:
Long-term rehabilitative therapy
Exercise programs
Rehabilitative therapy services, including spinal manipulation
therapy, for chronic problems or routine maintenance for chronic conditions

All charges. 26.
26 Page 27 28
2003 Keystone Health Plan Central 24 Section 5( a)
Speech Therapy You Pay
60 visits per condition per calendar year for the services of qualified
speech therapists
Nothing when we prior authorize
your treatment and you are referred by your Plan provider.

Hearing services (testing, treatment, and supplies)
Hearing screenings for children through age 17 (see Preventive care,
children)

Nothing if you receive these
services during an associated office visit or if we authorize the

service and your provider refers
you.

$10 per office visit if you must have an office visit to receive
these services.

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

All charges.

Vision services (testing, treatment, and supplies)
Vision screening to determine the need for vision correction for
children through age 17 (see preventive care)

Vision screening for diagnostic purposes when related to a medical diagnosis when provided or referred by your Plan doctor

Nothing if you receive these
services during an associated office visit or if we authorize the

service and your provider refers
you.

$10 per office visit if you must have an office visit to receive
these services.

Note: If you are diabetic you may self-refer for one diabetic retinopathy screening to a Plan ophthalmologist or optometrist. You will receive a
letter and reminder card notifying you of this benefit each year. Take this card with you to your appointment with the Plan eye specialist.
Nothing

Not covered:
Eyeglasses or contact lenses or the fitting of contact lenses, except one pair of standard eyeglasses or contact lenses following cataract

surgery when the physician does not prescribe an intraocular lens.
Radial keratotomy and other refractive surgery

All charges. 27.
27 Page 28 29
2003 Keystone Health Plan Central 25 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

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
Artificial limbs and eyes; stump hose.
Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy

Intraocular lenses following cataract removal
Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome

Foot orthotics when an integral part of a leg brace or for severe diabetic foot disease
Braces
Internal prosthetic devices, such as artificial joints, pacemakers, defibrillators, cochlear implants, and surgically implanted breast

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

Nothing when prior authorized by
us and purchased from an approved supplier.

Not covered:
Orthopedic and corrective shoes
Arch supports
Heel pads and heel cups
Foot orthotics when not an integral part of a leg brace or for severe diabetic foot disease

Lumbosacral supports
Cost of penile implanted device

All charges. 28.
28 Page 29 30
2003 Keystone Health Plan Central 26 Section 5( a)
Durable medical equipment (DME) You Pay
Rental or purchase, at our option, including repair and adjustment, of durable medical equipment prescribed by your Plan physician, such as
oxygen and dialysis equipment. Under this benefit, we also cover:
hospital beds
wheelchairs
crutches
canes
walkers
traction equipment
physiotherapy equipment
ostomy supplies
insulin pumps, and diabetic orthotics

Note: Diabetic -related supplies and blood glucose monitors are covered
under Prescription drug benefits.

Nothing when prior authorized by us and purchased from an
approved supplier.
$10 per office visit for evaluation or fitting.

Note: All DME rentals and all
DME purchases with a cost of $250 or more per item now require

the provider to obtain prior
approval from the Plan.

Hair prostheses limited to 2 per member per calendar year with a maximum Plan payment of $400 per prosthesis Any remaining amount above the
Plan maximum of $400 per
prosthesis, with a limit of 2 per member per calendar year.

Oral appliances for sleep apnea are limited to a maximum Plan payment of $340 per appliance Any remaining amount above the
Plan maximum of $340 per appliance.

Not covered:
Durable medical equipment requested specifically for travel purposes, recreational or athletic activities or when the intended use

is primarily outside the home.
Replacement of lost or stolen items within the expected useful life of the originally purchased durable medical equipment.

Supplies determined by KHP Central to be not medically necessary.

All charges. 29.
29 Page 30 31
2003 Keystone Health Plan Central 27 Section 5( a)
Home health services You Pay
Home health care ordered by a Plan physician and provided by a
registered nurs e (R. N.), licensed practical nurse (L. P. N.), licensed vocational nurse (L. V. N.), or home health aide.

Services include oxygen therapy, intravenous therapy and
medications.

Nothing when we prior authorize
your treatment.

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

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

All charges.

Chiropractic
You can receive chiropractic services or manipulation therapy services for acute care when the services are associated with an
accident or injury and prior authorized by KHP Central. You must seek treatment within one week of the accident or injury and your
benefit period is limited to a maximum of two (2) weeks of acute
care. Services are limited to X-rays, an initial consultation or office visit, certain types of manipulation therapy and physical therapy.

Nothing for therapy when we prior authorize your treatment;
$10 per office visit to your primary care physician or
specialist.

Not covered:
Chronic problems and routine chiropractic maintenance services
All charges.

Alternative treatments
Not covered:
Naturopathic services
Hypnotherapy
Biofeedback
Acupuncture
Massage Therapy

All charges. 30.
30 Page 31 32

2003 Keystone Health Plan Central 28 Section 5( a)
Educational classes and programs You Pay
Coverage includes:

Childbirth Preparation Classes: You can receive up to a $75
reimbursement for Childbirth Preparation Classes. After you enroll in a course and make the initial payment, forward your certificate of

completion and your receipt to us for reimbursement.

Any balance over our $75 reimbursement.

Diabetes Education Classes. You are eligible to attend diabetic education classes through approved facilities. These classes are
designed to provide you with the skills necessary to manage
diabetes. The classes, which require prior authorization, are available to all of our members with a diagnosis of diabetes.

Nothing when we prior authorize your treatment.

We offer Disease Management Programs that are briefly described below. We continually evaluate various disease states and introduce new
programs as appropriate. In addition, we offer Intense Care Management for members with particularly complicated disease states. In these
situations, care managers work with you to design a personalized
program with your special needs in mind.

Information on any of these programs can be obtained by contacting a customer service representative or accessing our website at
www. khpc. com.
Asthma Health Management Program. Symptoms associated with asthma can affect all aspects of life --home, work and play. The
objective of the Asthma Health Management Program is to improve the quality of life by reducing symptoms through assessment, education, and
interventions designed to meet asthmatic Members' individual needs.
Our program is designed to empower individuals to take greater responsibility in the management of their disease.

Nothing.

Diabetes Health Management Program. Diabetes Health Management
Program objectives include preventing the development or progression of diabetes related complications. The program focuses on educating diabetic

members about improved self-care, lifestyle modification and personal
empowerment. Our program consists of educational mailings, assessment, and interventions based on individualized need.

Depression Health Management Program. This program is designed to
improve our Members' ability to recognize signs and symptoms of depression and to seek and receive appropriate treatment. The program

includes both Member and provider education which focus on early
detection, appropriate treatment interventions, reducing the stigma associated with depression, efficient utilization of resources, and other

measures to improve Members' psychosocial functioning.
Nicotine Cessation Health Management Program. Our Nicotine Cessation Program includes individual assessment, behavioral counseling,

telephone support, regular commu nication with the PCP and nicotine replacement therapy, when appropriate.

Nothing. 31.
31 Page 32 33
2003 Keystone Health Plan Central 29 Section 5( b)
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
I M
P O
R T
A N
T

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

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

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

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

precertification.

I M
P O
R T
A N
T

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

Nothing when we prior authorize
your treatment.

Not covered:
Reversal of voluntary sterilization
Routine treatment of conditions of the foot; see Foot Care
Any services determined to be not medically necessary by KHP Central

All charges. 32.
32 Page 33 34
2003 Keystone Health Plan Central 30 Section 5( b)
Reconstructive surgery You pay
Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if:
-the condition produced a major effect on the member's appearance and

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

Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of

congenital anomalies are: protruding ear deformities; cleft lip; cleft
palate; birth marks; webbed fingers; and webbed toes.

All stages of breast reconstruction surgery following a mastectomy, such as:

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

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

Nothing when we prior authorize your treatment.

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
Any services determined to be not medically necessary by KHP
Central

All charges. 33.
33 Page 34 35
2003 Keystone Health Plan Central 31 Section 5( b)
Oral and maxillofacial surgery You pay
Oral and maxillofacial surgical procedures include, but are not limited to:

Surgical correction of congenital defects, such as cleft lip and cleft palate;
Medical or surgical procedures occurring within or adjacent to the oral cavity or sinuses including, but not limited to, treatment of
fractures and excision of tumors and cysts; Removal of stones from salivary ducts;
Excision of leukoplakia or malignancies; Services for the extraction of impacted teeth when partially or
totally covered by bone. Services will be fully covered and may be provided to you on an outpatient or, when medically necessary,
inpatient basis; Other surgical procedures that do not involve the teeth or their
supporting structures; and Treatment of TMJ, including surgical and non-surgical intervention,
corrective orthopedic appliances and physical therapy.
Note: If you receive services on an inpatient basis, your doctor must obtain prior authorization from us before we will cover your surgery.

Nothing.

Not covered:
Oral implants and transplants
Procedures that involve the teeth or their supporting structures (such
as the periodontal membrane, gingiva, and alveolar bone), including any dental care involved in the treatment of

temporomandibular joint (TMJ) pain dysfunction syndrome

All charges. 34.
34 Page 35 36
2003 Keystone Health Plan Central 32 Section 5( b)
Organ/ tissue transplants You pay
Include but are not limited to:
Cornea
Heart
Heart/ lung
Kidney
Liver
Lung: Single Double
Pancreas
Small bowel
Allogeneic (donor) bone marrow transplants
Autologous bone marrow transplants (autologous stem cell and peripheral stem cell support) for the following conditions: acute

lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's
lymphoma; advanced non-Hodgkin's lymphoma; advanced neuroblastoma; breast cancer; multiple myeloma; epithelial ovarian

cancer; and testicular, mediastinal, retroperitoneal and ovarian germ
cell tumors.

Intestinal transplants (small intestine) and the small intestine with the liver or small intestine with multiple organs such as the liver,

stomach, and pancreas.
If not eligible for payment by any other source, the following services of donors to a KHP Central Member recipient are covered:

removal of the organ from the donor; donor preparatory pathologic and/ or medical examinations; donor post-surgical care.

Nothing when we prior authorize
your treatment.

Not covered:
Donor screening tests and donor search expenses
Transplants not listed as covered
Any treatment, procedure, facility, equipment, drug, drug
application, drug usage device or supply, which we determine is not accepted as standard medical treatment for the condition being

treated. We rely on available credible data and the advice of the
medical community, including but not limited to medical consultants, medical journals and/ or government regulations, to

guide us in our decisions.
Any such items requiring federal or other governmental agency approval for which approval has not been granted for the condition

being treated or the manner in which the items are being used at the
time services were rendered or requested.

All charges. 35.
35 Page 36 37
2003 Keystone Health Plan Central 33 Section 5( b)
Anesthesia You pay
Professional services provided in

Hospital (inpatient)
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center
Office

Nothing when we prior authorize
your treatment. 36.
36 Page 37 38
2003 Keystone Health Plan Central 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
Section 5( a) or (b).

YOUR PLAN PROVIDER MUST GET PRIOR AUTHORIZATION FOR ALL HOSPITAL STAYS. Please refer to Section 3 to be sure which services

require preauthorization.

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

Nothing when we prior authorize
your treatment.

Not covered:
Custodial care
Non-covered facilities, such as nursing homes and schools
Personal comfort items, such as telephone, television, barber services,
guest meals and beds
Private nursing care unless medically necessary
Take-home items
Whole blood, blood plasma or blood components

All charges. 37.
37 Page 38 39
2003 Keystone Health Plan Central 35 Section 5( c)
Outpatient hospital or ambulatorysurgical 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
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 when we prior authorize your treatment.

Not covered: Whole blood, blood and blood products. All charges.
Extended care benefits/ skilled nursing care facility benefits
Extended care benefit: You are eligible for an unlimited number of days of extended care when full time skilled nursing care is
necessary and confinement in a skilled nursing facility is determined
to be medically appropriate by your Plan doctor and approved by us. We cover all necessary services including but not limited to:

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

doctor.

Nothing when we prior authorize
your treatment.

Not covered: custodial care, domiciliary care, residential care, protective and supportive care including educational services, rest cures and
convalescent care.
All charges.

Hospice care
You are eligible for supportive and palliative care up to a maximum
of $7500 when you become terminally ill with a life expectancy of six months or less. These services must be provided in your home

and can include outpatient care and family counseling. These
services are provided under the direction of your Plan doctor, who certifies that you are in the terminal stages of illness, with a life

expectancy of approximately six months or less.

Nothing when we prior authorize
your treatment.

Not covered: Independent nursing, homemaker services, and inpatient hospice care All charges. 38.
38 Page 39 40
2003 Keystone Health Plan Central 36 Section 5( c)
Ambulance You pay
You can receive medically necessary ambulance services when required in connection with emergency services or when your Plan provider orders
and we prior authorize them in connection with non-emergent care.

Nothing when we prior authorize your treatment. 39.
39 Page 40 41
2003 Keystone Health Plan Central 37 Section 5( d)
Section 5 (d). Emergency services/ accidents
I M
P O
R T
A N
T

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

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

coverage, including with Medicare.

I M
P O
R T
A N
T
What is a medical emergency?
An "Emergency Service" is defined as any health care service provided to you or someone in your family after the sudden onset of a medical condition that manifests itself by acute symptoms of sufficient severity or

severe pain, such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:
Placing your health, or with respect to a pregnant woman, the health of the woman or her unborn child in serious jeopardy;
Serious impairment to bodily functions; or
Serious dysfunction of any bodily organ or part.
Transportation and related emergency services provided by a licensed ambulance service are also covered benefits, if the condition is as described above. Some problems are emergencies because, if not treated

promptly, they might become more serious; examples include deep cuts and broken bones. Others are emergencies because they are potentially life threatening, such as heart attacks, strokes, poisonings,
gunshot wounds, or sudden inability to breathe. There are many other acute conditions that we may
determine are medical emergencies what they all have in common is the need for quick action.

What to do in case of emergency:
In a true Emergency, your first concern is to obtain necessary medical treatment. If the circumstances
prevent you from contacting your PCP, seek Emergency medical care from the nearest appropriate facility. A Referral from your PCP is not required in a true Emergency.

If KHP Central determines that the services constitute an Emergency Service as defined above, charges incurred will be covered by KHP Central. Otherwise, the services will NOT be covered by KHP Central.
NOTE: Please contact your PCP within forty-eight (48) hours after the incident so that necessary follow-up care can be arranged. Your PCP's phone number is on the front of your ID card. You can also get this phone number
from us by calling our Customer Service Department at 1-800-622-2843 (TDD 1-800-669-7075).
Emergencies within our service area: You should follow the steps described above; get medical care for yourself or the person who needs it first. You or a family member should contact your PCP as soon as

possible, but within 48 hours unless it was not reasonably possible to do so.
Emergencies outside our service area: You should follow the steps described above; get medical care for yourself or the person who needs it first. You or a family member should contact your PCP as soon as

possible, but within 48 hours unless it was not reasonably possible to do so.

What to do in case of an urgent situation:
Urgent care is care for an unexpected illness or injury which does not require emergency services but which may need prompt medical attention. Some examples of urgent situations are: cold, sore throat, cough, fever, vomiting,

sprain, strain, cramps, diarrhea, bumps, bruises, small lacerations, minor burns, earache, rashes, swollen glands, and possible broken bones. 40.
40 Page 41 42

2003 Keystone Health Plan Central 38 Section 5( d)
Urgent care within our service area: In the event of an urgent situation, first call your PCP. He or she will give
you instructions and refer medical care appropriate to the situation. In most circumstances, you will NOT be directed to an emergency room of a hospital for urgent Care. In the event that you are unable to obtain a PCP

referral for medically necessary care in advance of receipt of the urgent care services, you should notify the PCP
within 48 hours of the receipt of care or the next business day.

Urgent care outside our service area: In the event that you require urgent care outside of the service area, you
should contact BlueCard at 1-800-810-2583 or via the Internet at www. bcbs. com to determine if there is a BlueCard participating provider in the area. If there is such a provider, BlueCard will provide a list of area

providers who can deliver the care you require. You will then be responsible for choosing a Provider and
arranging an appointment. If there is not a participating provider in the area, you will need to contact your PCP. In either case, you should contact your Primary Care Physician within forty-eight (48) hours of receiving the care

to inform them of the visit. You must contact your PCP prior to receiving care under BlueCard Follow-Up care.
Urgent Care received outside the Service Area will be considered covered only if, in the determination of KHP Central:

You could not have anticipated the need for such services prior to leaving the Service Area; and
You contact BlueCard prior to service; or
Your Primary Care Physician coordinates the service.

Benefit Description You pay
Emergency within our service area

Emergency care at a doctor's office

Emergency care at an urgent care center
Emergency care as an outpatient or inpatient at a hospital,
including doctors' services

$10 per office visit during normal office hours; $20
per office visit after hours
usually scheduled for appointments.

$25 per visit; waived if
we authorize your admittance.

Not covered: Elective or non-emergency care All charges when we do
not prior authorize your treatment. 41.
41 Page 42 43
2003 Keystone Health Plan Central 39 Section 5( d)
Emergency outside our service area You pay
Emergency care at a doctor's office
Emergency care at an urgent care center
Emergency care as an outpatient or inpatient at a hospital, including doctors' services

Same as for Emergency within our service area.

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

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

All charges when we do
not prior authorize your treatment.

Ambulance
Professional ambulance services when medically appropriate. These include, but are not limited to:

Air ambulance
Basic life support
Advanced life support
Invalid coach service
See 5( c) for non-emergency service.

You pay nothing when we authorize your
treatment.

Not covered: ambulance services when not medically necessary or not authorized by us. All charges. 42.
42 Page 43 44
2003 Keystone Health Plan Central 40 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
I M
P O
R T
A N
T

When you get our approval for services and follow a treatment plan we approve, cost-sharing and limitations for Plan mental health and substance abuse benefits will be no greater than for
similar benefits for other illnesses and conditions.
Here are some important things to keep in mind about these benefits:
All benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other
coverage, including with Medicare.
YOU MUST GET PRIOR AUTHORIZATION FOR CERTAIN SERVICES. See the instructions after the benefits description below.

I M
P O
R T
A N
T

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 clinically appropriate to treat your condition and only when you receive
the care as part of a treatment plan that we approve.

Your cost sharing
responsibilities are no greater than for other

illnesses or conditions.

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

$10 per office visit.

Mental health and substance abuse benefits -Continued on next page 43.
43 Page 44 45
2003 Keystone Health Plan Central 41 Section 5( e)
Mental health and substance abuse benefits (Continued) You pay
Diagnostic tests Nothing if you receive these
services during an associated
office visit or if we authorize the service and your provider

refers you.

$10 per office visit if you must have an office visit to receive
these services.

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

Nothing when we prior authorize your treatment.

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.

Your mental health and substance abuse treatment is provided through a subcontract with PacifiCare Behavioral Health, a behavioral health managed care company. PacifiCare Behavioral Health maintains a network of qualified mental
health care professionals who offer care to our members. You are eligible for a full range of services including inpatient
care, partial hospital programs, outpatient treatment and other levels of care appropriate to individual needs. Typically, a copayment of $10 for each outpatient counseling visit is required.

Contacting Your Mental Health Provider.
You must contact PacifiCare Behavioral Health (PBH) at 1-800-216-9748 (TDD number at 1-888-877-5378) to identify PBH network providers and determine which provider best meets your needs. If outpatient non-emergency services are

not received from a PacifiCare Behavioral Health network provider, these will NOT be covered. If you are faced with a
crisis, contact PBH at 1-800-216-9748 (TDD number 1-888-877-5378). PacifiCare Behavioral Health Care Management Team and network providers are available 24 hours a day, 7 days a week, to offer assistance and coordinate

care. PacifiCare also offers translator services to its non-English speaking members. To access this service, simply
contact PacifiCare at 1-800-216-9748. The Behavioral Health Provider you choose will be responsible for providing and/ or coordinating your mental health/ substance abuse treatment.

Inpatient Services -Mental Health or Substance Abuse. If a need for inpatient care is identified, the inpatient stay
must be prior authorized by PacifiCare Behavioral Health. PacifiCare Behavioral Health must prior authorize all non-emergency inpatient services.

Emergency Services. Emergency services do not have to be prior authorized, but you or your family should contact
your PCP or PacifiCare Behavioral Health within 48 hours of receiving these services unless it is not reasonably possible to do so.

Limitation We may limit your benefits if you do not obtain a treatment plan. 44.
44 Page 45 46

2003 Keystone Health Plan Central 42 Section 5( f)
Section 5 (f). Prescription drug benefits
I
M P

O
R T

A
N T

Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart beginning on page 44.

All benefits are subject to the definitions, limitations and exclusions in this brochure
and are payable only when we determine they are medically necessary.

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

other coverage, including with Medicare.

I
M P

O
R T

A
N T

There are important features you should be aware of. These include:
Who can write your prescription? A plan provider or a provider to whom you have been referred must write the prescription.

Where you can obtain them. You have the option of going to any participating pharmacy or using the mail service pharmacy. At a participating pharmacy, simply show your KHP Central ID card when you
present your prescription and you pay only the amount of the copayment or coinsurance specified by your KHP Central prescription drug benefit.

If, for any reason, the participating pharmacy is unable to process your prescription, you may need to pay the full cost of the prescription. You may then submit a Member Direct Submission Form to Express
Scripts, KHP Central's Pharmacy Benefit Manager, for reimbursement of KHP Central's cost, less the
amount of your copayment or coinsurance. All Member Direct Submission Forms must be submitted within ninety (90) days of the pharmacy receipt date. A Member Direct Submission Form can be

obtained by calling KHP Central's Customer Service Department at 1-800-622-2843 (TDD 1-800-669-7075),
or by e-mailing us at CustomerService@ khpc. com.

If you go to a non-participating pharmacy, you are responsible for paying the full cost of your prescription at the time of service. Only in the case of an emergency will reimbursement be considered for a

prescription filled at a non-participating pharmacy. If this situation occurs, please submit a letter of explanation, along with your receipt, to KHP Central at the following address: KHP Central Customer
Service Department, P. O. Box 898880, Camp Hill, PA 17089-8880. If after reviewing your request, KHP Central agrees that the situation was an emergency, you will be reimbursed, less your copayment or
coinsurance, for the cost of the prescription drug. You must submit your receipt within ninety (90) days of the pharmacy receipt date to be considered for reimbursement.

Prescription mail service is provided through the Express Scripts Mail Service Pharmacy. Using the mail service pharmacy for maintenance drugs (drugs used on an ongoing basis for chronic conditions) helps to
save you time and money by having prescription drugs delivered directly to your home. An Express
Scripts Mail Service Pharmacy packet can be obtained by calling KHP Central's Customer Service Department at 1-800-622-2843. Follow the directions that are included in the packet to order your

prescriptions. Or, you can order your prescriptions online by visiting KHP Central's website at
www. khpc. com. This will provide you with a link to Express Scripts' online pharmacy.

You may return drugs to Express Scripts that were filled at the Express Scripts Mail Service Pharmacy in
the following instances:
When the prescription is filled incorrectly (not as written by the prescribing provider).
When the prescription is damaged during shipment.
When the prescription has been changed to another drug without the prescribing provider's approval. In the event that any of the situations outlined above occurs, your account with Express Scripts will be

credited the amount of your copayment or coinsurance. Drugs that are returned to Express Scripts for any
reason other than those listed above will not result in any type of account credit. This includes reasons such as discontinuation of treatment or cost of the drug. 45.
45 Page 46 47

2003 Keystone Health Plan Central 43 Section 5( f)
We use a formulary. KHP Central uses a drug formulary to help manage your prescription drug benefit. The KHP Central drug formulary is a list of medications intended to guide your provider's prescription
drug prescribing decisions. The KHP Central Pharmacy and Therapeutics Committee (P& T Committee) developed the drug formulary. The P& T Committee meets quarterly to review new and existing
prescription drugs on the basis of safety, effectiveness, and cost in order to ensure that the drug formulary remains responsive to the needs of members and providers. Therefore, the drug formulary is subject to
change throughout the year. Updates to the drug formulary will be reported quarterly in the KHP Central
member newsletter.

Under the KHP Central drug formulary, drugs are classified into one of three tiers generic drugs (1 st
tier), preferred brand drugs (2 nd tier), or non-preferred brand drugs (3 rd tier). Copayments are assigned for each tier and increase incrementally from the first through the last tier. If you have questions regarding

the tier placement of a prescription drug, or if you would like to request a copy of KHP Central's drug
formulary, call KHP Central's Customer Service Department at 1-800-622-2843 or visit KHP Central's website at www. khpc. com.

These are the dispensing limitations. KHP Central encourages the use of Generic Drugs through the generic program. When a generic drug is dispensed, you are responsible for paying only the applicable
generic copayment or coinsurance. When a brand drug is dispensed that has a generic equivalent, you are
responsible for paying the applicable brand copayment or coinsurance plus the difference in price between the brand drug and its generic equivalent, up to the original cost of the brand drug. KHP Central

has a Brand Drug Consideration Process whereby a provider may request that coverage for a preferred or
non-preferred brand drug be granted when medical necessity is substantiated in writing. When granted, you are responsible for paying only the applicable brand drug copayment or coinsurance. Note: When a

brand drug is dispensed that has no generic equivalent, you are responsible for paying only the applicable
brand drug copayment or coinsurance.

Up to a ninety (90) day supply of drugs can be obtained at a participating pharmacy by paying your
applicable copayment or coinsurance for each thirty (30) day supply or unit-of-use. You can request that your prescription be refilled after approximately seventy-five percent (75%) of the quantity has been used.

When you use the mail service pharmacy, you can purchase up to a ninety (90) day supply of drugs at one time by paying your applicable mail service copayment or coinsurance for each prescription. You will
receive instructions with each order explaining how to reorder your drugs. Yo u can request that your mail service prescription be refilled after approximately sixty percent (60%) of the quantity has been used.

Why use generic drugs? All drugs have a generic or chemical name. When a company first develops a new drug, it gives the drug its brand name as part of its marketing plan. The FDA (Food and Drug
Administration) regulates generic drugs in the same way they approve and regulate brand name drugs. Generic drug makers must prove to the FDA that the active ingredients in the generic drug have the same
medical effect as its brand-name counterpart and must contain equal amounts of the same active ingredients, in the same dosage.

The key to the effectiveness of a drug -either brand-name or generic -is its active ingredients. Its inactive ingredients determine the size, shape and color of a particular drug. Inactive ingredients, like dyes, fillers
and preservatives, do not affect the way the active ingredients work. These inactive ingredients often make generic drugs look different from their brand-name counterparts.

Developing new drugs is expensive. Companies that develop new drugs are given patent protection for the drug. Upon expiration, other companies can produce the generic drug. These companies do not have
to spend as much money researching and developing the generic drug as was needed to originally develop
the drug. This enables companies to produce generic drugs at a lower cost.

The price of a generic drug can be 15 to 80 percent less than its brand-name equivalent. These savings help keep your benefit costs lower. Generic drugs are strictly regulated for quality and consistency.
Some people think that lower-priced generic drugs lack quality. This is not true. 46.
46 Page 47 48

2003 Keystone Health Plan Central 44 Section 5( f)
Nearly half of all brand-name drugs have a generic counterpart. However, since generic drugs aren't available until a drug's patent has expired, some drugs are only available as a brand-name from a single
manufacturer.
When your doctor writes a prescription, ask him/ her to sign the prescription to allow for generic
substitution. All 50 states have laws allowing your pharmacist -with your doctor's approval -to dispense generic drugs for prescriptions written for the brand-name drug. As always, if you have any questions,

ask your doctor or pharmacist.
Some drugs require prior authorization. The Plan has a prior authorization process in place through their Pharmacy Benefit Manager, Express Scripts, to review requests for certain prescription drugs and
compare them with clinical guidelines for appropriateness. Delays may occur in receiving these drugs to allow for clinical review of provider submitted information.

Another form of prior authorization that KHP Central uses is step-therapy. Step-therapy applies to select classes of prescription drugs, whereby a second-line drug is only authorized if the therapy outcome is not
satisfactory to a first-line, or prerequisite drug. If a first-line drug has not been tried, the second-line drug will not be covered. If the prescribing provider believes that it is medically necessary for a second-line
drug to be used without trial of a first-line drug, the provider can request consideration through Express Scripts. If a member is currently taking a second-line drug, then continuance on that drug is permitted
without trial of a first-line drug.
Questions regarding which prescription drugs require prior authorization may be directed to the Plan's Customer Service Department at 1-800-622-2843 (TDD 1-800-669-7075). Additionally a list of drugs
requiring prior authorization is available on Keystone Health Plan Central's website at www. khpc. com. Updates to the prior authorization list will be reported to members in Keystone Health Plan Central's
quarterly member newsletter.
If your drug requires prior authorization, your doctor may either call Express Scripts at 1-800-889-0376 or fax a completed Prescription Prior Authorization Form, along with any supporting documentation, to
Express Scripts at 1-800-357-9577. You or your doctor can download a Prescription Prior Authorization Form from our website at www. khpc. com .

If you are given a prescription for a drug that requires prior authorization and try to obtain the drug at the pharmacy without having obtained prior authorization, your doctor will receive a phone call from the
pharmacist and/ or Express Scripts to obtain the information. Therefore, it will be more convenient for you and your provider to provide this information in advance. If necessary, the Express Scripts reviewers will
contact your provider to clarify information provided on the Prescription Prior Authorization Form. Applying specific prior authorization criteria, the reviewer will determine if the request is approved or
denied within two (2) working days from the date Express Scripts receives all of the applicable information.

If the medication is authorized, the requestor (the prescribing physician and/ or dispensing pharmacy) will be notified (via phone or fax) of the decision within one (1) working day of making the decision. Up to a
one-year authorization will be granted for the medication with each subsequent one-year authorization effective with a new prior authorization approval.

If the drug is denied, the requestor (prescribing physician and/ or dispensing pharmacy) will be initially notified (via phone or fax) of the decision within one (1) working day of making the decision. The denial
decision, including appeal information, will also be confirmed and communicated in writing to you, with carbon copy (cc) forwarded to the prescribing provider and to us within two (2) working days of making
the decision. You and/ or the prescribing provider, with your written consent, may file a grievance. See page 50 of this brochure for information on filing a grievance with us.
Prescription drug benefits begin on the next page. 47.
47 Page 48 49
2003 Keystone Health Plan Central 45 Section 5( f)
Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan
provider and obtained from a Plan pharmacy or through our mail service pharmacy:

Drugs on the Keystone Health Plan Central drug formulary
Drugs for which a prescription is required by State or Federal law of the United States require a provider's prescription for their purchase,

except those listed as Not covered.
Insulin
Diabetic supplies including alcohol wipes/ pads, syringes, needles, glucose test strips, lancets, and one (1) blood glucose monitor in a

calendar year
Compounded preparations containing at least one prescription drug
Contraceptive drugs and devices
Disposable needles and syringes for the administration of covered medications

Oral chemotherapy

At a participating pharmacy:
A $10 (generic)/ $25 (preferred brand)/ $40 (non-preferred

brand) copayment
for up to a 30-day supply per prescription unit or refill;

A $20 (generic)/ $50
(preferred brand)/ $80 (non-preferred brand) copayment

for up to a 60-day supply per
prescription unit or refill;

A $30 (generic)/ $75 (preferred brand)/ $120 (non-preferred

brand) copayment for up to a 90-day supply per
prescription unit or refill.
From the Express Scripts mail service pharmacy:

A $20 (generic)/ $50
(preferred brand)/ $80 (non-preferred brand) copayment

for up to a 90-day supply per
prescription unit or refill.

Note:
If a preferred brand drug is
dispensed that has a generic equivalent, you will be

responsible for paying the
preferred brand drug copayment plus the

difference in price between
the preferred brand drug and the generic equivalent, up to

the original cost of the
preferred brand drug.

If a non-preferred brand drug is dispensed that has a

generic equivalent, you will be responsible for paying the
non-preferred brand drug
copayment plus the difference in price between

the non-preferred brand drug
and the generic equivalent, up to the original cost of the

non-preferred brand drug. 48.
48 Page 49 50
2003 Keystone Health Plan Central 46 Section 5( f)
Covered medications and supplies (continued) You Pay
Drugs for sexual dysfunction are subject to dose or quantity limitations. Call the Plan for specific limitations.
Oral drugs used to treat infertility can be purchased from a
participating pharmacy or from the mail service pharmacy. Quantities are limited to a maximum of a 90-day supply.

NOTE: Oral drugs used to treat infertility are covered as long as infertility is not due, in part or in its entirety, to either party (whether a KHP Central
member or not) having undergone a voluntary sterilization procedure
and/ or reversal of the voluntary sterilization procedure that was not successful.

50% coinsurance.

Not covered:
Drugs that do not legally require a written prescription from a health care professional licensed to prescribe drugs (other than insulin)

Drugs that have an over-the-counter (non-prescription) equivalent
Nutritional or dietary supplements including vitamins and nutritional supplements available without a prescription

Medical supplies such as dressings and antiseptics, except diabetic
supplies as indicated on the benefit list
Drugs and supplies for cosmetic purposes
Drugs used in conjunction with non-covered medical services
Drugs to enhance physical or athletic performance
Drugs to promote weight loss, except for treatment of morbid obesity*
Drugs which are investigational or experimental in nature, as determined by Keystone Health Plan Central in accordance with this

Program
Immunization agents, biological sera, blood or blood product
Prescription drugs received in and/ or billed by a home health care
agency, hospital, skilled nursing facility, assisted living facility or similar institution which may be provided under the medical benefit

Venoms, allergy serums and desensitization serums
Smoking Cessation drugs and products *
Drugs prescribed and administered in the provider's office
Replacement prescription resulting from loss, theft, or damage
Except in emergency situations, drugs purchased from a non-participating
pharmacy
Request for reimbursement filed more than ninety (90) days after the pharmacy receipt date

*Note: When smoking cessation drugs and products, and drugs to promote weight loss (except for treatment of morbid obesity, which is
a covered benefit) are prescribed by a KHP Central participating provider or a provider to whom you have been referred, they may be
obtained at a participating pharmacy or mail service pharmacy at a
coinsurance equal to 100% of KHP Central's cost of the prescription drug. Otherwise, these drugs are considered not covered under your

prescription drug benefit.

All Charges 49.
49 Page 50 51

2003 Keystone Health Plan Central 47 Section 5( g)
Section 5 (g). Special Features
Feature Description

BlueCard Urgent Care Out of Area Services

Away From Home Care-Guest
Membership

If you are traveling outside the Plan's service area and require urgent care,
you need to use the following procedure:

Contact the 24-hour, toll-free provider locator service at
1-800-810-2583 or log on to www. bcbs. com.
You will receive information regarding three available local providers (names, addresses, phone numbers, and directions)

who can meet your medical needs.
You will need to select a provider and schedule your own appointment.

At the appointment, you must present your Plan Medical ID card and pay the applicable copayment while you are at your
appointment.
You must contact your Primary Care Physician to advise the
office of your need for medical attention and coordinate any necessary follow up care. Your PCP must coordinate your

follow up care or it will not be covered.
In the event of an Emergency: The member seeks immediate assistance at the nearest medical facility. The member should contact his or her Primary
Care Physician within 48 hours after the incident so that necessary follow-up care can be arranged.

If you or a dependent will be out of the area for an extended period, such as a child at an out of area college, you may wish to enroll in our Away From
Home Guest Membership program as described below. Guest memberships
give you and your dependents coverage (similar to that provided by KHP Central) at the Blue Cross/ Blue Shield HMO in that particular geographic

area. You will have a Primary Care Physician (PCP) at the guest HMO, just
like you did through KHP Central. Essentially, you are covered under two plans at the same time, with no additional cost to you.

When could a guest membership work for you or your family members? If
your away-from-home travel is more extensive than day trips or week vacations, a guest membership may be the answer you are looking for.

Members who take extended business trips (three to six months), students at
college, or families living apart may all take advantage of the benefit of a guest membership.

To find out if you or your Dependents are eligible for the Guest Membership
Program, please call KHP Central's Customer Service Department at 1-800-622-2843 toll-free (TDD number at 1-800-669-7075 for the hearing

impaired).
Please note that if you will be out of our service area for greater than six months or if you change your permanent residence to an address outside of

the service area, you will not be eligible for the Guest Membership program.

Keeping Well You will receive KHP Central's member newsletter four times each year, keeping you updated on health-related topics of seasonal interest as well as informing you of updates to your coverage with us. 50.
50 Page 51 52

2003 Keystone Health Plan Central 48 Section 5( g)
HealthLink You will have easy access to health information whenever you need it, 24 hours a day, 365 days a year. This is an over-the-phone audio system giving you access to over 1,100 health related topics.
www. khpc. com You can search our website for participating doctors, hospitals and pharmacies, ask us questions, obtain information about our drug formulary, obtain various forms, read about our health management and educational
programs or link to other health care-related sites. 51.
51 Page 52 53
2003 Keystone Health Plan Central 49 Section 5( h)
Section 5 (h). Dental benefits
I M
P O
R T
A N
T

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

Plan doctors must provide or arrange your care.
We have no calendar year deductible.
We cover hospitalization for dental procedures only when certain nondental physical impairments exist which makes hospitalization necessary to safeguard the health of the

patient. See Section 5( c) for inpatient hospital benefits. We do not cover the dental procedure unless it is described below.

I M
P O
R T
A N
T

Accidental injury benefit You pay
We cover restorative services and supplies necessary to promptly repair (but not replace) sound natural
teeth. The need for these services must result fro m
an accidental injury. You must seek treatment within 24 hours of the accident, unless it is not

feasible due to medical conditions. We do not cover
accidental injuries due to chewing, biting or injuries resulting from dental disease.

Nothing

Dental benefits
We have no other dental benefits. 52.
52 Page 53 54
2003 Keystone Health Plan Central 50 Section 5( i)
Section 5 (i). Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed
claim about them. Fees you pay for these services do not count toward FEHB deductibles or catastrophic protection out-of-pocket maximums.

Wellness Discount Directory
Keystone Health Plan Central (KHP Central) believes that providing access to health care is important even when
you're not sick. To help encourage you to improve and maintain your overall health, we've arranged for you to receive discounts for health and fitness services at certain facilities within the KHP Central service area. The

Wellness Discount Directory lists all of the facilities, organizations, and practitioners that offer discounts. This
information is available from KHP Central in hard copy or on our website. Participants in the program are listed by county and may include: Acupuncture, Chiropractic, Massage Therapy, Fitness Centers, and Nutrition Centers. You

must show your KHP Central identification card to obtain the applicable discounts.
These discounts are not included in the KHP Central health benefits plan and are provided strictly as a convenience and courtesy to KHP Central members. 53.
53 Page 54 55
2003 Keystone Health Plan Central 51 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 pages 13-14.

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; or
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program.
Services, drugs, or supplies you receive without charge while in active military service. 54.
54 Page 55 56
2003 Keystone Health Plan Central 52 Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or fill your prescription drugs at Plan pharmacies, you will not have to file claims. Just present your identification card and pay your copayment or
coinsurance.
You will only need to file a claim when you receive emergency services from non-plan providers. Sometimes these providers bill us directly. Check with the provider. If you need to file the claim, here is the process:

Medical and hospital benefits In certain instances, you may be asked to pay for medical services or supplies at the time of service. This most commonly occurs with
emergency services outside of the service area. For out-of-area
emergency services, your KHP Central identification card has national recognition because of our licensure with the Blue Cross and Blue Shield

Association. However, we cannot ensure that all out-of-area hospitals
and physicians will bill us directly. You can direct the physician or hospital to call the toll-free number on the reverse side of your

identification card if they have questions about your health plan.
Physicians must file on the form HCFA-1500, Health Insurance Claim Form. Facilities will file on the UB-92 form.

When you must file a claim such as for services you receive outside of the Plan's service area submit it on the HCFA-1500 form or a claim
form that includes the information shown below. Bills and receipts
should be itemized and show:

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

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

Submit your claims to: Keystone Health Plan Central, P. O. Box 898880, Camp Hill, PA 17089-8880. 55.
55 Page 56 57
2003 Keystone Health Plan Central 53 Section 7
Prescription drugs You may be asked to pay more than your copayment or coinsurance for prescription drugs in an emergency situation. If you must file a claim for
prescription drugs, contact us at 1-800-622-2843 and we will help you.
You must request any reimbursement within 90 days of the pharmacy receipt date.

Submit your claims to: Keystone Health Plan Central, P. O. Box
898880, Camp Hill, PA 17089-8880

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. 56.
56 Page 57 58
2003 Keystone Health Plan Central 54 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: Keystone Health Plan Central, FEP Denial Reconsideration Committee, P. O. Box 890163, Camp Hill, PA 17089-0163; and

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

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

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

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

Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Contracts Division 3,
1900 E Street, NW, Washington, DC 20415-3630. 57.
57 Page 58 59
2003 Keystone Health Plan Central 55 Section 8
The Disputed Claims Process (Continued)
Send OPM the following information:
A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;

Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms;
Copies of all letters you sent to us about the claim;
Copies of all letters we sent to you about the claim; and
Your daytime phone number and the best time to call.

Note: If you want OPM to review more than one claim, you must clearly identify which documents apply
to which claim.

Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representative, such as medical providers, must include a copy of your specific written consent with the

review request.
Note: The above deadlines may be extended if you show that you were unable to meet the deadline because of reasons beyond your control.

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

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

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

You may not sue until you have completed the disputed claims process. Further, Federal law governs your lawsuit, benefits, and payment of benefits. The Federal court will base its review on the record that was

before OPM when OPM decided to uphold or overturn our decision. You may recover only the amount of benefits in dispute.

NOTE: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and
(a) We haven't responded yet to your initial request for care or preauthorization/ prior authorization, then
call us at 1-800-622-2843 (TDD number 1-800-669-7075) and we will expedite our review; or

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

You may call OPM's Health Benefits Contracts Division 3 at 202/ 606-0755 between 8 a. m. and 5 p. m. eastern time. 58.
58 Page 59 60
2003 Keystone Health Plan Central 56 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.

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 plan 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 (Part A or Part B) The Original Medicare Plan (Original Medicare) is available
everywhere in the United States. It is the way everyone used to get Medicare benefits and is the way most people get their Medicare 59.
59 Page 60 61
2003 Keystone Health Plan Central 57 Section 9
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. Your care must be authorized by your Plan PCP and we will not waive any of our copayments or coinsurance.

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

When we are the primary payer, we process the claim first.
When Original Medicare is the primary payer, Medicare processes your claim first. In most cases, your claims will
be coordinated automatically and we will then provide
secondary benefits for covered charges. You will not need to do anything. To find out if you need to do something to

file your claims, call us at 1-800-622-2843.
We do not waive any costs if the Original Medicare Plan is your primary payer. 60.
60 Page 61 62
2003 Keystone Health Plan Central 58 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) Areanactiveemployee withtheFederalgovernment (includingwhenyouor afamilymemberare eligibleforMedicaresolely becauseofadisability),

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

b) The position is not excluded from FEHB
(Ask your employing office which of these applies to you.)

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

(for other services)

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

(except for claims related to Workers'

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

1) Are within the first 30 months of eligibility to receive Part A benefits solely because of ESRD,
2) Have completed the 30-month ESRD coordination period and are
still eligible for Medicare due to ESRD,

3) Become eligible for Medicare due to ESRD after Medicare became primary for you under another provision,

C. When you or a covered family member have FEHB and
1) Are eligible for Medicare based on disability and,
a) Are an annuitant, or
b) Are an active employee, or

c) Are a former spouse of an annuitant, or
d) Are a former spouse of an active employee 61.
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2003 Keystone Health Plan Central 59 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
FEH B 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 plan's Medicare managed care plan and also
remain enrolled in our FEHB plan. We will still provide benefits
when your Medicare managed care plan is primary, even out of the managed care plan's network and/ or service area (if you use our Plan

providers), but we will not waive any of our copayments or
coinsurance. If you enroll in a Medicare managed care plan, tell us. We will need to know whether you are in the Original Medicare Plan

or in a Medicare managed care plan so we can correctly coordinate
benefits with Medicare.

Suspended FEHB coverage to enroll in a Medicare managed
care plan: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in a Medicare managed care

plan, eliminating your FEHB premium. (OPM does not contribute to
your Medicare managed care plan premium). For information on suspending your FEHB enrollment, contact your retirement office.

If you later want to re-enroll in the FEHB Program, generally you
may do so only at the next open season unless you involuntarily lose coverage or move out of the Medicare managed care plan's service

area.

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

will not ask you to enroll in it.

TRICARE and CHAMPVA TRICARE is the health care program for eligible dependents of military persons and retirees of the military. TRICARE includes the
CHAMPUS program. CHAMPVA provides health coverage to disabled Veterans and their eligible dependents. If TRICARE or
CHAMPVA and this Plan cover you, we pay first. See your
TRICARE or CHAMPVA Health Benefits Advisor if you have questions about these programs. 62.
62 Page 63 64
2003 Keystone Health Plan Central 60 Section 9
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
OWCP or a similar agency pays for through a third party injury
settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws.

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

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

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

FEHB Program, generally you may do so only at the next Open
Season unless you involuntarily lose coverage under the State Program.

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

When others are respons ible When you receive money to compensate you for for injuries medical or hospital care for injuries or illness caused by another
person, you must reimburse us for any expenses we paid. However, we will cover the cost of treatment that exceeds the amount you
received in the settlement.
If you do not seek damages you must agree to let us try. This is
called subrogation. If you need more information, contact us for our subrogation procedures. 63.
63 Page 64 65
2003 Keystone Health Plan Central 61 Section 10
Section 10. Definitions of terms we use in this brochure
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on
December 31 of the same year.

Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. See page 15.

Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page15.
Covered services Care we provide benefits for, as described in this brochure.
Custodial care Treatment or services, regardless of who recommends them or where they are provided, that could be rendered safely and reasonably by a
person not medically skilled, or that are designed mainly to help the
patient with daily living activities. Custodial care that lasts 90 days or more is sometimes know as Long term care.

Experimental or investigational services We rely on available, credible data and on the advice of the general
medical community. The general medical community includes, but is not
limited to, medical consultants, medical journals and governmental regulations. The data from these sources is used to determine if any

treatment, procedure, facility, equipment, drug, drug application, drug
usage device, or supply is not accepted as standard medical treatment for the condition being treated. The data is also used to determine if any

such items that require Federal or other governmental agency approval
were not granted such approval at the time the services were rendered or requested.

Group health coverage Health coverage you receive from this Plan when you join through the FEHB.
Medical necessity Services or supplies provided to you by a health care provider that we determine are:
Appropriate and necessary for the diagnosis and/ or the direct care and treatment of your medical condition, disease, illness or injury; and are
essential for improving and/ or maintaining your current health status;
In accordance with accepted standards of good medical practice;
Consistent with our protocols and utilization guidelines;
Not primarily for your convenience and/ or that of your family, physician or other health care provider; and

Provided at the most appropriate level of service, setting or supply necessary to safely diagnose or treat you. When applied to Hospital
Services, this further means that you require care in an emergency
room or as an Inpatient due to your symptoms or condition, and that you cannot receive safe or adequate care as an Outpatient in another

setting.

Us/ We Us, we and KHP Central refer to Keystone Health Plan Central and our affiliated providers.

You You refers to the enrollee and each covered family member. 64.
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2003 Keystone Health Plan Central 62 Section 11
Section 11. FEHB facts
No pre -existing condition We will not refuse to cover the treatment of a condition that you had limitation before you enrolled in this Plan solely because you had the condition before you enrolled.

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

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

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

Types of coverage available Self Only coverage is for you alone. Self and Family coverage is for for you and your family you, your spouse, and your unmarried dependent children under age 22, including any

foster children or stepchildren your employing or retirement office authorizes coverage for. Under certain circumstances, you may also continue coverage for a disabled child 22
years of age or older who is incapable of self-support.
If you have a Self Only enrollment, you may change to a Self and Family enrollment if
you marry, give birth, or add a child to your family. You may change your enrollment 31 days before to 60 days after that event. The Self and Family enrollment begins on the

first day of the pay period in which the child is born or becomes an eligible family
member. When you change to Self and Family because you marry, the change is effective on the first day of the pay period that begins after your employing office receives your

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

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

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

If this law applies to you, you must enroll for Self and Family coverage in a health plan
that provides full benefits in the area where your children live or provide documentation to your employing office that you have obtained other health benefits coverage for your

children. If you do not do so, your employing office will enroll you involuntarily as
follows: 65.
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2003 Keystone Health Plan Central 63 Section 11
If you have no FEHB coverage, your employing office will enroll you for Self and
Family coverage in the Blue Cross and Blue Shield Service Benefit Plan's Basic Option.

if you have a Self Only enrollment in a fee-for-service plan or in an HMO that serves
the area where your children live, your employing office will change your enrollment to Self and Family in the same option of the same plan; or

if you are enrolled in an HMO that does not serve the area where the children live,
your employing office will change your enrollment to Self and Family in the Blue Cross and Blue Shield Service Benefit Plan's Basic Option.

As long as the court/ administrative order is in effect, and you have at least one child identified in the order who is still eligible under the FEHB Program, you cannot cancel
your enrollment, change to Self Only, or change to a plan that doesn't serve the area in
which your children live, unless you provide documentation that you have other coverage for the children. If the court/ administrative order is still in effect when you retire, and

you have at least one child still eligible for FEHB coverage, you must continue your
FEHB coverage into retire ment (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 coverage continue to get benefits under your former spouse's enrollment. This is the case even

when the court has ordered your former spouse to supply health coverage to you. But,
you may be eligible for your own FEHB coverage under the spouse equity law or Temporary Continuation of Coverage (TCC). If you are recently divorced or are

anticipating a divorce, contact your ex-spouse's employing or retirement office to get RI
70-5, the Guide to Federal Employees Health Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees, or other information about your coverage

choices. You can also download the guide from OPM's website, www. opm. gov/ insure. 66.
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2003 Keystone Health Plan Central 64 Section 11
Temporary Continuation of Coverage If you leave Federal service, or if you lose coverage because you no
(TCC) longer qualify as a family member, you may be eligible for Temporary Continuation of Coverage (TCC). For example, you can receive TCC if you are not able

to continue your FEHB enrollment after you retire, if you lose your job, if you are a
covered dependent child and you turn 22 or marry, etc.

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

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

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

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

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

Getting a Certificate of The Health Insurance Portability and Accountability Act of 1996 (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/ health); refer to the "TCC and HIPAA" frequently asked questions. These highlight HIPAA rules, such as

the requirement that Federal employees must exhaust any TCC eligibility as one
condition for guaranteed access to individual health coverage under HIPAA, and have information about Federal and State agencies you can contact for more information. 67.
67 Page 68 69

2003 Keystone Health Plan Central 65 Long Term Care Insurance
Long Term Care Insurance Is Still Available
Open Season for Long Term Care Insurance
You can protect yourself against the high cost of long term care by applying for insurance in the Federal Long Term Care Insurance Program.
Open Season to apply for long term care insurance through LTC Partners ends on December 31, 2002.
If you're a Federal employee, you and your spouse need only answer a few questions about your health during Open Season.
If you apply during the Open Season, your premiums are based on your age as of July 1, 2002. After Open Season, your premiums are based on your age at the time LTC Partners receives your application.

FEHB Doesn't Cover It
Neither FEHB plans nor Medicare cover the cost of long term care. Also called "custodial care", long term care helps you perform the activities of daily living such as bathing or dressing yourself. It can also provide help you may need due to a
severe cognitive impairment such as Alzheimer's disease.
You Can Also Apply Later, But
Employees and their spouses can still apply for coverage after the Federal Long Term Care Insurance Program Open Season ends, but they will have to answer more health-related questions.
For annuitants and other qualified relatives, the number of health-related questions that you need to answer is the same during
and after the Open Season.

You Must Act to Receive an Application

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

Find Out More Contact LTC Partners by calling 1-800-LTC-FEDS (1-800-582-3337) (TDD for the hearing impaired: 1-800-843-
3557) or visiting www. ltcfeds. com to get more information and to request an application. 68.
68 Page 69 70
2003 Keystone Health Plan Central 66 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 49 Allergy tests 22
Allogeneic (donor) bone marrow transplant 32
Alternative treatment 27 Ambulance 39
Anesthesia 33 Autologous bone marrow
transplant 32 Biopsy 29
Blood and blood plasma 34 Breast cancer screening 18
Casts 34 Catastrophic protection 15
Changes for 2003 8 Chemotherapy 23
Childbirth 20 Chiropractic 27

Cholesterol tests 18
Claims 52 Coinsurance 61

Colorectal cancer screening 18 Congenital anomalies 29
Contraceptive devices and drugs 45 Coordination of benefits 56
Covered charges 52, 61 Covered providers 9

Crutches 22 Deductible 15
Definitions 61 Dental care 49
Diagnostic services 17 Disputed claims review 54
Donor expenses (transplants) 32 Dressings 34
Durable medical equipment (DME) 26
Educational classes and programs 28 Effective date of enrollment 4
Emergency 37 Experimental or investigational 61

Eyeglasses 24 Family planning 20
Fecal occult blood test 18 General Exclusions 51
Hearing services 24 Home health services 27
Hospice care 35 Home nursing care 27
Hospital 12, 34 Immunizations 19
Infertility 21 Inhospital physician care 34
Inpatient Hospital Benefits 34 Insulin 45
Laboratory and pathological services 18
Machine diagnostic tests 18 Magnetic Resonance Imagings
(MRIs) 18 Mail Order Prescription Drugs 42
Mammograms 18 Maternity Benefits 20
Medicaid 60 Medically necessary 61
Medicare 56 Members 4
Mental Conditions/ Substance Abuse Benefits 40
Newborn care 20 Non-FEHB Benefits 50
Nurse Licensed Practical Nurse 27
Nurse Anesthetist 33 Registered Nurse 27
Nursery charges 20 Obstetrical care 20
Occupational therapy 23 Office visits 17
Oral and maxillofacial surgery 31 Orthopedic devices 25
Ostomy and catheter supplies 26 Out-of-pocket expenses 15

Outpatient facility care 35 Oxygen 27
Pap test 18 Physical examination 17
Physical therapy 23 Preventive care, adult 18
Preventive care, children 19 Prescription drugs 42
Preventive services 18 Prior authorization 13
Prostate cancer screening 18 Prosthetic devices 25
Psychologist 40 Radiation therapy 23
Rehabilitation therapies 23
Renal dialysis 23 Room and board 34

Second surgical opinion 17 Skilled nursing facility care 35
Smoking cessation 28 Speech therapy 24
Splints 34 Sterilization procedures 20
Subrogation 60 Substance abuse 40
Surgery 29 Anesthesia 33
Oral 31 Outpatient 35
Reconstructive 30 Syringes 45
Temporary continuation of coverage 63
Transplants 32 Treatment therapies 23

Vision services 24 Well child care 19
Wheelchairs 26 Workers' compensation 60
X-rays 18 69.
69 Page 70 71
2003 Keystone Health Plan Central 67 Summary
Summary of benefits for Keystone Health Plan Central-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 copayment: $10 primary care; $10 specialist 17

Services provided by a hospital:
Inpatient.......................................................................................................
Outpatient....................................................................................................
Nothing
Nothing
34

Emergency benefits:
In-area .........................................................................................................

Out-of-area .................................................................................................

$25 per emergency room visit
$25 per emergency room visit

38
39
Mental health and substance abuse treatment .......................................... Regular cost sharing 40
Prescription drugs...........................................................................................
For up to a 90-day supply per prescription unit or refill for generic drugs or name brand drugs
At a participating retail pharmacy:
$10/$ 25/$ 40 copayment for up to a 30-day supply

$20/$ 50/$ 80 copayment for
up to a 60-day supply

$30/$ 75/$ 120 copayment for up to a 90-day supply

From the mail service pharmacy: $20/$ 50/$ 80 copayment for up
to a 90-day supply

Note: When a generic drug is
dispensed, you are responsible for paying only the applicable generic

copayment. When a brand drug is
dispensed that has a generic equivalent, you are responsible for

paying the applicable brand
copayment plus the difference in price between the brand drug and

its generic equivalent, up to the
original cost of the brand drug.

42 70.
70 Page 71 72

2003 Keystone Health Plan Central 68 Summary
Dental Care ..................................................................................................
We cover restorative services and supplies necessary to promptly repair (but not replace) sound natural teeth. The need for these
services must result from an accidental injury.

Nothing 49

Vision Care .................................................................................................. No benefit. 24
Special features: BlueCard Urgent Care Out of Area Services; Away From Home Care-Guest
Membership; Keeping Well; HealthLink; and www. khpc. com.
47

Protection against catastrophic costs (your out-of-pocket maximum) ...............................................................
We do not have an out-of-pocket maximum 15 71.
71 Page 72
2003 Keystone Health Plan Central 69 Rates
2003 Rate Information for
KEYSTONE HEALTH PLAN CENTRAL

Non-Postal rates apply to most non-Postal enrollees. If you are in a special enrollment category, refer to the FEHB Guide for that category or contact the agency that maintains your health benefits
enrollment.
Postal rates apply to career Postal Service employees. Most employees should refer to the FEHB Guide for United States Postal Service Employees, RI 70-2. Different postal rates apply and a
special FEHB guide is published for Postal Service Inspectors and Office of Inspector General (OIG) employees (see RI 70-2IN).

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

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

Self Only S41 $109.30 $46.91 $236.82 $101. 64 $129.03 $27.18
Self and Family S42 $249.62 $128.74 $540.84 $278. 94 $294.70 $83.66 72.

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