Document Body Page Navigation Panel Document Outline

UHP HEALTHCARE

Federal Employees Health Benefits Program
2003 Plan Brochure
Accessible Version

Document Outline

Office of Personnel Management Letter
Notice of the Office of Personnel Management Privacy Practices
Table of Contents
Introduction
Plain Language
Stop Health Care Fraud
Section 1. Facts about this HMO
Service Area
Section 2. How we change for 2003
Section 3. What you must do to get covered care
- Identification cards
- Where you get covered care
- What you must do to get covered care
- Circumstances beyond our control
- Services requiring our prior approval
Section 4. Your costs for covered services
- Your catastrophic protection out-of-pocket maximum
Section 5. Benefits Overview
- Section 5(a) Medical services and supplies provided by physicians and other health care professionals
- Section 5(b). Surgical and anethesia services provided by physicians and other health care professionals
- Section 5(c) Services by a hospital or other facility, and ambulance services
- Section 5(d). Emergency services/accidents
- Section 5(e). Mental health and substance abuse benefits
  - Pre-authorization
- Section 5(f). Prescription drug benefits
  - Covered medications and supplies
- Section 5(g). Special features
- Section 5(h). Dental benefits
- Section 5(i) Non-FEHB benefits available to Plan members
Section 6. General exclusion - things we don't cover
Section 7. Filing a claim for covered services
Section 8. The disputed claim
Section 9. Coordinating benefits with other coverage
- What is Medicare?
- When you have other health coverage
- Primary Payer Chart
- TRICARE and CHAMPVA
- Workers' Compensation
- Medicaid
- When other Government agencies are responsible for your care
- When others are responsible for your injuries
Section 10. Definition of terms we use in this brochure
Section 11. FEHB facts
Long Term Care Insurance
Index
Summary of beneifts for 2003
2003 Rate Information

Pages 1--58

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

2
2003 A Health Maintenance Organization
Serving: Los Angeles, Orange, Riverside and San Bernardino Counties
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:
C41 Self Only
C42 Self and Family

RI 73-269

UHP HEALTHCARE http:// www. uhphealthcare. com
This Plan has accreditation from
the JCAHO. See the 2003 Guide
for information on JCAHO

For changes
in benefits,
see page 8

Authorized for distribution by the: 1.
1 Page 2 3
2.
2 Page 3 4
Notice of the Office of Personnel Management's
Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED
AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE
REVIEW IT CAREFULLY.

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

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

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

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

To communicate with your FEHB health plan when you or someone you have authorized to act on your behalf
asks for our assistance regarding a benefit or customer service issue.

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

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

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

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

Get a listing of those getting your personal medical information from OPM in the past 6 years. The listing will not
cover your personal medical information that was given to you or your personal representative, any information that
you authorized OPM to release, or that was given out for law enforcement purposes or to pay for your health care or a
disputed claim.

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).

2003 UHP HEALTHCARE 3.
3 Page 4 5
Ask OPM to limit how your personal medical information is used or given out. However, OPM may not be able
to agree to your request if the information is used to conduct operations in the manner described above.

Get a separate paper copy of this notice.

For more information on exercising your rights set out in this notice, look at www. opm. gov/ insure on the web. You may
also call 202-606-0191 and ask for 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.

2003 UHP HEALTHCARE 4.
4 Page 5 6
2 2003 UHP HEALTHCARE Table of Contents 2
Table of Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Plain Language. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Stop Health Care Fraud . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Section 1 Facts about this HMO plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
How we pay providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Your Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Service Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Section 2. How we change for 2003. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Program-wide changes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Changes to this Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Section 3. How you get care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Identification cards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Where you get covered care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Plan providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Plan facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
What you must do to get covered care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Primary care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Specialty care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Hospital care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Circumstances beyond our control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Services requiring our prior approval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Section 4. Your costs for covered services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Copayments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Deductible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Coinsurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Your catastrophic protection out-of-pocket maximum. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Section 5. Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
(a) Medical services and supplies provided by physicians and other health care professionals . . . . . . . 14
(b) Surgical and anesthesia services provided by physicians and other health care professionals . . . . . 23
(c) Services provided by a hospital or other facility, and ambulance services . . . . . . . . . . . . . . . . . . . . 26
(d) Emergency services/ accidents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
(e) Mental health and substance abuse benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
(f) Prescription drug benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 5.
5 Page 6 7
3 2003 UHP HEALTHCARE Table of Contents
Table of Contents (Continued)
(g) Special features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Flexible benefits option . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
(h) Dental benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
(i) Non-FEHB benefits available to Plan members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Section 6. General exclusions things we don't cover . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Section 7. Filing a claim for covered services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Section 8. The disputed claims process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Section 9. Coordinating benefits with other coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
When you have other health coverage...
What is Medicare. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Medicare managed care plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
TRICARE and CHAMPVA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Workers' Compensation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Other Government agencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
When others are responsible for injuries. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Section 10. Definitions of terms we use in this brochure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Section 11. FEHB facts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Coverage information
No pre-existing condition limitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Where you get information about enrolling in the FEHB Program . . . . . . . . . . . . . . . . . . . . . 48
Types of coverage available for you and your family . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Children's Equity Act . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
When benefits and premiums start . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
When you lose benefits
When FEHB coverage ends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Spouse equity coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Temporary Continuation of Coverage (TCC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Converting to individual coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Getting a certificate of Group Health Plan coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Long term care insurance is still available . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53
Summary of benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54
Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 55 6.
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4 2003 UHP HEALTHCARE Introduction
Introduction
This brochure describes the benefits of UHP HEALTHCARE under contract CS 2032 with the Office of Personnel
Management (OPM), as authorized by the Federal Employees Health Benefits law. The address for UHP HEALTHCARE
administrative offices is:

UHP HEALTHCARE
3405 W. Imperial Highway
Inglewood, CA 90303

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 for 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 are
summarized on page 55. 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 UHP HEALTHCARE.

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 us know. Visit OPM's
"Rate Us" feedback area at www. opm. gov/ insure or e-mail us at fehbwebcomments@ opm. gov. You may also write to
OPM at the Office of Personnel Management, Office of Insurance Planning and Evaluation Division, 1900 E Street,
NW, Washington, DC 20415-3650. 7.
7 Page 8 9
5 2003 UHP HEALTHCARE Stop Health Care Fraud
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 xxx/ xxx-xxxx and explain the situation.
If we do not resolve the issue:

CALL --THE HEALTHCARE FRAUD HOTLINE
202-418-3300

OR WRITE TO:
The United States Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E. Srreet, NW, Room 6400
Washington, DC 20415

Do not maintain as a family member on your policy:
your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise); or
your child over age 22 (unless he/ she is disabled and incapable of self support).
If you have any questions about the eligibility of a dependent, check with your personnel office if you are
employed or with OPM if you are retired.
You can be prosecuted for fraud and your agency may take action against you if you falsify a claim to obtain
FEHB benefits or try to obtain services for someone who is not an eligible family member or who is no longer
enrolled in the Plan. 8.
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6 2003 UHP HEALTHCARE 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
co-payments, coinsurance, and deductibles described in this brochure. When you receive emergency services from
non-Plan providers, you may have to submit claim forms.

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

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 co-payments or
coinsurance.

UHP HEALTHCARE is a non-profit, federally qualified and state licensed health maintenance organization. It has a
combination group practice and IPA health-care delivery system, serving members in parts of Los Angeles, Orange and
San Bernardino counties. Each member must live or work within UHP's Service Area to enroll and may choose his or
her own primary care doctor from the staff of the medical group or IPA office selected.

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:

UHP HEALTHCARE has an overall Satisfaction Rating of 92%, from the 2002 Member Satisfaction Survey
We were founded in 1973
UHP HEALTHCARE is a not-for-profit, Federally Qualified HMO.

If you want more information about us, call 800/ 544-0088, or write to Member Services. You may also contact us by
fax at 310/ 412-1288 or visit our website at www. uhphealthcare. com. 9.
9 Page 10 11
7 2003 UHP HEALTHCARE Section 1
Service Area
To enroll in this Plan, you must live in our Service Area.

Los Angeles County
90001-08 90240-42 90601-08 90846 91340 91612
90010-29 90245 90631 91001 91343-45 91702
90031-42 90247-50 90637-40 91006 91356 91706
90056-59 90254-55 90650 91010 91364 91722-24
90061-69 90260-62 90660 91016 91367 91731-33
90071 90266 90670 91024 91401-03 91740
90074 90270 90701 91030 91405-06 91744-48
90077 90274 90706 91010-08 91411 91754
90079 90277-78 90710 91125 91423 91765
90089 90280-81 90712-17 91302-07 91436 91770
90201 90291-93 90732 91311 91501-02 91775-77
90203 90301-05 90744-48 91316 91504-06 91789-92
90210-13 90308-10 90801-15 91324-26 91509 91801
90220-22 90401-05 90822 91330-31 91601-02 91803
90230-31 90501-06 90840 91335 91604-08 93063

Orange County
90620-23 90742-43 92626-28 92670 92799 92825
90630 92601 92631-33 92683-84 92087 92895
90680 92605 92635 92686-87 92812
90720 92615 92640-49 92701-08 92814
90740 92621-22 92655 92728 92716

San Bernardino County
91739 92318 92336 92354 92376 92427
92316 92324 92345-46 92369 92401-18

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 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. 10.
10 Page 11 12
8 2003 UHP HEALTHCARE 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 Personnel Management's Privacy Practices is included.

A section on the Children's Equity Act describes when an employee is required to maintain Self and Family
coverage.

Program information on TRICARE and CHAMPVA explains how annuitants or former spouses may suspend their
FEHB Program enrollment.

Program information on Medicare is revised.
By law, the DoD/ FEHB Demonstration project ends on December 31, 2002.

Changes to this Plan
Your share of the non-Postal premium will increase by 32.2% for Self Only or 32.1% for Self and Family.

The copay for a 30-day supply of prescription drugs has increased to $10 for generic drugs and $20 for brand name
drugs. 11.
11 Page 12 13
Section 3. What you must do to get covered 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 800/ 544-0088; or write us at 3405 West
Imperial Highway, Inglewood, California 90303; or look us
up on our website at www. uhphealthcare. com.

Where you get covered care You get care from "Plan providers" and "Plan facilities." You will only pay co-payments, deductibles, and/ or coinsurance
as described in this brochure, and you will not have to file
claims.

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

We list Plan providers in the provider directory, which we
update periodically. The list is also on our website.

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

What you must do to get covered care It depends on the type of care you need. First, you and each family member must choose a primary care physician. This
decision is important since your primary care physician
provides or arranges for most of your health care. To select a
primary care physician, consult the "Primary Care Physician"
section of the UHP HEALTHCARE Provider Directory. Choose
either a clinic or an individual physician. Your family
members can choose their own primary care physicians from
this section too.

Primary care Your primary care physician can be "Family Practice,"
"General Practice," "Pediatrics," (for children only), "Internal
Medicine" or an "OB/ GYN" (for women only). Note that not
all OB/ GYNs choose to be primary care physicians; some
prefer a specialty practice only. 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.

9 2003 UHP HEALTHCARE Section 3 12.
12 Page 13 14
10 2003 UHP HEALTHCARE Section 3
Specialty care Your primary care physician will refer you to a specialist for
needed care. When you receive a referral from your primary
care physician, you must return to the primary care physician
after the consultation, unless your primary care physician
authorized a certain number of visits without additional
referrals. The primary care physician must provide or
authorize all follow-up care. Do not go to the specialist for
return visits unless your primary care physician gives you a
referral. However, you may see an OB/ GYN within your
Primary Care Physician's medical group without a referral.

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 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.

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 13.
13 Page 14 15
circumstances, you can continue to see your specialist until
the end of your postpartum care, even if it is beyond the 90
days.

Hospital care Your Plan primary care physician or specialist will make
necessary hospital arrangements and supervise your care.
This includes admission to a skilled nursing or other type of
facility.

If you are in the hospital when your enrollment in our Plan
begins, call our customer service department immediately at
800/ 544-0088. 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 92nd day after you become a member of this Plan,
whichever happens first.

These provisions apply only to the benefits of the
hospitalized person.

Circumstances beyond our control Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be

unable to provide them. In that case, we will make all
reasonable efforts to provide you with the necessary care.

Services requiring our prior approval Your primary care physician has authority to refer you for most services. For certain services, however, your physician

must obtain approval from us. Before giving approval, we
consider if the service is covered, medically necessary, and
follows generally accepted medical practice.

11 2003 UHP HEALTHCARE Section 3 14.
14 Page 15 16
Section 4. Your costs for covered services
You must share the cost of some services You are responsible for:
Copayments A copayment is a fixed amount of money you pay to the
provider, facility, pharmacy, etc. when you receive services.

Example: When you see your primary care physician you
pay a co-payment of $10 per office visit.

Deductible A deductible is a fixed expense you must incur for certain
covered services and supplies before we start paying benefits
for them. Co-payments do not count toward any deductible.
UHP HEALTHCARE does not have a deductible.

Coinsurance Coinsurance is the percentage of our negotiated fee that you
must pay for your care.

Example: In our Plan, you pay $50 or 50% of the charges for
emergency services.

Your catastrophic protection We do not have a catastrophic protection out-of-pocket out-of-pocket maximum maximum.

12 2003 UHP HEALTHCARE Section 4 15.
15 Page 16 17
Section 5. Benefits OVERVIEW (See page 8 for how our benefits changed this year and page 54 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 General Exclusions in Section 6; they apply to the benefits in the following
subsections. To obtain claims forms, claims filing advice, or more information about our benefits, contact us at
800/ 544-0088 or our website at www. uhphealthcare. com.

(a) Medical services and supplies provided by physicians and other health care professionals . . . . . . . . . . . . . . .14-22
Diagnostic and treatment services Hearing services (testing, treatment, and supplies)
Lab, X-ray, and other diagnostic tests Vision services (testing, treatment, and supplies)
Preventive care, adult Foot care
Preventive care, children Orthopedic and prosthetic devices
Maternity care Durable medical equipment (DME)
Family planning Home health services
Infertility services Chiropractic
Allergy care Alternative treatments
Treatment therapies Educational classes and programs
Physical and occupational therapies
Speech therapy

(b) Surgical and anesthesia services provided by physicians and other health care professionals . . . . . . . . . . . . .23-25
Surgical procedures Oral and maxillofacial surgery
Reconstructive surgery Organ/ tissue transplants
Anesthesia

(c) Services provided by a hospital or other facility, and ambulance services . . . . . . . . . . . . . . . . . . . . . . . . . . . .26-28
Inpatient hospital Extended care benefits/ skilled nursing care
Outpatient hospital or ambulatory facility benefits
surgical center Hospice care
Ambulance

(d) Emergency services/ accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29-30
Medical emergency
Ambulance
(e) Mental health and substance abuse benefits .......................................................................................................... 31-32
(f) Prescription drug benefits ...................................................................................................................................... 33-34
(g) Special features ........................................................................................................................................................... 35
Flexible benefits option ....................................................................................................................................... 35
(h) Dental benefits............................................................................................................................................................. 36
(i) Non-FEHB benefits available to Plan members ......................................................................................................... 37
Summary of benefits ................................................................................................................................................. 54

13 2003 UHP HEALTHCARE Section 5 16.
16 Page 17 18
14 2003 UHP HEALTHCARE Section 5( a)
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Section 5 (a) Medical services and supplies provided by physicians and other health
care professionals

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.

Professional services of physicians
In physician's office $10 per visit

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

At home -Doctor's house call $10 per visit
At home -Visits by nurses and health aids Nothing

Benefit Description You pay
Diagnostic and treatment services 17.
17 Page 18 19
15
Lab, and other diagnostic tests You pay
Tests, such as: Nothing if you receive these services
Blood tests during your office visit; otherwise,
Urinalysis $10 per office visit
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG

Preventive care, adult
Routine screenings, such as: $10 per office visit
Total Blood Cholesterol -once every three years
Colorectal Cancer Screening, including
-Fecal occult blood test\
-Sigmoidoscopy, screening -every five years starting
at age 50

Routine Prostate Specific Antigen (PSA) test -one annually $10 per office visit
for men age 40 and older

Routine pap test $10 per office visit
Note: The office visit is covered if pap test is received on the
same day; see Diagnosis and Treatment, above.

Routine mammogram -covered for women age 35 and older, $10 per office visit
as follows:

From age 35 through 39, one during this five year period
From age 40 through 64, one every calendar year
At age 65 and older, one every two consecutive
calendar years

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

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

Childhood immunizations)
Influenza vaccines, annually
Pneumococcal vaccine, age 65 and over

2003 UHP HEALTHCARE Section 5( a) 18.
18 Page 19 20
16 2003 UHP HEALTHCARE Section 5( a)
Preventive care, children You pay
Childhood immunizations recommended by the $10 per office visit
American Academy of Pediatrics

Well-child care charges for routine examinations, $10 per office visit
immunizations and care (through age 22)

Examinations, 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
(through age 22)

Maternity care
Complete maternity (obstetrical) care, such as: $10 per office visit
Prenatal care
Delivery
Postnatal care
Note: Here are some things to keep in mind:
You do not need to pre-certify your normal delivery;
see page 11 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.
UHP HEALTHCARE 's physicians will extend your inpatient
stay if medically necessary.

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).

Not covered: Routine sonograms to determine fetal age, All charges
size or sex 19.
19 Page 20 21
17 2003 UHP HEALTHCARE Section 5a
Family planning You pay
A range of voluntary family planning services, $10 per office visit
limited to:

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 benefit.

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

Infertility services
Diagnosis and treatment of infertility, such as: $10 per office visit
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.

Not covered: All charges
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 20.
20 Page 21 22
18 2003 UHP HEALTHCARE Section 5a
Allergy care You pay
Testing and treatment $10 per office visit
Allergy injection

Allergy serum Nothing

Not covered: provocative food testing and sublingual All charges
allergy desensitization

Treatment therapies
Chemotherapy and radiation therapy $10 per office visit
Note: High dose chemotherapy in association with autologous
bone marrow transplants are limited to those transplants listed
under Organ/ Tissue Transplants on page 25.

Respiratory and inhalation therapy
Dialysis -Hemodialysis and peritoneal dialysis
Intravenous (IV)/ Infusion Therapy -Home IV and
antibiotic therapy

Growth hormone therapy (GHT)
Note: Growth hormone is covered under the prescription
drug benefit

Note: -We will only cover GHT when we preauthorize the
treatment. Your primary care physician will contact the Plan
to establish that the GHT is medically necessary. We will
only cover GHT services from the date your physician
submits the information. GHT requires that it is medically
necessary and receives the prior authorization of the Plan.
We will not cover the GHT or related services and supplies
if the medical criteria are not met. UHP HEALTHCARE defines
GHT as a medical benefit. 21.
21 Page 22 23
19 2003 UHP HEALTHCARE Section 5( a)
Physical and occupational therapies You pay
60 visits per condition for the services of each of the $10 per office visit
following:

qualified physical therapists and $10 per outpatient visit
occupational therapists.

Note: We only cover therapy to restore bodily function when Nothing per visit during covered
here has been a total or partial loss of bodily function due to inpatient admission
illness or injury.

Cardiac rehabilitation following a heart transplant, bypass
surgery or a myocardial infarction, is provided for up to
60 sessions.

Speech therapy
Provided on an inpatient or outpatient basis for up to two $10 per office visit
consecutive months per condition as medically necessary when $10 per outpatient visit
provided by qualified speech therapists.

60 visits per condition Nothing per visit during covered
inpatient admission

Not covered: All charges
long-term rehabilitative therapy
exercise programs

Hearing services (testing, treatment, and supplies)
First hearing aid and testing only when necessitated by $10 per office visit
accidental injury

Hearing testing for children through age 17 (see Preventive
care, children)

Not covered: All charges.
all other hearing testing
hearing aids, testing and examinations 22.
22 Page 23 24
20 2003 UHP HEALTHCARE Section 5( a)
Vision services (testing, treatment, and supplies) You pay
One pair of eyeglasses or contact lenses to correct an $10 per office visit
impairment directly caused by accidental ocular injury or
intraocular surgery (such as for cataracts)

Eye exam to determine the need for vision correction for $10 per office visit
children through age 17 (see Preventive Care for Children)

Not covered: All charges.
Eyeglasses or contact lenses and, after age 17,
examinations for them

Eye exercises and orthoptics
Radial keratotomy and other refractive surgery

Foot care
Routine foot care when you are under active treatment for a $10 per office visit
metabolic or peripheral vascular disease, such as diabetes.

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

Not covered: All charges.
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) 23.
23 Page 24 25
21 2003 UHP HEALTHCARE Section 5( a)
Orthopedic and prosthetic devices You pay
Artificial limbs and eyes; stump hose $10 per office visit
Externally worn breast prostheses and surgical bras,
including necessary replacements, following a mastectomy

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

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

Not covered: All charges.
Orthopedic and corrective shoes
Arch supports
Foot orthotics
Heel pads and heel cups
Lumbosacral supports
Corsets, trusses, elastic stockings, support hose, and
other supportive devices

Prosthetic replacements provided less than 12 months
after the last one we covered.

Durable medical equipment (DME)
Rental or purchase, at our option, including repair and $10 per covered item
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;
walkers;
blood glucose monitors; and
insulin pumps.
Note: Call us at 1-800-544-0088 as soon as your Plan
physician prescribes this equipment. If you require equipment
not covered, UHP HEALTHCARE will arrange with a health care
provider to rent or sell you durable medical equipment at
discounted rates. Call for more information.

Not covered: All charges.
Motorized wheel chairs;
Bedside commodes 24.
24 Page 25 26
22 2003 UHP HEALTHCARE Section 5( a)
Home health services You pay
Home health care ordered by a Plan physician and provided $10 per office visit
by a registered nurse (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.

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.

Chiropractic You pay
Manipulation of the spine and extremities $10 per office visit

Adjunctive procedures such as ultrasound, electrical
muscle stimulation, vibratory therapy, and cold pack
application.

Alternative treatments
Acupuncture -by a doctor of medicine or osteopathy for: $10 per office visit
anesthesia, pain relief

Not covered: All charges
naturopathic services
hypnotherapy
biofeedback

Educational classes and programs
Coverage is limited to: Nothing
Smoking Cessation -up to $100 for one smoking cessation
program per member per lifetime, including such related
expenses such as drugs.

Diabetes self-management
Prenatal classes 25.
25 Page 26 27
Section 5 (b). Surgical and anesthesia services provided by physicians and other
health care professionals
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.
UHP HEALTHCARE has 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. Any costs associated with the
facility charge (i. e. hospital, surgical center, etc.) are covered in Section 5 (c).

A comprehensive range of services, such as: $10 per office visit
Operative procedures
Treatment of fractures, including casting
Normal pre-and post-operative care by the surgeon
Correction of amblyopia and strabismus
Endoscopy procedures
Biopsy procedures
Removal of tumors and cysts
Correction of congenital anomalies (see reconstructive
surgery)

Surgical treatment of morbid obesity a condition in
which an individual weighs 100 pounds or 100% over
his or her normal weight according to current underwriting
standards; eligible members must be age 18 or over

Insertion of internal prosthetic devices. See 5( a) -
Orthopedic and prosthetic devices for device coverage
information.

Voluntary sterilization (e. g., Tubal ligation, Vasectomy) $10 per visit
Treatment of burns

Not covered: All charges
Reversal of voluntary sterilization
Routine treatment of conditions of the foot; see Foot Care.

23 2003 UHP HEALTHCARE Section 5( b)

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Surgical procedures 26.
26 Page 27 28
24 2003 UHP HEALTHCARE Section 5( b)
Reconstructive surgery You pay
Surgery to correct a functional defect $10 per office visit
Surgery to correct a condition caused by injury or illness if:
-the condition produced a major effect on the
member's appearance and
-the condition can reasonably be expected to
be corrected by such surgery

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

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

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

Not covered: All Charges
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

Oral and maxillofacial surgery
Oral surgical procedures, limited to: $10 per office visit
Reduction of fractures of the jaws or facial bones;
Surgical correction of cleft lip, cleft palate or
severe functional malocclusion;
Removal of stones from salivary ducts;
Excision of leukoplakia or malignancies;
Excision of cysts and incision of abscesses when
done as independent procedures; and
Other surgical procedures that do not involve the
teeth or their supporting structures.

Not covered: All charges
Oral implants and transplants
Procedures that involve the teeth or their supporting
structures (such as the periodontal membrane, gingiva,
and alveolar bone) 27.
27 Page 28 29
25 2003 UHP HEALTHCARE Section 5( b)
Organ/ tissue transplants You pay
Limited to: Nothing
Cornea

Heart
Heart/ lung
Kidney
Liver
Lung: Single -Double
Pancreas
Allogenic (donor) bone marrow transplants;
Autologous bone marrow transplants (autologous stem
cell and peripheral stem cell support) for the following
conditions with the prior approval by a UHP HEALTHCARE
Medical Director: 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.

National Transplant Program
Limited Benefits -Treatment for breast cancer, multiple
myeloma, and epithelial ovarian cancer may be provided in an
NCI-or NIH-approved clinical trial at a Plan-designated center
of excellence and if approved by the Plan's medical director in
accordance with the Plan's protocols.

Note: We cover related medical and hospital expenses of the
donor when the recipient is a member of UHP HEALTHCARE.

Not covered: All charges
Donor screening tests and donor search expenses, except
those performed for the actual donor
Implants of artificial organs
Transplants not listed as covered

Anesthesia
Professional services provided in -$10 per office visit
Hospital (inpatient)

Professional services provided in -$10 per office visit
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center
Office 28.
28 Page 29 30
26 2003 UHP HEALTHCARE Section 5( c)
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Section 5 (c). Services provided by a hospital or other facility, and ambulance services
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).

Room and board, such as Nothing
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: Nothing
Operating, recovery, maternity, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays
Administration of blood and blood products
Blood or blood plasma, if not donated or replaced
Dressings, splints, casts, and sterile tray services
Medical supplies and equipment, including oxygen
Anesthetics, including nurse anesthetist services
Take-home items
Medical supplies, appliances, medical equipment and any
covered items billed by a hospital for use at home

Not covered: All charges.
Custodial care
Non-covered facilities, such as nursing homes, schools
Personal comfort items, such as telephone, television,
barber services, guest meals and beds
Private nursing care

Benefit Description You pay
Inpatient hospital 29.
29 Page 30 31
27 2003 UHP HEALTHCARE Section 5( c)
Outpatient hospital or ambulatory surgical center You pay
Operating, recovery, and other treatment rooms Nothing
Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology services
Administration of blood, blood plasma, and other biologicals
Blood and blood plasma, if not donated or replaced
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.

Not covered: blood and blood derivatives not replaced by All charges
the member

Extended care benefits/ skilled nursing care
facility benefits

UHP HEALTHCARE provides a comprehensive range of benefits Nothing
for up to 30 days per calendar year when full-time skilled nursing
care is necessary and confinement in a skilled nursing facility is
medically appropriate as determined by a UHP HEALTHCARE
doctor and approved by UHP HEALTHCARE. All necessary
services are covered, including:

Bed, board and general nursing care
Drugs, biologicals, supplies, and equipment ordinarily
provided or arranged by the skilled nursing facility
when prescribed by a UHP doctor.

Not covered: custodial care All Charges 30.
30 Page 31 32
28 2003 UHP HEALTHCARE Section 5( c)
Hospice care You pay
Supportive and palliative care for a terminally ill member is Nothing
covered in the home or hospice facility. Services include
inpatient and outpatient care, and family counseling; these
services are provided under the direction of a UHP doctor who
certifies that the patient is in the terminal stages of illness,
with a life expectancy of approximately six months or less.

Not covered: Independent nursing, homemaker services All charges

Ambulance
Local professional ambulance service when medically Nothing
appropriate 31.
31 Page 32 33
Section 5 (d). Emergency services/ accidents
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.
UHP HEALTHCARE has 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.

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

What to do in case of emergency:
In case of an emergency within the service area, call 911 or go to the nearest hospital emergency room for treatment.
For urgent care you may call your primary care physician (PCP) or UHP HEALTHCARE at (800) 624-4318. NOTE:
Within the service area would be those ZIP code areas serviced by UHP HEALTHCARE. Out of area would be all other
ZIP codes within the U. S. wherein you should call 911 or go to the nearest emergency facility.

Emergency care at a doctor's office $50 or 50% of charges,
whichever is less.

Emergency care at an urgent care center Co-pays are waived if you are
admitted to the hospital

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

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

29 2003 UHP HEALTHCARE Section 5( d)

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Benefit Description You pay
Emergency within our service area 32.
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30 2003 UHP HEALTHCARE Section 5( d)
Emergency outside our service area You pay
Emergency care at a doctor's office $50 or 50% of charges,
whichever is less.

Emergency care at an urgent care center Copays are waived if you are
admitted to the hospital

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

Not covered: All charges.
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

Ambulance
Professional ambulance service when medically appropriate. No charge
See 5( c) for non-emergency service.

Not covered: All Charges
air ambulance 33.
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Section 5 (e). Mental health and substance abuse benefits
Parity
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.
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 PREAUTHORIZATION OF THESE SERVICES. See
the instructions after the benefits description below.

All diagnostic and treatment services recommended by a Plan Your cost sharing responsibilities
provider and contained in a treatment plan that we approve. are no greater than for other illness
The treatment plan may include services, drugs, and supplies or conditions.
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.

Professional services, including individual or group therapy $10 per visit
by providers such as psychiatrists, psychologists, or
clinical social workers
Medication management

Diagnostic tests $10 per office visit
Services provided by a hospital or other facility Nothing
Services in approved alternative care settings such as
partial hospitalization, half-way house, residential
treatment, full-day hospitalization, facility based intensive
outpatient treatment

Not covered: Services we have not approved.
Note: OPM will base its review of disputes about All charges.
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.

31 2003 UHP HEALTHCARE Section 5( e)

Benefit Description You pay
Mental health and substance abuse benefits 34.
34 Page 35 36
Pre-authorization To be eligible to receive these benefits you must follow your treatment plan and all the following authorization processes: Your primary care physician has authority to refer you for
most services. For certain services, however, your physician must obtain approval from us.
Before giving approval, we consider if the service is covered, medically necessary, and
follows generally accepted medical practice.

We call this review and approval process "prior authorization." Your physician must obtain
prior authorization for the services such as inpatient hospitalizations and most visits to a
specialist. Before giving approval, we consider if the service is medically necessary, and if it
follows generally accepted medical practice. UHP will provide benefits for covered services
only when the services are medically necessary to prevent, diagnose or treat your illness or
condition. Services must be received at Plan facilities, hospitals and other facilities in our
service area that we contract with to provide covered services to our members. We list these
in the provider directory, which we update periodically.

You and each family member must choose a primary care physician when you enroll in this
Plan. This decision is important since your primary care physician provides or arranges for
most of your health care. To select a primary care physician, consult the "Primary Care
Physician" section of the UHP HEALTHCARE Provider Directory. Choose either a clinic or an
individual physician. Your family members can choose their own primary care physicians
from this section too. You may obtain a provider directory by calling UHP HEALTHCARE
Member Services at 1-800-544-0088. The list is also on our website:
www. uhphealthcare. com.

LIMITATIONS We may limit your benefits if you do not obtain a treatment plan.

32 2003 UHP HEALTHCARE Section 5( e) 35.
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Section 5 (f). Prescription drug benefits
Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart beginning
on the next page.
All benefits are subject to the definitions, limitations and exclusions in this
brochure and are payable only when we determine they are medically
necessary.
UHP HEALTHCARE has 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.

There are important features you should be aware of. These include:
Who can write your prescription. A plan physician must write the prescription.
Where you can obtain them. You must fill the prescription at a plan pharmacy.

We use a formulary. UHP HEALTHCARE's Formulary Pharmacy & Therapeutics Advisory Committee, which is part of
UHP HEALTHCARE's Utilization Management Program, determines which drugs are to be included in UHP's drug
formulary. The Committee is an advisory group consisting of medical, pharmacy and other professionals. This
committee serves as the governing body for the Formulary system and currently includes the UHP Medical Director,
contracted Medical Group Prescribers, the UHP Pharmacy Director, contracted Pharmacy Provider Pharmacists, and the
UHP Utilization Management Director. The primary purposes of the UHP Formulary Pharmacy & Therapeutics
Advisory Committee are to develop UHP's medication formulary and to provide members cost-effective and quality
drug therapy.

These are the dispensing limitations. Drugs are prescribed by a UHP or referral doctor and obtained at a UHP
pharmacy will be dispensed for up to a 30-day supply or 100 unit supply, whichever is less; or one commercially
prepared unit (i. e., one inhaler, one vial ophthalmic medication or insulin). You pay a $10 copay per prescription unit
or refill for generic drugs or for name brand drugs when generic substitution is not permissible. You pay $20 for name
brand drugs when generic substitutions are available. When generic substitution is permissible (i. e., a generic drug is
available and the prescribing doctor does not request the use of a name brand drug), but you request the name brand
drug, you pay the price difference between the generic and the name brand drug as well as the $20 copay per
prescription

Drugs are prescribed by UHP doctors and dispensed in accordance with UHP HEALTHCARE's drug formulary.
Nonformulary drugs will be covered when prescribed by a UHP doctor. UHP HEALTHCARE must arrange for the
nonformulary drug to be dispensed when requested to do so by the prescribing doctor.

Why use generic drugs?
1. Generic drugs offer a safe and economic way to meet your prescription drug needs.

2. Generic drugs contain the same active ingredients and are equivalent in strength and dosage to the original brand
name product.

3. The U. S. Food and Drug Administration sets quality standards for generic drugs to ensure that these drugs meet the
same standards of quality and strength as brand name drugs.

4. A generic prescription costs you -and us -less than a name brand prescription.
When you have to file a claim -to file a claim, you should contact (800) 544-0088 for the Member Services
Department at UHP HEALTHCARE.

33 2003 UHP HEALTHCARE Section 5( f) 36.
36 Page 37 38
Drugs are prescribed by UHP doctors and dispensed in accordance $10 per generic prescription unit
with UHP HEALTHCARE's drug formulary. Nonformulary drugs will (30 day supply or 100 units,
be covered when prescribed by a UHP doctor. UHP HEALTHCARE whichever is less). Also applies
must arrange for the nonformulary drug to be dispensed when to brand name drugs when generic
requested to do so by the prescribing doctor. drugs are not available.

We cover the following medications and supplies prescribed $20 for brand name formulary
by a Plan physician and obtained from a Plan pharmacy. and non-formulary drugs

Drugs and medicines that by Federal law of the United
States require a physician's prescription for their purchase,
except those listed as Not covered.

Oral and injectable contraceptive drugs; contraceptive
diaphragms

Implanted contraceptive devices; you pay nothing for device;
implantation and removal is provided by UHP HEALTHCARE

Insulin (a copay charge applies to each vial)
Intrauterine devices
Diabetic supplies, including insulin syringes, needles,
glucose test tablets and test tape, Benedict's solution or
equivalent and acetone test tablets

Disposable needles and syringes needed to inject covered
prescribed medication

Drugs to treat sexual dysfunction
Oral fertility drugs
Fertility drugs, and injectables are covered under the
Medical and Surgical Benefits

Not covered: All Charges
Drugs available without a prescription or for which there
is a nonprescription equivalent available

Drugs obtained at a non-UHP pharmacy except for
out-of-area emergencies

Vitamins and nutritional substances that can be purchased
without a prescription

Medical supplies such as dressings and antiseptics
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Non-prescription contraceptive drugs and devices
Implanted time-release medications, except Norplant

34 2003 UHP HEALTHCARE Section 5( f)

Benefit Description You pay
Covered medications and supplies 37.
37 Page 38 39
Feature Description
Section 5 (g). Special features

Flexible benefits option Under the flexible benefits option, we determine the most effective way to
provide services.

We may identify medically appropriate alternatives to traditional care and
coordinate other benefits as a less costly alternative benefit.

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

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

35 2003 UHP HEALTHCARE Section 5( g) 38.
38 Page 39 40
Section 5 (h). Dental benefits
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and
exclusions in this brochure and are payable only when we determine they are
medically necessary.
Plan dentists must provide or arrange your care.
The calendar year deductible is: {plan specific} $275 per person ($ 550 per
family). The calendar year deductible applies to almost all benefits in this
Section. We added "( No deductible)" to show when the calendar year
deductible does not apply. {If you want, you can say, "We added asterisks - -to
show when the calendar year deductible does not apply."} {If HMO -if
you don't have deductible, remove this check mark or say "We have no
calendar year deductible.}
We cover hospitalization for dental procedures only when a nondental physical
impairment exists which makes hospitalization necessary to safeguard the
health of the patient. See Section 5 (c) for inpatient hospital benefits. We do
not cover the dental procedure unless it is described below. {Hospitalization for
dental procedures is optional, but strongly recommended to reduce risk of
emergency hospitalizations.}
Be sure to read Section 4, Your costs for covered services, for valuable
information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.

We cover restorative services and supplies necessary to Nothing
promptly repair (but not replace) sound natural teeth. The need
for these services must result from an accidental injury.

We have no other dental benefits.

36 2003 UHP HEALTHCARE Section 5( h)

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Dental benefits 39.
39 Page 40 41
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 out-of-
pocket maximums.

Medicare prepaid plan enrollment -UHP HEALTHCARE offers Medicare recipients the opportunity to enroll in
UHP HEALTHCARE through Medicare. As indicated on Page 45, annuitants and former spouses with FEHB
coverage and Medicare Parts A and B may elect to drop their FEHB coverage and enroll in a Medicare prepaid
plan when one is available in their area. They amy then later re-enroll in the FEHB program. Contact your
retirement system for information on dropping your FEHB enrollment and changing to a Medicare prepaid
plan. Contact us at 1-800/ 847-1222 for information on UHP's Medicare prepaid plan and the cost of that
enrollment.

37 2003 UHP HEALTHCARE Section 5( i) 40.
40 Page 41 42
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.

We do not cover the following:

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

Services, drugs, or supplies related to sex transformations;
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program; or,
Services, drugs, or supplies you receive without charge while in active military service.

38 2003 UHP HEALTHCARE Section 6 41.
41 Page 42 43
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at Plan
pharmacies, you will not have to file claims. Just present your identification card and pay your co-payment,
coinsurance, or deductible.

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

Medical, hospital and prescription In most cases, providers and facilities file claims for you. prescription drug benefits Physicians must file on the form HCFA-1500, Health
Insurance Claim Form. Facilities will file on the UB-92
form. For claims questions and assistance, call us at
800/ 544-0088.

When you must file a claim such as for out-of-area care
submit it on the HCFA-1500 or a claim form that includes
the information shown below. Bills and receipts should be
itemized and show:

Covered member's name and ID number;

Name and address of the physician or facility that
provided the service or supply;

Dates you received the services or supplies;
Diagnosis;
Type of each service or supply;
The charge for each service or supply;
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: UHP HEALTHCARE, 3405 W.
Imperial Highway, Inglewood, CA 90303

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.

39 2003 UHP HEALTHCARE Section 7 42.
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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 pre-authorization:

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: UHP HEALTHCARE, 3405 W. Imperial Highway, Inglewood, CA 90303; and

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

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

you a copy of our request-go to step 3.
3 You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days. If we do not receive the information within 60 days, we will decide within 30 days of the date the

information was due. We will base our decision on the information we already have.
We will write to you with our decision.

4 If you do not agree with our decision, you may ask OPM to review it. You must write to OPM within: a. 90 days after the date of our letter upholding our initial decision; or

b. 120 days after you first wrote to us if we did not answer that request in some way within 30
days; or
c. 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.

40 2003 UHP HEALTHCARE Section 8 43.
43 Page 44 45
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 different claims, 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, or supplies or from the year in which you were denied prior
approval. This is the only deadline that may not be extended.
OPM may disclose the information it collects during the review process to support their disputed
claim decision. This information will become part of the court record.

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

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

(a) We haven't responded yet to your initial request for care or preauthorization/ prior approval, then call us at
800/ 544-0088 and we will expedite our review; or

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

You can call OPM's Health Benefits Contracts Division 3 at 202/ 606-0755 between 8 a. m. and 5 p. m. eastern
time.

41 2003 UHP HEALTHCARE Section 8 44.
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Section 9. Coordinating benefits with other coverage
When you have other health coverage You must tell us if you are covered or a family member is covered 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 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.

42 2003 UHP HEALTHCARE Section 9 45.
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The Original Medicare Plan The Original Medicare Plan (Original Medicare) is available
(Part A or Part B) everywhere in the United States. It is the way everyone used
to get Medicare benefits and is the way most people get their
Medicare Part A and Part B benefits now. You may go to any
doctor, specialist, or hospital that accepts Medicare. The
Original Medicare Plan pays its share and you pay your
share. Some things are not covered under Original Medicare,
like prescription drugs.

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

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

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 pay the
balance of covered charges. You will not need to do
anything. To find out if you need to do something about
filing your claims, call us at 1-800-544-0088.

We do not waive any costs if the Original Medicare Plan
is your primary payer.

43 2003 UHP HEALTHCARE Section 9 46.
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44 2003 UHP HEALTHCARE 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

A. When either you or your covered spouse are age 65 or over and ... Then the primary payer is... .
Original MedicarE This Plan
1) Are an active employee with the Federal government (including
when you or a family member are eligible for Medicare solely
because of a disability),

2) Are an annuitant,
3) Are a reemployed annuitant with the Federal government when...
a) The position is excluded from FEHB, or
b) The position is not excluded from FEHB
(Ask your employing office which of these applies to you.)

4) Are a Federal judge who retired under title 28, U. S. C., or a Tax
Court judge who retired under Section 7447 of title 26, U. S. C. (or if
your covered spouse is this type of judge),

5) Are enrolled in Part B only, regardless of your employment status,
(for Part B services) (for other
services)

6) Are a former Federal employee receiving Workers' Compensation
Workers' Compensation.) and the Office of Workers' Compensation (except for claims
Programs has determined that you are unable to return to duty, related to
Wor ker s'
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
d) Are a former spouse of an active employee 47.
47 Page 48 49
Medicare managed care plan If you are eligible for Medicare, you may choose to enroll in
and get your Medicare benefits from a Medicare managed
care plan. These are health care choices (like HMOs) in
some areas of the country. In most Medicare managed care
plans, you can only go to doctors, specialists, or hospitals that
are part of the plan. Medicare managed care plans provide
all the benefits that Original Medicare covers. Some cover
extras, like prescription drugs. To learn more about enrolling
in a Medicare managed care plan, contact Medicare at 1-800-
MEDICARE (1-800-633-4227) or at www. medicare. gov.

If you enroll in a Medicare managed care plan, the following
options are available to you:

This Plan and our Medicare managed care plan: You may
enroll in our Medicare managed care plan and also remain
enrolled in our FEHB plan. In this case, we do not waive
cost sharing for your FEHB coverage.

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

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

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

45 2003 UHP HEALTHCARE Section 9 48.
48 Page 49 50
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 responsible 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.

46 2003 UHP HEALTHCARE Section 9 49.
49 Page 50 51
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 12.

Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 12.
Covered services Care we provide benefits for, as described in this brochure.
Custodial care Services which are not intended to cure a patient's condition or which do not require the continued attention of medical
personnel; examples include assistance in the activities of
daily living. (NOTE: Custodial care that lasts 90 days or
more is sometimes known as Long term care).

The determination that a service is experimental or
investigational is based on (1) reference to relevant federal
regulations, such as those contained in Title 42, Code of
Federal Regulations, Chapter IV (Health Finance
Administration) and Title 21, Code of Federal Regulations,
Chapter I (Food and Drug Administration); (2) consultation
and provider organizations, academic and professional
specialists pertinent to the specific service; and (3) reference
to current medical literature.

Plan Allowance We base UHP allowance on the reasonable and customary charge.

Us/ We Us and we refer to UHP HEALTHCARE.
You You refers to the enrollee and each covered family member.

47 2003 UHP HEALTHCARE Section 10 50.
50 Page 51 52
Section 11. FEHB facts
No pre-existing condition limitation We will not refuse to cover the treatment of a condition that you had before you enrolled in this Plan solely because you
had the condition before you enrolled.
Where you can get information about See www. opm. gov/ insure. Also, your employing or enrolling in the FEHB Program retirement office can answer your questions, and give you a
Guide to Federal Employees Health Benefits Plans, brochures
for other plans, and other materials you need to make an
informed decision about your FEHB coverage. These
materials tell you:

When you may change your enrollment;
How you can cover your family members;
What happens when you transfer to another Federal
agency, go on leave without pay, enter military service,
or retire;
When your enrollment ends; 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 for you and your family coverage is for you, your spouse, and your unmarried
dependent children under age 22, including any foster
children or stepchildren your employing or retirement office
authorizes coverage for. Under certain circumstances, you
may also continue coverage for a disabled child 22 years of
age or older who is incapable of self-support.

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

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

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

48 2003 UHP HEALTHCARE Section 11 51.
51 Page 52 53
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 ina health plan that provides full benefits in
the area where your children live or provide documentation to
your employing office that you have obtained other health
benefits coverage for your children. If you do not do so, your
employing office will enroll you involuntarily as follows:

If you have no FEHB coverage, your employing office
will enroll you for Self and Family coverage in the Blue
Cross and Blue Shield Service Benefit Plan's Basic
Option.
if you have a Self Only enrollment in a fee-for-service
plan or in an HMO that serves the area where your
children live, your employing office will change your
enrollment to Self and Family in the same option of the
same plan; or
if you are enrolled in an HMO that does not serve the
area where the children live, your employing office will
change your enrollment to Self and Family in the Blue
Cross and Blue Shield Benefit Plan's Basic Option.

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

When benefits and premiums start The benefits in this brochure are effective on January 1. If you joined this Plan during Open Season, your coverage

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

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

49 2003 UHP HEALTHCARE Section 11 52.
52 Page 53 54
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,
coverage you may not continue to get benefits under your former
spouse's enrollment. This is the case even when the court has
ordered your former spouse to supply health coverage to you.
But, you may be eligible for your own FEHB coverage under
the spouse equity law of Temporary Continuation of
Coverage (TCC). If you are recently divorced or are
anticipating a divorce, contact your ex-spouse's employing or
retirement office to get RI 70-5, the Guide to Federal
Employees Health Benefits Plans for Temporary Continuation
of Coverage and Former Spouse Enrollees, or other
information about your coverage choices. You can also
download the guide from OPM's website,
www. opm. gov/ insure.

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

You may not elect TCC if you are fired from your Federal job
due to gross misconduct.

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

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

You decided not to receive coverage under TCC or the
spouse equity law; or

You are not eligible for coverage under TCC or the
spouse equity law.

If you leave Federal service, your employing office will
notify you of your right to convert. You must apply in

50 2003 UHP HEALTHCARE Section 11 53.
53 Page 54 55
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
Group Health Plan Coverage The Health Insurance Portability and Accountability Act of
1996 (HIPAA) is a Federal law that offers limited Federal
protections for health coverage availability and continuity to
people who lose employer group coverage. If you leave the
FEHB Program, we will give you a Certificate of Group
Health Plan Coverage that indicates how long you have been
enrolled with us. You can use this certificate when getting
health insurance or other health care coverage. Your new
plan must reduce or eliminate waiting periods, limitations, or
exclusions for health related conditions based on the
information in the certificate, as long as you enroll within 63
days of losing coverage under this Plan. If you have been
enrolled with us for less than 12 months, but were previously
enrolled in other FEHB plans, you may also request a
certificate from those plans. For more information, get OPM
pamphlet RI 79-27, Temporary Continuation of Coverage
(TCC) under the FEHB Program. See also the FEHB web site
(www. opm. gov/ insure/ health); refer to the "TCC and
HIPAA" frequently asked question. 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.

51 2003 UHP HEALTHCARE Section 11 54.
54 Page 55 56
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 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) (DDD for the hearing
impaired: 1-800-843-3357) or visiting www. ltdfeds. com to get more information and to request an application.

52 2003 UHP HEALTHCARE Long Term Care Insurance 55.
55 Page 56 57
53
Index
{Use this list as a base; remove terms you don't use; add as appropriate.}
Do not rely on this page; it is for your convenience and may not show all pages where the terms appear.

2003 UHP HEALTHCARE Index
Accidental injury 19, 24, 35
Allergy tests 18
Alternative treatment 22
Allogenetic (donor) bone marrow
transplant 25
Ambulance 26, 28
Anesthesia 22, 23, 25, 27
Autologous bone marrow
transplant 18
Biopsies 23
Birthing centers 16
Blood and blood plasma 26, 27
Breast cancer screening 18
Casts 23, 26, 27
Catastrophic protection out-of-pocket
maximum 12
Changes for 2003 8
Chemotherapy 18
Childbirth 16
Chiropractic 22
Cholesterol tests 15
Circumcision 16
Claims 39
Coinsurance 12
Colorectal cancer screening 15
Congenital anomalies 23
Contraceptive devices and drugs 35
Coordination of benefits 44
Covered charges 43
Covered providers 9
Crutches 21
Deductible 37, 39
Definitions 47
Dental care 36
Diagnostic services 14
Disputed claims review 40
Donor expenses (transplants) 25
Dressings 26
Durable medical equipment
(DME) 21
Educational classes and programs 22
Effective date of enrollment 9, 47
Emergency 29
Experimental or investigational 38
Eyeglasses 20
Family planning 17
Fecal occult blood test 15
Fraud 5
General Exclusions 38
Hearing services 19

Home health services 22
Hospice care 28
Home nursing care 22
Hospital 11
Immunizations 6, 15, 16
Infertility 17
In-hospital physician care 14
Inpatient Hospital Benefits 26
Insulin 21, 33, 34
Laboratory and pathological
services 26, 27
Machine diagnostic tests 15
Magnetic Resonance Imagings
(MRIs) 15
Mail Order Prescription Drugs 33
Mammograms 15
Maternity Benefits 16, 26
Medicaid 46
Medically necessary 11, 31, 38
Medicare 43, 45
Members 41
Mental Conditions/ Substance
Abuse Benefits 31
Neurological testing 31
Newborn care 16
Non-FEHB Benefits 37
Nurse
Licensed Practical Nurse 22
Nurse Anesthetist 26
Nurse Midwife 22
Nurse Practitioner 28
Psychiatric Nurse 31
Registered Nurse 22
Nursery charges 16
Obstetrical care 16
Occupational therapy 19
Ocular injury 20
Office visits 6, 14
Oral and maxillofacial surgery 24
Orthopedic devices 21
Ostomy and catheter supplies 26, 27
Out-of-pocket expenses 12
Outpatient facility care 27
Oxygen 27
Pap test 15
Physical examination 6, 15
Physical therapy 19
Physician 14
Pre-admission testing 32
Precertification 16

Preventive care, adult 15
Preventive care, children 16
Prescription drugs 33
Preventive services 15, 16
Prior approval 31
Prostate cancer screening 15
Prosthetic devices 21
Psychologist 31
Psychotherapy 31
Radiation therapy 15
Renal dialysis 42
Room and board 26
Second surgical opinion 14
Skilled nursing facility care 27
Smoking cessation 22
Speech therapy 19
Splints 26
Sterilization procedures 17
Subrogation 46
Substance abuse 31
Surgery 23
Anesthesia 25
Oral 24
Outpatient 27
Reconstructive 24
Syringes 34
Temporary continuation of
coverage 49-51
Transplants 19, 24, 25, 35
Treatment therapies 28
Vision services 20
Well child care 16
Wheelchairs 21
Workers' compensation 46
X-rays 15 56.
56 Page 57 58
Summary of benefits for UHP HEALTHCARE -2003
Do not rely on this chart alone. All benefits are provided in full unless indicated and are subject to the definitions,
limitations, and exclusions in this brochure. On this page we summarize specific expenses we cover; for more
detail, look inside.

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

We only cover services provided or arranged by Plan physicians, except in emergencies.

Benefits You Pay Page
Medical services provided by physicians:
Diagnostic and treatment services provided in the office.............. Office visit copay: $10 primary 17
care; $10specialist

Services provided by a hospital:
Inpatient........................................................................................... Nothing 26
Outpatient ........................................................................................ Nothing 27
Walk-In, $20 copay

Emergency benefits:
In-area............................................................................................. $50 or 50% of charges, 29
whichever is less

Out-of-area ..................................................................................... $50 or 50% of charges, 30
whichever is less

Mental health and substance abuse treatment ................................... Regular cost sharing 31
Prescription drugs .............................................................................. $10 Generic 33
$20 Name Brand Formulary
Cost sharing applies when
generic is available

Dental Care ........................................................................................ Accidental injury benefit only 36
Vision Care ........................................................................................ No benefit.
Special Features:
Flexible benefits option.................................................................. 35

Protection against catastrophic costs (Your catastrophic out of We do not have an
pocket maximum................................................................................ out-of-pocket maximum 12

54 2003 UHP HEALTHCARE Summary 57.
57 Page 58
55 2003 UHP HEALTHCARE Rate Information
2003 Rate Information for UHP HEALTHCARE
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 special FEHB guides are 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 Code Gov't Your Gov't Your USPS Your
Enrollment Share Share Share Share Share Share

High Option C41 79.05 26.35 171.28 57.09 93.54 11.86
Self Only

High Option C42 168.32 56.11 364.70 121.57 199.18 25.25
Self & Family 58.

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