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CIGNA HealthCare of California, Inc.

Federal Employees Health Benefits Program
2003 Plan Brochure
Accessible Version

Document Outline

Introduction
Plain Language
Stop Health Care Fraud!
Section 1. Facts about this HMO plan
- How we pay providers
- Who provides my health care?
- Your Rights
- Service Area
Section 2. How we change for 2003
- Program-wide changes
- Changes to this Plan
Section 3. How you get care
- Identification cards
- Where you get covered care
  - Plan providers
  - Plan facilities
- What you must do to get covered care
- Circumstances beyond our control
- Services requiring our prior approval
Section 4. Your costs for covered services
- Copayments
- Deductible
- Coinsurance
Your catastrophic protection out-of-pocket maximum for copayments
Section 5. Benefits
- OVERVIEW
- Section 5(a). Medical services and supplies provided by physicians and other health care professionals
- Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
- Section 5(c). Services provided by a hospital or other facility, and ambulance services
- Section 5(d). Emergency services/accidents
- Section 5(e). Mental health and substance abuse benefits
- Section 5 (f). Prescription drug benefits
- Section 5(g). Special features
- Section 5(h). Dental benefits
- Section 5(i). Non-FEHB benefits available to Plan members
Section 6. General exclusions things we dont cover
Section 7. Filing a claim for covered services
Section 8. The disputed claims process
Section 9. Coordinating benefits with other coverage
- When you have other health coverage
Section 10. Definitions of terms we use in this brochure
Section 11. FEHB facts
- No pre-existing condition limitation
- Where you can get information about enrolling in the FEHB Program
- Types of coverage available for you and your family
- Childrens Equity Act
- When benefits and premiums start
- When you retire
When you lose benefits
- When FEHB coverage ends
- Spouse equity coverage
- Temporary continuation of coverage (TCC)
- Converting to individual coverage
- Getting a Certificate of Group Health Plan Coverage
Long Term Care Insurance Is Still Available!
Index
Summary of benefits
Rates

Pages 1--60

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

A Health Maintenance Organization
Serving: Greater California
Enrollment in this Plan is limited. You must live or work in our Geographic service
area to enroll. See page 7 for requirements.

CIGNA HealthCare of California, Inc.
http://www.cigna.com/healthcare

RI 73-402
2003
For changes
in benefits
see page 9.

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

Enrollment codes for this Plan:
9T1 Self Only
9T2 Self and Family

HealthCare

Authorized for distribution by the:
United States Office of Personnel Management

Retirement and Insurance Service
http:// www. opm. gov/ insure 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). 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 follow-
ing address:

Privacy Complaints
Office of Personnel Management
P.O. Box 707
Washington, DC 20004-0707

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

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

2003 CIGNA HealthCare of California, Inc.4Introduction/Plain Language/Advisory
Introduction
This brochure describes the benefits of CIGNA HealthCare of California, Inc. under our contract (CS 2841) with the
Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. The address for
CIGNA HealthCare of California, Inc.'s administrative office is:

CIGNA HealthCare of California, Inc.
400 North Brand Boulevard
Glendale, California 91203

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

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

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

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

Except for necessary technical terms, we use common words. For instance, "you" means the enrollee or family
member; "we" means CIGNA HealthCare of California, Inc.

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

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

If you have comments or suggestions about how to improve the structure of this brochure, let OPM know. Visit OPM's
"Rate Us" feedback area at www.opm.gov/insure or e-mail OPM at fehbwebcomments@opm.gov. You may also write to
OPM at the Office of Personnel Management, Office of Insurance Planning and Evaluation Division, 1900 E Street,
NW, Washington, DC 20415-3650. 7.
7 Page 8 9
2003 CIGNA HealthCare of California, Inc. 5 Introduction/Plain Language/Advisory
Stop Health Care Fraud!
Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefit (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 providers, or authorized plan or OPM representative.

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

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

If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service,
or misrepresented any information, do the following:

Call the provider and ask for an explanation. There may be an error.
If the provider does not resolve the matter, call us at 1-800-CIGNA24 (1-800-244-6224) and explain the situation.
If we do not resolve the issue:

CALL THE HEALTH CARE FRAUD HOTLINE
202-418-3300

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

Do not maintain as a family member on your policy:
your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise); or
your child over age 22 (unless he/she is disabled and incapable of self support).
If you have any questions about the eligibility of a dependent, check with your personnel office if you are employed
or with OPM if you are retired.

You can be prosecuted for fraud and your agency may take action against you if you falsify a claim to obtain FEHB
benefits or try to obtain services for someone who is not an eligible family member or who is no longer enrolled in
the Plan. 8.
8 Page 9 10
2003 CIGNA HealthCare of California, Inc. 6 Section 1
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and other
providers that contract with us. These Plan providers coordinate your health care services. The Plan is solely responsible
for the selection of these providers in your area. Contact the Plan for a copy of their most recent provider directory.

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

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

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

How we pay providers
We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure. These Plan
providers accept a negotiated payment from us, and you will only be responsible for your copayments or coinsurance. We
compensate our participating providers in ways that are intended to emphasize preventive care, promote quality of care,
and assure the most appropriate use of medical services. You can discuss with your provider how he is compensated by
us. The methods we use to compensate participating providers are:

Discounted fee for service payment for service is based on an agreed upon discounted amount for the services provided.
Capitation Physicians, provider groups and physician/hospital organizations are paid a fixed amount at regular intervals
for each Member assigned to the physician, provider group or physician/hospital organization, whether or not services are
provided. This payment covers the physician and/or, where applicable, hospital or other services covered under the
benefit plan. Medical groups and physician/hospital organizations may in turn compensate providers using a variety of
methods.

Capitation offers health care providers a predictable income, encourages Physicians to keep people well through preven-
tive care, eliminates the financial incentive to provide services that will not benefit the patient, and reduces paperwork.

Providers paid on a "capitated" basis may participate with us in a risk sharing arrangement. They agree upon a target
amount for the cost of certain health care services, and they share all or some of the amount by which actual costs are
over target. Provider services are monitored for appropriate utilization, accessibility, quality and Member satisfaction.

We may also work with third parties who administer payments to Participating Providers. Under these arrangements, we
pay the third party a fixed monthly amount for these services. Providers are compensated by the third party for services
provided to Healthplan participants from the fixed amount. The compensation varies based on overall utilization.

Salary Physicians and other providers who are employed to work in our medical facilities are paid a salary. The
compensation is based on a dollar amount, decided in advance each year, that is guaranteed regardless of the services
provided. Physicians are eligible for any annual bonus based on quality of care, quality of service and appropriate use of
Medical Services.

Bonuses and Incentives Eligible Physicians may receive additional payments based on their performance. To determine
who qualifies, we evaluate Physician performance using criteria that may include quality of care, quality of service,
accountability and appropriate use of Medical Services. 9.
9 Page 10 11

2003 CIGNA HealthCare of California, Inc. 7 Section 1
Per Diem A specific amount is paid to a hospital per day for all health care received. The payment may vary by type of
service and length of stay.

Case Rate A specific amount is paid for all the care received in the hospital for each standard service category as
specified in our contract with the provider (e.g., for a normal maternity delivery).

Who provides my health care?
We contract with a group of doctors and hospitals to provide your health care. You will select a primary care physician
who supervises your total health care needs. You may see a Plan gynecologist for annual routine examination without a
referral. However, if your primary care physician is affiliated with a medical group, you must see a Plan gynecologist in
the same medical group.

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.

CIGNA HealthCare of California is in compliance with all State and Federal licensing and certification requirements
and has received its 3 year commendable certification by the National Committee on Quality Assurance (NCQA) in
September 2000.

CIGNA HealthCare of California is a Health Services Corporation licensed in the State of California since 1978.

If you want more information about us, call 1-800-CIGNA24 (1-800-244-6224), or write to CIGNA HealthCare of
California, Inc., 400 North Brand Boulevard, Glendale, California 91203. You may also visit our website at
www.cigna.com/healthcare.

Service Area
To enroll in this Plan, you must live in or work in our Service Area. This is where our providers practice. Where you live
or work will determine which service area you will access. For example, if you are in the Northern California Area, you
must obtain care from those providers within the Northern California network. You may not obtain care from a provider
in the Southern California network. Please refer to your directory or website for the zip codes in your particular network.
Our Service areas are:

Northern California Area
Service area: Alameda, Butte, Contra Costa, El Dorado, Fresno, Glenn, King, Marin, Placer, Sacramento, San Francisco,
San Joaquin, San Mateo, Santa Clara, Santa Cruz, Solano, Sonoma, Stanislaus, Tulare, and Yolo Counties. Merced
County is only partially covered, the zip codes lists below describe the areas that are covered in this county:

Merced: 95315, 95324
Southern California Area
Service area: Los Angeles, Orange, San Luis Obispo, Santa Barbara, and Ventura counties. Kern, Riverside and
San Bernardino counties are only partially covered, the zip code lists below describe the areas that are covered in these
counties:

Kern: 93203, 93205, 93206, 98215, 93216, 93217, 93220, 93222, 93224, 93225, 93226, 93238, 93240,
93241, 93243, 93249, 93250, 93251, 93252, 93255, 93263, 93268, 93276, 93280, 93283, 93285,
93287, 93300, 93301, 93302, 93303, 93304, 93305, 93306, 93307, 93308, 93309, 93311, 93312,
93313, 93380-9, 93390, 93399, 93501-5, 93516, 93518, 93519, 93523, 93524, 93527, 93528,
93531, 93554, 93555, 93556, 93560, 93561, 93570, 93581, 93582, 93596 10.
10 Page 11 12
2003 CIGNA HealthCare of California, Inc. 8 Section 1
Riverside: 91718-20, 91752, 91760, 92220, 92223, 92230, 92282, 92320, 92501-9, 92513-23, 92530-2,
92551-7, 92562-4, 92567, 92570-2, 92589-93, 92595, 92599, 92879, 92880, 92881, 92882

San Bernardino: 91701, 91708-10, 91729-30, 91737, 91739, 91743, 91758, 91760-4, 91784-6, 91798, 92301,
92307-9, 92311-3, 92316, 92317, 92324, 92329, 92334-7, 92340, 92342, 92345-6, 92350, 92354,
92356-9, 92368-9, 92372-7, 92392-4, 92397, 92399, 92400-16, 92418, 92420, 92423-4, 92427

San Diego Area
Service area: San Diego County

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. 11.
11 Page 12 13
2003 CIGNA HealthCare of California, Inc. 9 Section 2
Section 2. How we change for 2003
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5
Benefits. Also, we edited and clarified language throughout the brochure; any language changes not shown here is a
clarification that does not change benefits.

Program-wide changes
A Notice of the Office of Personnel Management's Privacy Practices is included.

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

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

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

Changes to this Plan
Your share of the non-Postal premium will increase by 14.8% for Self Only or 14.8% for Self and Family.

A Primary Care Physician's office visit copayment is now $15 per visit instead of $10 per visit.
Specialists' office visit copayments are now $25 per visit instead of $10 per visit.
The Inpatient hospital admission copayment is now $250 per admission. Previously you paid nothing.
The Outpatient hospital or ambulatory surgical center copayment is now $125 per admission. Previously you paid
nothing.

Physical, Speech and Occupational therapy office visit copayments are now $25 instead of $20.
Under the Prescription drug benefit, the retail pharmacy copayment for generic drugs is now $7 instead of $5.
Copayments for name brand formulary with or without generic equivalents have not changed.

Under the Prescription drug benefit, the mail order copayment for generic drugs is now $16 instead of $10.
Copayments for name brand formulary with or without generic equivalents have not changed.

Your catastrophic out-of-pocket maximum for Self Only enrollment is now $1,500 instead of $1,000; Self and Family
enrollment is now $3,000 instead of $2,000. 12.
12 Page 13 14

2003 CIGNA HealthCare of California, Inc. 10 Section 3
We will send you an identification (ID) card when you enroll. You should
carry your ID card with you at all times. You must show it whenever you
receive services from a Plan provider, or fill a prescription at a Plan pharmacy.
Until you receive your ID card, use your copy of the Health Benefits Election
Form, SF-2809, your health benefits enrollment confirmation (for annuitants),
or your Employee Express confirmation letter.

If you do not receive your ID card within 30 days after the effective date of
your enrollment, or if you need replacement cards, call us at 1-800-CIGNA24
(1-800-244-6224). You may also request replacement cards through our
website at www.cigna.com.

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

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 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.

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.
When you enroll, you choose a Primary Care Physician (PCP). Each family
member also chooses a PCP. Your PCP is your personal doctor and serves as
your health care manager. If you do not select a PCP, we will assign one for
you. If your PCP leaves our network, you will be able to choose a new PCP.
You may voluntarily change your PCP for other reasons but not more than
once in any calendar month. We reserve the right to determine the number
of times during a year that you will be allowed to change your PCP. If you
select a new PCP before the fifteenth day of the month, the designation will
be effective on the first day of the month following your selection. If you
select a new PCP on or after the fifteenth day of the month, the designation
will be effective on the first day of the month following the next full month.
For example, if you notify us on June 10, the change will be effective on
July 1. If you notify us on June 15, the change will be effective on August 1.

Some Primary Care Physicians belong to provider organizations which usually
refer you to a network of Specialty Care Physicians and Hospitals that are in
the provider organization. Your choice of Primary Care Physician may affect
the Hospital(s) and Specialty Care Physicians to which you may be referred.
Therefore, you may not have access to every specialist or Participating
Provider in your Service Area. Before you select a PCP, you should check to
see if that PCP is associated with the specialist or facility you prefer to use.

Identification cards
Where you get covered care
Plan providers

Plan facilities
What you must do to get covered care

Section 3. How you get care 13.
13 Page 14 15
2003 CIGNA HealthCare of California, Inc. 11 Section 3
Your primary care physician can be a general practitioner, family practitioner,
internist or pediatrician. Your primary care physician will provide most of
your health care, or give you a referral to see a specialist.

If you want to change primary care physicians or if your primary care
physician leaves the Plan, call us. We will help you select a new one.

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 addi-
tional referrals. The primary care physician must provide or authorize all
follow-up care. Do not go to the specialist for return visits unless your
primary care physician gives you a referral. You may see an OB/GYN for
well-woman care or go to a hospital for emergency care without a referral.
However, if your primary care physician is affiliated with a medical group,
you must see a Plan gynecologist in the same medical group.

Here are other things you should know about specialty care:
If you need to see a specialist frequently because of a chronic, complex,
or serious medical condition, your primary care physician will work with
the Plan to develop a treatment plan that allows you to see your specialist
for a certain number of visits without additional referrals. Your primary
care physician will use our criteria when creating your treatment plan
(the physician may have to get an authorization or approval beforehand).

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

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

If you have a chronic or disabling condition and lose access to your
specialist because we:

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

reduce our service area and you enroll in another FEHB Plan,
you may be able to continue seeing your specialist for up to 90 days after
you receive notice of the change. Contact us or, if we drop out of the
Program, contact your new plan.

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

Primary care
Specialty care 14.
14 Page 15 16
2003 CIGNA HealthCare of California, Inc. 12 Section 3
Your Plan primary care physician or specialist will make necessary hospital
arrangements and supervise your care. This includes admission to a skilled
nursing or other type of facility.

If you are in the hospital when your enrollment in our Plan begins, call
our customer service department immediately at 1-800-CIGNA24
(1-800-244-6224). 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.

Under certain extraordinary circumstances, such as natural disasters, we may
have to delay your services or we may be unable to provide them. In that case,
we will make all reasonable efforts to provide you with the necessary care.

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

A referral or Prior Authorization must be obtained prior to receiving services
performed by any health care provider EXCEPT:

For services provided by
Your Primary Care Physician;
OB/GYN Services (If your primary care physician is affiliated with a
medical group, you must see a Plan gynecologist in the same medical
group); and

Emergency Services or Urgently Needed Care.

A referral must be obtained directly from your Primary Care Physician. Your
Primary Care Physician must provide a referral if you receive services and
benefits such as Specialty Care Physician services. If you receive services
which require a referral without a referral from your Primary Care Physician,
you will be obligated to pay for the unauthorized Services. We will not pay
for unauthorized services.

Certain benefits and services require Prior Authorization from us. Prior
Authorization must always be obtained through your Plan Provider. If Prior
Authorization is required from us, your Primary Care Physician or Specialty
Care Physician will make arrangements with our Medical Director. Prior
Authorization is required for the following types of benefits and services
such as: Inpatient and Outpatient Hospital Services, Rehabilitative Therapy,
Skilled Nursing Facility Services, Home Health Services, Second Surgical
Opinions, Services provided by a Non-Plan Provider, Durable Medical
Equipment and Prosthetic Devices.

If your coverage is terminated prior to the date of service, the service will
not be covered, regardless of any Prior Authorization given by us or your
Primary or Specialty Care Physician.

Circumstances beyond our control
Services requiring our prior approval

Hospital care 15.
15 Page 16 17
2003 CIGNA HealthCare of California, Inc. 13 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:

A copayment is a fixed amount of money you pay to the provider, facility,
pharmacy, etc. when you receive services.

Example: When you see your primary care physician you pay a
copayment of $15 per office visit.

A deductible is a fixed expense you must incur for certain covered services
and supplies before we start paying benefits for them. We do not have a
deductible.

Note: If you change plans during open season, you do not have to start a
new deductible under your old plan between January 1 and the effective date
of your new plan. If you change plans at another time during the year, you
must begin a new deductible under your new plan.

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

Example: In our Plan, you pay 30% of our allowance for
infertility services.

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

Prescription drugs
Dental services
Mental Health/Substance Abuse
External prosthetic appliances
Infertility services

Be sure to keep accurate records of your copayments since you are
responsible for informing us when you reach the maximum.

Copayments
Deductible

Coinsurance
Your catastrophic protection out-of-pocket maximum
for copayments 16.
16 Page 17 18

2003 CIGNA HealthCare of California, Inc. 14 Section 5
Section 5. Benefits OVERVIEW (See page 9 for how our benefits changed this year and page 55 for a benefits summary.)
Note: This benefits section is divided into subsections. Please read the important things you should keep in mind at the
beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the following
subsections. To obtain claim forms, claims filing advice, or more information about our benefits, contact us at
1-800-CIGNA24 (1-800-244-6224) or at our website at www.cigna.com/healthcare.

Medical emergency
(d) Emergency services/accidents ......................................................................................................................... 28-29

Inpatient hospital
Outpatient hospital or ambulatory surgical center

(c) Services provided by a hospital or other facility, and ambulance services ..................................................... 25-27

Surgical procedures
Reconstructive surgery

(b) Surgical and anesthesia services provided by physicians and other health care professionals ....................... 22-24

Diagnostic and treatment services
Lab, X-ray, and other diagnostic tests
Preventive care, adult
Preventive care, children
Maternity care
Family planning
Infertility services
Allergy care
Treatment therapies
Physical and occupational therapies
Speech therapy

(a) Medical services and supplies provided by physicians and other health care professionals .......................... 15-21
Hearing services (testing, treatment, and supplies)

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

Oral and maxillofacial surgery
Organ/tissue transplants
Anesthesia

Extended care benefits/skilled nursing care facility benefits
Hospice care
Ambulance

(e) Mental health and substance abuse benefits .................................................................................................... 30-31
(f) Prescription drug benefits ................................................................................................................................ 32-33
(g) Special features .................................................................................................................................................... 34
Flexible benefits option
24 hour nurse line
Services for deaf and hearing impaired
High risk pregnancies
Centers of Excellence
Travel benefit/services overseas
(h) Dental benefits ...................................................................................................................................................... 35

(i) Non-FEHB benefits available to Plan members .................................................................................................. 36
Summary of benefits ............................................................................................................................................ 56

Ambulance 17.
17 Page 18 19
2003 CIGNA HealthCare of California, Inc. 15 Section 5(a)
Diagnostic and treatment services
Professional services of physicians
In physician's office
In an urgent care center
During a hospital stay
In a skilled nursing facility
Office medical consultations
Second surgical opinion

Lab, X-ray and other diagnostic tests
Tests, such as: Nothing
Blood tests
Urinalysis
Pap tests
Pathology
X-rays
Mammograms
CAT Scans/MRI
Ultrasound
Electrocardiogram and EEG

Note: You pay nothing for Lab, X-rays and other diagnostic tests, however a provider or facility copayment may apply depending on

where you receive the service. Refer to the physician's services in this section and facility charges in Section 5(c).

Benefit Description You pay
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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 informa-
tion about how cost sharing works. Also read Section 9 about coordinating
benefits with other coverage, including with Medicare.

$15 per visit to your primary care physician
$25 per visit to a specialist 18.
18 Page 19 20
2003 CIGNA HealthCare of California, Inc. 16 Section 5(a)
Preventive care, adult You pay
Routine screenings, such as: Nothing
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 for men age 40 and older

Routine pap test
Note: The office visit is covered if pap test is received on the same day; see Diagnostic and treatment services, above.

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

Note: You pay nothing for these routine screenings, tests and mammograms, however a provider or facility copayment may apply

depending on where you receive the service. Refer to the physician's services in this section and facility charges in Section 5(c).

Not covered: Physical exams required for obtaining or continuing All charges employment or insurance, attending schools or camp, or travel.
Routine immunizations, limited to: Nothing
Tetanus-diphtheria (Td) booster once every 10 years, ages 19 and over (except as provided for under Childhood immunizations)

Influenza vaccines, annually
Pneumococcal vaccines, age 65 and over

Preventive care, children
Childhood immunizations and injections recommended by the Nothing American Academy of Pediatrics

Well-child care charges for routine examinations, immunizations and care (under age 22)

Note: You pay nothing for childhood immunizations, however a provider or facility copayment may apply depending on
where you receive the service. Refer to the physician's services in this section and facility charges in Section 5(c).

Examinations, such as: $15 per office visit
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 (under age 22)
Note: You pay nothing for childhood immunizations, however a provider or facility copayment may apply depending on

where you receive the service. Refer to the physician's services in this section and facility charges in Section 5(c). 19.
19 Page 20 21
2003 CIGNA HealthCare of California, Inc. 17 Section 5(a)
Maternity care You pay
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care

Note: Here are some things to keep in mind:
You do not need to obtain prior authorization for your normal delivery; see page 12 for other circumstances, such as extended

stays for you or your baby.
You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will extend

your inpatient stay if medically necessary.
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. Circumcisions are paid under the
Surgical benefit and not Maternity Care.
We pay hospitalization and surgeon services (delivery) the same as for illness and injury. See Hospital benefits (Section 5(c)) and Surgery

benefits (Section 5(b)).

Not covered: Routine sonograms to determine fetal age, size or sex . All charges

Family planning
Voluntary sterilization (Procedure only) (See Surgical procedures Nothing Section 5(b)).

Note: You pay nothing for Voluntary sterilization, however a provider or facility copayment may apply depending on
where you receive the service. Refer to the physician's services in this section and facility charges in Section 5(c).

Surgically implanted contraceptives (such as Norplant)
Injectable contraceptive drugs (such as Depo provera)
Intrauterine devices (IUDs)

Note: We cover oral contraceptives under the prescription drug benefit.

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

Infertility services
Diagnosis of infertility $15 per visit to your primary care physician

$25 per visit to a specialist
Treatment of infertility, such as: 30% per treatment/surgical
Artificial insemination: procedure
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.

Infertility services continued on next page.

$15 for the first office visit to confirm pregnancy; no copay
for all pre-/post-delivery visits thereafter.

$15 per visit to your primary care physician
$25 per visit to a specialist 20.
20 Page 21 22
2003 CIGNA HealthCare of California, Inc. 18 Section 5(a)
Infertility services (continued) You pay
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 eggs

Allergy care
Testing and treatment
Allergy injection

Allergy serum Nothing
Not covered: All charges
Self-administered allergy injections

Treatment therapies
Chemotherapy and radiation therapy Nothing
Note: High dose chemotherapy in association with autologous bone marrow transplants are limited to those transplants listed under

Organ/Tissue Transplants on page 24.
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 therapy is covered under the prescription drug benefit.

Note: We will only cover GHT when your PCP has received our prior authorization Prior approval must be received before you begin
treatment; otherwise, we will only cover GHT services from the date your PCP receives prior authorization. If prior authorization is not
received or if we determine GHT is not medically necessary, we will not cover the GHT or related services and supplies. See Services
requiring our prior approval in Section 3.

Physical and occupational therapies
All medically necessary visits are covered if significant improvement $25 per office visit can be expected. Services of each of the following are covered.
qualified physical therapists;
occupational therapists;
chiropractors; and
cardiac and pulmonary rehabilitation programs.

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

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

$15 per visit to your primary care physician
$25 per visit to a specialist 21.
21 Page 22 23
2003 CIGNA HealthCare of California, Inc. 19 Section 5(a)
Speech therapy You pay
All medically necessary visits. $25 per visit

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

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

Vision services (testing, treatment, and supplies)
One eye refraction per year to provide a written lens prescription for eyeglasses.

One pair of eyeglasses or contact lenses for treatment of keratoconus or post-cataract surgery

Note: See Preventive care, children for eye exams for children.
Not covered: All charges
Eyeglasses or contact lenses
Eye exercises and orthoptics
Radial keratotomy and other refractive surgery

Foot care
Routine foot care when you are under active treatment for medical conditions such as diabetes; fungal infection of the nail beds, circulatory
impairment; immunocomprimised patients.
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)

$15 per visit to your primary care physician
$25 per visit to a specialist

$15 per visit to your primary care physician
$25 per visit to a specialist 22.
22 Page 23 24
2003 CIGNA HealthCare of California, Inc. 20 Section 5(a)
Orthopedic and prosthetic devices You pay
Artificial limbs and eyes; hands or hooks. You pay the first $200 per calendar year.

The maximum Plan allowance is $1,000 per calendar year.
Externally worn breast prostheses and surgical bras, including Nothing necessary replacements, following a mastectomy.

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

Not covered: All charges
orthopedic and corrective shoes
arch supports
foot orthotics and braces
heel pads and heel cups
lumbosacral supports
corsets, trusses, elastic stockings, support hose, and other supportive devices

prosthetic replacements due to wear and tear, loss, theft or destruction.
corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome

biomechanical devices
penile prosthetics

Durable medical equipment (DME)
We limit coverage to $3,500 per member per year. Nothing
Initial rental or purchase, at our option, including repair and adjustment, of durable medical equipment prescribed by your Plan physician and

received from a vendor approved by the Plan, such as:
oxygen tents;
dialysis equipment;
hospital beds;
wheelchairs (limited to the lowest cost alternative to satisfy medical necessity);

crutches;
walkers;
blood glucose monitors and blood glucose monitors for the legally blind;

insulin pumps and infusion devices;
respirators; and
oxygen tents.

Note: Your PCP will prescribe and arrange for a participating health care provider to rent or sell you the durable medical equipment.

We will not cover equipment received from a non-participating health care provider unless your PCP has received our prior authorization.

Durable medical equipment (DME) continued on next page 23.
23 Page 24 25
2003 CIGNA HealthCare of California, Inc. 21 Section 5(a)
Durable medical equipment (DME) (continued) You pay
Not covered: All charges
Hygienic or self-help items or equipment, or item or equipment that are primarily for comfort or convenience, such as bathtub chairs,

safety grab bars, stair gliders or elevators, over-the-bed tables, saunas or exercise equipment;

Environmental control equipment, such as air purifiers, humidifiers, and electrostatic machines;
Institutional equipment such as air fluidized beds and diathermy machines;
Consumable medical supplies including, but not limited to, bandages and other disposable supplies, skin preparations, test strips, ostomy
supplies, surgical leggings, elastic stockings and wigs.

Home health services
Home health care ordered by a Plan physician and provided by a Nothing 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: All charges
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;
services primarily for rest, domiciliary or convalescent care.

Chiropractic
See Physical and occupational therapies under this Section, Chiropractic Same as Physical and is part of Physical and occupational therapies. occupational therapies

Alternative treatments
No benefit All charges

Educational classes and programs
No benefit All charges 24.
24 Page 25 26
2003 CIGNA HealthCare of California, Inc. 22 Section 5(b)
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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.
We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information
about how cost sharing works. Also read Section 9 about coordinating benefits
with other coverage, including with Medicare.

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

YOUR PLAN PROVIDER MUST GET PRIOR AUTHORIZATION OF SOME
SURGICAL PROCEDURES. Please refer to the prior authorization information
shown in Section 3 to be sure which services require prior authorization and
identify which surgeries require prior authorization.

Benefit Description You pay
Surgical procedures
A comprehensive range of services, such as: Nothing
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 200% of his or her normal weight according to

the 1983 Metropolitan Life Insurance Company height-weight chart with a history of morbid obesity for at least 5 years and has
complied with more conservative methods of weight loss
Insertion of internal prosthetic devices. See 5(a) Orthopedic and prosthetic devices for device coverage information

Voluntary sterilization (e.g., Tubal ligation, Vasectomy)
Treatment of burns

Note: Generally, we pay for internal prostheses (devices) according to where the procedure is done. For example, we pay Hospital

benefits for a pacemaker and Surgery benefits for insertion of the pacemaker.

Surgical procedures continued on next page.

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2003 CIGNA HealthCare of California, Inc. 23 Section 5(b)
Surgical procedures (continued) You pay
Not covered: All charges
Reversal of voluntary sterilization
Routine treatment of conditions of the foot; see Foot care.
Cosmetic therapy or surgery primarily for the purpose of altering appearance.

Reconstructive surgery
Surgery to correct a functional defect Nothing
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, with the prior approval of Plan Medical Nothing Director, such as:

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)

Other surgical procedures which have not received prior approval from the Plan Medical Director. 26.
26 Page 27 28
2003 CIGNA HealthCare of California, Inc. 24 Section 5(b)
Organ/tissue transplants You pay
Limited to: Nothing
Cornea
Heart
Heart/lung
Kidney
Kidney/Pancreas
Pancreas
Liver
Lung
Allogenetic (donor) bone marrow/stem cell transplants
Autologous bone marrow transplants (autologous stem cell and peripheral stem cell support) for the following conditions: acute

lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's lymphoma; advanced non-Hodgkin's lymphoma; advanced
neuroblastoma; breast cancer; multiple myeloma; epithelial ovarian cancer; and testicular, mediastinal, retroperitoneal and
ovarian germ cell tumors
Intestinal transplants (small intestine) and the small intestine with the liver or small intestine with multiple organs such as the liver,

stomach and pancreas
National Transplant Program (NTP) please see Section 5(g), Special Features

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 we cover the recipient.

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 Nothing
Hospital (inpatient)
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center
Office 27.
27 Page 28 29
2003 CIGNA HealthCare of California, Inc. 25 Section 5(c)
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Inpatient hospital
Room and board, such as: $250 per admission
ward, semiprivate, or intensive care accommodations;
general nursing care; and
meals and special diets.

Note: If you request a private room and 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, blood products and other biologicals
Blood or blood plasma
Dressings, splints, casts, and sterile tray services
Medical supplies and equipment, including oxygen
Anesthetics and anesthesia services

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

Private nursing care

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.

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

The amounts listed below are for the charges billed by the facility (i.e., hospital
or surgical center) or ambulance service for your surgery or care. Any costs
associated with the professional charge (i.e., physicians, etc.) are covered in
Section 5(a) or (b).

YOUR PRIMARY CARE PHYSICIAN MUST OBTAIN OUR PRIOR AUTHORI-
ZATION FOR HOSPITAL STAYS, EXCEPT FOR EMERGENCIES. Please
refer to Section 3 to be sure which services require Prior Authorization.

Benefit Description You pay 28.
28 Page 29 30
2003 CIGNA HealthCare of California, Inc. 26 Section 5(c)
Outpatient hospital or ambulatory surgical center You pay
Operating, recovery, and other treatment rooms $125 per facility use
Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology services
Administration of blood, blood products and other biologicals
Blood and blood plasma
Pre-surgical testing
Dressings, casts, and sterile tray services
Medical supplies, including oxygen
Anesthetics and anesthesia services

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 the member All charges

Extended care benefits/skilled nursing care facility benefits
Benefits will be provided for up to 60 days per calendar year when Nothing full-time skilled nursing care is necessary and confinement in a skilled
nursing facility is medically appropriate as determined by a Plan doctor and approved by the Plan. Covered services include:

Skilled and general nursing services
Physicians visits
Physiotherapy
X-rays
Administration of drugs, medications and fluids

Not covered: All charges
personal comfort items, such as television and telephone

custodial care, rest cures, domiciliary or convalescent care 29.
29 Page 30 31
2003 CIGNA HealthCare of California, Inc. 27 Section 5(c)
Hospice care You pay
Supportive and palliative care for a terminally ill member is covered. Nothing Services are provided under the direction of a Plan doctor who certifies
that the patient is in the terminal stages of illness, with a life expectancy of approximately six (6) months or less.

Hospice care services include:
Inpatient care

outpatient care
physician services
psychologist, social worker or family counselor services for individual or family counseling

Not covered: All charges
Independent nursing
homemaker services, including services and supplies that are primarily to aid you or your dependent in daily living

services of a person who is a member of your family who normally resides in your house
services or supplies not listed in the Hospice Care Program
services for curative or life-prolonging procedures
services for respite care
nutritional supplements, non-prescription drugs or substances, medical supplies, vitamins or minerals

bereavement counseling

Ambulance
Local professional ambulance service when medically appropriate Nothing 30.
30 Page 31 32
2003 CIGNA HealthCare of California, Inc. 28 Section 5(d)
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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 and are payable only when we determine they are
medically necessary.

We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable informa-
tion 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:
Emergencies inside or outside our service area: In the event of an emergency, get help immediately. Go to the
nearest emergency room, the nearest hospital or call or ask someone to call 911 or your local emergency service,
police or fire department for help. You do not need a referral from your PCP for emergency services, but you do
need to call your PCP as soon as possible for further assistance and advice on follow-up care. If you require
specialty care or a hospital admission, your PCP will coordinate it and handle the necessary authorizations for care
or hospitalization. Participating providers are on call twenty-four (24) hours a day, seven (7) days a week, to assist
you when you need emergency services.

If you receive emergency services outside the service area, you must notify us as soon as reasonably possible. We
may arrange to have you transferred to a participating provider for continuing or follow-up care if it is determined
to be medically safe to do so.

Emergency services are defined as the medical, psychiatric, surgical, hospital and related health care services and
testing, including ambulance service, which are required to treat a bodily injury or a serious illness which could
reasonably be expected by a prudent layperson to result in serious medical complications, or in the case of a
pregnant woman, serious jeopardy to the health of the woman or her unborn child, loss of life or permanent
impairment to bodily functions in the absence of immediate medical attention. Examples of emergency situations
include, but are not limited to, uncontrolled bleeding, seizures or loss of consciousness, shortness of breath, chest
pains or severe squeezing sensations in the chest, suspected overdoes of medication or poisoning, sudden paralysis
or slurred speech, burns, cuts, and broken bones, or services required by you to determine if a psychiatric emer-
gency medical condition exists, and the care and treatment necessary to relieve or eliminate the psychiatric
emergency medical condition within the capability of the facility.

Continuing or follow-up treatment, whether in or out of the service area, is not covered unless it is provided or
arranged for by your PCP or upon prior authorization of our Medical Director. 31.
31 Page 32 33
2003 CIGNA HealthCare of California, Inc. 29 Section 5(d)
Benefit Description You pay
Emergency within our service area
Emergency care at a Plan doctor's office $15 per office visit
Emergency care at a Plan urgent care center $25 per office visit
Emergency care as an outpatient or inpatient at a hospital, $50 per office visit including doctors' services

Note: Urgent care center copay and emergency hospital care copay waived if admitted to hospital

Not covered: Elective care or non-emergency care All charges
Emergency outside our service area
Emergency care at a doctor's office $15 per office visit
Emergency care at an urgent care center $25 per office visit
Emergency care as an outpatient or inpatient at a hospital, $50 per office visit including doctors' services

Note: Urgent care center copay and emergency hospital care copay waived if admitted to hospital

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

Ambulance
Professional ambulance service when medically appropriate. Nothing
See 5(c) for non-emergency service. 32.
32 Page 33 34
2003 CIGNA HealthCare of California, Inc. 30 Section 5(e)
Mental health and substance abuse benefits
All diagnostic and treatment services recommended by a Plan Your cost sharing provider and contained in a treatment plan that we approve. The responsibilities are no
treatment plan may include services, drugs, and supplies described greater than for other elsewhere in this brochure. illness or conditions.

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 by $25 per office visit providers such as psychiatrists, psychologists, or clinical social
workers
Medication management

Diagnostic tests Nothing
Services provided by a hospital or other facility Your cost sharing responsibilities
Services in approved alternative care settings such as partial are no greater than for other hospitalization, facility based intensive outpatient treatment illness or conditions.

Not covered: Services we have not approved. All charges
Note: OPM will base its review of disputes about treatment plans on the treatment plan's clinical appropriateness. OPM will generally

not order us to pay or provide one clinically appropriate treatment plan in favor of another.

Mental health and substance abuse benefits continued on next page.

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Section 5(e). Mental health and substance abuse benefits
When you get our approval for services and follow a treatment plan we approve,
cost-sharing and limitations for Plan mental health and substance abuse benefits will
be no greater than for similar benefits for other illnesses and conditions.

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

YOU MUST GET PREAUTHORIZATION OF THESE SERVICES. See the
Instructions after the benefits description below.

Benefit Description You pay 33.
33 Page 34 35
2003 CIGNA HealthCare of California, Inc. 31 Section 5(e)
Mental health and substance abuse benefits (continued)
To be eligible to receive these benefits you must obtain a treatment plan and
follow all of the following authorization processes:

Mental Health and Substance Abuse Services are provided by CIGNA
Behavioral Health, Inc. You do not need a referral to receive these services.
However, to obtain these services, you must call CIGNA Behavioral Health
directly, their phone number can be found on your ID Card, to get more
information or speak with someone about a specific problem. A representa-
tive is available to assist you twenty-four (24) hours a day, seven (7) days a
week. The representative will provide you with a choice of providers in your
area and will authorize an appropriate number of visits.

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

Preauthorization 34.
34 Page 35 36
2003 CIGNA HealthCare of California, Inc. 32 Section 5(f)
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.

There are important features you should be aware of. These include:
Who can write your prescription. A plan physician or licensed dentist must write the prescription .
Where you can obtain them. You may fill the prescription at a plan retail pharmacy, or by plan mail-order
pharmacy. You must fill the prescription at a plan retail pharmacy. You may fill your maintenance medications
by mail through a plan mail-order pharmacy.

We use a formulary. A formulary is a listing of approved drug products. The drugs and medications included
have been approved in accordance with parameters established by Healthplan. This list is subject to periodic
review and is amended as required. Some medications require Prior Authorization.

These are the dispensing limitations.
Your copayment for generic retail prescription drugs that are on the formulary is $7. Your copayment for name
brand retail prescription drugs that are on the formulary but do not have a generic equivalent is $15. Your
copayment for name brand drugs that are on the formulary but do have a generic equivalent OR for drugs that
are not on the formulary is $35. Each prescription order or refill is limited to a consecutive thirty (30) day supply
at a retail participating pharmacy, unless limited by the drug manufacturer's packaging.

Maintenance medications prescribed by Plan doctors may also be obtained through our mail order program.
Your copayment for generic mail order prescription drugs that are on the formulary is $16. Your copayment for
name brand mail order drugs that are on the formulary but do not have a generic equivalent is $40. Your
copayment for name brand drugs that are on the formulary but do have a generic equivalent OR for drugs that
are not on the formulary is $100. Each prescription order or refill is limited to a consecutive ninety (90) day
supply at a mail order participating pharmacy, unless limited by the manufacturer's packaging.

Each prescription order or refill is further limited to:
"generic" drugs unless a generic alternative does not exist or substitution is not permitted by state law.
Coverage for prescription drugs are subject to a Copayment. In no event will the Copayment exceed the cost of
the drug.

Why use generic drugs? Generic drugs offer a safe and economic way to meet your prescription drug needs. The generic name of a drug is its chemical name; the name brand is the name under which the manufacturer advertises

and sells a drug. Under federal law, generic and name brand drugs must meet the same standards for safety, purity, strength, and effectiveness. A generic prescription costs you and us less than a name brand prescription.

When you have to file a claim. Please refer to Section 7 "Filing a claim for covered services" .
Prescription drug benefits begin on the next page.

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2003 CIGNA HealthCare of California, Inc. 33 Section 5(f)
Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan physician and obtained from a Plan pharmacy or through our
mail order program:
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.
Insulin
Disposable needles and syringes for the administration of covered medications

Drugs for sexual dysfunction (contact Plan for dose limits)
Oral and injectable contraceptive drugs and contraceptive devices (such as diaphragms)

Intravenous fluids and medications for home use.
Implanted time-release medications such as Norplant. Implanted time-release medications are covered under this Prescription drug

section and the office visit is covered under Medical services and supplies, Section 5(a), Family planning. There is no charge when the
device is implanted during a covered hospitalization.
Nutritional supplements (formulas) as medically necessary for the therapeutic treatment of phenylketonuria (PKU), branched-chain

ketonuria, galactosemia and homocystinuria as administered under the direction of a Primary Care Physician

Diabetic supplies such as test strips
Oral agent for controlling blood sugar

Not covered: All charges
Drugs and supplies for cosmetic purposes

Vitamins (except for prenatal vitamins), and fluoride products, nutrients and food supplements even if a physician prescribes or

administers them
Non-prescription medicines, over the counter drugs
Drugs obtained from a non-Plan pharmacy except for out-of-area emergencies

Medical supplies such as dressings and antiseptics
Drugs to enhance athletic performance
Smoking cessation drugs and medications, including nicotine patches
Diet pills or appetite suppressants (except when used in the treatment of morbid obesity)

Replacement of drugs due to loss or theft
Prescriptions more than one year from the original date of issue
Injectable fertility drugs (see Infertility benefit under Medical and Surgical Benefits for limited coverage)

Retail Pharmacy
$7 per generic formulary drug
$15 per name brand formulary drug

$35 per name brand formulary drug with generic equivalent OR
per non-formulary drug
Mail Order
(Maintenance medications only)

$16 per generic formulary drug
$40 per name brand formulary drug

$100 per name brand formulary drug with generic equivalent OR
per non-formulary drug
Note: If there is no generic equivalent available, you will

still have to pay the name brand copay 36.
36 Page 37 38
2003 CIGNA HealthCare of California, Inc. 34 Section 5(g)
Section 5(g). Special features
Feature Description

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.

For any of your health concerns, 24 hours a day, 7 days a week, you may
call 1-800-CIGNA24 (1-800-244-6224) and talk with a registered nurse
who will discuss treatment options and answer your health questions.

Deaf/Hearing impaired individuals may access the member services
department by calling their state relay line.

Healthy Babies is a program that provides guidance and support to women
from pre-pregnancy through post-partum care. This program is designed to
promote better maternity care, reduce the number of premature births and
educate expectant parents.

CIGNA HealthCare members have access to the CIGNA Lifesource Organ
Transplant Network which is an organization of participating hospitals
which provides organ transplant services. As part of the rigorous
credentialing program, each hospital's transplant program is evaluated for
patient outcome, as well as waiting period, housing arrangements, "patient
friendly" environment and the availability of transportation, before it is
included in the CIGNA Lifesource Organ Transplant Network .

We cover you for emergency services anywhere in the world.

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

Centers of Excellence
Travel benefit/services overseas

High risk pregnancies 37.
37 Page 38 39
2003 CIGNA HealthCare of California, Inc. 35 Section 5(h)
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.
We have no calendar year deductible.
We cover hospitalization for dental procedures only when prior authorized by
our Medical Director and a non-dental 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.

We cover anesthesia for dental procedures only when (a) age 7 years and under;
(b) developmentally disabled, regardless of age; or (c) health compromised and
general anesthesia is Medically Necessary, regardless of age; AND prior autho-
rized by the Plan Medical Director and a non-dental physical impairment exists
which makes hospitalization necessary to safeguard the health of the patient;
we do not cover the dental procedure unless it is described below.

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

Accidental injury benefit You pay
We cover restorative services and supplies necessary to promptly repair $15 per office visit (but not replace) sound natural teeth. The need for these services must
result from an accidental injury.

Dental benefits
We have no other dental benefits.

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2003 CIGNA HealthCare of California, Inc. 36 Section 5(i)
Section 5(i). Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed claim
about them. Fees you pay for these services do not count toward FEHB deductibles or catastrophic protection out-of-
pocket maximums.

Guest Privileges
If you or a covered family member temporarily moves outside of the service area for at least 90 days, you may be eligible
for the Plan's "guest privileges" program. The "guest privileges" program allows participants to enroll as "guests" in
another CIGNA HealthCare site. This program is only available when you or your covered family member is temporarily
relocating to an approved CIGNA guest site. Guest privileges is an ideal way to arrange for benefits in situations such as:
a temporary job transfer/work assignments; college child attending school away from home, etc. You should be aware
that your FEHBP benefits will NOT follow you to the guest site. You will be covered by the CIGNA HealthCare "guest
privileges" program plan of benefits. Contact member services at 1-800-CIGNA24 (1-800-244-6224) for more information.

CIGNA Dental Care
Health coverage for your mouth is available for FEHB program members at a very affordable cost. It is not necessary to
have CIGNA Medical Care to purchase CIGNA Dental Care for yourself and your family.

No deductibles
No annual maximums
No claim forms
No charge for preventive services (oral exams, x-rays, routine cleanings, fluoride treatments)
Low copayments required for other treatments (see Dental Fee Overview)
Orthodontic coverage for both children and adults for treatment started after the effective date of your plan

For questions about enrollment, call Wright & Co. at 1-800-51DENTAL. For questions about the CIGNA Dental Care
plan, call member services at 1-800-367-1037.

Members Choice allows you to select a different dental office for each covered member. To enroll in CIGNA Dental
Care, choose any network general dentist for yourself and each of your covered dependents from the CIGNA Dental Care
Network Directory, or access the dental office locator by calling 1-800-367-1037. 39.
39 Page 40 41
2003 CIGNA HealthCare of California, Inc. 37 Section 6
Section 6. General exclusions things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not
cover it unless your Plan doctor determines it is medically necessary to prevent, diagnose, or treat your illness,
disease, injury, or condition and we agree, as discussed under Services Requiring Our Prior Approval on page 12.

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

Services, drugs, or supplies related to sex transformations;
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program; or
Services, drugs, or supplies you receive without charge while in active military service. 40.
40 Page 41 42
2003 CIGNA HealthCare of California, Inc. 38 Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at Plan
pharmacies, you will not have to file claims. Just present your identification card and pay your copayment.

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

In most cases, providers and facilities file claims for you. Physicians must
file on the form HCFA-1500, Health Insurance Claim Form. Facilities will
file on the UB-92 form. For claims questions and assistance, call us at
1-800-CIGNA24 (1-800-244-6224).

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

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

Dates you received the services or supplies;
Diagnosis;
Type of each service or supply;
The charge for each service or supply;
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: Please refer to your ID card for the address to
mail any claims.

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.

Please reply promptly when we ask for additional information. We may
delay processing or deny your claim if you do not respond.

Medical, hospital and drug benefits
Deadline for filing your claim
When we need more information 41.
41 Page 42 43
2003 CIGNA HealthCare of California, Inc. 39 Section 8
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on
your claim or request for services, drugs, or supplies including a request for preauthorization:

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: CIGNA HealthCare of California, Inc., 400 North Brand Boulevard,
Glendale, California 91203; 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.

We have 30 days from the date we receive your request to:
(a) Pay the claim (or, if applicable, arrange for the health care provider to give you the care); or

(b) Write to you and maintain our denial go to step 4; or
(c) Ask you or your provider for more information. If we ask your provider, we will send you a copy of our
request go to step 3.

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.

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

120 days after you first wrote to us if we did not answer that request in some way within 30 days; or
120 days after we asked for additional information.

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

Send OPM the following information:
A statement about why you believe our decision was wrong, based on specific benefit provisions in this
brochure;

Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical
records, and explanation of benefits (EOB) forms;

Copies of all letters you sent to us about the claim;
Copies of all letters we sent to you about the claim; and
Your daytime phone number and the best time to call.

1
2
3
4

Step Description 42.
42 Page 43 44
2003 CIGNA HealthCare of California, Inc. 40 Section 8
The disputed claims process (continued)
Note: If you want OPM to review more than one claim, you must clearly identify which documents apply to
which claim.

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

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

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 adminis-
trative 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 authorization. This is the only deadline
that may not be extended.

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

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

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

(a) We haven't responded yet to your initial request for care or preauthorization/prior approval, then call us at
1-800-CIGNA24 (1-800-244-6224) 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 may call OPM's Health Benefits Contracts Division III at 202-606-0737 between 8 a.m. and 5 p.m. eastern time.

5 43.
43 Page 44 45
2003 CIGNA HealthCare of California, Inc. 41 Section 9
Section 9. Coordinating benefits with other coverage
You must tell us if you or a covered family member have coverage under
another group health plan or have automobile insurance that pays health care
expenses without regard to fault. This is called "double coverage."

When you have double coverage, one plan normally pays its benefits in full as
the primary payer and the other plan pays a reduced benefit as the secondary
payer. We, like other insurers, determine which coverage is primary according
to the National Association of Insurance Commissioners' guidelines.

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

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

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

Medicare has two parts:
Part A (Hospital Insurance). Most people do not have to pay for Part A.
If you or your spouse worked for at least 10 years in Medicare-covered
employment, you should be able to qualify for premium-free Part A
insurance. (Someone who was a Federal employee on January 1, 1983 or
since automatically qualifies.) Otherwise, if you are age 65 or older, you
may be able to buy it. Contact 1-800-MEDICARE for more information.

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

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

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

When you are enrolled in Original Medicare along with this plan, you still
need to follow the rules in this brochure for us to cover your care. Your care
must continue to be authorized by your Plan PCP, or recertified as required.

When you have other health coverage
The Original Medicare Plan (Part A or Part B)
What is Medicare? 44.
44 Page 45 46

2003 CIGNA HealthCare of California, Inc. 42 Section 9
We will not waive any of our copayments or coinsurance.
Claims process when you have the Original Medicare Plan You
probably will never have to file a claim form when you have both our
Plan and the Original Medicare Plan. Please note, if your Plan physician
does not participate in Medicare, you will have to file a claim with
Medicare.

When we are the primary payer, we process the claim first.
When Original Medicare is the primary payer, Medicare processes your
claim first. In most cases, your claims will be coordinated automatically
and we will then provide secondary benefits for covered charges. You
will not need to do anything. To find out if you need to do something to
file your claim, call us at 1-800-CIGNA24 (1-800-244-6224), or write to
CIGNA HealthCare of California, Inc., 400 North Brand Boulevard,
Glendale, California 91203. You may also visit our website at
www.cigna.com/healthcare. In this case we do not waive any out-of-
pocket costs.

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

(Primary payer chart begins on next page.) 45.
45 Page 46 47
2003 CIGNA HealthCare of California, Inc. 43 Section 9
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 eligible for Medicare based on disability, and
a) Are an annuitant, or 4

b) Are an active employee, or 4
c) Are a former spouse of an annuitant, or 4

d) Are a former spouse of an active employee 4

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), 4

2) Are an annuitant, 4
3) Are a reemployed annuitant with the Federal government when 4
a) The position is excluded from FEHB, or
b) The position is not excluded from FEHB 4
(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 4
spouse is this type of judge),

5) Are enrolled in Part B only, regardless of your employment status, 4 4
(for Part B (for other
services) services)

6) Are a former Federal employee receiving Workers' Compensation and 4
the Office of Workers' Compensation Programs has determined that (except for claims
you are unable to return to duty, related to Workers'
Compensation.)

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.

1) Are within the first 30 months of eligibility to receive Part A benefits 4
solely because of ESRD,

2) Have completed the 30-month ESRD coordination period and are 4
still eligible for Medicare due to ESRD,

3) Become eligible for Medicare due to ESRD after Medicare became 4
primary for you under another provision,

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

C. When you or a covered family member have FEHB and 46.
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2003 CIGNA HealthCare of California, Inc. 44 Section 9
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 another plan's Medicare managed care plan: You may
enroll in another plan's Medicare managed care plan and also remain enrolled
in our FEHB plan. We will still provide benefits when your Medicare
managed care plan is primary, even out of the managed care plan's network
and/or service area (if you use our Plan providers), but we will not waive any
of our copayments, coinsurance, or deductibles. If you enroll in a Medicare
managed care plan, tell us. We will need to know whether you are in the
Original Medicare Plan or in a Medicare managed care plan so we can
correctly coordinate benefits with Medicare.

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

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

TRICARE 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 Health Benefits Advisor if you have
questions about these programs.

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

Medicare managed care plan
If you do not enroll in Medicare Part A or Part B
TRICARE and CHAMPVA 47.
47 Page 48 49
2003 CIGNA HealthCare of California, Inc. 45 Section 9
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.

When you have this Plan and Medicaid, we pay first.
Suspended FEHB coverage to enroll in Medicaid or a similar State-
sponsored program or 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.

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

When you receive money to compensate you for 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.

Medicaid
When other Government agencies are responsible
for your care
When others are responsible for injuries

Workers' Compensation 48.
48 Page 49 50
2003 CIGNA HealthCare of California, Inc. 46 Section 10
Section 10. Definitions of terms we use in this brochure
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 is the percentage of our allowance that you must pay for your
care. See page 13.

A copayment is a fixed amount of money you pay when you receive covered
services. See page 13.

Care we provide benefits for, as described in this brochure.
Custodial care is care you receive when you need help performing activities
of daily living such as walking, grooming, bathing, dressing, getting in
and out of bed, toileting, eating, preparing foods, or taking medications that
can usually be self-administered. Custodial care that lasts 90 days or more is
sometimes known as Long Term Care. We do not cover Custodial Care.

A deductible is a fixed amount of covered expenses you must incur for
certain covered services and supplies before we start paying benefits for
those services. We have no deductible.

Experimental, investigational and unproven services are medical, surgical,
diagnostic, psychiatric, substance abuse or other health care technologies,
supplies, treatments, procedures, drug therapies or devices that are determined
by the Independent Review Process for Experimental and Investigational
Therapies (see "Section III. Agreement Provisions" ) and the Healthplan
Medical Director to be:

not approved by the U.S. Food and Drug Administration (FDA) to be
lawfully marketed for the proposed use and not recognized for the
treatment of the particular indication in one of the standard reference
compendia (The United States Pharmacopoeia Drug Information, The
American Medical Association Drug Evaluations; or the American
Hospital Formulary Service Drug Information) or in medical and scien-
tific evidence. Medical and scientific evidence means:

a. peer-reviewed literature, biomedical compendia, and other medical
literature that meet the criterial of the National Institute of Health's
National Library of Medicine for indexing in Index Medicus,
Excerpta Medicus (EMBASE), and MEDLARS database Health
Services Technology Assessment Research (HSTAR);
b. medical journals recognized by the Secretary of Health and Human
Services;
c. the following standard reference compendia: The American Hospital
Formulary Service-Drug Information, the American Medical Associa-
tion Drug Evaluation, the American Dental Association Accepted
Dental Therapeutics, and the United States Pharmacopoeia-Drug
Information;
d. findings, studies, or research conducted by or under the auspices of
federal government agencies and nationally recognized federal
research institutes; and
e. peer-reviewed abstracts accepted for presentation at major medical
association meetings.

the subject of review or approval by an Institutional Review Board for the
proposed use;

Calendar year
Coinsurance
Copayment

Deductible
Experimental or investigational services

Covered services
Custodial Care 49.
49 Page 50 51
2003 CIGNA HealthCare of California, Inc. 47 Section 10
the subject of an ongoing clinical trial that meets the definition of a phase
I, II or III Clinical Trial as set forth in the FDA regulations, regardless of
whether the trial is subject to FDA oversight ; or

not demonstrated, through existing peer-reviewed literature to be safe and
effective for treating or diagnosing the condition or illness for which its
use is proposed.

Medically necessary covered Services and Supplies are those Services and
Supplies that are determined by our Medical Director to be:

No more than required to meet your basic health needs; and
consistent with the diagnosis of the condition for which they are
required; and

consistent in type, frequency and duration of treatment with scientifically
based guidelines as determined by medical research; and

required for purposes other than the comfort and convenience of the
patient or his Physician; and

rendered in the least intensive setting that is appropriate for the delivery
of health care; and

of demonstrated medical value.

Us and we refer to CIGNA HealthCare of California, Inc.

You refers to the enrollee and each covered family member.

Medical necessity
Us/We
You 50.
50 Page 51 52

2003 CIGNA HealthCare of California, Inc. 48 Section 11
Section 11. FEHB facts
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.

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

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

When your enrollment ends; 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.

Self Only coverage is for you alone. Self and Family coverage is for you,
your spouse, and your unmarried dependent children under age 22, including
any foster children or stepchildren your employing or retirement office
authorizes coverage for. Under certain circumstances, you may also con-
tinue 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 enroll-
ment 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.

No pre-existing condition limitation
Where you can get information about
enrolling in the FEHB Program

Types of coverage available for you and your family 51.
51 Page 52 53
2003 CIGNA HealthCare of California, Inc. 49 Section 11
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) Pro-
gram, if you are an employee subject to a court or administrative order
requiring you to provide health benefits for your child(ren).

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

If you have no FEHB coverage, your employing office will enroll you for
Self and Family coverage in the option of 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 lower option of the Blue Cross and Blue Shield Service
Benefit Plan's Basic Option.

As long as the court/administrative order is in effect, and you have at least
one child identified in the order who is still eligible under the FEHB Pro-
gram, 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
lease 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.

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

When benefits and premiums start

Children's Equity Act

When you retire 52.
52 Page 53 54

2003 CIGNA HealthCare of California, Inc. 50 Section 11
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.

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

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 Continua-
tion of Coverage (TCC). For example, you can receive TCC if you are not
able to continue your FEHB enrollment after you retire, if you lose your job,
if you are a covered dependent child and you turn 22 or marry, etc.

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

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

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

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

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

If you leave Federal service, your employing office will notify you of your
right to convert. You must apply in writing to us within 31 days after you
receive this notice. However, if you are a family member who is losing
coverage, the employing or retirement office will not notify you. You must
apply in writing to us within 31 days after you are no longer eligible for
coverage.

When you lose benefits
When FEHB coverage ends

Temporary continuation of coverage (TCC)
Spouse equity coverage

Converting to individual coverage 53.
53 Page 54 55

2003 CIGNA HealthCare of California, Inc. 51 Section 11
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.

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 informa-
tion in the certificate, as long as you enroll within 63 days of losing coverage
under this Plan. If you have been enrolled with us for less than 12 months, but
were previously enrolled in other FEHB plans, you may also request a
certificate from those plans.

For more information, get OPM pamphlet RI 79-27, Temporary Continuation
of Coverage (TCC) under the FEHB Program. See also the FEHB web site
(www.opm.gov/insure/archive/health); refer to the "TCC and HIPAA" frequently
asked questions. These highlight HIPAA rules, such as the requirement that
Federal employees must exhaust any TCC eligibility as one condition for
guaranteed access to individual health coverage under HIPAA, and have
information about Federal and State agencies you can contact for more
information.

Getting a Certificate of Group Health Plan
Coverage 54.
54 Page 55 56

2003 CIGNA HealthCare of California, Inc. 52 Long Term Care Insurance
Long Term Care Insurance Is Still Available!
Open Season for Long Term Care Insurance
You can protect yourself against the high cost of long term care by applying for insurance in the Federal Long Term Care Insurance Program.

Open Season to apply for long term care insurance through LTC Partners ends on December 31, 2002.
If you're a Federal employee, you and your spouse need only answer a few questions about your health during Open Season.

If you apply during the Open Season, your premiums are based on your age as of July 1, 2002. After Open Season, your premiums are based on your age at the time LTC Partners receives your application.

FEHB Doesn't Cover It
Neither FEHB plans nor Medicare cover the cost of long term care. Also called "custodial care" , long term care helps you perform the activities of daily living such as bathing or dressing yourself. It can also provide help you

may need due to a severe cognitive impairment such as Alzheimer's disease.

You Can Also Apply Later, But...
Employees and their spouses can still apply for coverage after the Federal Long Term Care Insurance Program Open Season ends, but they will have to answer more health-related questions.

For annuitants and other qualified relatives, the number of health-related questions that you need to answer is the same during and after the Open Season.

You Must Act to Receive an Application
Unlike other benefit programs, YOU have to take action -you won't receive an application automatically. You must request one through the toll-free number or website listed below.

Open Season ends December 31, 2002 -act NOW so you won't miss the abbreviated underwriting available to employees and their spouses, and the July 1 "age freeze" !

Find Out More -Contact LTC Partners by calling 1-800-LTC-FEDS (1-800-582-3337) (TDD for the hearing
impaired: 1-800-843-3557) or visiting www.ltcfeds.com to get more information and to request an application. 55.
55 Page 56 57
2003 CIGNA HealthCare of California, Inc. 53 Index
Index
Do not rely on this page; it is for your convenience and does not explain your benefit coverage.
Allergy tests ................................... 18
Alternative treatment ..................... 21
Allogenetic (donor) bone marrow
transplant .................................... 24

Ambulance ..................................... 27
Anesthesia ...................................... 24
Autologous bone marrow
transplant .................................... 24

Biopsies ......................................... 22
Blood and blood plasma ................ 25
Casts .............................................. 25
Catastrophic protection
out-of-pocket maximum ............ 13

Changes for 2003 ............................. 9
Chemotherapy................................ 18
Cholesterol tests ............................. 16
Chiropractic ................................... 21
Claims ............................................ 38
Coinsurance ................................... 13
Colorectal cancer screening ........... 16
Congenital anomalies .................... 22
Contraceptive devices and drugs ... 17
Coordination of benefits ................ 41
Covered services ............................ 46
Crutches ......................................... 20
Deductible ...................................... 13
Definitions ..................................... 46
Dental care ..................................... 35
Diagnostic services ........................ 15
Disputed claims review ................. 39
Donor expenses (transplants) ........ 24
Dressings ....................................... 25
Durable medical equipment
(DME) ........................................ 20

Educational classes and programs .. 21
Effective date of enrollment .......... 46
Emergency ..................................... 28
Experimental or investigational ..... 46
Eyeglasses ...................................... 19

Family planning ............................. 17
Fecal occult blood test ................... 16
General Exclusions ........................ 37
Hearing services ............................ 19
Home health services ..................... 21
Hospice care .................................. 27
Home nursing care ......................... 21
Hospital .......................................... 25
Immunizations ............................... 16
Infertility ........................................ 17
In hospital physician care .............. 15
Inpatient Hospital Benefits ............ 25
Insulin ............................................ 33
Laboratory and pathological
services ....................................... 26

Magnetic Resonance Imagings
(MRIs) ........................................ 15

Mail Order Prescription Drugs ...... 33
Mammograms ................................ 16
Maternity Benefits ......................... 17
Medicaid ........................................ 45
Medically necessary ...................... 47
Medicare ........................................ 41
Mental Conditions/Substance
Abuse Benefits ........................... 30

Newborn care ................................. 17
Non-FEHB Benefits ...................... 36
Nurse
Licensed Practical Nurse ............ 21
Registered Nurse ........................ 34
Nursery charges ............................. 17
Obstetrical care .............................. 12
Occupational therapy ..................... 18
Office visits .................................... 15
Oral and maxillofacial surgery ...... 23
Orthopedic devices ........................ 19
Ostomy supplies ............................ 20
Out-of-pocket expenses ................. 13
Outpatient facility care .................. 26
Oxygen .......................................... 26

Pap test .......................................... 16
Physical examination ..................... 15
Physical therapy ............................. 18
Physician........................................ 15
Pre-admission testing ..................... 26
Preventive care, adult .................... 16
Preventive care, children ............... 16
Prescription drugs .......................... 32
Preventive services ........................ 16
Prior approval ................................ 12
Prior Authorization ........................ 12
Prostate cancer screening .............. 16
Prosthetic devices .......................... 20
Psychologist ................................... 30
Radiation therapy .......................... 18
Renal dialysis ................................. 41
Room and board ............................ 25
Second surgical opinion ................. 15
Skilled nursing facility care ........... 26
Smoking cessation ......................... 33
Speech therapy............................... 19
Splints ............................................ 25
Subrogation.................................... 45
Substance abuse ............................. 30
Surgery .......................................... 22
Anesthesia .............................. 24
Oral ......................................... 23
Outpatient ............................... 26
Reconstructive ........................ 23
Syringes ......................................... 33
Temporary continuation of
coverage ..................................... 50

Transplants ..................................... 24
Treatment therapies ....................... 18
Vision services ............................... 19
Well child care ............................... 16
Wheelchairs ................................... 20
Workers' compensation ................. 45
X-rays ............................................ 15 56.
56 Page 57 58
NOTES: 57.
57 Page 58 59
NOTES: 58.
58 Page 59 60
2002 CIGNA HealthCare of California, Inc. 56 Summary
Summary of benefits for CIGNA HealthCare of California, Inc. 2003
Do not rely on this chart alone. All benefits are provided in full unless indicated and are subject to the definitions,
limitations, and exclusions in this brochure. On this page we summarize specific expenses we cover; for more
detail, look inside.

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

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

Benefits You Pay Page

Office visit: $15 primary care; $25 specialist care
Medical services provided by physicians:
Diagnostic and treatment services provided in the office .....................................................................

Services provided by a hospital:
Inpatient ......................................................................
Outpatient ................................................................... $125 per facility use
$250 per admission

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

Mental health and substance abuse treatment ..................
Prescription drugs ............................................................

Protection against catastrophic costs (your catastrophic protection out-of-pocket maximum) ................................
Special features: Flexible benefits option; 24 hour nurse line; Services for deaf and hearing impaired; High risk pregnancies; Centers of Excellence; Travel benefit/services overseas .................................
Vision Care .......................................................................
Dental Care (Accidental injury benefit only) ...................

Nothing after $1,500/Self Only or $3,000/ Self and Family enrollment per year. This
copay maximum does not include Prescrip-tion drugs, Dental services, Mental Health/
Substance Abuse services, External prosthetics or Infertility services.

One refraction annually, office visit: $15 primary care; $25 specialist care
$15 office visit copay

Retail Pharmacy: $7 per generic formulary; $15 per name
brand formulary; $35 per name brand non-formulary.

Mail Order: (Maintenance Medications only)
$16 per generic formulary; $40 per name brand formulary; $100 per name brand
non-formulary.
Note: If there is no generic equivalent available, you will still have to pay the

brand name copay

Regular cost sharing.
Office visit: $15 per visit; $25 per urgent care center visit or $50 per
hospital emergency care visit

13
34

19
35

32
28
30
28

26
25

15 59.
59 Page 60
2003 Rate Information for
CIGNA HealthCare of California, Inc.

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

Postal rates apply to career Postal Service employees. Most employees should refer to the
FEHB Guide for United States Postal Service Employees, RI 70-2. Different postal rates apply
and a special FEHB guide is published for Postal Service Inspectors and Office of Inspector
General (OIG) employees (see RI 70-2IN).

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

Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly

Type of Gov't Your Gov't Your USPS Your Enrollment Code Share Share Share Share Share Share

Greater California
Self Only 9T1 $100.44 $33.48 $217.62 $72.54 $118.85 $15.07

Self and Family 9T2 $221.00 $73.67 $478.84 $159.61 $261.52 $33.15 60.

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