Pages 1--71

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

http:// www. bcbsmo. com 2003
A Health Maintenance Organization

For changes in benefits
see page 10
Serving: St. Louis, Central, and Southeast areas in Missouri and St. Clair and Madison counties in Illinois

Enrollment in this plan is limited. You must live in our Geographic service area to enroll. See page 9 for requirements.

This plan has excellent accreditation from the NCQA. See the 2003 Guide
for more information on accreditation.

Enrollment code: 9G1 Self Only
9G2 Self and Family

RI-73-516 1.
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2.
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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. 3.
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. Get a listing of those getting your personal medical information from OPM in the past 6 years. The listing
will not cover your personal medical information that was given to you or your personal representative, any information that you authorized OPM to release, or that was given out for law enforcement purposes or to

pay for your health care or a disputed claim. . Ask OPM to communicate with you in a different manner or at a different place (for example, by sending
materials to a P. O. Box instead of your home address). . Ask OPM to limit how your personal medical information is used or given out. However, OPM may not be
able to agree to your request if the information is used to conduct operations in the manner described above. . Get a separate paper copy of this notice.

For more information on exercising your rights set out in this notice, look at www. opm. gov/ insure on the web. You may also call 202-606-0191 and ask for OPM's FEHB Program privacy official for this purpose.
If you believe OPM has violated your privacy rights set out in this notice, you may file a complaint with OPM at the following address:
Privacy Complaints Office of Personnel Management
P. O. Box 707 Washington, DC 20004-0707

Filing a complaint will not affect your benefits under the FEHB Program. You also may file a complaint with the Secretary of the Department of Health and Human Services.
By law, OPM is required to follow the terms in this privacy notice. OPM has the right to change the way your personal medical information is used and given out. If OPM makes any changes, you will get a new notice by mail
within 60 days of the change. The privacy practices listed in this notice will be effective April 14, 2003. 4.
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Table of Contents
Introduction. ............................................................... 5
Plain Language............................................................... 5
Stop Health Care Fraud!................................................................................................................................................ 5
Section 1. Facts about this HMO plan.......................................................................................................................... 7
How we pay providers................................................................................................................................. 7
Who provides my health care? .................................................................................................................... 7
Your Rights ................................................................................................................................................. 7
Service Area ................................................................................................................................................ 9
Section 2. How we change for 2003.. ............................................................. 10
Program-wide changes .............................................................................................................................. 10
Changes to this Plan .................................................................................................................................. 10
Section 3. How you get care ... ................................................................................................................... 11
Identification cards .................................................................................................................................... 11
Where you get covered care ...................................................................................................................... 11
. Plan providers...................................................................................................................................... 11
. Plan facilities....................................................................................................................................... 11
What you must do to get covered care....................................................................................................... 11
. Primary care ........................................................................................................................................ 11
. Specialty care ...................................................................................................................................... 11
. Hospital care........................................................................................................................................ 13
Circumstances beyond our control ............................................................................................................ 13
Services requiring our prior approval ........................................................................................................ 13
Section 4. Your costs for covered services................................................................................................................. 14
. Copayments......................................................................................................................................... 14
. Deductible ........................................................................................................................................... 14
. Coinsurance......................................................................................................................................... 14
Your catastrophic protection out-of-pocket maximum.............................................................................. 14
Section 5. Benefits.............................................................. 15
Overview ................................................................................................................................................... 15
(a) Medical services and supplies provided by physicians and other health care professionals........... 16
(b) Surgical and anesthesia services provided by physicians and other health care professionals ....... 28
(c) Services provided by a hospital or other facility, and ambulance services ..................................... 33
(d) Emergency services/ accidents......................................................................................................... 36
(e) Mental health and substance abuse benefits.................................................................................... 39
(f) Prescription drug benefits ............................................................................................................... 41

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(g) Special features ............................................................................................................................... 44
. Flexible Benefits Option
. Services for deaf and hearing impaired
. Away From Home Care
. Blue Quality
. RightSteps .
. TakeCharge . Asthma Program
. TakeCharge . Diabetes Program
. Cardiovascular Education Program
(h) Dental benefits ................................................................................................................................ 46
(i) Non-FEHB benefits available to Plan members.............................................................................. 47
Section 6. General exclusions --things we don't cover .............................................................................................. 48
Section 7. Filing a claim for covered services ............................................................................................................ 49
Section 8. The disputed claims process ...................................................................................................................... 51
Section 9. Coordinating benefits with other coverage ................................................................................................ 53
When you have other health coverage
. What is Medicare............................................................................................................................... 53
. Medicare managed care plan ............................................................................................................. 56
. TRICARE and CHAMPVA .............................................................................................................. 56
. Workers' Compensation .................................................................................................................... 57
. Medicaid............................................................................................................................................ 57
. Other Government agencies .............................................................................................................. 57
. When others are responsible for injuries ........................................................................................... 57
Section 10. Definitions of terms we use in this brochure ........................................................................................... 58
Section 11. FEHB facts .............................................................................................................................................. 60
Coverage information .............................................................................................................................. 60
. No pre-existing condition limitation................................................................................................... 60
. Where you get information about enrolling in the FEHB Program.................................................... 60
. Types of coverage available for you and your family ........................................................................ 60
. Children's Equity Act......................................................................................................................... 60
. When benefits and premiums start ..................................................................................................... 61
. When you retire .................................................................................................................................. 61
When you lose benefits............................................................................................................................ 61
. When FEHB coverage ends................................................................................................................ 61
. Spouse equity coverage ...................................................................................................................... 61
. Temporary Continuation of Coverage (TCC)..................................................................................... 62
. Converting to individual coverage ..................................................................................................... 62
. Getting a Certificate of Group Health Plan Coverage ........................................................................ 62

2003 BlueCHOICE Table of Contents 3 6.
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Long-term care insurance is still available .................................................................................................................. 64
Index............................................................................................................................................................................ 65
Summary of benefits.................................................................................................................................................... 66
Rates .............................................................................................................................................................. Back cover

Blue Cross and Blue Shield of Missouri is the name RightCHOICE Managed Care, Inc. (RIT) uses to do business in most of Missouri. In Missouri, RIT administers the FEHB program. HMO Missouri, Inc. does business as BlueCHOICE. RIT and HMO Missouri, Inc. are independent
licensees of the Blue Cross and Blue Shield Association.

2003 BlueCHOICE Table of Contents 4 7.
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Introduction
This brochure describes the benefits of BlueCHOICE HMO under our contract (CS 2838) with the Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. This Plan is
underwritten by the Healthy Alliance Life Insurance Company. The address for administrative offices is:
BlueCHOICE 1831 Chestnut Street

St. Louis, Missouri 63103-2275
This brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations, and exclusions of this brochure. It is your responsibility to be informed about your health benefits.

If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in Self and Family coverage, each eligible family member is also entitled to these benefits. You do not have a right to
benefits that were available before January 1, 2003, unless those benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2003, and changes are summarized on page 10. 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 BlueCHOICE.

. We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the Office of Personnel Management. If we use others, we tell you what they mean first.
. Our brochure and other FEHB plans' brochures have the same format and similar descriptions to help you compare plans.
If you have comments or suggestions about how to improve the structure of this brochure, let OPM know. Visit OPM's "Rate Us" feedback area at www. opm. gov/ insure or e-mail OPM at fehbwebcomments@ opm. gov. You may
also write to OPM at the Office of Personnel Management, Office of Insurance Planning and Evaluation Division, 1900 E Street, NW Washington, DC 20415-3650.

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

Protect Yourself From Fraud -Here are some things you can do to prevent fraud:
. Be wary of giving your plan identification (ID) number over the telephone or to people you do not know, except
to your doctor, other provider, or authorized plan or OPM representative. . Let only the appropriate medical professionals review your medical record or recommend services.

. 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.

2003 BlueCHOICE 5 Introduction/ Plain Language/ Advisory 8.
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. 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 800/ 932-4480 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.

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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 us for a copy of our most recent provider directory.

HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in addition to treatment for illness and injury. Our providers follow generally accepted medical practice when
prescribing any course of treatment.
When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You only pay the copayments 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, hospitals and other types of providers 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. We reimburse primary care physicians through capitation, which includes the majority of services the primary care physician renders. We compensate certain services, such as immunizations or cardiac diagnostic testing
in the office as fee for service.
Who provides my health care?
This plan is an individual-practice Plan. All participating doctors practice in their own offices in the community. Unless it is an emergency, benefits are available only from doctors, hospitals and other health care providers that are

in the BlueCHOICE network. The Plan arranges with doctors and hospitals to provide medical care for both the prevention of disease and the treatment of serious illness.

You must select a primary care doctor for each covered family member. Approximately 1,300 primary care physicians participate in BlueCHOICE. For most care, you must contact your primary care doctor for a referral or
authorization before seeing any other doctor for specialty care or nonemergency hospital services. A wide variety of specialists are participating Plan doctors. Many are Board certified as indicated in the BlueCHOICE directory. If you
need hospital care, your Plan primary doctor will admit you to a participating hospital where he/ she has admitting privileges.

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 Web site (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.
About the plan and care management: Blue Cross and Blue Shield of Missouri has over 60 years of experience in the health insurance industry. We began as St. Louis Blue Cross in 1936. In 1945, Missouri Medical Service,
commonly known as Blue Shield, began business in the St. Louis area. The two companies merged in 1986, forming Blue Cross and Blue Shield of Missouri, a not-for-profit health service corporation. In 1994, Blue Cross and Blue
Shield of Missouri formed a new managed care company, Alliance Blue Cross Blue Shield.
Effective November 30, 2000, Blue Cross and Blue Shield of Missouri and its for-profit managed care subsidiary, Alliance Blue Cross Blue Shield, merged into a single, for-profit, publicly traded Delaware corporation. The
insurance-related business that was part of the old Blue Cross and Blue Shield of Missouri has been transferred to and assumed by Healthy Alliance Life Insurance Co., a wholly owned subsidiary of Blue Cross and Blue Shield of
Missouri, as part of the reorganization.
BlueCHOICE, the for-profit HMO subsidiary of Blue Cross and Blue Shield of Missouri, began operations in 1988.

2003 BlueCHOICE 7 Section 1 10.
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Blue Cross and Blue Shield of Missouri, BlueCHOICE and Healthy Alliance Life Insurance Co. are independent licensees of the Blue Cross and Blue Shield Association.
On Jan. 31, 2002, RightCHOICE Managed Care Inc. and WellPoint Health Networks Inc. merged. WellPoint, which is based in Thousand Oaks, Calif., serves the health care needs of 12 million members and more than 45 million
specialty members through Blue Cross of California, Blue Cross of Georgia, UNICARE and Blue Cross and Blue Shield of Missouri and its subsidiaries.

Utilization management services include: . Precertifications of medical/ surgical, mental health, rehabilitation, skilled nursing, outpatient and home health
care . Concurrent review of medical/ surgical, mental health, rehabilitation, skilled nursing, outpatient and home health
care . Retrospective review
. Discharge planning
. Alternative care planning
. Individual case management
. Appeal for denial of payment due to lack of medical necessity
. Medical review

Our contracts with network providers require them to handle all certifications for BlueCHOICE members. You will not have to be concerned about managed care procedures as long as your receive care from network providers.

We offer special programs to help members with health conditions such as asthma, diabetes and high-risk pregnancy. These are voluntary programs to help members manage their particular health condition. These programs are
explained in Section 5( g).
Accreditation status: BlueCHOICE is accredited by the National Committee for Quality Assurance (NCQA). The comprehensive review process evaluates how well a plan manages its benefits. The accreditation process evaluates
more than 60 standards in the following six categories: . quality management and improvement
. physician qualifications and evaluation
. members' rights and responsibilities
. preventive health services
. utilization management and
. medical records

Networks, providers and facilities: The BlueCHOICE network includes approximately 1,400 primary physicians, 4,000 specialists and 68 hospitals. Approximately 79 percent of network physicians are Board Certified and 85
percent are accepting new patients. The physician's Board status and whether or not he/ she is accepting new patients are included in the BlueCHOICE provider directory.

We have established credentialing polices that require us to select and recredential physicians every three years, based on an evaluation of their experience and training, board certification and staff privileges at network hospitals.
Our program goals are to support the development and maintenance of credentialing and recredentialing standards for our participating providers, review the qualifications of potential participating providers against established standards,
and to reassess the qualifications and performance of our network providers.
Our credentialing criteria for network hospitals include accreditation by the Joint Committee on Accreditation of Health Care Organizations (JCAHO), Medicare certification, effective utilization management pricing, geographic
location, scope of services and utilization experience.
If you want more information about us, call 1-800-932-4480, visit our website at www. bcbsmo. com., or write us at 471 Siemers, Cape Girardeau MO 63701. For the hearing impaired (TDD), call 1-800-822-1215.

2003 BlueCHOICE 8 Section 1 11.
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Service Area
To enroll in this Plan, you must live in our Service Area. This is where our providers practice. Our service area is:
The St. Louis Area, including the Missouri counties of Crawford, Franklin, Gasconade, Jefferson, Lincoln, Montgomery, Pike, St. Charles, St. Francois, St. Louis (City and County), Ste. Genevieve, Warren and Washington;
the Central Missouri Area counties of Audrain, Boone, Callaway, Camden, Chariton, Cole, Cooper, Howard, Macon, Maries, Miller, Moniteau, Monroe, Morgan, Osage, Phelps, Pulaski, and Randolph; the Southwest Missouri Area
counties of Barry, Barton, Cedar, Christian, Dade, Dallas, Douglas, Greene, Hickory, Jasper, Laclede, Lawrence, McDonald, Newton, Ozark, Polk, Stone, Taney, Texas, Webster and Wright.

You may also enroll with us if you live in the Illinois counties of Madison or St. Clair.
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 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. As a BlueCHOICE member, you may have access to physician care through the BlueCard
Traditional network. This nationwide network is made up of 9, 500 hospitals and 744, 000 physicians that participate with Blue Cross and Blue Shield Plans across the country. Benefits are easy to use a "suitcase" logo
on members' ID cards will identify them as BlueCard members. To locate a BlueCard provider outside the BlueCHOICE service area, members simply call the toll-free BlueCard Access number on their ID card (1-800-810-
blue) or visit the BlueCard Hospital and Doctor Finder at www. BCBS. com. Members should contact their primary care physician just as they would if they were at home. The primary care physician will provide a non-network
referral and coordinate care with the out-of-area provider as appropriate.

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Section 2. How we change for 2003
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5 Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here is a

clarification that does not change benefits.
Program-wide changes
. A Notice of the Office of Personnel Management's Privacy Practices is included. . A section on the Children's Equity Act describes when an employee is required to maintain Self and Family

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

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

Changes to this Plan
. Your share of the non-Postal premium will increase by 13. 8% for Self Only or 13. 8% for Self and Family.
. The following counties will no longer be a part of our service area: a) In Central Missouri: Adair, Linn, Putnam, Schuyler and Sullivan

b) In Southeast Missouri: Butler, Carter, Ripley and Wayne
. Copayments for prescription drug coverage will change to $7 for generic, $12 for preferred brand, and $25 for nonpreferred brand, for up to a 30-day supply. Mail order is 2 times the retail cost, so that copayments

will be $14 for generic, $24 for preferred brand and $50 for nonpreferred brand, for up to a 90-day supply. (Section 5( f))

. We clarified that the organ/ tissue transplant benefit covers "tandem" testicular and ovarian germ cell tumor autologous transplant treatment. (Section 5( b))
. Coverage for treatment received at an outpatient hospital or ambulatory surgical center will require a $10 copayment. (Section 5( c))
. We clarified that medications and supplies are not covered for loss or theft, travel (except in emergencies) or special packaging for drugs in nursing homes. (Section 5( f))
. We clarified that we do not cover services, drugs or supplies received from immediate relatives or household members, such as a spouse, parent, child, brother or sister, by blood, marriage or adoption. (Section 6)
. On Jan. 31, 2002, RightCHOICE Managed Care Inc. and WellPoint Health Networks Inc. merged. WellPoint, which is based in Thousand Oaks, Calif., serves the health care needs of 12 million members and
more than 45 million specialty members through Blue Cross of California, Blue Cross of Georgia, UNICARE and Blue Cross and Blue Shield of Missouri and its subsidiaries.

. Pharmacy services previously provided by Express Scripts, Inc., are now provided by WellPoint Pharmacy Management.
. We are developing a new mental health and substance abuse provider network. Updates will be provided in the first quarter of 2003.

2003 BlueCHOICE 10 Section 2 13.
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Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it
whenever you receive services from a Plan provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the
Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation (for annuitants), or your Employee Express confirmation
letter.
If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at
1-800-932-4480. You may also request replacement cards through our website at www. bcbsmo. com.
.

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

. Plan providers Plan providers are primary care physicians, specialists 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 annually. The BlueCHOICE directory is also on our website,
www. bcbsmo. com. The online directory is updated daily.
. Plan facilities Plan facilities are hospitals and other facilities in our service area that we
contract with to provide covered services to our members. We list these in the provider directory, which we update annually. 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.

Use the directory or website to select a physician convenient to you. Write the physician's office code number in the space provided on your
Provider Selection Card. You'll find the office code number listed before each primary care physician's name. See the Selection Card for
instructions.

What you must do to get covered care

. Primary care Your primary care physician can be a family or general practitioner,
internist, pediatrician or geriatrician. 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.
We will send you a new ID card with your new doctor's name and phone number on the front.

. Specialty care Your primary care physician will refer you to a specialist for needed care.
When you receive a referral from your primary care physician, you must return to the primary care physician after the consultation, unless your

primary care physician authorized a certain number of visits without

2003 BlueCHOICE 11 Section 3 14.
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additional referrals. The primary care physician must provide or authorize all follow-up care. Do not go to the specialist for return visits
unless your primary care physician gives you a referral. However, you may see a network OB/ GYN for any medically necessary OB/ GYN care
without a referral. And you may go to a network eye care provider for one routine vision exam each calendar year without a referral.

Here are other things you should know about specialty care:
. If you need to see a specialist frequently because of a chronic,
complex, or serious medical condition, your primary care physician will develop a treatment plan that allows you to see your specialist for

a certain number of visits without additional referrals. Your primary care physician will use our criteria when creating your treatment plan
(the physician may have to get an authorization or approval beforehand).

. If you are seeing a specialist when you enroll in our Plan, talk to your
primary care physician. Your primary care physician will decide what treatment you need. If he or she decides to refer you to a

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

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

until we can make arrangements for you to see someone else.
If you have a chronic or disabling condition and lose access to your specialist because we:

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

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

If you think you have a mental health or substance abuse problem, we encourage you to see your primary care physician, who will coordinate
your care. Your primary care physician may treat you or recommend that you call our mental health and substance abuse benefits manager.

If you do not wish to go through your primary care physician for care, you may call our mental health and substance abuse benefits manager
directly at 1-800-965-2583. A trained professional will evaluate your needs and authorize your care.

2003 BlueCHOICE 12 Section 3 15.
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. Hospital care Your Plan primary care physician or specialist will make necessary
hospital arrangements and supervise your care. This includes admission to a skilled nursing or other type of facility.

If you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at 1-800-932-4480. If you
are new to the FEHB Program, we will arrange for you to receive care.
If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:

. You are discharged, not merely moved to an alternative care center;
or

. The day your benefits from your former plan run out; or
. The 92 nd day after you become a member of this Plan, whichever
happens first.

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

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

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

We call this review and approval process precertification and recertification. Your physician must obtain precertification before you
can receive certain types of care, such as:
. Inpatient hospital care
. Outpatient hospital care
. Care in a freestanding surgery center or skilled nursing facility
. Home health care

Your physician must obtain recertification if your care needs to continue longer than originally certified.

Your BlueCHOICE primary care physician or specialist will handle all certification requirements for you. However, if you receive emergency
care at a non-network facility, you will need to contact us for approval. Please see Section 5( d) for further information.

2003 BlueCHOICE 13 Section 3 16.
16 Page 17 18
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
. Copayments A copayment is a fixed amount of money you pay to the provider,
facility, pharmacy, etc., when you receive services.

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

. Deductible We do not have a deductible.
. Coinsurance We do not have coinsurance.

After you pay 100% of your annual premium in copayments for one family member (per person), or 100% of your annual premium for two or
more family members (self and family), you do not have to make any further payments for certain services for the rest of the year. This is
called a catastrophic limit. However, copayments for your prescription drugs and dental services do not count toward these limits and you must
continue to make these payments.

Your catastrophic protection out-of-pocket maximum
for copayments

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

2003 BlueCHOICE 14 Section 4 17.
17 Page 18 19

Section 5. Benefits OVERVIEW (See page 10 for how our benefits changed this year and pages 66-67 for a benefits summary.)
NOTE: This benefits section is divided into subsections. Please read the important things you should keep in mind at the beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the
following subsections. To obtain claim forms, claims filing advice, or more information about our benefits, contact us at 1-800-932-4480 or at our website at www. bcbsmo. com.

(a) Medical services and supplies provided by physicians and other health care professionals.......................... 16-27
. Diagnostic and treatment services .
Lab, X-ray, and other diagnostic tests . Preventive care, adult

. Preventive care, children
. Maternity care .
Family planning . Infertility services

. Allergy care .
Treatment therapies . Physical and occupational therapies

. Speech therapy

. Hearing services (testing, treatment, and
supplies) . Vision services (testing, treatment, and

supplies) . Foot care
. Orthopedic and prosthetic devices .
Durable medical equipment (DME) . Home health services

. Chiropractic .
Alternative treatments . Educational classes & programs

(b) Surgical and anesthesia services provided by physicians and other health care professionals........................ 28-32
. Surgical procedures .
Reconstructive surgery . Oral and maxillofacial surgery . Organ/ tissue transplants . Anesthesia

(c) Services provided by a hospital or other facility, and ambulance services...................................................... 33-35
. Inpatient hospital .
Outpatient hospital or ambulatory surgical center . Extended care benefits/ skilled nursing care facility benefits . Hospice care

. Ambulance
(d) Emergency services/ accidents ......................................................................................................................... 36-38 . Medical emergency . Ambulance

(e) Mental health and substance abuse benefits................................. ................................................................... 39-40
(f) Prescription drug benefits................................................................................................................................. 41-43
(g) Special features................................................................................................................................................. 44-45
. Flexible benefits option
. Services for deaf and hearing impaired
. Away From Home Care
. Blue Quality
. RightSteps .
. TakeCharge . Asthma Program
. TakeCharge . Diabetes Program
. Cardiovascular Education Program
(h) Dental benefits.................................................................................................................................................. .... 46
(i) Non-FEHB benefits available to Plan members ................................................................................................... 47
Summary of benefits............................................................................................................................................... 66-67

2003 BlueCHOICE 15 Section 5 18.
18 Page 19 20
Section 5 (a). Medical services and supplies provided by physicians and other health care professionals
I M
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T

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

. Plan physicians must provide or arrange your care.
. Be sure to read Section 4, Your costs for covered services, for valuable information about
how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

I M
P O
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T

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

. Office medical consultations
. Second surgical opinion

$10 per office visit

Professional services of physicians
. In an urgent care center
. During a hospital stay
. In a skilled nursing facility

Nothing

At home $10 per visit
Not covered:
. Care that is not medically necessary

. Care that is investigational
. Care from a non-network provider without prior approval from us

All charges.

Diagnostic and treatment services --Continued on next page

2003 BlueCHOICE 16 Section 5( a) 19.
19 Page 20 21
Diagnostic and treatment services (Continued) You pay
Lab, X-ray and other diagnostic tests
Laboratory tests, such as:
. Blood tests
. Urinalysis
. Non-routine Pap tests
. Pathology
. X-rays
. Non-routine mammograms
. Cat Scans/ MRI
. Ultrasound
. Electrocardiogram and EEG

. Nothing if services are received
during your office visit

. $10 copay applies to services
received at outpatient facilities (Refer to Section 5( c))

Preventive care, adult
Routine screenings, such as:
. Total blood cholesterol once every three years*
. Colorectal cancer screening, including
__ Fecal occult blood test

$10 per office visit

__ Sigmoidoscopy, screening every five years starting at age 50*
And other diagnostic tests as recommended by the American Cancer Society Guidelines
. Chlamydial infection
. Routine Prostate Specific Antigen (PSA) test one annually for men age
40 and older*

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

*or more frequently if recommended by your BlueCHOICE physician.

2003 BlueCHOICE 17 Section 5( a) 20.
20 Page 21 22
Preventive care, adult (Continued) You pay
. Routine mammogram once per calendar year or more frequently if
recommended by a physician $10 per visit

Routine immunizations, limited to:
. Tetanus-diphtheria (Td) booster
ages 19 and over is based on medical necessity

. Influenza vaccines

. Pneumococcal vaccines

Nothing ($ 10 office visit copay applies to any other covered
services)

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

. Immunizations for travel or occupational reasons.

All charges.

Preventive care, children
. Childhood immunizations recommended by the American Academy
of Pediatrics Nothing ($ 10 office visit copay applies to any other covered services)

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

. Examinations, such as:
__ Eye exams to determine the need for vision correction

__ Ear exams to determine the need for hearing correction
__ Newborn hearing screening, rescreening and initial amplification
__ Examinations done on the day of immunizations

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

. Immunizations for travel or occupational reasons.

$10 per office visit

2003 BlueCHOICE 18 Section 5( a) 21.
21 Page 22 23
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 precertify your normal delivery; see page 13 for
specific details.

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

48 hours (or 96 hours after a cesarean delivery), we will cover two home visits by a registered nurse provided through a network home
health agency.
. We cover routine nursery care of the newborn child during the
covered portion of the mother's maternity stay. We will cover other care of an infant who requires non-routine treatment only if we

cover the infant under a Self and Family enrollment.
. We pay hospitalization and surgeon services (delivery) the same as
for illness and injury. See Hospital benefits (Section 5( c)) and Surgery benefits (Section 5( b)).

$10 (for first office visit only)
Nothing
Nothing
Not covered: Routine sonograms to determine fetal age, size or sex All charges
Family planning
A range of voluntary family planning services, limited to:
. Voluntary sterilization (See Surgical procedures Section 5 (b))
. Surgically implanted contraceptives
. Injectable contraceptive drugs (such as Depo provera)
. Intrauterine devices (IUDs)
. Diaphragms

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

$10 per office visit

Not covered: reversal of voluntary surgical sterilization, genetic counseling, voluntary abortions and related care. All charges.

2003 BlueCHOICE 19 Section 5( a) 22.
22 Page 23 24
Infertility services You pay
Diagnosis and treatment of infertility, limited to:
__ in vitro fertilization

__ gamete intrafallopian tube transfer (GIFT)
__ zygote intrafallopian tube transfer
However, we will only cover these treatments if you or your spouse:
(1) have not been able to become pregnant or sustain a pregnancy through reasonable, less costly and medically appropriate covered

infertility treatment;
(2) have not undergone four completed oocyte retrievals (except if a live birth follows a completed oocyte retrieval, then we will cover

two more completed oocyte retrievals); and
(3) have the procedures performed at medical facilities that conform to the American College of Obstetrics and Gynecology guidelines or to

the American Fertility Society's minimum standards for in vitro fertilization.

Artificial insemination: __
intravaginal insemination (IVI) __
intracervical insemination (ICI) __
intrauterine insemination (IUI)
Oral fertility drugs and injectable fertility drugs

Note: Preauthorization is required for fertility medication.

$10 per office visit
Nothing
We cover fertility drugs under the prescription drug benefit. Please
refer to Section 5( f).

Not covered
. Treatment for infertility following voluntary sterilization
. Cost of donor sperm
. Cost of donor egg
. Any treatment not specified above

All charges.

Allergy care
. Testing and treatment
. Allergy injection
$10 per office visit

$3 per visit ($ 10 office visit copay applies to any other covered
services)
. Allergy serum Nothing
Not covered: Provocative food testing and sublingual allergy desensitization All charges.

2003 BlueCHOICE 20 Section 5( a) 23.
23 Page 24 25
Treatment therapies You pay
. Chemotherapy and radiation therapy
Note: High-dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed under

Organ/ Tissue Transplants on page 31.
. Respiratory and inhalation therapy
. Dialysis hemodialysis and peritoneal dialysis
. Intravenous (IV)/ Infusion Therapy Home IV and antibiotic therapy
. Growth hormone therapy (GHT)
Note: Before administering any GHT treatment, your BlueCHOICE physician needs to obtain authorization by submitting a written request

to our Provider Services Unit. Please check with your BlueCHOICE physician before receiving GHT treatment.

We will not cover GHT or related services and supplies unless you have received prior authorization.
Growth hormone is covered as a medical benefit.

Nothing
$10 per visit outpatient
$10 per visit outpatient
Nothing
Nothing

Not covered:
Therapy that is not listed as covered in this booklet. For example, massage therapy or exercise conditioning.
All charges.

2003 BlueCHOICE 21 Section 5( a) 24.
24 Page 25 26
Physical and occupational therapies You pay
. 20 visits per calendar year for physical therapy and chiropractic care
combined, and

. 20 visits per calendar year for occupational therapy.
For the services of each of the following: __
qualified physical therapists and chiropractors, and __
occupational therapists.
Note: We only cover physical and occupational therapy to restore bodily function when there has been a total or partial loss of bodily

function due to illness or injury.
. Cardiac rehabilitation following, but not limited to, a heart transplant,
bypass surgery or a myocardial infarction, is provided for one consecutive 12-week program per calendar year

. Pulmonary rehabilitation for up to 14 sessions within 12 months and
then one session every 3 months thereafter

Note: See Chiropractic care

$10 per office visit
$10 per outpatient visit

Not covered:
. long-term rehabilitative therapy
. exercise programs

All charges.

Speech therapy
. 20 visits per calendar year $10 per office visit

2003 BlueCHOICE 22 Section 5( a) 25.
25 Page 26 27
Hearing services (testing, treatment, and supplies) You pay
. Routine hearing exams
. Newborn hearing, screening, rescreening and initial amplification
$10 per office visit

Not covered: . Hearing aids, testing and examinations for them, except for
newborns
All charges.

Vision services (testing, treatment, and supplies)
. Routine eye exam (one per calendar year)
. Eyeglasses and contact lenses are reimbursed up to $35 per 24-month
period when received from a BlueCHOICE vision care provider. In addition, reduced-cost glasses or contact lenses are available from

selected providers.

$10 per office visit

. One pair of eyeglasses or contact lenses to correct an impairment
directly caused by accidental ocular injury or intraocular surgery (such as for cataracts) $10 per office visit

. Eye exam to determine the need for vision correction for children (see
Preventive care, children)

. Annual eye refractions

$10 per office visit

Not covered:
. Eye exercises and orthoptics
. Radial keratotomy and other refractive surgery, including LASIK
procedures

All charges.

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

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

$10 per office visit

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

. Treatment of weak, strained or flat feet or bunions or spurs; and of
any instability, imbalance or subluxation of the foot (unless the treatment is by open cutting surgery)

All charges.

2003 BlueCHOICE 23 Section 5( a) 26.
26 Page 27 28
Orthopedic and prosthetic devices You pay
. Artificial limbs and eyes; stump hose
. Externally worn breast prostheses and surgical bras, including
necessary replacements, following a mastectomy

. Internal prosthetic devices, such as artificial joints, pacemakers,
cochlear implants; and surgically implanted breast implant following mastectomy.

Note: We pay internal prosthetic devices as hospital benefits; see Section 5 (c) for payment information. See 5( b) for coverage of the
surgery to insert the device.
. Corrective orthopedic appliances for non-dental treatment of
temporomandibular joint (TMJ) pain dysfunction syndrome.

. Compression (anti-embolic) stockings (up to 2 pairs per calendar
year); see page 25.

Nothing
$25 (per pair)
Not covered:
. orthopedic and corrective shoes
. arch supports
. foot orthotics
. heel pads and heel cups
. lumbosacral supports
. orthotic devices used primarily for convenience, comfort or for
participation in athletics

. corsets, trusses, support hose, and other supportive devices

All charges.

2003 BlueCHOICE 24 Section 5( a) 27.
27 Page 28 29
Durable medical equipment (DME) You pay
We cover the use of standard models of the durable medical equipment (DME) and medical supplies listed below when medically necessary to

treat certain conditions.
Your primary care physician or network specialist must give you a prescription for the equipment or supplies. You must obtain the
equipment or supplies from a network DME provider.
We only provide benefits up to our allowed amount for supplies and for basic models of equipment. If you want other than the basic model, you
must pay your copay and any charges above the allowed amount for the basic equipment. We determine what is a basic model.

Following is a list of covered equipment and medical supplies. The copay is shown at right.
Air flotation mattress and alternating pressure pump Apnea monitor (1)
Bi-directional Positive Airway Pressure (BIPAP) apparatus (1) Bili phototherapy system (1)
Blood glucose monitor (1) Bone growth stimulator (electrical) (2)
Canes Commode (bedside)
Compression (anti-embolic) stockings (up to 2 pairs per calendar year) Continuous Passive Motion (CPM) Devices
Continuous Positive Airway Pressure (CPAP) apparatus (1) Replacement CPAP apparatus
Continuous Positive Airway Pressure (CPAP) humidifier Crutches
Enteral feeding equipment Enteral feeding supplies
Formulas for treatment of phenylketonuria or any inherited disease of amino and organic acids, one month supply per copayment
Hospital bed (electric) Hospital bed (nonelectric)
Incontinence cathethers and irrigation supplies, one month supply per copayment (1)
Insulin pump (2) Insulin pump supplies (2)
Intermittent Positive Pressure Breathing Apparatus (IPPB) (1) Lymphedema pumps/ lymphedema sleeves
Mattress overlays Medical and post-surgical dressings, irrigation supplies, and
dressing tape, one month supply per copayment Nebulizer compressor (1)
Neuromuscular Electronic Stimulator (NMES) Ostomy supplies, all types, one month supply per copayment
Oxygen, one month supply per copayment Patient lifts
Peak flow meters Pulmoaids
Spacers for Metered Dose Inhalers (MDI) Sphygmomanometer for gestational hypertension
Suction catheters, one month supply per copayment (1)

$10 to $200
$ 10 $ 25
$ 50 $ 25
$ 25 $100
$ 10 $ 10
$ 25 (per pair) $ 25
$ 25 $ 25
$ 25 $ 10
$ 25 $ 10
$ 15
$ 50 $ 25
$ 10
$100 $ 25
$ 25 $ 50
$ 25 $ 10

$ 25 $ 25
$ 10 $ 50
$ 25 $ 10
$ 10 $ 10
$ 25 $ 10

2003 BlueCHOICE 25 Section 5( a) 28.
28 Page 29 30
Suction equipment Transcutaneous Electrical Nerve Stimulator (TENS) Units
Traction devices Walkers
Wheelchairs (electric) Wheelchairs (non-electric)
Wheelchair gel pads
The maximum benefit for a medically necessary nonstandard wheelchair is $2,000. The regular copay for a manual or electric
wheelchair applies. (2)
ABI Vest, used to treat members with cystic fibrosis, is available for $200 per month.

(1) Includes initial provision of nonpharmaceutical medically necessary
supplies.
(2) Subject to review by BlueCHOICE. To obtain more information,
you may contact us at 1-800-932-4480.

$ 25 $ 25
$ 25 $ 10
$ 50 $ 25
$ 10
$ 10

Not covered: . Dialysis equipment (rental or purchase)
. Equipment or supplies that are not listed as covered
. Nonstandard models of equipment

All charges.
Copay plus any charges above the allowed amount for the basic
equipment.

Home health services
. Home health care ordered by a Plan physician and provided by a
registered nurse (R. N.), licensed practical nurse (L. P. N.), licensed vocational nurse (L. V. N.), or home health aide. Your physician will

periodically review the program for appropriateness and need.
. Services include oxygen therapy, intravenous therapy and
medications.

Nothing

Not covered: . Nursing care requested by, or for the convenience of, the patient or
the patient's family. . Services primarily for hygiene, feeding, exercising, moving the
patient, homemaking, companionship or giving oral medication. . Home care primarily for personal assistance that does not include a
medical component and is not diagnostic, therapeutic, or rehabilitative.

All charges.

2003 BlueCHOICE 26 Section 5( a) 29.
29 Page 30 31
Chiropractic You pay
. 20 visits per calendar year for chiropractic care and physical therapy
combined

. Manipulation of the spine and extremities
. Adjunctive procedures such as ultrasound, electrical muscle
stimulation, vibratory therapy, and cold pack application

Note: See Physical therapy

$10 per office visit

Not covered:
. long-term rehabilitative therapy
. exercise programs
. maintenance care
. relaxation therapy

All charges.

Alternative treatments
See Non-FEHB benefits, page 47.
Educational classes and programs
. Smoking Cessation

. Asthma and diabetes self-management
Please refer to Mental health and substance abuse benefits in
Section 5( e); for prescription drug benefits, Section 5( f); and for non-FEHB
benefits, Section 5( i).
Please refer to Special features, Section 5( g).

2003 BlueCHOICE 27 Section 5( a) 30.
30 Page 31 32
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
I M
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A N
T

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

. Plan physicians must provide or arrange your care.
. Be sure to read Section 4, Your costs for covered services, for valuable information about how cost
sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

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

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

I M
P O
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A N
T

Benefit Description You pay
Surgical procedures
A comprehensive range of services, such as
. Operative procedures .
Treatment of fractures, including casting . Normal pre-and post-operative care by the surgeon

. Correction of amblyopia and strabismus .
Endoscopy procedures . Biopsy procedures

. Removal of tumors and cysts .
Correction of congenital anomalies (see reconstructive surgery) . Surgical treatment of morbid obesity --a condition in which an

individual weighs 100 pounds or 100% over his or her normal weight according to current underwriting standards; eligible
members must be age 18 or over . Insertion of internal prosthetic devices. See 5( a) Orthopedic and
prosthetic devices for device coverage information.

Nothing, unless services are received during an office visit,
then the $10 copay applies.

Surgical procedures continued on next page.
2003 BlueCHOICE 28 Section 5( b) 31.
31 Page 32 33
Surgical procedures (Continued) You pay
. 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.

Nothing, unless services are received during an office visit,
then the $10 copay applies.

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

Reconstructive surgery
. Surgery to correct a functional defect
. Surgery to correct a condition caused by injury or illness if: __
the condition produced a major effect on the 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.

Nothing, unless services are received during an office visit,
then the $10 copay applies.

. 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: . Cosmetic surgery any surgical procedure (or any portion of a

procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury

. Surgeries related to sex transformation

All charges

2003 BlueCHOICE 29 Section 5( b) 32.
32 Page 33 34
Oral and maxillofacial surgery
Oral surgical procedures, limited to: . Reduction of fractures of the jaws or facial bones;

. Surgical correction of cleft lip, cleft palate or severe functional
malocclusion; . Removal of stones from salivary ducts;

. Excision of leukoplakia or malignancies; .
Excision of cysts and incision of abscesses when done as independent procedures;

. Extractions of teeth that interfere with radiation therapy; .
Treatment of trauma resulting in injuries to the jaw, cheeks, lips, tongue, roof and floor of the mouth;

. Treatment of bony impactions; .
Surgical correction of anatomical abnormalities for treatment of temporomandibular disease when approved in advance by

BlueCHOICE; and . Other surgical procedures that do not involve the teeth or their
supporting structures.
General anesthesia for certain dental patients, limited to: . Children through age 4
. Severely disabled people; and .
People with medical or behavioral conditions that require hospitalization or general anesthesia for dental care.

The general anesthesia must be provided in a network hospital, network freestanding surgery center or dentist's office. A primary care
physician referral is required. The dental procedures themselves are not covered.

Nothing, unless services are received during an office visit,
then the $10 copay applies.

Nothing
Not covered:
. Oral implants and transplants .
Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone)

All charges.

2003 BlueCHOICE 30 Section 5( b) 33.
33 Page 34 35
Organ/ tissue transplants You pay
Limited to:
. Cornea
. Heart
. Heart/ lung
. Kidney
. Kidney/ pancreas
. Liver
. Lung: single double
. Pancreas
. Allogeneic bone marrow transplant, if the treatment is part of a
National Cancer Institute (NCI) phase III or IV trial, or the treatment is available elsewhere as part of a NCI phase III or IV

trial. Donor screening tests and donor search expenses are also covered for allogeneic bone marrow transplants.

. Autologous bone marrow transplants (autologous stem cell and
peripheral stem cell support) for the following conditions: acute lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's

lymphoma; advanced non-Hodgkin's lymphoma; advanced neuroblastoma; breast cancer; multiple myeloma; epithelial ovarian
cancer; and single or tandem 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): We are a member of the Blue Quality Centers for Transplants.

Note: Autologous bone marrow or stem cell transplants after high-dose chemotherapy to treat breast cancer, and related care, must be received
at St. Louis University Hospital/ SLU Care.
All care for transplants must be coordinated through BlueCHOICE in writing. The physician should send a letter to the BlueCHOICE
Medical Director requesting precertification.
If you live outside the St. Louis metropolitan area, we may cover up to $10,000 in reasonable and necessary expenses for transportation,
lodging and meals while you are away from home for the transplant. This must be approved in advance by Case Management.

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

Nothing

Not covered:
. Donor screening tests and donor search expenses, except those
performed for the actual donor
. Implants of artificial organs
. Transplants not listed as covered
. Organ donation expenses unless this program is covering the organ
transplantation.

All charges

2003 BlueCHOICE 31 Section 5( b) 34.
34 Page 35 36
Anesthesia You pay
Professional services provided in

. Hospital (inpatient)
General anesthesia for certain dental patients, limited to: . Children through age 4
. Severely disabled people; and .
People with medical or behavioral conditions that require hospitalization or general anesthesia for dental care.

The general anesthesia must be provided in a network hospital, network freestanding surgery center or dentist's office. A primary care
physician referral is required. The dental procedures themselves are not covered.

Nothing

Professional services provided in
. Hospital outpatient department .
Skilled nursing facility

. Ambulatory surgical center .
Office

Nothing
$10 per office visit

2003 BlueCHOICE 32 Section 5( b) 35.
35 Page 36 37
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
I M
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A N
T

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

. Plan physicians must provide or arrange your care and you must be hospitalized
in a Plan facility, unless it is an emergency, (see Section 5( d)).

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

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

Sections 5( a) or (b).
. YOUR PHYSICIAN MUST GET PRECERTIFICATION OF HOSPITAL STAYS. Please refer to Section 3 to be sure which services require

precertification.

I M
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T

Benefit Description You pay
Inpatient hospital
Room and board, such as . ward, semiprivate, or intensive care accommodations;

. general nursing care; and .
meals and special diets.

NOTE: If you want a private room when it is not medically necessary, you pay the additional charge above the semiprivate room rate.

Nothing

Inpatient hospital continued on next page.

2003 BlueCHOICE 33 Section 5( c) 36.
36 Page 37 38
Inpatient hospital (Continued) You pay
Other hospital services and supplies, such as: . Operating, recovery, maternity, and other treatment rooms

. Prescribed drugs and medicines .
Diagnostic laboratory tests and X-rays . Administration of blood and blood products

. Blood or blood plasma, if not donated or replaced .
Dressings, splints, casts, and sterile tray services . Medical supplies and equipment, including oxygen

. Anesthetics, including nurse anesthetist services .
Take-home items . Medical supplies, appliances, medical equipment, and any covered

items billed by a hospital for use at home

Nothing

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

. Private nursing care

All charges.

Outpatient hospital or ambulatory surgical center
. Operating, recovery, and other treatment rooms .
Prescribed drugs and medicines . Diagnostic laboratory tests, X-rays, and pathology services

. Administration of blood, blood plasma, and other biologicals .
Blood and blood plasma, if not donated or replaced . Pre-surgical testing

. Dressings, casts, and sterile tray services .
Medical supplies, including oxygen . Anesthetics and anesthesia service

NOTE: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment. We
do not cover the dental procedures.

$10 copay

2003 BlueCHOICE 34 Section 5( c) 37.
37 Page 38 39
Extended care benefits/ skilled nursing care facility benefits You pay
Extended care/ skilled nursing facility (SNF):

We cover treatment in a network skilled nursing facility for a condition that otherwise would require hospital confinement.

You may transfer directly from the hospital. If you do not, your primary care physician must obtain advance approval from
BlueCHOICE.
We will cover the care only as long as it is medically necessary. We will notify you if we determine SNF care is no longer necessary. Then
we will not cover any SNF charges after the date in the notice.
We cover the following SNF services:
. Semiprivate room and board (We will cover a private room if
BlueCHOICE agrees in advance that it is medically necessary. If not, you are responsible for any difference between the private

room and the semiprivate room.) . General nursing care
. Drugs, medications, biologicals, supplies, equipment and services
ordered by the attending network physician with the primary care physician's prior authorization.

Nothing

Not covered: custodial care All charges
Hospice care
When a terminally ill member's life expectancy has reached six months or less, the member may benefit from hospice care. This care provides

pain control and emotional support.

Your primary care physician must obtain advance approval from BlueCHOICE. You must go to a network hospital or receive care from
a network home health agency licensed to provide hospice care. The hospice provider will write a treatment plan for your signature.
BlueCHOICE and your primary care physician must coordinate your care.

We also cover inpatient hospice care for short-term pain control.

Nothing

Not covered: Independent nursing, homemaker services; bereavement services All charges
Ambulance
. Local professional ambulance service when medically appropriate Nothing

2003 BlueCHOICE 35 Section 5( c) 38.
38 Page 39 40
Section 5 (d). Emergency services/ accidents
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Here are some important things to keep in mind about these benefits:
. Please remember that all benefits are subject to the definitions, limitations, and exclusions
in this brochure and are payable only when we determine they are medically necessary.

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

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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 at network hospitals within our service area: If possible, when an unexpected condition arises, call your primary care physician unless you believe any
delay would be harmful. This applies even if it's after office hours. Your primary care physician will tell you whether to go to the emergency room. Your primary care physician's number is listed on the front of
your ID card.
If you need additional care after an emergency condition is stabilized, precertification is required. Your BlueCHOICE physician will handle this for you. We will make a decision about the care within 30
minutes after we receive all the necessary information.
When you need care right away but it is not an emergency, always call your primary care physician. Your primary care physician may have you come into the office for an urgent appointment. An urgent
appointment is one scheduled with a physician for the same day or during hours not normally used for appointments.

Emergencies at non-network hospitals (inside or outside our service area):
If possible, when an unexpected condition arises, call your primary care physician unless you believe any delay would be harmful. This applies even if it's after office hours. Your primary care physician will tell

you whether to go to the emergency room. Your primary care physician's number is listed on the front of your ID card.

If you receive emergency care before you call your primary care physician, you or a family member should notify your primary care physician as soon as possible. We encourage you to try to call within 24 hours.
Your primary care physician's number is listed on the front of your ID card.
If you need additional care after an emergency condition is stabilized, precertification is required. We will make a decision about the care within 30 minutes after we receive all the necessary information.

If you are admitted as an inpatient to a non-network hospital as a result of an emergency, you, your doctor or a family member should call BlueCHOICE as soon as possible for precertification of the case.
BlueCHOICE will cover your care until you are stabilized. Then you must transfer to a BlueCHOICE network hospital. The transfer must be coordinated through BlueCHOICE in advance.

2003 BlueCHOICE 36 Section 5( d) 39.
39 Page 40 41
BlueCHOICE will not provide benefits for continued care at a non-network hospital after you are stable enough to transfer.
When you need care right away but it is not an emergency, always call your primary care physician. Your primary care physician may have you come into the office for an urgent appointment. An urgent
appointment is one scheduled with a physician for the same day or during hours not normally used for appointments.

Benefit Description You pay
Emergency within our service area
. Emergency care at a doctor's office
. Emergency care at an urgent care center
. Emergency care as an outpatient or inpatient at a hospital,
including doctors' services

. Hospital observation
If you need follow-up care after emergency treatment, call your primary care physician. If your primary care physician cannot provide the care,

he or she will give you a written referral to a network specialist.
If you are treated in the emergency room and then held for observation, only one copay will be charged.

If you receive follow-up care without a written referral from your primary care physician, you must pay all charges.

$10 per office visit
$10 per office visit

$50 at emergency room( waived if
admitted)
$50 (waived if admitted)

Not covered: Elective care or non-emergency care All charges.
Emergency outside our service area

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

. Hospital observation

If you need follow-up care after emergency treatment, call your primary care physician. If your primary care physician cannot provide the care,
he or she will give you a written referral to a network specialist.
If you are treated in the emergency room and then held for observation, only one copay will be charged.

$10 per office visit
$10 per office visit

$50 at emergency room (waived if admitted)

$50 (waived if admitted)

2003 BlueCHOICE 37 Section 5( d) 40.
40 Page 41 42
Emergency outside our area (continued)
After your condition is stabilized, you, the hospital, a family member or a friend must call us for approval of continued care.

Benefits are available only until BlueCHOICE determines that your condition has improved enough for you to travel back to the
BlueCHOICE service area.
If you receive follow-up care without a written referral from your primary care physician, you must pay all charges.

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

All charges.

Ambulance
Professional ambulance and air ambulance service when medically appropriate. Transportation by air ambulance must be approved in

advance by BlueCHOICE.
See Section 5( c) for non-emergency service.

Nothing

2003 BlueCHOICE 38 Section 5( d) 41.
41 Page 42 43
Section 5 (e). Mental health and substance abuse benefits
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When you get our approval for services and follow a treatment plan we approve, cost-sharing and limitations for Plan mental health and substance abuse benefits will be no greater than for similar
benefits for other illnesses and conditions.
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.

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

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

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Benefit Description You pay
Mental health and substance abuse benefits
All diagnostic and treatment services recommended by a Plan provider and contained in a treatment plan that we approve. The treatment plan

may include services, drugs, and supplies described elsewhere in this brochure.

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

Copayments are the same as for any other illness or
condition.

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

. Medication management

$10 per office visit

Mental health and substance abuse benefits -Continued on next page

2003 BlueCHOICE 39 Section 5( e) 42.
42 Page 43 44
Mental health and substance abuse benefits (Continued) You pay
. Diagnostic tests $10 per office visit or test

. Individual and group therapy for the treatment of
smoking cessation Nothing

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

Nothing on inpatient basis; $10 per visit for outpatient

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

All charges.

Preauthorization To be eligible to receive these benefits you must obtain a treatment plan and follow all of the following authorization processes:
If you think you have a mental health or substance abuse problem, we encourage you to see your primary care physician. Your primary care
physician may treat you or may recommend that you call our mental health and substance abuse benefits manager.

If you do not wish to go through your primary care physician for mental illness or substance abuse care, to receive benefits you must call our
mental health and substance abuse benefits manager before you receive care. This number is 1-800-965-2583, and is also listed on your ID card.

Network providers will handle all authorizations for you. However, your benefits allow up to two visits each calendar year to diagnose and assess
a mental health condition, in or out of network, without authorization.

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

2003 BlueCHOICE 40 Section 5( e) 43.
43 Page 44 45
Section 5 (f). Prescription drug benefits
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Here are some important things to keep in mind about these benefits:
. We cover prescribed drugs and medications, as described in the chart beginning on the
next page.

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

. Some prescription drugs are covered only if your physician obtains prior authorization
from us. In addition, coverage for some drugs is provided in limited quantities.

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

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There are important features you should be aware of. These include:
. Who can write your prescription. A plan physician or plan dentist must write the prescription,
unless it is an emergency.

. Where you can obtain them. You must fill the prescription at a plan pharmacy, or by mail for a
maintenance medication.

. Reimbursement for prescriptions purchased out-of-area will be covered up to the allowed
amount after a $25 copayment.

. Most maintenance drugs are available through mail order. To find out if a certain maintenance
drug is available by mail order, call 1-800-655-1936.

. We use an incentive-based three-tier formulary. A formulary is a list of preferred drugs chosen
for use based upon their effectiveness, safety and cost. Drugs are prescribed by Plan doctors and dispensed in accordance with BlueCHOICE's drug formulary. Nonpreferred brand-name drugs will

be covered when prescribed by a Plan doctor. The Plan must authorize a nonpreferred brand-name drug before it may be dispensed. It is the prescribing doctor's responsibility to obtain the Plan's
authorization. You pay a $7 copay per prescription unit or refill for generic drugs; $12 for preferred brand-name drugs; and $25 for nonpreferred brand-name drugs. When a generic drug is available
but you or your physician request the brand-name drug, you pay the price difference between the generic and brand-name drug as well as the $7 copay per prescription or refill unless your physician
has obtained prior authorization for the brand-name drug. When the physician has obtained the prior authorization, you pay only the appropriate brand copay.

. These are the dispensing limitations. Prescription drugs prescribed by a Plan or referral doctor
and obtained at a Plan pharmacy will be dispensed for up to a 30-day supply for retail or one commercially prepared unit (i. e., one inhaler, one vial ophthalmic medication or insulin); and are

available at $7 for generic; $12 for preferred brand-name; and $25 for nonpreferred brand-name.
Mail order prescription drugs are dispensed for up to a 90-day supply, and are available at $14 for generic; $24 for preferred brand-name; and $50 for nonpreferred brand-name.

. Why use generic drugs? Generic drugs normally cost considerably less than brand-name drugs.
So, the copayment you pay for generic drugs is also lower. The generic name of a drug is its chemical name. The brand name is the trade name under which the drug is advertised and sold. By

law, generic and brand-name drugs must meet the same standards for safety, purity, strength and effectiveness. They are dispensed in the same dosage and taken in the same way.

. When you have to file a claim. Follow the same procedures for filing a prescription drug claim found in Section 7.
Prescription drug benefits begin on the next page.

2003 BlueCHOICE 41 Section 5( f) 44.
44 Page 45 46
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

and online 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.

. Drugs that under state law are dispensed only with a written
prescription from a physician or other lawful provider. . Insulin

. Disposable needles and syringes for the administration of covered
medications, including insulin . Drugs for sexual dysfunction (See Limited Drug Benefits below)

. FDA-approved prescription drugs and devices for birth control .
Diabetic test strips, lancets . FDA-approved medications for the treatment of tobacco use

Please note:
. Most prescriptions are limited to a 30-day supply each time the
prescription is filled.

. Refills your doctor authorizes are covered for up to 12 months from the
original prescription date. Then a new prescription is required.

. Some prescription drugs are covered only if your physician obtains
prior authorization from us. In addition, coverage for some drugs is provided in limited quantities.

. Intravenous fluids and medication for home use are provided under
home health services at no charge; and some injectable drugs are covered under Medical and Surgical Benefits.

Limited Drug Benefits Prescription benefits for the treatment of sexual dysfunction will only be
available with prior authorization where sexual dysfunction is secondary to a medical condition and the medical history and work-up is
documented. You must receive prior authorization before receiving any prescription for the treatment of sexual dysfunction. If approved, four
prescribed treatments per month will be available and subject to the nonpreferred brand-name copayment.

Retail (up to a 30-day supply) $7 generic
$12 preferred brand $25 nonpreferred brand

Mail order and online (up to a 90-day supply)
$14 generic $24 preferred brand
$50 nonpreferred brand

Note: If there is no generic equivalent available, you will still
have to pay the brand-name copay.

2003 BlueCHOICE 42 Section 5( f) 45.
45 Page 46 47

Covered medications and supplies (continued) You pay
Here are some things to keep in mind about our prescription drug program:

. A generic equivalent will be dispensed if it is available, unless your
physician specifically requires a name brand. If you receive a name-brand drug when a Federally approved generic drug is

available, whether or not your physician has specified Dispense as Written for the name-brand drug, you have to pay the difference in
cost between the name-brand drug and the generic, unless your physician has obtained prior authorization for the brand-name drug.

. We have an incentive-based, three-tier formulary. If your
physician believes a name-brand product is necessary or there is no generic available, your physician may prescribe a name-brand drug

from a formulary list. This list of name-brand drugs is a preferred list of drugs that we selected to meet patient needs at a lower cost.
To order a copy of our Preferred Drug List, please call Client Services at 1-800-932- 4480 or visit our website at
www. bcbsmo. com.

Not covered:
. Drugs for which there is a nonprescription equivalent available
. Drugs obtained at a non-Plan pharmacy (except out-of-area
emergencies) .
Vitamins and nutritional substances that can be purchased without a prescription

. Medical equipment, devices and supplies such as dressings and
antiseptics .
Drugs for cosmetic purposes .
Drugs to enhance athletic performance .
Test agents and devices .
Appetite suppressants and other drugs for weight loss .
Nonprescription medicines .
Replacement drugs due to loss or theft .
Travel (except for emergencies) . Special packaging for drugs in nursing homes

All Charges

2003 BlueCHOICE 43 Section 5( f) 46.
46 Page 47 48
Section 5 (g). Special features
Feature Description
Flexible Benefits Option Under the flexible benefits option, we determine the most effective way to provide services.

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

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

. The decision to offer an alternative benefit is solely ours, and we
may withdraw it at any time and resume regular contract benefits.

. Our decision to offer or withdraw alternative benefits is not subject
to OPM review under the disputed claims process.

Services for deaf and hearing impaired For the hearing impaired (TDD), call 1-800-822-1215.

Away From Home Care Through our BlueCard . program, BlueCHOICE offers its members medical care in emergency and urgent situations when traveling
outside the service area.
Also, members who are traveling for an extended time or who are on an extended work assignment in another city may be eligible to apply
for a Guest Membership in a local Blue Cross and Blue Shield HMO. The Guest Membership also temporarily covers dependent children
who are away at school or living in another city. For more information, see Section 1, page 9, or members can call Customer
Service at the number listed on the back of their ID card.

Blue Quality National Transplant Program (NTP): We are a member of the Blue Quality Centers for Transplants.

RightSteps . This is a voluntary program that strives to help mothers-to-be avoid potential problems during pregnancy. Pregnant women who choose to
participate are asked to complete a questionnaire within 20 weeks of becoming pregnant. An obstetrical registered nurse will then contact the
member periodically to provide information on pregnancy and childbirth. We encourage the member to have early, regular prenatal care and to pay
attention to her lifestyle behaviors. Mothers-to-be who participate in the program will also receive a nationally recognized book on pregnancy,
childbirth and infant care; up to a $40 reimbursement for the cost of a childbirth or parenting class; and a gift from us after the baby arrives.

TakeCharge . Asthma Program Our goal is to help our members who have asthma manage their disease more successfully. Working with the patient's physician, we provide case
management services to severe asthmatics through frequent phone calls, individual care plans, home health visits (as approved by the patient's
doctor), durable medical equipment benefits and asthma educational material. Adults and children with mild or moderate asthma receive
asthma educational materials as requested.

2003 BlueCHOICE 44 Section 5( g) 47.
47 Page 48 49
Section 5 (g). Special features
TakeCharge . Diabetes Program This comprehensive care and disease management program is designed to support the health care needs of people with diabetes. The program
is a complimentary, value-added service offered to members with diabetes to reinforce the diabetes treatment plan that has been designed
by each member's physician. The member's doctor and other members of the diabetes management team also receive information
about the program. This program provides newsletters, reminder cards and other important educational health information to members with
diabetes throughout the year.
Cardiovascular Education Program Through this member education program, we periodically send cardiovascular education materials to members who have

cardiovascular disease. The heart-related educational brochures are intended to reinforce the physician's advice on understanding
cardiovascular disease, risk factors and lifestyle modifications.
Note: Special programs such as RightSteps . , TakeCharge .

Asthma Program, TakeCharge . Diabetes Program and the
Cardiovascular Education Program are special programs
that are available to members who have primary health
coverage through BlueCHOICE.

2003 BlueCHOICE 45 Section 5( g) 48.
48 Page 49 50
Section 5 (h). Dental benefits
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Here are some important things to keep in mind about these benefits:
. Please remember that all benefits are subject to the definitions, limitations, and exclusions
in this brochure and are payable only when we determine they are medically necessary.

. Plan dentists must provide or arrange your care.

. We cover hospitalization for dental procedures only when a nondental physical
impairment exists, which makes hospitalization necessary to safeguard the health of the patient. See Section 5( c) for inpatient hospital benefits. We do not cover

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

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Dental Benefits
Service You pay

The following dental services are covered when provided by your participating Plan primary dentist:
. Office visit for oral examination, limited to two
visits per calendar year

. Oral prophylaxis (cleaning) as necessary, limited to
two visits per calendar year

. Topical application of fluorides is limited to two
courses of treatment per calendar year, limited to children under age 18

. Oral hygiene instruction
. Dietary advice and counseling
. Consultations with Primary Dentist

Not Covered: Any procedures or services not listed.

$ 5 per office visit

2003 BlueCHOICE 46 Section 5( h) 49.
49 Page 50 51
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 the FEHB out-of-pocket maximum. Your
medical program copay does not apply to these services. You must pay for the services or supplies when you receive them.

Wellness and Education Programs
Eat Smart: Learn to eat right and control your weight. You'll get $75 if you achieve your weight loss goal through a participating facility.

Breathe Easy: Smoking cessation classes offered in cooperation with local health care providers teach you some helpful tips for kicking the habit. Earn $50 for regular class attendance and for quitting smoking.
Physical Fitness: If you are 18 or older, we will reimburse you 25% (up to $100) for a single membership and 50% of annual dues (up to $200) for a family membership at the health club of your choice.
Self-Help Educational Information: Free literature is available on a variety of subjects, including stress, alcohol, drugs and cholesterol.

Discounted Services
Hearing Aids: Free hearing evaluations and savings on hearing aids are available through Accent Hearing Network providers and Southwest Hearing providers.

Vision Care: BlueCHOICE members may receive discounts on eye exams, lenses and frames by showing their ID card at a participating vision center. Members also can receive discounts off the regular retail price for all eye care
accessories, including contact lens solutions and non-prescription sunglasses. Members can obtain discounted eye wear and eye care services through Access Eye Care network, Unity Health Eye Care network or Crown Optical.*

*Savings on LASIK surgery are available to members through Crown Optical. For more information, contact Crown at 1-800-232-4526.
Alternative Health Programs through American Specialty Health Networks: BlueCHOICE provides access to an alternative health care discount program through American Specialty Health Networks (ASHN). BlueCHOICE
members can pay discounted fees when they see chiropractors, acupuncturists and massage therapists in ASHN's credentialed network. Members receive ASHN's toll-free telephone number to request provider directories and
program brochures when they enroll.
In addition, members can access ASHN's national network of fitness clubs at the clubs' lowest membership rates. Additionally, members can try the fitness facilities at no charge for one full week.

Additional discounts are available for everything from educational videos to herbal supplements ordered through the Internet. Just go to www. bcbsmo. com for additional information.

For more information on any of the special programs described on this page, call Client Services at 1-800-932-4480.

2003 BlueCHOICE 47 Section 5( i)
Note: We may receive payments from the providers of these discount programs to cover administrative and related costs associated with offering the programs and services to members. We do not select or recommend providers for
the discount programs and do not recommend or prescribe the services or treatments provided. We encourage members to consult with their physician about any of these services or products. 50.
50 Page 51 52
Section 6. General exclusions --things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not cover it unless your Plan doctor determines it is medically necessary to prevent, diagnose, or
treat your illness, disease, injury, or condition.
We do not cover the following:
. Care by non-Plan providers except for authorized referrals or emergencies (see Emergency
Benefits);

. Services, drugs, or supplies you receive while you are not enrolled in the 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.
. Services, drugs, or supplies you receive from immediate relatives or household members, such as
spouse, parent, child, brother or sister, by blood, marriage or adoption.

. Services, drugs, or supplies you receive without charge while in active military service.

2003 BlueCHOICE 48 Section 6 51.
51 Page 52 53
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:

Medical and hospital benefits 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 1-800-932-4480.

How to file a claim:
. You can obtain claim forms by calling Client Services at 1-800-932-4480.
The back of the claim form has complete filing instructions.

. You can use the same claim form to file a claim for all your health care
benefits, except for prescription drugs.

. You may submit claims for more than one person in the same envelope.
However, you must submit a separate claim form for each person. Attach each person's bill to the correct form.

. Complete the claim form fully and accurately. You must check "yes" or
"no" for each question. If you do not answer a question, we may have to return your claim to you. This is also true if you do not provide

additional information required.
. When you write in your identification number on the claim form, be sure
to include the first three digits.

. We can only accept itemized bills. Each bill must show: the name of the
patient; the name and address of the provider of care; a description of each service and the date provided; a diagnosis; and the charge for each

service.
. Canceled checks and nonitemized bills that show only "balance due" or
"for professional services rendered" are not sufficient.

. Include all bills for covered services not previously submitted.

. If you have paid the provider, mark each bill "paid."
. In some cases, we will pay you directly for covered services. In other
cases, we will pay the provider.

. Please keep copies of the completed claim form and itemized bills.

. Send your claims to the address shown on the form.

2003 BlueCHOICE 49 Section 7 52.
52 Page 53 54
Prescription drugs Major chains and independent pharmacies belong to your pharmacy network. At these pharmacies, if you show your BlueCHOICE ID card,
you should only be responsible for paying your share of the cost. The pharmacy should file your claim, and we will pay the pharmacy directly.

At a Non-Network Pharmacy: If you go to a non-network pharmacy in an urgent or emergency situation outside the BlueCHOICE service area,
you are responsible for paying for your prescription at the time of service and then filing a claim. Your program will not provide benefits if you use
a non-network pharmacy within the BlueCHOICE service area.
You can obtain a Prescription Drug Claim Form by calling Client Services at 1-800-932-4480.

You can file up to three prescriptions on each form. Please do not use a regular health benefits claim form to file your prescription drug claim. If
you do, your claim may be denied.
. Please fill out a separate claim form for each person and pharmacy.

. Be sure to provide all the information requested for each prescription.
You may need to have the pharmacy complete the form or get the information from the pharmacy.

. Then you or the pharmacist should fill out the pharmacy's name,
address and National Association of Board of Pharmacy (NABP) number.

. On the completed form, tape your original itemized prescription drug
receipt( s). Please do not send cash register receipts, canceled checks, bottle labels, copies of the original prescription drug receipts, or your

own itemization of charges.
. The receipt( s) must show: the prescription number, the patient's
name, the name of the drug, the quantity and unit dose, and the strength of the drug.

. Sign the claim form. Then mail it and your receipt( s) to the address
shown on the form.

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

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

2003 BlueCHOICE 50 Section 7 53.
53 Page 54 55
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your claim or request for services, drugs, or supplies including a request for preauthorization:

Step Description
1 Ask us in writing to reconsider our initial decision. You must:
(a) Write to us within six months from the date of our decision; and (b) Send your request to us at: BlueCHOICE Grievance Unit
P. O. Box 66828 St. Louis, MO 63166-6828
(c) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure; and
(d) Include copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms.

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

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

. 90 days after the date of our letter upholding our initial decision; or
. 120 days after you first wrote to us --if we did not answer that request in some way within 30 days; or
. 120 days after we asked for additional information.

Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Health Benefits Contracts Division 2, 1900 E Street, NW, Washington, DC 20415-3620.

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

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

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

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

2003 BlueCHOICE 51 Section 8 54.
54 Page 55 56
The Disputed Claims process (Continued)
Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representative, such as medical providers, must include a copy of your specific written consent with the
review request.
Note: The above deadlines may be extended if you show that you were unable to meet the deadline because of reasons beyond your control.

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

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

OPM may disclose the information it collects during the review process to support its 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 1-800-932-4480 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 it can give your claim
expedited treatment too, or

. You may call OPM's Health Benefits Contracts Division 2 at 202/ 606-3818 between 8 a. m. and 5 p. m.
Eastern time.

2003 BlueCHOICE 52 Section 8 55.
55 Page 56 57
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 other health 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. All programs together will not pay more than 100% of allowable expenses. The allowable expense is the maximum amount that a plan will pay for
covered services. We will not pay more than our allowance.
Medicare is a Health Insurance Program for: What is Medicare?
. 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 The Original Medicare Plan (Original Medicare) is available everywhere in the
(Part A or Part B) 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 and you will still be responsible for the Plan's copayments.

2003 BlueCHOICE 53 Section 9 56.
56 Page 57 58
. Filing a claim When this Plan is primary and you have a claim for covered services that you
must file yourself, please follow the claim filing instruction in Section 7.

Once you receive an Explanation of Benefits (EOB) from us, then file a claim for your Medicare benefits. (For information on filing a Medicare claim, contact
your Social Security office.) When Original Medicare is primary you must submit your claims to Medicare first. The federal government requires most health care
providers and suppliers to file your Medicare claims for you. So in most cases, you shouldn't need to file a claim to obtain your Medicare benefits.

Also, in most cases, you shouldn't need to file to receive the benefits of this program. If the services or supplies are covered by Medicare, the Medicare
carrier will usually forward your medical claim to us. Then we will provide the benefits of this program automatically in most cases.

You should not submit a claim for benefits of this program if your Medicare Summary Notice (MSN) states, in part: "This information is being sent to your
private insurer." This note means that the Medicare carrier is submitting your claim to us. Then we can provide the benefits of this program. If this note is on
your MSN, please do not submit a claim to us. Also, please let your providers of care know that they should not submit your claim to us. When we receive
duplicate claims, this increases costs.
Your MSN may not indicate that your claim has been referred to supplemental claims processing. In that case, you should file your own claim.

. To file your own claim To file, send us a copy of your MSN. Include a completed claim form and
copies of your itemized bills. Send the information to the address shown on the claim form.

You should also file a claim if you receive services or supplies that are not covered by Medicare but are covered by this program. Send a completed claim
form and copies of your itemized bills to us.
(Primary payer chart begins on next page.)

2003 BlueCHOICE 54 Section 9 57.
57 Page 58 59
The following chart illustrates whether the Original Medicare Plan or this Plan should be the primary payer for you according to your employment status and other factors determined by Medicare. It is critical that you tell us if you or
a covered family member has Medicare coverage so we can administer these requirements correctly.
Primary Payer Chart
Then the primary payer is A. When either you or your covered spouse are age 65 or over and

OriginalMedicare This Plan
1) Areanactiveemployee withtheFederalgovernment (includingwhenyouor afamilymemberare eligibleforMedicaresolely becauseofadisability),

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

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

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

(for other services)

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

(except for claims related to Workers'

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

1) Are within the first 30 months of eligibility to receive Part A benefits solely because of ESRD,
2) Have completed the 30-month ESRD coordination period and are still eligible for Medicare due to ESRD,
3) Become eligible for Medicare due to ESRD after Medicare became primary for you under another provision,
C. When you or a covered family member have FEHB and
1) Are eligible for Medicare based on disability, and
a) Are an annuitant
b) Are an active employee, or

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

2003 BlueCHOICE 55 Section 9 58.
58 Page 59 60

. Medicare managed care plan If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare managed care plan. These are health
care choices (like HMOs) in some areas of the country. In most Medicare managed care plans, you can only go to doctors, specialists, or
hospitals that are part of the plan. Medicare managed care plans provide all the benefits that Original Medicare covers. Some cover extras, like
prescription drugs. To learn more about enrolling in a Medicare managed care plan, contact Medicare at 1-800-MEDICARE (1-800-633-
4227) or at www. medicare. gov.
If you enroll in a Medicare managed care plan, the following options are available to you:

This Plan and 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 you will still be responsible for copayments. If you enroll in a
Medicare managed care plan, tell us. We will need to know whether you are in the Original Medicare Plan or in a Medicare managed care plan so
we can correctly coordinate benefits with Medicare.
Suspended FEHB coverage to enroll in a Medicare managed care plan: If you are an annuitant or former spouse, you can suspend your
FEHB coverage to enroll in a Medicare managed care plan, eliminating your FEHB premium. (OPM does not contribute to your Medicare
managed care plan premium.) For information on suspending your FEHB enrollment, contact your retirement office. If you later want to re-enroll
in the FEHB Program, generally you may do so only at the next open season unless you involuntarily lose coverage or move out of the
Medicare managed care plan's service area.
. If you do not enroll in If you do not have one or both Parts of Medicare, you can still be covered
Medicare Part A or B 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 & CHAMPVA TRICARE is the health care program for eligible dependents of military persons and retirees of the military. TRICARE includes the CHAMPUS
program. CHAMPVA provides health coverage to disabled Veterans and their dependents. If both TRICARE or CHAMPVA and this Plan cover
you, we pay first. See your TRICARE or CHAMPVA Health Benefits Advisor if you have questions about these programs.

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

2003 BlueCHOICE 56 Section 9 59.
59 Page 60 61
Workers' Compensation We do not cover services that:
. you need because of a workplace-related illness or injury that the
Office of Workers' Compensation Programs (OWCP) or a similar Federal or State agency determines they must provide; or

. OWCP or a similar agency pays for through a third-party injury
settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws.

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

Medicaid When you have this Plan and Medicaid, we pay first.
Suspended FEHB coverage to enroll in Medicaid or a similar State-sponsored program of medical assistance: If you are an annuitant or
former spouse, you can suspend your FEHB coverage to enroll in one of these State programs, eliminating your FEHB premium. For information
on suspending your FEHB enrollment, contact your retirement office. If you later want to re-enroll in the FEHB Program, generally you may do
so only at the next Open Season unless you involuntarily lose coverage under the State program.

When other Government agencies We do not cover services and supplies when a local, State, are responsible for your care or Federal Government agency directly or indirectly pays for them.
When others are responsible When you receive money to compensate you for medical or hospital for injuries 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.

2003 BlueCHOICE 57 Section 9 60.
60 Page 61 62
Section 10. Definitions of terms we use in this brochure
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on
December 31 of the same year.

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

Covered services Care we provide benefits for, as described in this brochure.
Custodial care Services that do not seek to cure, but are provided primarily for the convenience of the patient or his or her family, the maintenance of the
patient, or to assist the patient in meeting his or her activities of daily living, rather than primarily for therapeutic value in the treatment of a
Condition. Custodial care includes, but is not limited to, help in walking, bathing, dressing, eating, preparation of special diets, supervision over
self-administration of medications not requiring constant attention of trained medical personnel, or acting as a companion or sitter. Custodial
care that lasts 90 days or more is sometimes known as Long term care.
Note: BlueCHOICE will have the sole discretion to determine whether care is Custodial care. BlueCHOICE may consult with professional peer
review committees or other appropriate sources for recommendations.

Experimental or investigational services A drug, device or biological product is experimental or investigational if
the drug, device, or biological product cannot be lawfully marketed without approval of the U. S. Food and Drug Administration (FDA) and
approval for marketing has not been given at the time it is furnished. Approval means all forms of acceptance by the FDA.

An FDA-approved drug, device or biological product (for use other than its intended purpose and labeled indications), or medical treatment or
procedure is experimental or investigational if
1) reliable evidence shows that it is the subject of ongoing phase I, II or III clinical trials or under study to determine its maximum
tolerated dose, its toxicity, its safety, or 2) reliable evidence shows that the consensus of opinion among
experts regarding the drug, device, or biological product or medical treatment or procedure is that further studies or clinical
trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the
standard means of treatment or diagnosis.
Reliable evidence shall mean only published reports and articles in the authorized medical and scientific literature; the written protocol or
protocols used by the treating facility or the protocol( s) of another facility studying substantially the same drug, device or medical treatment or
procedure; or the written informed consent used by the treating facility or by another facility studying substantially the same drug, device or
medical treatment or procedure. FDA-approved drugs, devices, or biological products used for their
intended purpose and labeled indication and those that have received

2003 BlueCHOICE 58 Section 10 61.
61 Page 62 63
FDA approval subject to postmarketing approval clinical trials, and devices classified by the FDA as "Category B Non-experimental/
Investigational Devices" are not considered experimental or investigational.

Group health coverage A health benefit plan that is offered to employees through their place of employment or to the membership of a sponsoring organization such as a
union or association.

Medical necessity We only cover care that is medically necessary. But we do not cover all medically necessary care. Even if the type of care is covered in general,
the care is not covered if we determine it was not medically necessary in a specific case. BlueCHOICE must agree that care was medically
necessary.
However, in some cases, you will not have to pay for care that was not medically necessary. In these cases, the provider is responsible. You do
not need to pay if all of the following are true: . You obtained the proper referral for the care.
. BlueCHOICE did not notify you in advance that the care was not
medically necessary. . The services would have been covered if they were medically

necessary.
To be medically necessary, care must be provided to diagnose or treat a condition. Also, the type and level of care must be necessary and
appropriate. We use current standards of medical practice to decide necessity and appropriateness. The type and level of care must not be
more than what is necessary.
For example, surgery may not be medically necessary for your condition if your provider has not tried more conservative treatment. Also,
inpatient care is not medically necessary if appropriate care is available on an outpatient basis.

Plan allowance The maximum amount we will pay for covered services.
Us/ We Us and we refer to BlueCHOICE.
You You refers to the enrollee and each covered family member.

2003 BlueCHOICE 59 Section 10 62.
62 Page 63 64
Section 11. FEHB facts
No pre-existing condition We will not refuse to cover the treatment of a condition that you had limitation before you enrolled in this Plan solely because you had the condition
before you enrolled.
Where you can get information See www. opm. gov/ insure. Also, your employing or retirement office about enrolling in the can answer your questions, and give you a Guide to Federal Employees
FEHB Program Health Benefits Plans, brochures for other plans, and other materials you need to make an informed decision about your FEHB coverage. These
materials tell you:
. When you may change your enrollment;
. How you can cover your family members;
. What happens when you transfer to another Federal agency, go on
leave without pay, enter military service, or retire;

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

employing or retirement office.
Types of coverage available Self Only coverage is for you alone. Self and Family coverage is for for you and your family you, your spouse, and your unmarried dependent children under age 22,
including any foster children or stepchildren your employing or retirement office authorizes coverage for. Under certain circumstances,
you may also continue coverage for a disabled child 22 years of age or older who is incapable of self-support.

If you have a Self Only enrollment, you may change to a Self and Family enrollment if you marry, give birth, or add a child to your family. You
may change your enrollment 31 days before to 60 days after that event. The Self and Family enrollment begins on the first day of the pay period
in which the child is born or becomes an eligible family member. When you change to Self and Family because you marry, the change is effective
on the first day of the pay period that begins after your employing office receives your enrollment form; benefits will not be available to your
spouse until you marry.
Your employing or retirement office will not notify you when a family member is no longer eligible to receive health benefits, nor will we.
Please tell us immediately when you add or remove family members from your coverage for any reason, including divorce, or when your child
under age 22 marries or turns 22.
If you or one of your family members is enrolled in one FEHB plan, that person may not be enrolled in or covered as a family member by another
FEHB plan.

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

2003 BlueCHOICE 60 Section 11 63.
63 Page 64 65
If this law applies to you, you must enroll for Self and Family coverage in a health plan that provides full benefits in the area where your children
live or provide documentation to your employing office that you have obtained other health benefits coverage for your children. If you do not
do so, your employing office will enroll you involuntarily as follows:
. If you have no FEHB coverage, your employing office will enroll
you for Self and Family coverage in the Blue Cross and Blue Shield Service Benefit Plan's Basic Option,

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

option of the same plan; or . if you are enrolled in an HMO that does not serve the area where the
children live, your employing office will change your enrollment to Self and Family in the Blue Cross and Blue Shield Service Benefit
Plan's Basic Option.
As long as the court/ administrative order is in effect, and you have at least one child identified in the order who is still eligible under the FEHB
Program, you cannot cancel your enrollment, change to Self Only, or change to a plan that doesn't serve the area in which your children live,
unless you provide documentation that you have other coverage for the children. If the court/ administrative order is still in effect when you
retire, and you have at least one child still eligible for FEHB coverage, you must continue your FEHB coverage into retirement (if eligible) and
cannot make any changes after retirement. Contact your employing office for further information.

When benefits and The benefits in this brochure are effective on January 1. If you joined premiums start this plan during Open Season, your coverage begins on the first day of
your first pay period that starts on or after January 1. Annuitants' coverage and premiums begin on January 1. If you joined at any other
time during the year, your employing office will tell you the effective date of coverage.

When you retire When you retire, you can usually stay in the FEHB Program. Generally, you must have been enrolled in the FEHB Program for the last five years
of your Federal service. If you do not meet this requirement, you may be eligible for other forms of coverage, such as temporary continuation of
coverage (TCC).
When you lose benefits
. When FEHB coverage ends You will receive an additional 31 days of coverage, for no additional
premium, when:

. Your enrollment ends, unless you cancel your enrollment, or
. You are a family member no longer eligible for coverage.
You may be eligible for spouse equity coverage or Temporary Continuation of Coverage.

. Spouse equity If you are divorced from a Federal employee or annuitant, you may not
coverage continue to get benefits under your former spouse's enrollment. This is the case even when the court has ordered your former spouse to supply

health coverage to you. But, you may be eligible for your own FEHB coverage under the spouse equity law or Temporary Continuation of
Coverage (TCC). If you are recently divorced or are anticipating a

2003 BlueCHOICE 61 Section 11 64.
64 Page 65 66

divorce, contact your ex-spouse's employing or retirement office to get RI 70-5, the Guide to Federal Employees Health Benefits Plans for
Temporary Continuation of Coverage and Former Spouse Enrollees, or other information about your coverage choices. You can also download
the guide from OPM's website, www. opm. gov/ insure.
. Temporary Continuation If you leave Federal service, or if you lose coverage because you no
of coverage (TCC) longer qualify as a family member, you may be eligible for Temporary Continuation of Coverage (TCC). For example, you can receive TCC if

you are not able to continue your FEHB enrollment after you retire, if you lose your job, if you are a covered dependent child and you turn 22
or marry, etc.
You may not elect TCC if you are fired from your Federal job due to gross misconduct.

Enrolling in TCC. Get the RI 79-27, which describes TCC, and the RI 70-5, the Guide to Federal Employees Health Benefits Plans for
Temporary Continuation of Coverage and Former Spouse Enrollees, from your employing or retirement office or from www. opm. gov/ insure.
It explains what you have to do to enroll.
. Converting to You may convert to a non-FEHB individual conversion policy if:
individual coverage . Your coverage under TCC or the spouse equity law ends (If you

canceled your coverage or did not pay your premium, you cannot convert.);

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

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

If you leave Federal service, your employing office will notify you of your right to convert. You must apply in writing to us within 31 days

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

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

Getting a Certificate of The Health Insurance Portability and Accountability Act of 1996 Group Health Plan Coverage (HIPAA) is a Federal law that offers limited Federal protections for
health coverage availability and continuity to people who lose employer group coverage. If you leave the FEHB Program, we will give you a
Certificate of Group Health Plan Coverage that indicates how long you have been enrolled with us. You can use this certificate when getting
health insurance or other health care coverage. Your new plan must reduce or eliminate waiting periods, limitations, or exclusions for health
related conditions based on the information in the certificate, as long as you enroll within 63 days of losing coverage under this Plan. If you have
been enrolled with us for less than 12 months, but were previously enrolled in other FEHB plans, you may also request a certificate from
those plans.

2003 BlueCHOICE 62 Section 11 65.
65 Page 66 67

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

2003 BlueCHOICE 63 Section 11 66.
66 Page 67 68

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.

2003 BlueCHOICE 64 Long Term Care Insurance 67.
67 Page 68 69
Index Do not rely on this page; it is for your convenience and may not show all pages where the terms appear.
Laboratory and pathological services 17, 34 Allergy tests 20 . Reconstructive 29 Syringes 42 Alternative treatment 47
Temporary continuation of coverage 61, 62, 63 Magnetic Resonance Imagings (MRIs) 17 Allogenetic (donor) bone marrow transplant 31
Transplants 31, 44 Mail order prescription drugs 41, 42, 66 Ambulance 33, 35, 38 Treatment therapies 21 Anesthesia 28, 30, 32, 34
Vision services 23 Mammograms 17 Autologous bone marrow transplant 21, 31 Well child care 18 Maternity benefits 19, 34
Blood and blood plasma 34 Wheelchairs 26 Medicaid 57 Casts 28, 34 Workers' compensation 55, 57 Medically necessary 13, 48, 59
X-rays 17, 34 Medicare 10, 53, 54, 55, 56, 64 Catastrophic protection 14, 67 Mental conditions/ substance
abuse benefits 10, 12, 39, 40 Changes for 2003 10 Chemotherapy 21, 31 Childbirth 44
Newborn care 18, 19, 23 Chiropractic 22, 27 Non-FEHB benefits 47 Cholesterol tests 17, 47
Nurse Claims 11, 15, 49, 50, 51, 52, 54 Licensed Practical Nurse 26 Coinsurance 14
Registered Nurse 19, 26, 44 Colorectal cancer screening 17 Nursery charges 19 Congenital anomalies 28, 29
Obstetrical care 19 Contraceptive devices and drugs 19 Occupational therapy 22 Coordination of benefits 53
Ocular injury 23 Covered charges 14 Office visits 16 Covered providers 8, 40
Oral and maxillofacial surgery 30 Crutches 25 Orthopedic devices 24 Deductible 14
Ostomy and catheter supplies 25 Definitions 58, 59 Out-of-pocket expenses 14 Dental care 30, 32, 46
Outpatient facility care 34 Diagnostic services 16, 17, 34, 39, 40 Oxygen 25, 26, 34
Pap test 17 Disputed claims review 51, 52 Physical examination 17, 18 Donor expenses (transplants) 31
Physical therapy 22 Dressings 34 Precertification 13, 36 Durable medical equipment
(DME) 25, 26, 43 Preventive care, adult 17, 18 Preventive care, children 18 Educational classes and programs 47
Prescription drugs 41, 42, 43, 50 Effective date of enrollment 11, 58, 61 Prior approval 13
Prostate cancer screening 17 Emergency 7, 9, 13, 36, 37, 38 Prosthetic devices 24 Experimental or investigational
48, 58, 59 Psychologist 39 Radiation therapy 21 Eyeglasses 23
Renal dialysis 21 Family planning 19 Room and board 33, 35 Fecal occult blood test 17
Fraud 5, 6 Second surgical opinion 16 Skilled nursing facility care 35 General Exclusions 48
Smoking cessation 27, 40, 47 Hearing services 23 Speech therapy 22 Home health services 26
Splints 34 Hospice care 35 Sterilization procedures 19, 29 Hospital 33, 34, 35, 36, 53
Subrogation 57 Immunizations 18 Substance abuse 12, 39, 40 Infertility 20
Surgery 28 Inhospital physician care 16 . Anesthesia 28, 32 Inpatient hospital benefits 33, 34
. Oral 30 Insulin 41, 42 . Outpatient 34

2003 BlueCHOICE 65 Index 68.
68 Page 69 70
Summary of benefits for BlueCHOICE 2003
. Do not rely on this chart alone. All benefits are provided in full unless indicated and are subject to the
definitions, limitations, and exclusions in this brochure. On this page we summarize specific expenses we cover; for more detail, look inside.

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

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

Benefits You Pay Page
Medical services provided by physicians:
. Diagnostic and treatment services provided in the office................. Office visit copay: $10 16

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

. Outpatient.........................................................................................
Nothing

$10 copay

33
34

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

. Out-of-area......................................................................................
$ 50 per emergency room visit

$ 50 per emergency room visit

37
37

Mental health and substance abuse treatment ..................................... Regular cost sharing 39
Prescription drugs.................................................................................

Mail order .............................................................................................
$7 generic $12 preferred brand name
$25 nonpreferred brand name

$14 generic $24 preferred brand name
$50 nonpreferred brand name

41

Dental Care....................................................................................... Preventive care only; $5 copay 46
Vision Care....................................................................................... Routine eye exam (one per
calendar year); $10 per office visit. Eyeglasses and contact

lenses are reimbursed up to $35 per 24-month period when
received from a BlueCHOICE vision care provider. In addition,
reduced-cost glasses or contact lenses are available from selected
providers.

23

2003 BlueCHOICE 66 Summary 69.
69 Page 70 71
Special features: . Flexible Benefits Option
. Services for deaf and hearing impaired .
Away From Home Care . Blue Quality

. RightSteps . .
TakeCharge . Asthma Program . TakeCharge . Diabetes Program

. Cardiovascular Education Program

44

Protection against catastrophic costs (your catastrophic protection out-of-pocket maximum) ................... After you pay 100% of your annual
premium in copayments for one family member (per person), or
100% of your annual premium for two or more family members (self
and family), you do not have to make any further payments for
certain services for the rest of the year. Some costs do not count
toward this protection.

14

2003 BlueCHOICE 67 Summary 70.
70 Page 71
2003 Rate Information for BlueCHOICE
Non-Postal rates apply to most non-Postal enrollees. If you are in a special enrollment category, refer to the FEHB Guide for that category or contact the agency that maintains your health benefits
enrollment.
Postal rates apply to career Postal Service employees. Most employees should refer to the FEHB Guide for United States Postal Service Employees, RI 70-2. Different postal rates apply and a
special FEHB guide is published for Postal Service Inspectors and Office of Inspector General (OIG) employees (see RI 70-2IN).

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

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

Self Only 9G1 $104. 71 $34.90 $226. 87 $75.62 $123. 90 $15.71
Self and Family 9G2 $226. 70 $75.56 $491. 18 $163. 72 $268. 26 $34.00

2003 BlueCHOICE 68 71.

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