PacifiCare Asia Pacific

Federal Employees Health Benefits Program
2003 Plan Brochure
Accessible Version

Pages 1--65

Page 1


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

2
PacifiCare Asia Pacific http:// www. pacificare. com
2003 A Health Maintenance Organization

Serving: The Island of Guam, the Commonwealth of the Northern Mariana Islands, and
the Republic of Belau (Palau)

Enrollment in this Plan is limited; you must live or work in our geographic service
area to enroll. See page 6 for requirements.

Enrollment codes for this Plan:
High Option JK1 Self only
JK2 Self and Family

Standard Option JK4 Self Only
JK5 Self and Family

RI 73-776

For changes
in benefits,
see page 7. 1.
1 Page 2 3
Dear Federal Employees Health Benefits Program Participant:
I am pleased to present this Federal Employees Health Benefits (FEHB) Program plan brochure for 2003. The brochure explains all the benefits this health plan offers to its enrollees. Since
benefits can vary from year to year, you should review your plan's brochure every Open Season. Fundamentally, I believe that FEHB participants are wise enough to determine the care
options best suited for themselves and their families.
In keeping with the President's health care agenda, we remain committed to providing FEHB members with affordable, quality health care choices. Our strategy to maintain quality and cost
this year rested on four initiatives. First, I met with FEHB carriers and challenged them to contain costs, maintain quality, and keep the FEHB Program a model of consumer choice and
on the cutting edge of employer-provided health benefits. I asked the plans for their best ideas to help hold down premiums and promote quality. And, I encouraged them to explore all
reasonable options to constrain premium increases while maintaining a benefits program that is highly valued by our employees and retirees, as well as attractive to prospective Federal
employees. Second, I met with our own FEHB negotiating team here at OPM and I challenged them to conduct tough negotiations on your behalf. Third, OPM initiated a comprehensive
outside audit to review the potential costs of federal and state mandates over the past decade, so that this agency is better prepared to tell you, the Congress and others the true cost of mandated
services. Fourth, we have maintained a respectful and full engagement with the OPM Inspector General (IG) and have supported all of his efforts to investigate fraud and waste within the
FEHB and other programs. Positive relations with the IG are essential and I am proud of our strong relationship.

The FEHB Program is market-driven. The health care marketplace has experienced significant increases in health care cost trends in recent years. Despite its size, the FEHB Program is not
immune to such market forces. We have worked with this plan and all the other plans in the Program to provide health plan choices that maintain competitive benefit packages and yet keep
health care affordable.
Now, it is your turn. We believe if you review this health plan brochure and the FEHB Guide you will have what you need to make an informed decision on health care for you and your
family. We suggest you also visit our web site at www. opm. gov/ insure.

Sincerely,

Kay Coles James Director 2.
2 Page 3 4
Notice of the Office of Personnel Managements
Privacy Practices

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

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

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

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

To communicate with your FEHB health plan when you or someone you have authorized to act on your
behalf asks for our assistance regarding a benefit or customer service issue.
To review, make a decision, or litigate your disputed claim.
For OPM and the General Accounting Office when conducting audits.

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

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

By law, you have the right to:
See and get a copy of your personal medical information held by OPM.
Amend any of your personal medical information created by OPM if you believe that it is wrong or if
information is missing, and OPM agrees. If OPM disagrees, you may have a statement of your disagreement
added to your personal medical information. 3.
3 Page 4 5
Get a listing of those getting your personal medical information from OPM in the past 6 years. The listing
will not cover your personal medical information that was given to you or your personal representative, any
information that you authorized OPM to release, or that was given out for law enforcement purposes or to
pay for your health care or a disputed claim.
Ask OPM to communicate with you in a different manner or at a different place (for example, by sending
materials to a P. O. Box instead of your home address).
Ask OPM to limit how your personal medical information is used or given out. However, OPM may not be
able to agree to your request if the information is used to conduct operations in the manner described above.
Get a separate paper copy of this notice.

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

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

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

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

By law, OPM is required to follow the terms in this privacy notice. OPM has the right to change the way your
personal medical information is used and given out. If OPM makes any changes, you will get a new notice by mail
within 60 days of the change. The privacy practices listed in this notice will be effective April 14, 2003. 4.
4 Page 5 6
5.
5 Page 6 7
2003 PacifiCare Asia Pacific 2 Table of Contents
Table of Contents
Introduction ...................................................................................................................................................................... 4
Plain Language .................................................................................................................................................................. 4
Stop Health Care Fraud!.................................................................................................................................................... 4
Section 1. Facts about this HMO plan ............................................................................................................................. 6
How we pay providers .................................................................................................................................... 6
Your Rights ..................................................................................................................................................... 6
Service Area.................................................................................................................................................... 6
Section 2. How we change for 2003 ................................................................................................................................ 7
Program-wide changes.................................................................................................................................... 7
Changes to this Plan........................................................................................................................................ 7
Section 3. How you get care ............................................................................................................................................ 8
Identification cards ......................................................................................................................................... 8
Where you get covered care ........................................................................................................................... 8
Plan providers........................................................................................................................................... 8
Plan facilities ............................................................................................................................................ 8
What you must do to get covered care........................................................................................................... 8
Primary care.............................................................................................................................................. 8
Specialty care............................................................................................................................................ 8
Hospital care........................................................................................................................................... 10
Circumstances beyond our control............................................................................................................... 10
Services requiring our prior approval .......................................................................................................... 10
Section 4. Your costs for covered services.................................................................................................................... 11
Copayments ............................................................................................................................................ 11
Deductible............................................................................................................................................... 11
Coinsurance ............................................................................................................................................ 11
Your catastropic protection out-of-pocket maximum ................................................................................. 11
Section 5. Benefits .......................................................................................................................................................... 12
Overview ....................................................................................................................................................... 12
(a) Medical services and supplies provided by physicians and other health care professionals .......... 13
(b) Surgical and anesthesia services provided by physicians and other health care professionals ...... 24
(c) Services provided by a hospital or other facility, and ambulance services ..................................... 28
(d) Emergency services/ accidents........................................................................................................... 32
(e) Mental health and substance abuse benefits ..................................................................................... 34
(f) Prescription drug benefits.................................................................................................................. 37
(g) Special features .................................................................................................................................. 39
Health Improvement
PacifiCare Health Centers 6.
6 Page 7 8
2003 PacifiCare Asia Pacific 3 Table of Contents
Sagua Managu Birthing Center
(h) Dental benefits ................................................................................................................................... 40
(i) Non-FEHB benefits available to Plan members............................................................................... 41
Section 6. General exclusions --things we don't cover ............................................................................................... 43
Section 7. Filing a claim for covered services............................................................................................................... 44
Section 8. The disputed claims process ......................................................................................................................... 45
Section 9. Coordinating benefits with other coverage .................................................................................................. 47
When you have other health coverage

What is Medicare ............................................................................................................................. 47
Medicare managed care plan........................................................................................................... 47
TRICARE and CHAMPVA............................................................................................................ 50
Worker's Compensation.................................................................................................................. 51
Medicaid........................................................................................................................................... 51
Other Government agencies ............................................................................................................ 51
When others are responsible for injuries................................................................................................ 51
Section 10. Definitions of terms we use in this brochure ............................................................................................. 52
Section 11. FEHB facts .................................................................................................................................................. 53

Coverage information
No pre-existing condition limitation ............................................................................................... 53
Where you get information about enrolling in the FEHB Program............................................... 53
Types of coverage available for you and your family.................................................................... 53
Children's Equity Act.................................................................................................................... 53
When benefits and premiums start.................................................................................................. 54
When you retire................................................................................................................................ 54
When you lose benefits
When FEHB coverage ends ............................................................................................................ 54
Spouse equity coverage ................................................................................................................... 54
Temporary Continuation of Coverage (TCC)................................................................................. 54
Converting to individual coverage .................................................................................................. 55
Getting a Certificate of Group Health Plan Coverage.................................................................... 55
Long term care insurance is still available ..................................................................................................................... 56
Index................................................................................................................................................................................. 57
Summary of benefits........................................................................................................................................................ 59
Rates................................................................................................................................................................... Back cover 7.
7 Page 8 9
2003 PacifiCare Asia Pacific 4 Introduction/ Plain Language/ Advisory
Introduction
This brochure describes the benefits of PacifiCare Health Plans under our contract (CS 2825) with the Office of
Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. The address for the
administrative offices is:

PacifiCare Health Insurance Company Micronesia
DBA PacifiCare Asia Pacific owned by PacifiCare Health Plans
P. O. Box 6578 Tamuning, Guam 96931

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

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

OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2003, and
changes are summarized on page 5. 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 PacifiCare Asia Pacific.

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 this brochure, let us know. Visit OPM's "Rate Us"
feedback area at www. opm. gov/ insure or e-mail us at fehbwebcomments@ opm. gov or write to OPM at 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: 8.
8 Page 9 10
2003 PacifiCare Asia Pacific 5 Introduction/ Plain Language/ Advisory
Be wary of giving your plan identification (ID) number over the telephone or to people you do not know, except
to your doctor, other provider, or authorized plan or OPM representative.

Let only the appropriate medical professionals review your medical record or recommend services.
Avoid using health care providers who say that an item or service is not usually covered, but they know how to
bill us to get it paid.
Carefully review explanations of benefits (EOBs) that you receive from us.
Do not ask your doctor to make false entries on certificates, bills or records in order to get us to pay for an item or
service.
If you suspect that a provider has charged you for services you did not receive, billed you twice for the same
service, or misrepresented any information, do the following:
Call the provider and ask for an explanation. There may be an error.
If the provider does not resolve the matter, call us at 1/ 671-647-3526 and explain the situation.
If we do not resolve the issue:

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

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

OR WRITE TO:
The United States Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street, NW, Room 6400
Washington, DC 20415 9.
9 Page 10 11
2003 PacifiCare Asia Pacific 6 Section 1
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and
other providers that contract with us. These Plan providers coordinate your health care services. The Plan is solely
responsible for the selection of these providers in your area. Contact the Plan for a copy of their most recent provider
directory.

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

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

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

How we pay providers
We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure. These
Plan providers accept a negotiated payment from us, and you will only be responsible for your copayments or
coinsurance. PacifiCare Health Insurance Company of Micronesia (PHICM), Inc. dba PacifiCare Asia Pacific is a
Mixed Model Plan. This means the doctors provide care in contracted medical centers or in their own offices.

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

PHICM, dba PacifiCare Asia Pacific, has met all the licensing requirements needed on Guam, in the
Commonwealth of the Northern Mariana Islands and the Republic of Belau (Palau) to conduct business as an
insurance company
PacifiCare has been operating on Guam for 28 years
We are a for-profit organization

If you want more information about us, call 1/ 671-647-3526 or write to PacifiCare at P. O. Box 6578, Tamuning,
Guam 96931. You may also contact us by fax at 1/ 671-646-6923 or visit our website at www. pacificare. com.

Service Area
To enroll in this Plan, you must live in or work in our Service Area. This is where our providers practice.
Our service area is: The Island of Guam, the Commonwealth of the Northern Mariana Islands and the Republic of
Belau (Palau).

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 health care services for members outside of our
service area unless the services have prior plan approval. Medicare beneficiaries may only receive services at a plan
participating Medicare contracted facility.

If you or a covered family member move outside of our service area, you should enroll in another plan. If your
dependents live out of the area (for example, if your child goes to college in the United States), you should consider
enrolling in a fee-for-service plan or an HMO that has agreements with affiliates in other areas. If you or a family
member move, you do not have to wait until Open Season to change plans. Contact your employing or retirement
office. 10.
10 Page 11 12
2003 PacifiCare Asia Pacific 7 Section 2
Section 2. How we change for 2003
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section
5 Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here
is a clarification that does not change benefits.

Program-wide changes
A Notice of the Office of Personnel Management's Privacy Practices is included.
A section on the Children's Equity Act describes when an employee is required to maintain Self and Family
coverage.
Program information on TRICARE and CHAMPVA explains how annuitants or former spouses may suspend
their FEHB Program enrollment.
Program information on Medicare is revised.

Changes to this Plan
Your share of the High Option non-Postal premium will decrease by 19.4% for Self only or 40.3% for Self and
Family.
Your share of the Standard Option non-Postal premium will decrease by 8.4% for Self only or 8.4% for Self and
Family. 11.
11 Page 12 13
2003 PacifiCare Asia Pacific 8 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it
whenever you receive services from a Plan provider, or fill a prescription
at a Plan pharmacy. Until you receive your ID card, use your copy of the
Health Benefits Election Form, SF-2809, your health benefits enrollment
confirmation (for annuitants), or your Employee Express confirmation
letter.

If you do not receive your ID card within 30 days after the effective date
of your enrollment, or if you need replacement cards, call us at
1-671-647-3526 or write to us at P. O. Box 6578 Tamuning, Guam
96931. You may also request replacement cards through our website at
www. pacificare. com

Where you get covered care You get care from "Plan providers" and "Plan facilities." You will only pay copayments, and/ or deductibles, and you will not have to file claims.
Medicare beneficiaries may only receive services at a plan participating
Medicare contracted facility.

Plan providers Plan providers are physicians and other health care professionals in our
service area that we contract with to provide covered services to our
members. We credential Plan providers according to national standards.
We list Plan providers in the provider directory, which we update
periodically. The list is also on our website.

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

What you must do It depends on the type of care you need. First, you and each family to get covered care member must choose a primary care physician. This decision is
important since your primary care physician provides or arranges for
most of your health care. In selecting a primary care physician, call the
PacifiCare Asia Pacific Customer Service Department at 1-671-647-
3526. You may have a different primary care physician for each family
member.

Primary care Your primary care physician can be a family practitioner, internist , or pediatrician for children under 18 years of age . 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.
You may change your primary care physician as often as once a month.
Your change to the new primary care physician will be effective on the
first of the following month.

Specialty care Your primary care physician will refer you to a specialist for needed care.
When you receive a referral from your primary care physician, you must
return to the primary care physician after the consultation, unless your
primary care physician authorized a certain number of visits without
additional referrals. The primary care physician must provide or 12.
12 Page 13 14
2003 PacifiCare Asia Pacific 9 Section 3
authorize all follow up care. Do not go to a specialist for return visits
unless your primary care physician gives you a referral.

However, for well-woman care, you may see an OB/ GYN within your
provider group without a referral.

You may access mental health care and behavioral health care through
your primary care physician for an initial consultation. You must return
to your primary care physician after your consultation with the specialist.
If your specialist recommends additional visits or services, your primary
care physician will review the recommendation and authorize the visits
or services as appropriate. You should not continue seeing the specialist
after the initial consultation unless your primary care physician and the
Plan's Medical Management Department has authorized the 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 at 1-671-647-3526
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. 13.
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2003 PacifiCare Asia Pacific 10 Section 3
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 1-671-647-3526. 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 hospital benefit of the hospitalized
person.

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

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

medically necessary, and follows generally accepted medical practice.
We call this review and approval process preauthorization. Your
physician must obtain preauthorization for the following services such as,
but not limited to:

All surgical procedures Audiological exams
Bone density studies CT scans
Growth Hormone Therapy (GHT) Hospitalization
MRIs Off-island referrals, consultations and procedures
Out-of-area hospitalization Plastic/ reconstructive consultation and procedures
Podiatry consultations and procedures Sleep studies
Specialty care Specialty care follow up (testing and procedures)
Other procedures including colonoscopy and endoscopy
Emergency services do not require preauthorization. However, you or
your family member must notify the Plan within 48 hours, or as soon as
is reasonably possible, in order for the services to be covered. 14.
14 Page 15 16
2003 PacifiCare Asia Pacific 11 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc. when you receive services.

Example: When you see your primary care physician you pay a
copayment of $10 per office visit for High Option and $15 per office
visit for Standard Option and when you go in the hospital, you pay
nothing per admission under High Option or $150 per admission under
Standard Option.

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

Example: When you need emergency care outside our service area,
under the Standard Option, you pay 20% of the first $500, then you are
responsible for all charges thereafter.

Your catastrophic protection After your copayments total $3000 per person and $6000 per family
out-of-pocket maximum for enrollment (Standard Option) and $1,000 per person or $3,000 per family
deductibles, coinsurance, and enrollment (High Option) in any calendar year, you do not have to pay
copayments any more for covered services. However, copayments for the following services do not count toward your out-of-pocket maximum, and you must

continue to pay copayments for these services:

Prescription Drugs Contraceptive Devices
Dental Services Vision Hardware
Chiropractic Services Other supplemental benefits
Payments made in excess of eligible charges Services not covered

Be sure to keep accurate records of your copayments since you are
responsible for informing us when you reach the maximum. 15.
15 Page 16 17
2003 PacifiCare Asia Pacific 12 Section 5
Section 5. Benefits OVERVIEW
(See page 7 for how our benefits changed this year and page 59 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. To obtain claims forms, claims filing advice, or more information about our benefits,
contact us at 1/ 671-647-3526 or at our website at www. pacificare. com/ asia pacific.

(a) Medical services and supplies provided by physicians and other health care professionals ..................................... 13-23

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

(b) Surgical and anesthesia services provided by physicians and other health care professionals................................. 24-27
Surgical procedures Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services................................................................ 28-31

Inpatient hospital Outpatient hospital or ambulatory surgical center Extended care benefits/ skilled nursing care facility benefits Hospice care
Ambulance
(d) Emergency services/ accidents ..................................................................................................................................... 32-33
Medical emergency Ambulance

(e) Mental health and substance abuse benefits ............................................................................................................... 34-36
(f) Prescription drug benefits ............................................................................................................................................ 37-38
(g) Special features ............................................................................................................................................................ 39
PacifiCare Health Centers( PHC) Urgent Care Center
Health Improvement Programs
(h) Dental benefits.............................................................................................................................................................. 40

(i) Non-FEHB benefits available to Plan members ......................................................................................................... 41-42

Summary of benefits............................................................................................................................................................ 59 16.
16 Page 17 18
2003 PacifiCare Asia Pacific 13 Section 5( a)
Section 5 (a) Medical services and supplies provided by physicians and
other health care professionals

I M
P O
R T
A N
T

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

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

coverage, including with Medicare.
Referrals to doctors or facilities not on Guam can only be made to those under contract to provide service off-island. A written referral must be made by a Plan provider and

approved by the PacifiCare Medical Management Department.

I
M P

O R
T A
N T

Benefit Description You pay
Diagnostic and treatment services You pay Standard Option You pay -High Option
Professional services of physicians
In physician's office
In an urgent care center
Office medical consultations
Second surgical opinion

$15 per office visit $10 per office visit

Physicians' house calls or visits by nurses and
health aides
Nothing Nothing

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

Nothing Nothing

Not covered:
Off-island care without prior authorization, except in the case of emergency All charges All charges 17.
17 Page 18 19
2003 PacifiCare Asia Pacific 14 Section 5( a)
Lab, X-ray and other diagnostic tests You pay Standard Option You pay -High Option
Tests such as:
Blood tests Urinalysis
Non-routine pap-tests
Pathology
Electrocardiogram and EEG

Nothing Nothing

X-rays
Non routine mammograms
Ultrasound
CT scans/ MRI (prior authorization required)

$15 per office visit in
addition to regular office
visit copay

$10 per office visit in
addition to regular
office visit copay

Preventive care, adult
Routine screenings, such as, but not limited to:
Total Blood Cholesterol once every three years

Colorectal Cancer Screening, including:
-Fecal occult blood test
-Sigmoidoscopy, screening every five years
starting at age 50

Routine Prostate Specific Antigen (PSA) test one
annually for men age 40 and older

Routine pap test
Routine mammogram covered for women age 35
and older, as follows:

From age 35 through 39, one during this five year period

From age 40 through 64, one every calendar year
At age 65 and older, one every two consecutive calendar years

Nothing
$15 copayment in addition
to your regular office visit
copay

Nothing
$10 copayment in
addition to your regular
office visit copay

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

All charges. All charges.

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

under Childhood immunizations)
Influenza vaccines, annually

Pneumococcal vaccine, age 65 and over

Nothing Nothing 18.
18 Page 19 20
2003 PacifiCare Asia Pacific 15 Section 5( a)
Preventive care, children You pay Standard Option You pay High Option
Childhood immunizations recommended by the American Academy of Pediatrics Nothing if included as part of office visit Nothing if included as part of office visit

Well-child care charges for routine examinations and care up to age 22, such as:
-Eye exams through age 17 to determine the
need for vision correction.

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

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

$15 per office visit $10 per office visit

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

All charges. All charges.

Maternity care
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 22 for other circumstances,

such as extended stays for you or your baby.

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

We cover routine nursery care of the newborn
child during the covered portion of the
mother's maternity stay. We will cover other
care of an infant who requires non-routine
treatment only if we cover the infant under a
Self and Family enrollment. The newborn
must be enrolled within 60 days of birth.

(Maternity Care Continued on next page)

$15 per office visit; $150
copay per admission for
inpatient services

$10 per office visit;
Nothing for inpatient
services 19.
19 Page 20 21
2003 PacifiCare Asia Pacific 16 Section 5( a)
Maternity care (Continued) You pay Standard Option You pay -High Option
Circumcisions are covered under Surgical Benefits. See section 5( b)
We pay hospitalization and surgeon services (delivery) the same as for illness and injury.
See Hospital benefits (Section 5c) and
Surgery benefits (Section 5b)

Note: We will cover labor and delivery at the
Sagua Managu Birthing Center at 100% for both
Standard Option and High Option. See "Special
Features", page 43.

$15 per office visit; $150
copay per admission for
inpatient services

Note: Delivery is covered under
inpatient services see section
5( c)

$10 per office visit;
Nothing for inpatient
services

Not covered:
Routine sonograms (ultrasound) to determine sex
All charges 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)
NOTE: We cover oral contraceptives and
diaphragms under the prescription drug benefit.

$15 per office visit
Note: Injectable
contraceptive drugs
require an additional
copay of $15.

$10 per office visit
Note: Injectable
contraceptive drugs
require an additional
copay of $15.

Not covered:
Reversal of voluntary surgical sterilization
Genetic counseling,

All charges. All charges. 20.
20 Page 21 22
2003 PacifiCare Asia Pacific 17 Section 5( a)
Infertility services You pay Standard Option You pay -High Option
Diagnosis and treatment of infertility, such as:
Artificial insemination: -intravaginal insemination (IVI)

-intracervical insemination (ICI)
Injectable Fertility drugs

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

50% of charges $10 per office visit

Not covered:
Assisted reproductive technology (ART) procedures, such as:

-in vitro fertilization
-embryo transfer, gamete GIFT, and zygote
ZIFT

-Zygote transfer
intrauterine insemination (IUI)

Services and supplies related to excluded ART procedures

Cost of donor sperm
Cost of donor egg

All charges. All charges.

Allergy care
Testing and treatment
Allergy injection
$15 per office visit. $10 per office visit

Allergy serum Nothing Nothing
Not covered:
Provocative food testing and sublingual allergy desensitization 21.
21 Page 22 23
2003 PacifiCare Asia Pacific 18 Section 5( a)
Treatment therapies You pay Standard Option You pay High Option
Chemotherapy and radiation therapy
Note: High dose chemotherapy in association
with autologous bone marrow transplants are
limited to those listed under Organ/ Tissue
Transplants on page 27.

Respiratory and inhalation therapy
Intravenous (IV)/ Infusion Therapy
Growth hormone therapy (GHT)

Note: We will only cover GHT when we
preauthorize the treatment. Call 1/ 671-646-6956
for prior authorization. We will ask you to
submit information that establishes that the GHT
is medically necessary. Ask us to authorize
GHT before you begin treatment; otherwise, we
will only cover GHT services from the date you
submit the information. If you do not ask or if
we determine GHT is not medically necessary,
we will not cover the GHT or related services and
supplies. See Services requiring our prior
approval in Section 3.

Note: We cover GHT drugs under the
Prescription Drug benefit

$15 per office visit; $150
copay per admission for
inpatient services

$10 per office visit;
Nothing for inpatient
services

Dialysis-hemodialysis and peritoneal dialysis Applies to hospital admission only $10 per office visit , nothing for inpatient
Physical and Occupational
Therapies

Up to two (2) consecutive months per condition for the services of each of the
following:
-qualified physical therapists;
-occupational therapists.

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

$15 per office visit
nothing for home visits
nothing during covered
inpatient hospitalization

$10 per office visit
nothing for home visits
nothing during covered
inpatient hospitalization

(Physical and Occupational Theraies continued
on next page). 22.
22 Page 23 24
2003 PacifiCare Asia Pacific 19 Section 5( a)
Physical and Occupational
Therapies (Continued)
You pay Standard Option You pay High Option

Not covered:
long-term rehabilitative therapy
exercise programs, lifestyle modification programs

equipment, supplies or customized devices related to rehabilitative therapies, except
those provided under Section 5( a) Durable
Medical Equipment

services provided by schools or government programs

All charges. All charges.

Cardiac Rehabilitation
Cardiac rehabiliation following a heart
transplant, bypass surgery or amyocardial
infarction, is provided for up to 90 days.

$15 per office visit
nothing for home visits
nothing during covered
inpatient hospitalization

$10 per office visit
nothing for home visits
nothing during covered
inpatient hospitalization

Speech Therapy
Unlimited services for the services of:
Qualified Speech Therapists

Note: All therapies are subject to medical necessity

$15 copayment per office visit;
Nothing during covered inpatient
hospitalization

$10 copayment per office visit
Nothing during covered inpatien
hospitalization

Hearing services (testing and
treatment)

Hearing testing and treatment for adults when medically indicated for other than
hearing aids
Hearing testing for children through age 17 (see Preventive care, children)

$15 per office visit $10 per office visit

Not covered:
All other hearing testing Hearing aids, testing and examinations for

them

All charges. All charges. 23.
23 Page 24 25
2003 PacifiCare Asia Pacific 20 Section 5( a)
Vision services (testing, treatment, and supplies) You pay Standard Option You pay High Option
Medical and surgical benefits for the diagnosis
and treatment of diseases of the eye
$15 per office visit $10 per office visit

Prescription eyeglasses or prescription
contact lenses
All charges above $100
at participating providers
All charges above $100 at
participating providers

Eye exam to determine the need for vision
correction for children through age 17 (see
Preventive care, children)

Annual eye refractions
Plan pays $30 maximum allowance towards
basic vision exams

Plan pays $50 maximum allowance towards
comprehensive exam

$15 per office visit and
all charges over the
Plan's maximum
allowance for a basic or
comprehensive exam

$10 per office visit and all
charges over the Plan's
maximum allowance for a
basic or comprehensive
exam

Not covered:
Eye exercises and orthoptics (vision therapy)
Radial keratotomy and other refractive
surgery such as LASIK surgery

All charges. All charges.

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

$15 per office visit $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. All charges. 24.
24 Page 25 26
2003 PacifiCare Asia Pacific 21 Section 5( a)
Orthopedic and prosthetic devices You pay -Standard Option You pay High Option
Externally worn breast prostheses and surgical bras, including necessary
replacements, following a mastectomy (up
to two surgical bras per benefit year)

Internal prosthetic devices such as pacemakers, stents, leads, intraocular lens

implants, cochlear implants and surgically
implanted breast implant following
mastectomy. Note: See Section 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.

$15 per office visit plus
an additional 20% of the
cost

$15 per office visit

$10 per office visit
$10 per office visit

Orthopedic devices, such as braces All charges -Benefits are not available under
Standard Option
$10 copayment per visit

Not covered:
Arch supports
Artificial eyes
Artificial joints and limbs
Braces and splints
Corsets, trusses, elastic stockings, support hose, stump hose and other supportive

devices
Foot orthotics
Heel pads and heel cups
Lumbosacral supports
Orthopedic and corrective shoes
Over-the-counter (OTC) items Prosthetic replacements provided less than 3

years after the last one we covered
Other internal prosthetics such as heart valves, automatic implantable cardioverter

defibrillator (AICD) and other implantable
devices not specified above

All charges. All charges. 25.
25 Page 26 27
2003 PacifiCare Asia Pacific 22 Section 5( a)
Durable medical equipment (DME) You pay -Standard Option You pay High Option
Rental or purchase, at our option, including
repair and adjustment, of durable medical
equipment prescribed by your Plan physician.
Under this benefit, we cover:

Manual hospital beds;
Standard manual wheelchairs;
Crutches/ walk aids;

Note: Call us at 1/ 671-647-3526 as soon as your Plan physician prescribes this
equipment. We will arrange with a health
care provider to rent or sell you durable
medical equipment at discounted rates and
will tell you more about this service when
you call.

All charges -Benefits are not available under
Standard Option
Any deposit required towards
rental or purchase.

Not covered:
Motorized wheel chairs
Glucose monitors

Insulin pumps
CPAP (Continuous Positive Airway Pressure)

BPAP (Bi-level Positive Airway Pressure)

All charges. All charges.

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.

Services include oxygen therapy, intravenous therapy and medications.

Services ordered by a physician for members who are
confined to the home.

Nursing
Physical therapy, speech therapy, occupational therapy, and respiratory therapy

Medical supplies included in the home health plan of care

(Home Health Services continued on next page)

Nothing. Nothing. 26.
26 Page 27 28
2003 PacifiCare Asia Pacific 23 Section 5( a)
Home health services (Continued) You pay -Standard Option You pay High Option
Not covered:
Nursing care requested by, or for the convenience of, the patient or the patient's

family;
Services primarily for personal assistance that does not include a medical component

and is not diagnostic, therapeutic or
rehabilitative.

All charges. All charges.

Chiropractic
Chiropractic services -You may self refer to a
participating chiropractor for up to 10 visits per calendar
year. Services are limited to:

Manipulation of the spine and
extremities

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

All charges above $25
.
All charges above $25

Alternative treatments
No b enefit All charges All charges
Educational classes and programs
Coverage is limited to programs administered
through the PacifiCare Health Center only:

Smoking Cessation
Diabetes management classes
Taking Charge of your Heart Health
Note: Please call the PacifiCare Customer
Service Department at 1-671-647-3526 to find
out if your class or program has a nominal
charge.

Some programs may
have a nominal
charge.

Note: Nicotine
replacement
prescription is
available at a $20
copayment

Some programs
may have a
nominal charge.

Note: Nicotine
replacement prescription
is available at a $20
copayment 27.
27 Page 28 29
2003 PacifiCare Asia Pacific 24 Section 5( b)
Section 5 (b). Surgical and anesthesia services provided by physicians and other health
care professionals

I M
P O
R T
A N
T

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 PREAUTHORIZATION OF ALL SURGICAL PROCEDURES. Please refer to the prior authorization information shown in Section 3 to be sure which services require

prior authorization and identify which surgeries require preauthorization
Referrals to doctors or facilities not on Guam can only be made to those under contract to provide service off-island. A written referral must be made by a Plan provider and approved by the PacifiCare

Medical Management Department

I M
P O
R T
A N
T

Benefit Description You pay
Surgical procedures You pay Standard Option You pay -High Option
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)

Circumcision
Insertion of internal prosthetic devices. Note: See 5( a) Orthopedic braces and prosthetic

devices for device coverage information
Surgical treatment of morbid obesity
Cardiac surgery for the implantation of stents, leads and pacemakers

Cardiac surgery for the implantation of valves

(Surgical procedures continued on next page)

$15 per office visit; $150
copay per admission for
inpatient services.

$10 per office visit;
Nothing for inpatient
services 28.
28 Page 29 30
2003 PacifiCare Asia Pacific 25 Section 5( b)
Surgical procedures (Continued) You pay Standard Option You pay -High Option
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. Plan pays for the cost of the insertion
only.

$15 per office visit; $150
copay per admission for
inpatient services.

$10 per office visit;
Nothing for inpatient
services.

Not covered:
Reversal of voluntary sterilization.
Routine treatment of conditions of the foot.

All charges. 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 toe

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

(Reconstructive surgery continued on next page)

$15 per office visit; $150
copay per admission for
inpatient services

$10 per office visit;
Nothing for
inpatient services 29.
29 Page 30 31
2003 PacifiCare Asia Pacific 26 Section 5( b)
Reconstructive surgery (Continued) You pay -Standard Option You pay -High Option
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 All charges

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; and

Other surgical procedures that do not involve the teeth or their supporting structures.
TMJ surgery and other related non-dental treatment

$15 per office visit;
$150 per admission for
inpatient services

$10 per office visit;
Nothing for
inpatient services

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

gingiva, and alveolar bone)

Other dental related services for treatment of TMJ

All charges. All charges. 30.
30 Page 31 32
2003 PacifiCare Asia Pacific 27 Section 5( b)
Organ/ tissue transplants You pay -Standard Option You pay High Option
Limited to:
Cornea
Heart
Kidney
Liver
Allogeneic (donor) bone marrow transplants

Autologous bone marrow transplants (autologous stem cell and peripheral stem cell

support) for the following conditions: acute
lymphocytic or non-lymphocytic leukemia;
advanced Hodgkin's lymphoma; advanced non-Hodgkin's
lymphoma; advanced
neuroblastoma; breast cancer; multiple
myeloma; epithelial ovarian cancer; and
testicular, mediastinal, retroperitoneal and
ovarian germ cell tumors

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

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

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

$15 per office visit; $150
copay per admission for
inpatient services

$10 per office visit;
Nothing for inpatient
services

Not covered:
Donor screening tests and donor search expenses, except those performed for the

actual donor
Implants of non-human or artificial organs

Transplants not listed as covered

Transportation, lodging and living expenses

All charges All charges

Anesthesia
Professional services provided in
Hospital (inpatient) Hospital outpatient department

Skilled nursing facility
Ambulatory surgical center Office

Nothing Nothing 31.
31 Page 32 33
2003 PacifiCare Asia Pacific 28 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility, and
ambulance services

I M
P O
R T
A N
T

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

medically necessary.
Plan physicians must provide or arrange your care and you must be hospitalized in a Plan facility.

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
The amounts listed below are for the charges billed by the facility (i. e., hospital or surgical center) or ambulance service for your surgery or care. Any costs

associated with the professional charge (i. e., physicians, etc.) are covered in
Section 5( a) or (b).

YOUR PHYSICIAN MUST GET PREAUTHORIZATION OF HOSPITAL STAYS. Please refer to Section 3 to be sure which services require

precertification.
Referrals to doctors or facilities not on Guam can only be made to those under contract to provide service off-island. A written referral must be made by a Plan

provider and approved by the PacifiCare Medical Management Department.

I M
P O
R T
A N
T

Benefit Description You pay
Inpatient hospital You pay Standard Option You pay -High Option

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.

(Inpatient hospital continued on next page)

$150 copay per admission Nothing

. 32.
32 Page 33 34
2003 PacifiCare Asia Pacific 29 Section 5( c)
Inpatient hospital (Continued) You pay Standard Option You pay -High Option
Other hospital services and supplies, such as:
Operating, recovery, maternity and other treatment rooms

Prescribed drugs and medicines
Diagnostic laboratory tests, x-rays and pathology tests

Administration of blood and blood products
Facility fees, including, but not limited to dressings, splints, casts, and sterile tray services

Medical supplies and equipment, including oxygen
Anesthetics, including nurse anesthetist services
Rehabilitative therapies See 5( a) for benefit limitations.

Nothing Nothing

Not covered:
Any inpatient dental procedure
Blood and blood products, whether synthetic or natural

Custodial care
Internal prosthetics except for those covered under Section 5( a) Prosthetic and Orthopedic

Devices.
Medical supplies, appliances, medical equipment, and any covered items billed by a

hospital for use at home
Non-covered facilities, such as nursing homes, schools

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

Take-home items

All charges. All charges. 33.
33 Page 34 35
2003 PacifiCare Asia Pacific 30 Section 5( c)
You pay -Standard Option You pay -High Option
Operating, recovery, and other treatment rooms

Diagnostic laboratory tests, and pathology services
Administration of blood, blood plasma, and other biologicals
Pre-surgical testing
Anesthetics and anesthesia service
Facility fees, including but not limited to, dressings, splints, casts, sterile tray services

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

Diagnostic mammograms
Ultrasound
CT scans/ MRI (prior authorization required)
X-rays

$15 per office visit
$150 per hospital
admission

$15 per office visit in
addition to regular
office visit copay

$10 per office visit
Nothing for inpatient
hospitalization

$10 per office visit in
addition to regular
office visit copay

Not covered:
Blood and blood products, whether synthetic or natural All charges All charges

Skilled nursing care facility benefits
The Plan provides a comprehensive range of benefits
when full-time skilled nursing care and confinement
in a skilled nursing facility is medically appropriate
as determined by a Plan doctor and approved by the
Plan.

Standard Option 60 days per calendar year
High Option 100 days per calendar year
All necessary services are covered, including:
Bed, board and general nursing care
Drugs, biologicals, supplies, and equipment ordinarily provided or arranged by the skilled

nursing facility when prescribed by a Plan
doctor.

Nothing Nothing

Outpatient hospital or ambulatory surgical center

(Skilled nursing care facility benefits continued
on next page) 34.
34 Page 35 36
2003 PacifiCare Asia Pacific 31 Section 5( c)
Skilled nursing care facility benefits (Continued) You pay -Standard Option You pay -High Option
Not covered:
blood and blood products, whether synthetic or natural

custodial care

All charges All charges

Hospice care
Supportive and palliative care for a terminally ill
member is covered in the home or hospice facility
when approved by the Plan's Medical Management
Department. Services are provided under the
direction of a Plan doctor who certifies that the
patient is in the terminal stages of illness, with a
life expectancy of approximately six months or
less.

Services include
inpatient and outpatient care
family counseling
Note: This benefit is limited to a maximum of up
to 180 days per lifetime.

Nothing Nothing

Not covered:
Independent nursing
Homemaker services

All charges All charges

Ambulance
Local ground ambulance service when medically appropriate.

Not covered:
Transports that we determine are not medically necessary.

Air ambulance services

Nothing
All charges.
Nothing
All charges. 35.
35 Page 36 37
2003 PacifiCare Asia Pacific 32 Section 5( d)
Section 5 (d). Emergency services/ accidents
I M
P O
R T
A N
T

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

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

What to do in case of emergency?
In a life or limb threatening emergency, call 911 or go to the nearest hospital emergency room or other facility for
treatment. You do not need authorization from your primary care physician (PCP) before you go. True emergency
is covered no matter where you are.

Emergencies within our service area: If you are in our service area and receive emergency care that results in your hospitalization, notify your PCP on the first business day following your admission, so that he or she can

coordinate any follow-up treatment.
When you need urgent care while you are in our service area, call your PCP. Your PCP can assess the situation and
decide what type of care you need. Ask your PCP about after-hours and "on-call" procedures now, before you need
these services. If your PCP's office is closed, you may access the PHC Urgent Care Center.

Emergencies outside the service area: If you receive emergency or urgent care outside our service area, you must contact the PacifiCare Customer Service Department on 1 671-647-3526 within 48 hours, unless it was not

reasonably possible to do so, to let us know what has happened and where you went for care; otherwise, your care
will not be covered We may arrange for your transfer to a Plan facility as soon as it is medically appropriate to do
so.

When you have to file a claim: Please refer to Section 7 for information on how to file a claim, or contact our Customer Service Department at 1-671-647-3526.

Note: We do not coordinate benefits for outpatient prescription drugs.

Emergency services benefits begin on next page 36.
36 Page 37 38
2003 PacifiCare Asia Pacific 33 Section 5( d)
Benefit Description You pay
Emergency within our service area You pay -Standard Option You pay -High Option

Emergency care at a doctor's office
Urgent care at PacifiCare Health Center (PHC)
$15 per office visit $10 per office visit

Emergency care in a hospital emergency room $75 per emergency room visit and all
charges after $500
Note: We will waive the
$75 copay if you are
admitted in the hospital.

$50 per emergency room
visit and all charges after
$500

Note: We will waive the
$50 copay if you are
admitted in the hospital

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
20% of the first $500 of
charges and all charges
after $500 per visit

Note: If emergency
results in admission to the
hospital, only the $150
copay applies.

$50 per visit and all
charges after $500 per
visit

Note: If emergency
results in admission to the
hospital, the $50 copay is
waived.

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

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

the service area

All charges. All charges.

Ambulance
Ground ambulance service when medically
necessary.

See 5( c) for non-emergency service.

Nothing Nothing

Not covered:
air ambulance services
transport that we determine is not medically necessary

All charges. All charges. 37.
37 Page 38 39
2003 PacifiCare Asia Pacific 34 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
I M
P O
R T
A N
T

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

Here are some important things to keep in mind about these benefits:
All benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary. Access to services must

be through our behavioral health network managers.
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.

I M
P O
R T
A N
T

Description You pay
Mental health and substance abuse benefits You pay Standard Option You pay -High Option

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.

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

Medication management
Diagnosis and treatment of psychiatric conditions,
mental illness or disorders of children, adolescents,
and adults: Outpatient services include:

Diagnostic tests crisis intervention and stabilization for acute
episodes

Psychological testing necessary to determine appropriate psychiatric treatment

Psychiatric treatment (including individual and group therapy visits)
Medication evaluation and management

(Mental health and substance abuse benefit continued on
next page)

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

Your cost sharing
responsibilities are
no greater than for
other illness or
conditions. 38.
38 Page 39 40
2003 PacifiCare Asia Pacific 35 Section 5( e)
Mental health and substance abuse benefit (Continued) You pay Standard Option You pay -High Option
Diagnosis and treatment of alcoholism and drug abuse.
Outpatient services include:

Detoxification (the withdrawal process from physically-addictive drugs and/ or alcohol when

withdrawal is likely to cause medical or life-threatening
complications)

Treatment and counseling (including individual and group
therapy visits)

$15 per office visit $10 per office visit

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

Day treatment programs for substance abuse

$150 copayment per
admission
Nothing

Not covered:
Services we have not approved Evaluation or therapy on court order or as a condition of

parole or probation, or otherwise required by the
criminal justice system, unless determined by a Plan
physician to be medically necessary and appropriate

All charges. All charges

Preauthorization To be eligible to receive these enhanced mental health and substance abuse benefits you must follow your treatment plan and all of our network
authorization processes. Please call 1/ 671-647-3526 for more information.

Special transitional benefit If a mental health or substance abuse professional provider is treating you under our plan as of January 1, 2003, you will be eligible for continued coverage with
your provider for up to 90 days under the following conditions:
If your mental health or substance abuse professional provider with whom you are currently in treatment leaves the plan at our request for other than cause.

If this condition applies to you, we will allow you reasonable time to transfer your care to a Plan mental health or substance abuse professional provider. During the
transitional period, you may continue to see your treating provider. This transitional period will begin with our notice to you of the change in coverage and will end 90
days after you receive our notice. If we write to you before October 1, 2003, the 90-day period ends before January 1 and this transitional benefit does not apply. 39.
39 Page 40 41
2003 PacifiCare Asia Pacific 36 Section 5( e)
Network limitation We may limit your benefits if you do not obtain a treatment plan.
How to submit network claims If you have out-of-pocket expenses for covered services, PacifiCare will reimburse you for those allowable charges, minus any applicable co-payments.
You should contact the PacifiCare Customer Service
Department at 1/ 671-647-3526 and provide PacifiCare with a copy of your
bill, your proof of payment and a brief description of what happened. 40.
40 Page 41 42
2003 PacifiCare Asia Pacific 37 Section 5( f )
Section 5 (f). Prescription drug benefits
I
M
P
O
R
T
A
N
T

Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart beginning on 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.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with
other coverage, including with Medicare.

I
M
P
O
R
T
A
N
T

There are important features you should be aware of. These include:
Who can write your prescription. A licensed physician must write the prescription
Where you can obtain them. You must fill the prescription at a plan pharmacy or through the Plan's mail-order program

We use a formulary. The PacifiCare Formulary is a list of over 1600 prescription drugs that Plan physicians use as a guide when prescribing medications for patients. The Formulary plays an
important role in providing safe, effective and affordable prescription drugs to PacifiCare members.
It also allows us to work together with physicians and pharmacies to ensure that our members are
getting the drug therapy they need. A Pharmacy and Therapeutics Committee consisting of Plan
physicians and pharmacists evaluate prescription drugs based on safety, effectiveness, quality
treatment and overall value. The committee considers first and foremost the safety and
effectiveness of a medication before reviewing the cost. PacifiCare physicians will request prior
authorization for some non-formulary drugs. A Plan physician may initiate the prior authorization
request simply by phoning or faxing in the request. Requests are generally processed within ten
minutes although a few require up to 2 working days when additional information is needed from
the physician.

These are the dispensing limitations. Prescription drugs will be dispensed for up to a 30-day supply or one commercially prepared unit per copay (i. e., one inhaler, one vial of ophthalmic

medication, one tube of ointment, one vial of insulin). For drugs that could be habit forming, the
prescription unit is set at a smaller quantity for the protection and safety of our members.

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,
and your physician has not specified Dispense as Written for the name brand drug, you have to pay
the non-formulary copay.

Prescription drugs can also be obtained through the mail order program for up to a 90 day supply of oral
medication; 6 vials of insulin; or 3 commercially prepared units (i. e., inhaler, vials ophthalmic
medication or topical ointments or creams). Call 1( 800) 531-3341 for mail order customer service.

Why use generic drugs? To reduce your out-of-pocket expenses! A generic drug is the chemical equivalent of a corresponding brand name drug. Generic drugs are less expensive than brand name

drugs; therefore, you may reduce your out-of-pocket costs by choosing to use a generic drug.
When you have to file a claim: Please refer to Section 7 for information on how to file a pharmacy claim, or contact our Customer Service Department at 1-671-647-3526.

(Prescription drug benefits begin on the next page) 41.
41 Page 42 43
2003 PacifiCare Asia Pacific 38 Section 5( f )
Benefit Description You pay
Covered medications and supplies You pay -Standard Option You pay -High Option
We cover the following medications and supplies
prescribed by a Plan physician and obtained from a Plan
pharmacy or through our mail order program:

Drugs and medicines that by Federal law of the United States require a physician's prescription for their
purchase, except those listed as Not covered.
Insulin, copay charged to each vial Disposable needles and syringes for the administration

of covered medications; lancets
Oral contraceptive drugs (Injectable and implantable contraceptive drugs are covered under

Section 5( a) Family Planning)
Contraceptive diaphragms

Growth hormone

Drugs for sexual dysfunction are covered when Plan criteria is met. Contact Plan for dose limits.

Fertility drugs

$5 for each generic or
brand formulary
prescription unit or
refill

$20 for each non-formulary
prescription
unit or refill

$5 each
50% per prescription unit or
refill up to the dosage limits
and all charges above that
limit

50% per prescription unit or
refill up to the dosage limits
and all charges above that
limit

$5 for each generic or
brand formulary
prescription unit or
refill

$20 for each non-formulary
prescription
unit or refill

$5 each
50% per prescription unit or
refill up to the dosage limits
and all charges above that
limit

Nothing

Not covered:
Drugs and supplies for cosmetic purposes
Vitamins, nutrients and food supplements even if a physician prescribes or administers

them unless listed in the Formulary
Non-prescription medicines

Drugs obtained at a non-Plan pharmacy
Drugs to enhance athletic performance
Medical supplies (such as dressing and antiseptics)

Hospital take-home drugs
Weight loss medications including anorexients, anti-obesity agents, appetite
suppressants or anorexiogenic agents

All charges. All charges. 42.
42 Page 43 44
2003 PacifiCare Asia Pacific 39 Section 5( g)
Section 5 (g). Special Features
Feature Description

PacifiCare Health
Center -Urgent Care
Center

Extended care hours are available to Plan members. If your primary
care physician's clinic is closed, you may avail of the PHC's Urgent
Care services.

Health Improvement
Programs

The following programs are available to members at the PacifiCare
Health Center only:

Taking Charge of Diabetes: a self-directed intervention program that
addresses both self-care and lifestyle areas. The major components
are interactive member materials, telephonic support, and provider
reporting.

Taking Charge of Your Heart Health: a self directed lifestyle
management program focusing on behavior modification with diet,
exercise, stress, tobacco use and self-care.

Stop Smoking Program: highly effective self-paced smoking
cessation program designed to meet individual needs. The major
components are counselor support and interactive member materials.
This program requires a $20 copayment for materials and a $20
copayment for a nicotine replacement prescription.

Senior Member Health Questionnaire: a program designed to
identify patient health needs and positively affect their overall health.

Sagua Managu
Birthing Center

Labor and delivery is covered at 100%. 43.
43 Page 44 45
2003 PacifiCare Asia Pacific 40 Section 5( h)
Section 5 (h). Dental benefits
I M
P O
R T
A N
T

Plan dentists must provide or arrange your care.
We cover hospitalization for dental procedures only when a nondental physical impairment exists which makes hospitalization necessary to safeguard the health of the patient; we do not cover the

dental procedure unless it is described below.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with
Medicare.
Dental services are limited to $1, 500 plan maximum per member per benefit year (High Option and Standard Option).

I M
P O
R T
A N
T

Emergency Care for Accidental Dental Injury You Pay (High Option and
Standard Option)

We cover restorative services and supplies necessary to promptly repair (but not replace) sound natural teeth. The
need for these services must result from an accidental injury. You pay nothing. If you are outside the service area
and receive services from a non-plan dentist, we will reimburse you up to $100.00

Dental Benefits
Service You pay

(Standard Option)
You pay
(High Option)
OFFICE VISIT
X-rays, including bitewings (once a year) and panoramic
(once every three years) oral examination and treatment
plan; vitality test; and oral cancer exam

PREVENTIVE SERVICES
Prophylaxis (once every 6 month); sealants (up to age
12); annual topical application of fluoride (up to age 12);

RESTORATIVE DENTISTRY
Amalgam -one, two or three surfaces; composite--one or
two surfaces anterior only

SIMPLE EXTRACTIONS
Simple extraction for fully erupted teeth only

PROSTHODONTICS
Full and partial dentures; crowns and bridges; repair;
relining and/ or reconstruction of dentures

Nothing
Nothing
All charges
All charges
All charges

Nothing
Nothing
20% of covered charges
20% of covered charges
75% of covered charges 44.
44 Page 45 46
2003 PacifiCare Asia Pacific 41 Section 5( i)
Section 5( i). Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed
claim about them. Fees you pay for these services do not count toward FEHB deductibles or out-of-pocket maximums.

Supplemental Dental Coverage
PacifiCare Asia Pacific offers a dental plan to supplement the dental coverage provided in the PacifiCare FEHBP plan
option you have selected. Enrollment in the supplemental dental coverage will supersede your FEHB dental coverage.
The supplemental dental plan covers services provided by participating dental providers and provides coverage as
follows:

Service You pay
DIAGNOSTIC SERVICE
Routine x-rays (full mouth series are limted to once every
three years and include eighteen x-rays or four bitewings,
two Pas and a panograph), clinical examination and other
diagnostic treatment planning (exams are limited to one
per benefit year for members 12 and older).

Nothing

PREVENTIVE SERVICE
Routine teeth cleaning (prophylaxis), and fluoride
treatment and sealants for children up to the age of 12

Nothing

RESTORATIVE SERVICE
Routine fillings (silver amalgam and anterior composite
second bicuspid to second bicuspid). Posterior composites
are not covered, however an allowance for a comparable
silver almagam restoration will be made. The difference in
fees is the member's responsibility

Nothing

SIMPLE EXTRACTIONS
Simple non-surgical extractions of fully erupted teeth
only. Extractions solely for the purpose of orthodontic
treatment are not covered. Surgical extractions of
unerupted or impacted teeth and general anesthesia are
not covered.

Nothing

ENDODONTICS
Root canal fillings, pulp treatment.
50% of covered charges 45.
45 Page 46 47
2003 PacifiCare Asia Pacific 42 Section 5( i)
Service You pay
PERIODONTICS
Consultation, evaluation, and treatment of soft tissue and
bones supporting teeth, subgingival curettage, gross
Scaling, subgingival scaling and root planing, periodontal
maintenance (applicable only to member's undergoing or
who have completed periodontal treatment) and
periodontal surgery.

50% of covered charges

PROSTHODONTICS
Full and partial dentures; repairs, relining and/ or
reconstruction of dentures. Porcelain and/ or gold crowns
and bridges, space maintainers, resin and stainless steel
crowns. Occlusal guards are not covered.

50% of covered charges

Dental Plan Maximum
The supplemental dental plan will pay a maximum of
$1,500 per member per calendar year.

For more details on the coverage and cost of the supplemental dental plan and how to enroll, call 1/ 671-647-
3526. 46.
46 Page 47 48
2003 PacifiCare Asia Pacific Section 6
Section 6. General exclusions --things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a
benefit, we will not cover it unless your Plan doctor determines it is medically necessary to
prevent, diagnose, or treat your illness, disease, injury or condition and we agree, as discussed
under What Services Require Our Prior Approval on page 10. We do not cover the following:

Care by non-Plan providers except for authorized referrals or emergencies (see Emergency Benefits)

Services, drugs, or supplies you receive while you are not enrolled in this Plan;
Services, drugs, or supplies that are not medically necessary;
Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice;

Experimental or investigational procedures, treatments, drugs or devices;
Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of

rape or incest;
Services, drugs, or supplies related to sex transformations; or
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program.

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

43 47.
47 Page 48 49
2003 PacifiCare Asia Pacific 44 Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at
Plan pharmacies, you will not have to file claims. Just present your identification card and pay your copayment,, or
deductible.

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

Medical, hospital and drug In most cases, providers and facilities file claims for you. Physicians
benefits 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/ 671-647-3526.

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

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

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

Receipts, if you paid for your services.
Submit your claims to: P. O. Box 6578
Tamuning, Guam 96931

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. 48.
48 Page 49 50
2003 PacifiCare Asia Pacific 45 Section 8
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on
your claim or request for services, drugs, or supplies including a request for prior authorization:

Step Description

1 Ask us in writing to reconsider our initial decision. You must: Write to us within 6 months from the date of our decision; and
Send your request to us at: P. O. Box 6578, Tamuning, Guam 96931; and
Include a statement about why you believe our initial decision was wrong, based on specific
benefit provisions in this brochure; and

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

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

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

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

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

(a)
(b)
(c)

(d) 49.
49 Page 50 51
2003 PacifiCare Asia Pacific 46 Section 8
The Disputed Claim Process (Continued)
Send OPM the following information:
A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;

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

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

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

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

5 OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct. OPM will send you a final decision within 60 days. There are no other administrative appeals.
If you do not agree with OPM's decision, your only recourse is to sue. If you decide to sue, you must file
the suit against OPM in Federal court by December 31 of the third year after the year in which you received
the disputed services, drugs 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 their disputed claim
decision. This information will become part of the court record.

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

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

(a) We haven't responded yet to your initial request for care or prior authorization/ prior approval, then call us at
1/ 671-647-3526 and we will expedite our review; or

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

You can call OPM's Health Benefits Contracts Division 3 at 202/ 606-0737 between 8 a. m. and 5 p. m. eastern time. 50.
50 Page 51 52
2003 PacifiCare Asia Pacific 47 Section 9
Section 9. Coordinating benefits with other coverage
When you have other health coverage You must tell us if you or a covered family member have coverage under another group health plan or have automobile insurance that pays health
care expenses without regard to fault. This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in full as the primary payer and the other plan pays a reduced benefit as the
secondary payer. We, like other insurers, determine which coverage is primary according to the National Association of Insurance
Commissioners' guidelines.
When we are the primary payer, we will pay the benefits described in this brochure.

When we are the secondary payer, we will determine our allowance. After the primary plan pays, we will pay what is left of our allowance, up
to our regular benefit. We will not pay more than our allowance.
What is Medicare? Medicare is a Health Insurance Program for: People 65 years of age and older.

Some people with disabilities, under 65 years of age.
People with End-State 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 (Part A or Part B) The Original Medicare Plan (Original Medicare) is available everywhere
in the United States. It is the way everyone used to get Medicare benefits and is the way most people get their Medicare 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 in enrolled Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care.
Your care must continue to be authorized by your Plan PCP, or preauthorized as required.

We will not waive any of our copayments and coinsurance. 51.
51 Page 52 53
2003 PacifiCare Asia Pacific 48 Section 9
Claims process when you have the Original Medicare Plan -You
probably will never have to file a claim form when you have both
our Plan and the Original Medicare Plan.

When we are the primary payer, we process the claim first.
When Original Medicare is the primary payer, Medicare processes
your claim first. In most cases, your claims will be coordinated
automatically and we will pay the balance of covered charges. You
will not need to do anything. To find out if you need to do something
about filing your claims, call us at 1/ 671-647-3526 or visit our web
site at www. pacificare. com

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

(Primary payer chart begins on next page.) 52.
52 Page 53 54
2003 PacifiCare Asia Pacific 49 Section 9
The following chart illustrates whether the Original Medicare Plan or this Plan should be the primary payer for you
according to your employment status and other factors determined by Medicare. It is critical that you tell us if you or
a covered family member has Medicare coverage so we can administer these requirements correctly.

Primary Payer Chart
Then the primary payer is A. When either you --or your covered spouse --are age 65 or over and

Original Medicare This Plan
1) Are an active employee with the Federal government (including when you or
a family member are eligible for Medicare solely because of a disability),

2) Are an annuitant,
a) Are a reemployed annuitant with the Federal government when

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

3) 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),

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

(for other
services)

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

(except for claims
related to Workers'
Compensation.)

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

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

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

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

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

a) Are an annuitant, or

b) Are an active employee, or
c) Are a former spouse of an annuitant
d) Are a former spouse of an active employee 53.
53 Page 54 55
2003 PacifiCare Asia Pacific 50 Section 9
Medicare managed care plan If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare Managed Care Plan. These are health
care choices (like HMOs) in some areas of the country. In most
Medicare managed care plans, you can only go to the 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, but we will not waive any
of our copayments, coinsurance, or deductibles. If you enroll in a
Medicare managed care plan, tell us. We will need to know whether you
are in the Original Medicare Plan or in a Medicare managed care plan so
we can correctly coordinate benefits with Medicare.

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

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

TRICARE and CHAMPVA TRICARE is the health care program for eligible dependents of military persons and retirees of the military. TRICARE includes the CHAMPUS
program. CHAMPVA provides health coverage to disabled Veterans and
their eligible dependents. If both TRICARE or CHAMPVAand 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 one of theses 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. 54.
54 Page 55 56
2003 PacifiCare Asia Pacific 51 Section 9
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.

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 care
for injuries 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. 55.
55 Page 56 57
2003 PacifiCare Asia Pacific 52 Section 10
Section 10. Definitions of terms we use in this brochure
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on
December 31 of the same year.

Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. See page 22

Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 12
Covered services Care we provide benefits for, as described in this brochure.
Custodial Care Day to day care that can be provided by a non-medical individual. Custodial care that lasts longer than 90 days may be considered Long
Term Care

Deductible A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for
those services. See page 11.

Experimental or Our National and Regional Medical Committees determine whether or
Investigational services not treatments, procedures and drugs are no longer considered experimental or investigational. Our determinations are based on the

safety and efficacy of new medical procedures, technologies, devices and
drugs.

Medical necessity Medical necessity refers to medical services or hospital services which are determined by us to be:

Rendered for the treatment or diagnosis of an injury or illness; and
Appropriate for the symptoms, consistent with diagnosis, and
otherwise in accordance with sufficient scientific evidence and
professionally recognized standards; and
Not furnished primarily for the convenience of the member, the
attending physician, or other provider of service; and
Furnished in the most economically efficient manner which may be
provided safely and effectively to the Member.

Plan allowance Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. Plans determine their allowances in
different ways. We determine our allowance by our contracted rate with
the participating provider. If the charges exceed our contracted rate, you
will be responsible for the excess over the allowance in addition to your
coinsurance

Us/ We Us and we refer to PacifiCare Asia Pacific
You You refers to the enrollee and each covered family member. 56.
56 Page 57 58
2003 PacifiCare Asia Pacific 53 Section 11
Section 11. FEHB facts
No pre-existing condition We will not refuse to cover the treatment of a condition that you had
limitation before you enrolled in this Plan solely because you had the condition before you enrolled.

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

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

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

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

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

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

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

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

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

If this law applies to you, you must enroll for Self and Family coverage in a health plan
that provides full benefits in the area where your children live or provide documentation
to your employing office that you have obtained other health benefits coverage for your
children. If you do not do so, your employing office will enroll you involuntarily as
follows: 57.
57 Page 58 59
2003 PacifiCare Asia Pacific 54 Section 11
If you have no FEHB coverage, your employing office will enroll you for Self and Family coverage in the Blue Cross and Blue Shield Service Benefit Plan's Basic
Option;
if you have a self only enrollment in a fee-for-service plan or in an HMO that serves the area where your children live, your employing office will change your enrollment

to Self and Family in the same option of the same plan; or
if you are enrolled in an HMO that does not serve the area where the children live, your employing office will change your enrollment to Self and Family in the Blue

Cross and Blue Shield Service Benefit Plan's Basic Option.
As long as the court/ administrative order is in effect, and you have at least one child
identified in the order who is still eligible under the FEHB Program, you cannot cancel
your enrollment, change to self only, or change to a plan that doesn't serve the area in
which your children live, unless you provide documentation that you have other coverage
for the children. If the court/ administrative order is still in effect when you retire, and
you have at least one child still eligible for FEHB coverage, you must continue your
FEHB coverage into 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 this Plan during
premuim start Open Season, your coverage and premiums begin on the first day of your first pay period that starts on or after January 1. Annuitants' coverage and premiums begin on January 1.

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

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

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

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

when the court has ordered your former spouse to supply health coverage to you. But,
you may be eligible for your own FEHB coverage under the spouse equity law or
Temporary Continuation of Coverage (TCC). If you are recently divorced or are
anticipating a divorce, contact your ex-spouse's employing or retirement office to get RI
70-5, the Guide to Federal Employees Health Benefits Plans for Temporary Continuation
of Coverage and Former Spouse Enrollees, or other information about your coverage
choices. You can also download a guide from OPM's website, www. opm. gov/ insure

Temporary Continuation If you leave Federal service, or if you lose coverage because you no longer qualify as a of Coverage 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. 58.
58 Page 59 60
2003 PacifiCare Asia Pacific 55 Section 11
Enrolling in TCC. Get the RI 79-27, which describes TCC, and the RI 70-5, the Guide
to Federal Employees Health Benefits Plans for Temporary Continuation of Coverage
and Former Spouse Enrollees, from your employing or retirement office or from
www. opm. gov/ insure. It explains what you have to do to enroll.

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

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

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

Getting a Certificate of Group The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a Federal
Health Plan Coverage law that offers limited Federal protections for health coverage availability and continuity to people who lose employer group coverage. If you leave the FEHB Program, we will give

you a Certificate of Group Health Plan Coverage that indicates how long you have been enrolled with
us. You can use this certificate when getting health insurance or other health care coverage. Your new
plan must reduce or eliminate waiting periods, limitations, or exclusions for health related conditions
based on the information in the certificate, as long as you enroll within 63 days of losing coverage
under this Plan. If you have been enrolled with us for less than 12 months, but were previously
enrolled in other FEHB plans, you may also request a certificate from those plans. For more
information, get OPM pamphlet RI 79-27, Temporary Continuation of Coverage (TCC)
under the FEHB Program. See also the FEHB web site (www. opm. gov/ insure/ health);
refer to the "TCC and HIPAA" frequently asked questions. These 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. 59.
59 Page 60 61
2003 PacifiCare Asia Pacific 56 Long Term Care Insurance
Long Term Care Insurance Is Still Available!
Open Season for Long Term Care Insurance
You can protect yourself against the high cost of long term care by applying for insurance in the Federal Long Term Care Insurance Program.
Open Season to apply for long term care insurance through LTC Partners ends on December 31, 2002. If you're a Federal employee, you and your spouse need only answer a few questions about your health during Open Season.
If you apply during the Open Season, your premiums are based on your age as of July 1, 2002. After Open Season, your premiums are based on your age at the time LTC Partners receives your application.

FEHB Doesn't Cover It
Neither FEHB plans nor Medicare cover the cost of long term care. Also called "custodial care", long term care helps you perform the activities of daily living such as bathing or dressing yourself. It can also provide help you may need due to a
severe cognitive impairment such as Alzheimer's disease.
You Can Also Apply Later, But

Employees and their spouses can still apply for coverage after the Federal Long Term Care Insurance Program Open Season ends, but they will have to answer more health-related questions.
For annuitants and other qualified relatives, the number of health-related questions that you need to answer is the same during and after the Open Season.

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

Find Out More Contact LTC Partners by calling 1-800-LTC-FEDS (1-800-582-3337) (TDD for the hear impaired: 1-800-843-
3557) or visiting www. ltcfeds. com to get more information and to request an application. 60.
60 Page 61 62
2003 PacifiCare Asia Pacific 57 Index
Index
Do not rely on this page; it is for your convenience and may not show all pages where the terms appear.

Accidental injury 26, 40 Allergy tests 12, 17
Allogeneic( donor) bone marrow transplants 27

Alternative treatment 12, 23 Ambulance 20, 22, 28
Anesthesia 24, 27, 29 Autologous bone marrow
transplant 18, 27
Biopsies 24 Birthing centers 16, 39
Blood and blood plasma 29-31 Breast cancer screening 27

Casts 24, 29, 30 Catastrophic protection out-of-pocket
maximum 11 Changes for 2002 7
Chemotherapy 18 Chiropractic 12, 23
Claims 44-49 Coinsurance 44, 47, 50, 52
Colorectal cancer screening 14 Congenital anomalies 24, 25
Contraceptive devices and drugs 16, 38 Coordination of benefits 47
Covered charges 48
Crutches 22

Deductible 8, 11 Definitions 52
Dental care 40 Diagnostic services 41
Disputed claims review 45-46 Donor expenses (transplants) 27
Dressings 30 Durable medical equipment
(DME) 12, 19, 22
Educational classes and programs 23, 39
Effective date of enrollment 4, 8, 12
Emergency 6, 10, 40 Experimental or investigational
43, 52 Eyeglasses 20

Family planning 12, 16, 38 Fecal occult blood test 14
General Exclusions 44
Hearing services 12, 15, 19 Home health services 22-23
Hospice care 31 Home nursing care 22-23
Hospital 13, 28, 33
Immunizations 14-15 Infertility 17
Inhospital physician care 13 Inpatient Hospital Benefits 28-29
Insulin 37-38
Laboratory and pathological services 29

Magnetic Resonance Imagings (MRIs) 14, 30
Mail Order Prescription Drugs 37, 38
Mammograms 14, 30 Maternity Benefits 15
Medicaid 51 Medically necessary 43
Medicare 47-49 Mental Conditions/ Substance
Abuse Benefits 34-35
Newborn care 15 Non-FEHB Benefits 41
Nurse Licensed Practical Nurse 22
Nurse Anesthetist 29 Registered Nurse 22

Obstetrical care 15 Occupational therapy 18
Office visits 10 Oral and maxillofacial surgery 26
Orthopedic devices 29 Out-of-pocket expenses 60
Outpatient facility care 33 Oxygen 22, 29

Pap test 14 Physical examination 14, 15
Physical therapy 22 Preauthorization 24, 28, 34,
35
Precertification 28 Preventive care, adult 14

Preventive care, children 15 Prescription drugs 16, 32, 37
Preventive services 40, 41 Prior approval 18
Prostate cancer screening 14 Prosthetic devices 21, 24
Psychologist 34 Psychotherapy 34

Radiation therapy 18 Renal dialysis 47, 49
Room and board 28
Second surgical opinion 13 Skilled nursing facility care 30
Smoking cessation 24, 44 Speech therapy 19
Splints 21, 29-30 Sterilization procedures 16,
25 Subrogation 51
Substance abuse 34-35, 59 Surgery 24-27
Anesthesia 27 Reconstructive 25-26
Syringes 38
Temporary continuation of coverage 55
Transplants 27 Treatment Therapies 18

Vision services 11, 20
Well child care 15 Wheelchairs 22
Workers' compensation 51
X-rays 29-30, 40-41 61.
61 Page 62 63
2003 PacifiCare Asia Pacific 58
NOTES: 62.
62 Page 63 64
2003 PacifiCare Asia Pacific 59
Summary of benefits for the PacifiCare Asia Pacific 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
Medical services provided by physicians:
Diagnostic and treatment services provided in the office.................... Office visit copayment: $10 primary care; $10 specialist for
High Option
Office visit copayment: $15
primary care; $15 specialist for
Standard Option

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

Outpatient ..............................................................................................

Nothing per admission for high
Option

$150 copayment per admission
for Standard Option

Outpatient services are covered
at your office visit copayment

28
30
Emergency benefits:
In-area..................................................................................................

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

$50 copayment for High Option
$75 copayment for Standard
Option per emergency visit and
all charges over $500

$50 copayment per emergency
room visit High Option and all
charges after $500. 20% of 1 st
$500 for Standard Option and
all charges after $500

33
33

Mental health and substance abuse treatment..........................................
Prescription drugs ..................................................................................... $5 copayment for formulary
prescriptions $20 for non-formulary
prescriptions

Dental Care ............................................................................................ Nothing for preventive
services; (shouldn't this be
percentage?) scheduled
allowance for other services
High Option only

Vision Care ............................................................................................ Office visit copayment: $10 for
High Option; $15 for Standard
Option

Page 63.
63 Page 64 65
2003 PacifiCare Asia Pacific 60
Benefits You Pay Page
Special features: 39
Catastrophic protection out of pocket maxium..................................... Nothing after $1,000/ Self Only
or $3,000/ Family enrollment per
year for High Option

Nothing after $3,000/ Self Only
or $6,000/ Family enrollment per