UPMC Health Plan

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
UPMC Health Plan http:// www. upmchealthplan. com
2003

Serving: Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Cameron, Clearfield, Crawford, Erie, Elk, Fayette, Forest, Greene, Indiana, Jefferson,
Lawrence, McKean, Mercer, Somerset, Venango, Washington, Warren and Westmoreland

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:
8W1 Self Only 8W2 Self and Family

New Service Area expansion. See page 6.

RI 73-797

For changes in benefits
see page 8.

A Health Maintenance Organization

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

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

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

OPM has the right to use and give out your personal medical information to administer the FEHB Program. For example:
To communicate with your FEHB health plan when you or someone you have authorized to act on your behalf asks for our assistance regarding a benefit or customer service issue.
To review, make a decision, or litigate your disputed claim. For OPM and the General Accounting Office when conducting audits.

OPM may use or give out your personal medical information for the following purposes under limited circumstances:
For Government healthcare oversight activities (such as fraud and abuse investigations), For research studies that meet all privacy law requirements (such as for medical research or education), and
To avoid a serious and imminent threat to health or safety.
By law, OPM must have your written permission (an "authorization") to use or give out your personal medical information for any
purpose that is not set out in this notice. You may take back (" revoke") your written permission at any time, except if OPM has
already acted based on your permission.

By law, you have the right to:
See and get a copy of your personal medical information held by OPM. Amend any of your personal medical information created by OPM if you believe that it is wrong or if information is missing,
and OPM agrees. If OPM disagrees, you may have a statement of your disagreement added to your personal medical
information.
Get a listing of those getting your personal medical information from OPM in the past 6 years. The listing will not cover your personal medical information that was given to you or your personal representative, any information that you authorized

OPM to release, or that was given out for law enforcement purposes or to pay for your health care or a disputed claim. 3.
3 Page 4 5
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 UPMC Health Plan 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
Who provides my health care?.............................................................................................................................................. 6
Your Rights........................................................................................................................................................................... 6
Service Area.......................................................................................................................................................................... 6
Section 2. How we change for 2003 ...................................................................................................................................................... 8
Program-wide changes .......................................................................................................................................................... 8
Changes to this Plan.............................................................................................................................................................. 8
Section 3. How you get care ................................................................................................................................................................. 9
Identification cards................................................................................................................................................................ 9
Where you get covered care.................................................................................................................................................. 9
Plan providers ................................................................................................................................................................. 9
Plan facilities .................................................................................................................................................................. 9
What you must do to get covered care .................................................................................................................................. 9
Primary care.................................................................................................................................................................... 9
Specialty care.................................................................................................................................................................. 9
Hospital care ................................................................................................................................................................. 10
Circumstances beyond our control...................................................................................................................................... 10
Services requiring our prior approval.................................................................................................................................. 10
Section 4. Your costs for covered services .......................................................................................................................................... 12
Copayments .................................................................................................................................................................. 12
Deductible..................................................................................................................................................................... 12
Coinsurance .................................................................................................................................................................. 12
Your catastrophic protection out-of-pocket maximum....................................................................................................... 12
Section 5. Benefits ............................................................................................................................................................................... 13
Overview............................................................................................................................................................................. 13
(a) Medical services and supplies provided by physicians and other health care professionals .................................... 14
(b) Surgical and anesthesia services provided by physicians and other health care professionals................................. 26
(c) Services provided by a hospital or other facility, and ambulance services............................................................... 31
(d) Emergency services/ accidents .................................................................................................................................. 34
(e) Mental health and substance abuse benefits ............................................................................................................. 36
(f) Prescription drug benefits......................................................................................................................................... 38
(g) Special features ....................................................................................................................................................... 42
Flexible benefits option 6.
6 Page 7 8
2003 UPMC Health Plan 3 Table of Contents
(h) Dental benefits.......................................................................................................................................................... 43
(i) Non-FEHB benefits available to Plan members....................................................................................................... 44
Section 6. General exclusions --things we don't cover........................................................................................................................ 45
Section 7. Filing a claim for covered services ......................................................................................................................................... 46

Section 8. The disputed claims process................................................................................................................................................ 47
Section 9. Coordinating benefits with other coverage ........................................................................................................................ 49
When you have other health coverage............................................................................................................................ 49
What is Medicare........................................................................................................................................................... 49
Medicare managed care plan ......................................................................................................................................... 51
TRICARE and CHAMPVA ......................................................................................................................................... 51
Workers' Compensation................................................................................................................................................ 51
Medicaid ....................................................................................................................................................................... 52
Other Government agencies .......................................................................................................................................... 52
When others are responsible for injuries ...................................................................................................................... 52
Section 10. Definitions of terms we use in this brochure...................................................................................................................... 53
Section 11. FEHB facts ........................................................................................................................................................................ 54
Coverage information........................................................................................................................................................ 54
No pre-existing condition limitation ......................................................................................................................... 54
Where you get information about enrolling in the FEHB Program........................................................................... 54
Types of coverage available for you and your family............................................................................................... 54
Children's Equity Act ........................................................................................................................................... 54
When benefits and premiums start ............................................................................................................................ 55
When you retire......................................................................................................................................................... 55
When you lose benefits ..................................................................................................................................................... 55
When FEHB coverage ends ...................................................................................................................................... 55
Spouse equity coverage............................................................................................................................................ 55
Temporary Continuation of Coverage (TCC) .......................................................................................................... 55
Converting to individual coverage ........................................................................................................................... 56
Getting a Certificate of Group Health Plan Coverage.............................................................................................. 56
Long term care insurance is still available ............................................................................................................................................ 57

Index ......................................................................................................................................................................................... 58
Summary of benefits ............................................................................................................................................................................. 59
Rates ....................................................................................................................................................................................... Back cover 7.
7 Page 8 9
2003 UPMC Health Plan 4 Introduction/ Plain Language/ Advisory
Introduction
UPMC Health Plan One Chatham Center
112 Washington Place Pittsburgh, PA 15219

This brochure describes the benefits of UPMC Health Plan under our contract (CS 2856) with the Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law.
This brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations, and exclusions of this brochure. It is your responsibility to be informed about your health benefits.
If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in Self and Family coverage, each eligible family member is also entitled to these benefits. You do not have a right to benefits that were available
before January 1, 2003, unless those benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2003 and changes are summarized on page 7. 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 UPMC Health Plan..

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

Our brochure and other FEHB plans' brochures have the same format and similar descriptions to help you compare plans.
If you have comments or suggestions about how to improve the structure of this brochure, let OPM know. Visit OPM's "Rate Us" feedback area at www. opm. gov/ insure or e-mail OPM at fehbwebcomments@ opm. gov. You may also write to OPM at the
office of Personnel Management, Office of Insurance Planning and Evaluation Division, 1900 E Street, NW Washington, DC 20415-3650.

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

Protect Yourself From Fraud -Here are some things you can do to prevent fraud:
Be wary of giving your plan identification (ID) number over the telephone or to people you do not know, except to your doctor, other provider, or authorized plan or OPM representative.
Let only the appropriate medical professionals review your medical record or recommend services. Avoid using health care providers who say that an item or service is not usually covered, but they know how to bill us to get
it paid. 8.
8 Page 9 10
2003 UPMC Health Plan 5 Introduction/ Plain Language/ Advisory
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 1-888-876-2756 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 FEHBP
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 UPMC Health Plan 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.

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.
Licensed through the PA Insurance Department
NCQA First review scheduled for 2002
Years in existence five (5) years
Profit status Not-for-profit
Member rights and appeals/ grievance
Accessing emergency care
Member cost sharing
If you want more information about us, call 1-888-876-2756, or write to UPMC Health Plan Member Services, One Chatham Center, 112 Washington Place, Pittsburgh, PA 15219. You may also contact us by fax at (412) 454-7711 or visit our website at

www. upmchealthplan. 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: Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Cameron, Clearfield, Crawford, Erie, Elk, Fayette, Forest, Greene,
Indiana, Jefferson, Lawrence, McKean, Mercer, Somerset, Venango, Washington, Warren and Westmoreland counties.
Ordinarily, you must get your care from providers who contract with us. If you receive care outside our service area, we will pay only for emergency care benefits. We will not pay for any other health care services out of our service area unless the services have prior
plan approval.
If you or a covered family member move outside of our service area, you can enroll in another plan. If your dependents live out of the area (for example, if your child goes to college in another state), you should consider enrolling in a fee-for-service plan or an HMO 10.
10 Page 11 12
2003 UPMC Health Plan 7 Section 1
that has agreements with affiliates in other areas. If you or a family member move, you do not have to wait until Open Season to change plans. Contact your employing or retirement office. 11.
11 Page 12 13
2003 UPMC Health Plan 8 Section 2
Section 2. How we change for 2003
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5 Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here is a clarification that does not change
benefits.
Program-wide changes

We changed the address for sending disputed claims to OPM. (Section 8)
A Notice of the Office of Personnel Management's Privacy Practices is included.
A section on the Children's Equity Act describes when an employee is required to maintain Self and Family coverage.
Program information on TRICARE and CHAMPVA explains how annuitants or former spouses may suspend their FEHB Program enrollment

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

Your share of the non-Postal premium will increase by 41% for Self Only or 41% for Self and Family.
Pharmacy copayments now include a third tier copayment for non-preferred brand medications.
Emergency room copayment increases from $30 to $50.
Skilled nursing care is now limited to 100 days.
There is a new service area expansion. Please see page 7 12.
12 Page 13 14
2003 UPMC Health Plan 9 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services from a Plan
provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits
enrollment confirmation (for annuitants), or your Employee Express confirmation letter.
If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 1-888-876-8756.

Where you get covered care You get care from "Plan providers" and "Plan facilities." You will only pay copayments, and you will not have to file claims.
Plan providers Plan providers are 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. The list of providers in our directories include Primary Care
Physicians, Specialists, Ancillary Providers, Hospitals and Pharmacies.
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.
It depends on the type of care you need. First, you and each family member must choose a primary care physician. This decision is important since your primary care physician
provides or arranges for most of your health care. Choose a PCP at the time of enrollment (women may also choose an OB/ GYN for all female-related services). List the PCP
name and 4-digit practice number on your enrollment form.
Primary care Your primary care physician can be a family or general practitioner, internist, pediatrician. Your primary care physician will provide most of your health care, or give
you a referral to see a specialist.
If you want to change primary care physicians or if your primary care physician leaves the Plan, call us. We will help you select a new one.

Specialty care Your primary care physician will refer you to a specialist for needed care. However, you may see any specialist in the UPMC Health Plan network at anytime without a referral.
Simply choose a network specialist, present your identification card at the time of your visit and you will be charged slightly higher office visit copay. Any medically necessary
prescribed services ordered by the treating specialist are covered at 100%
Here are other things you should know about specialty care:
If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician will work with your specialist and
UPMC Health Plan to develop a treatment plan that allows you to see your specialist for a certain number of visits without additional referrals. Your primary care
physician will use our criteria when creating your treatment plan (the physician may have to get an authorization or approval beforehand).

What you must do to get covered care 13.
13 Page 14 15
2003 UPMC Health Plan 10 Section 3
If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician. Your primary care physician will decide what treatment you need. If he or
she decides to refer you to a specialist, ask if you can see your current specialist. If your current specialist does not participate with us, you must receive treatment from a
specialist who does. Generally, we will not pay for you to see a specialist who does not participate with our Plan.

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

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

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

plan.
If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can continue to see your specialist until
the end of your postpartum care, even if it is beyond the 90 days.
Hospital care Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled nursing or other type of
facility.
If you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at 1-888-876-2756. If you are new to the FEHB
Program, we will arrange for you to receive care.
If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:

You are discharged, not merely moved to an alternative care center; or
The day your benefits from your former plan run out; or
The 92 nd day after you become a member of this Plan, whichever happens first.
These provisions apply only to the benefits of the hospitalized person.

Circumstances beyond our control Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In that case, we will make all
reasonable efforts to provide you with the necessary care.
Your primary care physician has authority to refer you for most services. For certain services, however, your physician must obtain approval from us. Before giving approval,
we consider if the service is covered, medically necessary, and follows generally accepted medical practice.

Services requiring our prior approval 14.
14 Page 15 16
2003 UPMC Health Plan 11 Section 3
Your treating physician will contact UPMC Health Plan to coordinate your services. UPMC Health Plan will let you and your treating physician know the decision. Should
you disagree with the decision, you may file a complaint with UPMC Health Plan Member Services. 15.
15 Page 16 17
2003 UPMC Health Plan 12 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 and when you go in the hospital, you pay nothing.
Deductible We do not have a deductible
Coinsurance We do not have coinsurance.

We do not have a catastrophic protection out-of-pocket maximum. Your catastrophic protection
out-of-pocket maximum 16.
16 Page 17 18
2003 UPMC Health Plan 13 Section 5
Section 5. Benefits --OVERVIEW
(See page 8 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. Also read the General Exclusions in Section 6; they apply to the benefits in the following subsections. To obtain
claims forms, claims filing advice, or more information about our benefits, contact us at 1-888-876-2756 or at our website at www. upmchealthplan. com.
(a) Medical services and supplies provided by physicians and other health care professionals........................................................ 14-25
Diagnostic and treatment services Lab, X-ray, and other diagnostic tests
Preventive care, adult Preventive care, children
Maternity care Family planning
Infertility services Allergy care
Treatment therapies Physical and occupational therapies

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

(b) Surgical and anesthesia services provided by physicians and other health care professionals ................................................ 26-30
Surgical procedures Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services .............................................................................. 31-33
Inpatient hospital Outpatient hospital or ambulatory surgical center Extended care benefits/ skilled nursing care facility benefits Hospice care
Ambulance
(d) Emergency services/ accidents ................................................................................................................................................. 34-35 Medical emergency Ambulance

(e) Mental health and substance abuse benefits ............................................................................................................................ 36-37
(f) Prescription drug benefits ........................................................................................................................................................ 38-41
(g) Special features ............................................................................................................................................................................. 42 Flexible benefits option

Women select a network OB/ GYN in addition to a PCP and self-refer for all female-related services.
Members may self-refer to any network chiropractor.
Emergency and urgent care travel assistance through Assist America.
(h) Dental discount program benefits ................................................................................................................................................. 43
(i) Non-FEHB benefits available to Plan members ............................................................................................................................ 44
Summary of benefits ............................................................................................................................................................................. 59 17.
17 Page 18 19
2003 UPMC Health Plan 14 Section 5( a)
Section 5 (a). Medical services and supplies provided by physicians and other health care professionals
I M
P O
R T
A N
T

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

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

I M
P O
R T
A N
T

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

$10 per office visit
$10 per visit to your primary care physician
$10 per visit to a specialist if referred by your PCP
$30 per visit to a network specialist if self-referred

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

$10 per office visit

At home Nothing
Diagnostic and treatment services --continued on next page 18.
18 Page 19 20
2003 UPMC Health Plan 15 Section 5( a)
Diagnostic and treatment services (continued) You pay
Lab, X-ray and other diagnostic tests
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
CAT Scans/ MRI
Ultrasound
Electrocardiogram and EEG

Nothing if you receive these services during your office visit; otherwise, $10 per
office visit

Preventive care, adult
Routine screenings, such as:
Total Blood Cholesterol once every three years
Colorectal Cancer Screening, including

Fecal occult blood test
Sigmoidoscopy, screening every five years starting at age 50

Nothing.

Routine Prostate Specific Antigen (PSA test) one annually for men age 40 and older Nothing
Routine pap test
Note: The office visit is covered if pap test is received on the same day; see Diagnosis and Treatment, above.
Nothing

Preventive Care -Adult --continued on next page 19.
19 Page 20 21
2003 UPMC Health Plan 16 Section 5( a)
Preventive care, adult (continued) You pay
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.

Not covered: Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, or travel. 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 vaccine, annually, age 65 and over

Nothing

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

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

Ear exams through age 17 to determine the need for hearing correction
Examinations done on the day of immunizations ( under age 22)

Nothing. 20.
20 Page 21 22
2003 UPMC Health Plan 17 Section 5( a)
Maternity care You pay
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Note: Here are some things to keep in mind:
You do not need to precertify your normal delivery.
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.

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

Nothing.

Not covered: Routine sonograms to determine fetal age, size or sex All charges.
Family planning
A range of voluntary family planning services, limited to:
Voluntary sterilization (See Surgical procedures Section 5 (b))
Surgically implanted contraceptives (such as Norplant)
Injectable contraceptive drugs (such as Depo provera)
Intrauterine devices (IUDs)
Diaphragms
NOTE: We cover oral contraceptives under the prescription drug benefit.

$10 per office visit

Not covered: reversal of voluntary surgical sterilization, genetic counseling, All charges. 21.
21 Page 22 23
2003 UPMC Health Plan 18 Section 5( a)
Infertility services You pay
Diagnosis and treatment of infertility, such as:
Artificial insemination:
intravaginal insemination (IVI) intracervical insemination (ICI)

intrauterine insemination (IUI)

$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 Services and supplies related to excluded ART procedures

Cost of donor sperm
Cost of donor egg
Fertility drugs

All charges.

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

Allergy serum Nothing
Not covered: provocative food testing and sublingual allergy desensitization All charges. 22.
22 Page 23 24
2003 UPMC Health Plan 19 Section 5( a)
Treatment therapies You pay
Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone marrow transplants are limited to those transplants listed under

Organ/ Tissue Transplants on page 29.
Respiratory and inhalation therapy
Dialysis hemodialysis and peritoneal dialysis
Intravenous (IV)/ Infusion Therapy Home IV and antibiotic therapy

Growth hormone therapy (GHT)
Note: Growth hormone is covered under the prescription drug benefit.
Note: We will only cover GHT when we preauthorize the treatment. Your Primary Care Physician will coordinate this process for you.. 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.

Nothing. 23.
23 Page 24 25
2003 UPMC Health Plan 20 Section 5( a)
Physical and occupational therapies
60 visits per condition for the services of each of the following:
qualified physical therapists and 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.
Cardiac rehabilitation following a heart transplant, bypass surgery or a
myocardial infarction, is provided without limitations.

$10 per visit
$10 per outpatient visit
Nothing per visit during covered inpatient

Not covered:
long-term rehabilitative therapy
exercise programs

All charges.

Speech therapy
60 visits per condition per year. $10 per visit 24.
24 Page 25 26
2003 UPMC Health Plan 21 Section 5( a)
Hearing services (testing, treatment, and supplies) You pay
First hearing aid and testing only when necessitated by accidental injury

Hearing testing for children through age 17 (see Preventive care, children)
Nothing.

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

Vision services (testing, treatment, and supplies)
One pair of eyeglasses or contact lenses to correct an impairment directly caused by accidental ocular injury or intraocular surgery
(such as for cataracts)
$10 per office visit

Eye exam to determine the need for vision correction for children up to age 22 (see Preventive care, children)
Annual eye refractions
Under 22 once every twelve (12) months
Over 22 once every twenty-four (24) months

Nothing.

Not covered:
Eyeglasses or contact lenses and, after age 22, examinations for them

Eye exercises and orthoptics
Radial keratotomy and other refractive surgery

All charges. 25.
25 Page 26 27
2003 UPMC Health Plan 22 Section 5( a)
Foot care You pay
Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes.

See orthopedic and prosthetic devices for information on podiatric shoe inserts.
$25 per office visit

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

except as stated above
Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the

treatment is by open cutting surgery)

All charges.

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

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

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

Nothing

Orthopedic and prosthetic devices-Continued on next page 26.
26 Page 27 28
2003 UPMC Health Plan 23 Section 5( a)
Orthopedic and prosthetic devices (Continued) You pay
Not covered:
orthopedic and corrective shoes
arch supports
foot orthotics
heel pads and heel cups
lumbosacral supports
corsets, trusses, elastic stockings, support hose, and other supportive devices

prosthetic replacements provided less than 3 years after the last one we covered

All charges.

Durable medical equipment (DME)
Rental or purchase, at our option, including repair and adjustment, of durable medical equipment prescribed by your Plan physician, such as

oxygen and dialysis equipment. Under this benefit, we also cover:
hospital beds;
wheelchairs;
crutches;
walkers;
blood glucose monitors; and
insulin pumps.
Note: Call us at 1-888-860-2273 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.

Nothing.

Not covered: Motorized wheel chairs
Repair, replacement or duplication for health services except when necessitated due to a change in the Member's medical condition.
All charges. 27.
27 Page 28 29
2003 UPMC Health Plan 24 Section 5( a)
Home health services You pay
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.

Nothing.

Not covered: nursing care requested by, or for the convenience of, the patient or
the patient's family; Home healthcare primarily for personal assistance that does not
include a medical component and is not diagnostic, therapeutic, or rehabilitative.

All charges.

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

Limit of 25 visits per calendar year
No PCP referral required

$10 per office visit

Not covered:
Acupuncture services
Naturopathic services
Hypnotherapy
Biofeedback

All charges. 28.
28 Page 29 30
2003 UPMC Health Plan 25 Section 5( a)
Educational classes and programs You pay
Coverage is limited to:

Diabetes self-management
$10 per office visit 29.
29 Page 30 31
2003 UPMC Health Plan 26 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

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.).

I M
P O
R T
A N
T

Benefit Description You pay
Surgical procedures
A comprehensive range of services, such as: Operative procedures

Treatment of fractures, including casting Normal pre-and post-operative care by the surgeon
Correction of amblyopia and strabismus Endoscopy procedures
Biopsy procedures Removal of tumors and cysts
Correction of congenital anomalies (see reconstructive surgery) Surgical treatment of morbid obesity --a condition in which an
individual weighs 100 pounds or 100% over his or her normal weight according to current underwriting standards; eligible
members must be age 18 or over Insertion of internal prosthetic devices. See 5( a) Orthopedic
and prosthetic devices for device coverage information.

$10 per office visit. Nothing for hospital visits.

Surgical procedures continued on next page. 30.
30 Page 31 32
2003 UPMC Health Plan 27 Section 5( b)
Surgical procedures (continued) You pay
Voluntary sterilization (e. g., Tubal Ligation, Vasectomy)

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

a pacemaker and Surgery benefits for insertion of the pacemaker.

$10 per office visit

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

Reconstructive surgery
Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if:

the condition produced a major effect on the member's appearance and

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

Nothing.

Reconstructive surgery --continued on next page 31.
31 Page 32 33
2003 UPMC Health Plan 28 Section 5( b)
Reconstructive surgery (continued) You pay
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.

Nothing.

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.

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.
Treatment of TMJ.

$10 per office visit

Not covered: Oral implants and transplants
Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone)
All charges. 32.
32 Page 33 34
2003 UPMC Health Plan 29 Section 5( b)
Organ/ tissue transplants You pay
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single Double
Pancreas
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 National Transplant Program (NTP) UPMC Health Plan utilizes

the top transplant centers in Western Pennsylvania. Should care not be available in Western Pennsylvania, UPMC Health Plan will
arrange for services out of the area.
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.

Nothing

Not covered: Donor screening tests and donor search expenses, except those
performed for the actual donor Implants of artificial organs

Transplants not listed as covered

All charges. 33.
33 Page 34 35
2003 UPMC Health Plan 30 Section 5( b)
Anesthesia You pay
Professional services provided in
Hospital (inpatient)
Nothing

Professional services provided in
Hospital outpatient department Skilled nursing facility

Ambulatory surgical center Office

Nothing. 34.
34 Page 35 36
2003 UPMC Health Plan 31 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 Sections 5( a) or (b).

I M
P O
R T
A N
T

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

general nursing care; and meals and special diets.

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

Nothing

Inpatient hospital continued on next page. 35.
35 Page 36 37
2003 UPMC Health Plan 32 Section 5( c)
Inpatient hospital (continued) You pay
Other hospital services and supplies, such as: Operating, recovery, maternity, and other treatment rooms

Prescribed drugs and medicines Diagnostic laboratory tests and X-rays
Administration of blood and blood products Blood or blood plasma, if not donated or replaced
Dressings, splints, casts, and sterile tray services Medical supplies and equipment, including oxygen
Anesthetics, including nurse anesthetist services Take-home items
Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home (Note: calendar year
deductible applies.)

Nothing

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

All charges.

Outpatient hospital or ambulatory surgical center
Operating, recovery, and other treatment rooms Prescribed drugs and medicines

Diagnostic laboratory tests, X-rays, and pathology services Administration of blood, blood plasma, and other biologicals
Blood and blood plasma, if not donated or replaced Pre-surgical testing
Dressings, casts, and sterile tray services Medical supplies, including oxygen
Anesthetics and anesthesia service
NOTE: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment. We
do not cover the dental procedures.

Nothing

Not covered: blood and blood derivatives not replaced by the member All charges. 36.
36 Page 37 38
2003 UPMC Health Plan 33 Section 5( c)
Extended care benefits/ skilled nursing care facility benefits You pay
Extended care benefit: 100 days per condition.

The plan provides a comprehensive range of benefits with no dollar or day limit when full-time skilled nursing care is necessary and
confinement in a skilled nursing facility is medically appropriate as determined by a Plan doctor and approved by the Plan. You pay
nothing. 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

Not covered: custodial care All charges.
Hospice care
Supportive and palliative care for a terminally ill member is covered in the home or hospice facility. Services include inpatient and outpatient

care, and family counseling; these services are provided under the direction of a Plan doctor who certifies that the patient is in the terminal
stages of illness, with a life expectancy of approximately six months or less.

Nothing

Not covered: Independent nursing, homemaker services All charges.
Ambulance
Local professional ambulance service when medically appropriate and ordered and authorized by a Plan doctor. Nothing 37.
37 Page 38 39
2003 UPMC Health Plan 34 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.
We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

I M
P O
R T
A N
T
What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or could result in serious injury or disability, and requires immediate medical or surgical care. Some problems are emergencies

because, if not treated promptly, they might become more serious; examples include deep cuts and broken bones. Others are emergencies because they are potentially life-threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or
sudden inability to breathe. There are many other acute conditions that we may determine are medical emergencies what they all have in common is the need for quick action.

What to do in case of emergency:
Emergencies within our service area: If you are in an emergency situation, please call your primary care doctor. In extreme emergencies, if you are unable to
contact your doctor, contact the local emergency system (e. g. the 911 telephone system) or go immediately to the nearest hospital emergency room. Be sure to tell the emergency personnel that you are a Plan member so they can notify the Plan
Member Services 1-888-876-2756. You or a family member must notify the Plan within 48 hours unless it was not reasonable to do so. It is your responsibility to ensure that the Plan has been timely notified.

If you need to be hospitalized, the Plan must be notified within 48 hours or on the first working day following your admission, unless it was not reasonably possible to notify the Plan within that time. If you are hospitalized in non-Plan
facilities, and a Plan doctor believes care can be better provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges covered in full. Benefits are available for care from non-Plan providers in medical
emergency only if delay in reaching a Plan provider would result in death, disability or significant jeopardy to your condition.

To be covered by this Plan, any follow-up care recommended by non-Par providers must be approved by the Plan or Provided by the Plan providers.
Emergencies outside our service area:
Benefits are available for any medically necessary health service that is immediately required because of injury or unforeseen illness. If you need to be hospitalized, the Plan must be notified within 48 hours or on the first working day

following your admission unless it was not reasonably possible to notify the Plan within that time (Member Services 1-888-876-2756). If a Plan doctor believes care can be better provided in a Plan hospital, you would be transferred when medically
feasible with any ambulance charges covered in full. 38.
38 Page 39 40
2003 UPMC Health Plan 35 Section 5( d)
Benefit Description You pay
Emergency within our service area
Emergency care at a doctor's office

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

$50 copayment per emergency room visit .

Not covered: Elective care or non-emergency care All charges.
Emergency outside our service area
Emergency care at a doctor's office Emergency care at an urgent care center

Emergency care as an outpatient or inpatient at a hospital, including doctors' services
$50 copayment per emergency room visit.

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

All charges.

Ambulance
Professional ambulance service when medically appropriate, including air ambulance.

See 5( c) for non-emergency service.
Nothing. 39.
39 Page 40 41
2003UPMC Health Plan 36 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.
We do not have a calendar year deductible.

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

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

I M
P O
R T
A N
T

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

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

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

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

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

Medication management

$10 per visit.

Mental health and substance abuse benefits -continued on next page 40.
40 Page 41 42
2003UPMC Health Plan 37 Section 5( e)
Mental health and substance abuse benefits (continued) You pay
Diagnostic tests Nothing.

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

Nothing

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

order us to pay or provide one clinically appropriate treatment plan in favor of another.

All charges.

Preauthorization To be eligible to receive these benefits you must obtain a treatment plan and follow all of the following authorization processes:
Self-referral to network providers: Call 1-888-251-0083. Providers are also listed in the UPMC Health Plan directory under Behavioral Health.
Outpatient care unlimited outpatient visits to Plan doctors, consultants or other psychiatric personnel each calendar year; you pay $10 copay for each covered visit.
Inpatient care unlimited days of hospitalization each calendar year for Hospital Services provided for Behavioral Health service Inpatient treatment by a Hospital or Facility provider.

Limitation We may limit your benefits if you do not obtain a treatment plan. 41.
41 Page 42 43
2003 UPMC Health Plan 38 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.

We have no calendar year deductible.
Certain medications may require prior authorization with UPMC Health Plan doctors the first time they are prescribed. Your physician will coordinate this process through your Plan for you.

I M
P O
R T
A N
T 42.
42 Page 43 44
2003 UPMC Health Plan 39 Section 5( f)
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 by mail for a maintenance medication.

We use a formulary. UPMC Health Plan doctors and pharmacists have developed the Your Choice Pharmacy Plan for commonly used medications. Your Choice is designed to identify equally effective but
lower cost medications and to recommend them as "first-choice" medications to doctors and their patients. By using Your Choice medications, you and your doctor have access to high quality and effective
medications that help manage prescription drug costs and keep your copayments low.
Please refer to the Your Choice Pharmacy Program brochure in your UPMC Health Plan enrollment packet.
If you have any questions, please talk with your doctor, call UPMC Health Plan Member Services at 1-888-876-2756, or visit our website at www. upmchealthplan. com.

These are the dispensing limitations. Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan participating pharmacy will be dispensed for up to a 30-day supply or one commercially
prepared unit (i. e., one inhaler, one vial insulin); or prescriptions obtained through the Plan participating mail order pharmacy will be dispensed for up to a 90-day supply for Plan approved medications. Medications will
be dispensed based upon FDA guidelines.
$5 copayment per prescription unit or refill for generic drugs.
$15 copayment for preferred brand name drugs when generic substitution is not permissible.
$35 copayment for non-preferred brand name drugs.
The 90-day mail order program, through RX Partners, is for maintenance medications that you take on a regular, long-term basis. You will receive a 90-day supply of your medication for two copayments ($ 10

generic, $30 preferred brand-name and $70 non-preferred brand name). These "maintenance drugs" may include medications to reduce blood pressure or treat respiratory conditions, asthma, diabetes, arthritis or
high cholesterol. To verify if your medications can be dispensed through the mail order program, please contact Curascript 1-877-787-6279. Some medications are prohibited from being sent through the mail.

Refills using the Mail Order program to avoid running out of your prescription medication, re-order when you have a 21 day supply remaining. For refills, you may re-order either by mail, by phone, or online.
Should you request a refill too early, Curascript will contact you to explain when your refill will be mailed to you.

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. Members who pay out of pocket for a prescription will be reimbursed, simply by completing a prescription reimbursement form. Members will be reimbursed 100% minus the

applicable copayment. Please contact Member Services at 1-888-876-2756 to request a prescription reimbursement form. 43.
43 Page 44 45
2003 UPMC Health Plan 40 Section 5( f)
Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan physician and obtained from a Plan pharmacy or through our mail order

program: Drugs and medicines that by Federal law of the United States
require a physician's prescription for their purchase, except those listed as Not covered.
Insulin Disposable needles and syringes for the administration of covered
medications Drugs for sexual dysfunction (see Prior authorization below)
Contraceptive drugs and devices
Prior authorization for drugs treating sexual dysfunction will be coordinated by your PCP.

Retail (for each 30 day supply)
Generic: $5 copayment
Preferred Brand-name: $15 copayment
Non-preferred Brand-name: $35 copayment
Mail Order (for a 90 day supply)
Generic: $10 copayment
Preferred Brand-name: $30 copayment
Non-preferred Brand-name: $70 copayment
Note: If there is no generic equivalent available, you will still have to pay the

brand name copay.

Covered medications and supplies --continued on next page 44.
44 Page 45 46
2003 UPMC Health Plan 41 Section 5( f)
Covered medications and supplies (continued) You pay
Here are some things to keep in mind about our prescription drug program:
A generic equivalent will be dispensed if it is available, unless your physician specifically requires a name brand. If you receive a
name brand drug when a Federally-approved generic drug is available, and your physician has not specified Dispense as Written
for the name brand drug, you have to pay the difference in cost between the name brand drug and the generic.

We have an open formulary. If your physician believes a name brand product is necessary or there is no generic available, your
physician may prescribe a name brand drug from a formulary list. This list of name brand drugs is a preferred list of drugs that we
selected to meet patient needs at a lower cost. To order a prescription drug brochure, call 1-888-876-2756.

Not covered:
Drugs and supplies for cosmetic purposes
Drugs to enhance athletic performance
Fertility drugs
Drugs obtained at a non-Plan pharmacy; except for out-of-area emergencies

Vitamins, nutrients and food supplements even if a physician prescribes or administers them
Nonprescription medicines
Medical supplies such as dressings and antiseptics
Smoking cessation drugs and medications (nicotine patches and nicotine gums)

Drugs available without a prescription or for which there is a nonprescription equivalent available.
Food supplements and other nutritional and over-the-counter electrolyte supplements except as required to treat phenylketonuria
(PKU)

All charges. 45.
45 Page 46 47
2003 UPMC Health Plan 42 Section 5( g)
Section 5 (g). Special Features
Feature Description

Flexible benefits option Under the flexible benefits option, we determine the most effective way to provide services.
We may identify medically appropriate alternatives to traditional care and coordinate other benefits as a less costly alternative benefit.

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

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

Direct Access to Network Specialists Members may self-refer at anytime to any network specialist for a $30 office visit copayment per visit. Prescribed services ordered by the treating specialist (i. e. x-rays, labs) are covered at 100%.
Direct Access for Women to their OB/ GYN Women may choose a network OB/ GYN in addition to their PCP. Women may self-refer for all female-related services directly to their selected OB/ GYN a referral from the PCP is never needed. Should female members want to
change their selected OB/ GYN, simply call Member Services at 1-888-876-2756 and the change will be made over the phone.

Direct Access to Network Chiropractors Members may go directly to any network chiropractor without a referral from the PCP. Visit requires a $10 copayment. There is a limit of 25 visits per calendar year.

Travel benefit/ services overseas UPMC Health Plan provides an additional service for emergencies outside the Service area called Assist America. Any time you need care when traveling more than 100 miles from home, Assist America can help to direct you to the
closest, most appropriate medical facility. This service is available 24 hours per day, 365 days per year for urgent or emergency care while outside the
Service Area. Please call Assist America in the USA at 1-800-872-1414 and outside the USA at 301-656-4152 46.
46 Page 47 48
2003 UPMC Health Plan 43 Section 5( j)
Section 5 (h). Dental benefits
I M
P O
R T
A N
T

Plan dentists must provide or arrange your care.
We have no calendar year deductible.
We cover hospitalization for dental procedures only when a nondental physical impairment exists which makes hospitalization necessary to safeguard the health of the patient; 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.

I M
P O
R T
A N
T

Accidental injury benefit You pay
We cover restorative services and supplies necessary to promptly repair (but not replace) sound natural teeth. The need for these services must

result from an accidental injury.
Nothing. 47.
47 Page 48 49
2003 UPMC Health Plan 44 Section 5( j)
Section 5 (j). 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.

Dental Discount Program All new and current members have available to them a Dental Discount Program administered through Doral Dental USA. Members can receive preventive services (which include cleanings, exams
and x-rays) and other dental services (fillings, root canals, crowns and even orthodontics) at fees that are lower than usual and customary charges.

Discounts are based upon a fee schedule, which is subject to change. Prior to receiving services, please contact your participating dentist or Doral Dental to determine what will be your financial responsibility.
Simply choose a participating Doral Dental dentist and present your UPMC Health Plan identification card at the time of service to receive your dental benefits (there is no additional enrollment form or ID card needed). A
complete participating dentist list and description of your benefits is included in your UPMC Health Plan enrollment packet.

Wellness Programs UPMC Health Plan, together with UPMC Health System, offers a variety of health promotion and wellness classes (most free of charge) for conditions such as diabetes, childbirth, cancer support groups and
smoking cessation. The classes are taught by trained professionals and are held at convenient locations throughout the area. Descriptions of classes can be found in the Healthy Living Rewards brochure. To get information and
details on registration, call 1-800-533-UPMC (8762).
One-to-One Program The One-to-One Program was designed to recognize and address the unique health care needs of women. Offered in partnership with Magee-Womens Hospital, this innovative program provides
comprehensive, prevention-focused health care services, including gynecology, gynecologic oncology, assisted reproduction, a neo-natal intensive care unit as well as a comprehensive maternity program for all pregnant women
enrolled as members in UPMC Health Plan. For more information, or to participate in the One-to-One Program, please contact UPMC Health Plan Member Services at 1-888-876-2756.

Healthy Living Rewards The Healthy Living Rewards program offers value added savings to UPMC Health Plan members. As a member, you are eligible to receive discounts on products and services that promote healthy
lifestyles, such as fitness clubs, sporting goods stores and health food stores. Show your UPMC Health Plan identification card at the time of purchase to receive your savings. The discounts apply to services where insurance
coverage may not exist. A listing of participating vendors can be obtained by calling UPMC Health Plan Member Services at 1-888-876-2756. 48.
48 Page 49 50
2003 UPMC Health Plan 45 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.
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; or

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. 49.
49 Page 50 51
2003 UPMC Health Plan 46 Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at Plan pharmacies, you will not have to file claims. Just present your identification card and pay your copayment.

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

Medical and Hospital benefits In most cases, providers and facilities file claims for you. Physicians must file on the form HCFA-1500, Health Insurance Claim Form. Facilities will file on the UB-92 form.
For claims questions and assistance, call us at 1-888-876-2756.
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:
UPMC Health Plan Claims Department
P. O. Box 2999
Pittsburgh, PA 15230-2999

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. 50.
50 Page 51 52
2003 UPMC Health Plan 47 Section 8
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your claim or request for services, drugs, or supplies including a request for preauthorization:

Step Description
1 Ask us in writing to reconsider our initial decision. You must: (a) Write to us within 6 months from the date of our decision; and
(b) Send your request to us at: UPMC Health Plan, Member Services, One Chatham Center, 112 Washington Place, Pittsburgh, PA 15219; and

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

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

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

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

Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Contracts Division 3, 1900 E Street, NW, Washington, DC 20415-3630. 51.
51 Page 52 53
2003 UPMC Health Plan 48 Section 8
The Disputed Claims process (Continued)
Send OPM the following information:
A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;
Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms;

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

Note: If you want OPM to review more than one claim, you must clearly identify which documents apply to which claim.
Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representative, such as medical providers, must include a copy of your specific written consent with the review request.

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

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

NOTE: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and
(a) We haven't responded yet to your initial request for care or preauthorization/ prior approval, then call us at 1-888-876-2756 and we will expedite our review; or
(b) We denied your initial request for care or preauthorization/ prior approval, then:
If we expedite our review and maintain our denial, we will inform OPM so that they can give your claim expedited treatment too, or

You may call OPM's Health Benefits Contracts Division 3 at 202/ 606-0737 between 8 a. m. and 5 p. m. eastern time. 52.
52 Page 53 54
2003 UPMC Health Plan 49 Section 9
Section 9. Coordinating benefits with other coverage
When you have other health coverage You must tell us if you or a covered family member have coverage under another group health plan or have automobile insurance that pays health care expenses without regard
to fault. This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in full as the primary payer and the other plan pays a reduced benefit as the secondary payer. We, like
other insurers, determine which coverage is primary according to the National Association of Insurance Commissioners' guidelines.

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

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

Medicare has two parts:
Part A (Hospital Insurance). Most people do not have to pay for Part A. If you or your spouse worked for at least 10 years in Medicare-covered employment, you

should be able to qualify for premium-free Part A insurance. (Someone who was a Federal employee on January 1, 1983 or since automatically qualifies.) Otherwise, if
you are age 65 or older, you may be able to buy it. Contact 1-800-MEDICARE for more information.

Part B (Medical Insurance). Most people pay monthly for Part B. Generally, Part B premiums are withheld from your monthly Social Security check or your retirement
check.
If you are eligible for Medicare, you may have choices in how you get your health care. Medicare + Choice is the term used to describe the various health plan choices available

to Medicare beneficiaries. The information in the next few pages shows how we coordinate benefits with Medicare, depending on the type of Medicare managed care plan
you have.
The Original Medicare Plan (Original Medicare) is available everywhere in the United States. It is the way everyone used to get Medicare benefits and is the way most people
get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist, or hospital that accepts Medicare. The Original Medicare Plan pays its share and you pay
your share. Some things are not covered under Original Medicare, like prescription drugs.

When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care. Your care must continue to be
authorized by your Plan PCP.
We will not waive any of our copayments.
(Primary payer chart begins on next page.)

The Original Medicare Plan (Part A or Part B) 53.
53 Page 54 55
2003 UPMC Health Plan 50 Section 9
The following chart illustrates whether the Original Medicare Plan or this Plan should be the primary payer for you according to your employment status and other factors determined by Medicare. It is critical that you tell us if you or a covered family member
has Medicare coverage so we can administer these requirements correctly.
Primary Payer Chart
Then the primary payer is A. When either you or your covered spouse --are age 65 or over and

Original Medicare This Plan
1) Areanactiveemployee withthe Federalgovernment(includingwhen youora familymemberare eligibleforMedicaresolely becauseofadisability), .

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

a) The position is excluded from FEHB, or

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

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

covered spouse is this type of judge), .
5) Are enrolled in Part B only, regardless of your employment status, . (for Part B services) . (for other services)
6) Are a former Federal employee receiving Workers' Compensation and the Office of Workers' Compensation Programs has determined that
you are unable to return to duty,

.
(except for claims related to Workers'

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

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

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

If your Plan physician does not participate in Medicare, you will have to file a claim with Medicare. 54.
54 Page 55 56
2003 UPMC Health Plan 51 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 then provide secondary benefits for covered charges. You will not need to do anything. To find

out if you need to do something to file your claims, call us at 1-888-876-2756 or visit us online at www. upmchealthplan. com.

Medicare managed care plan If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare managed care plan. These are health care choices (like HMOs)
in some areas of the country. In most Medicare managed care plans, you can only go to doctors, specialists, or hospitals that are part of the plan. Medicare managed care plans
provide all the benefits that Original Medicare covers. Some cover extras, like prescription drugs. To learn more about enrolling in a Medicare managed care plan,
contact Medicare at 1-800-MEDICARE (1-800-633-4227) or at www. medicare. gov.
If you enroll in a Medicare managed care plan, the following options are available to you:
This Plan and another plan's Medicare managed care plan: You may enroll in another plan's Medicare managed care plan and also remain enrolled in our FEHB plan.
We will still provide benefits when your Medicare managed care plan is primary, even out of the managed care plan's network and/ or service area (if you use our Plan
providers), but we will not waive any of our copayments. If you enroll in a Medicare managed care plan, tell us. We will need to know whether you are in the Original
Medicare Plan or in a Medicare managed care plan so we can correctly coordinate benefits with Medicare.

Suspended FEHB coverage to enroll in a Medicare managed care plan: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in a Medicare
managed care plan, eliminating your FEHB premium. (OPM does not contribute to your Medicare managed care plan premium.) For information on suspending your FEHB
enrollment, contact your retirement office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next open season unless you involuntarily
lose coverage or move out of the Medicare managed care plan's service area.
If you do not 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 TRICARE or CHAMPVA and this Plan cover you, we pay first. See your TRICARE or
CHAMPVA Health Benefits Advisor if you have questions about these programs.

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

If you do not enroll in Medicare Part A or Part B 55.
55 Page 56 57
2003 UPMC Health Plan 52 Section 9
OWCP or a similar agency pays for through a third party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws.
Once OWCP or similar agency pays its maximum benefits for your treatment, we will cover your care. You must use our providers.

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

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

When others are responsible When you receive money to compensate you for for injuries medical or hospital care for injuries or illness caused by another person, you must
reimburse us for any expenses we paid. However, we will cover the cost of treatment that exceeds the amount you received in the settlement.

If you do not seek damages you must agree to let us try. This is called subrogation. If you need more information, contact us for our subrogation procedures. 56.
56 Page 57 58
2003 UPMC Health Plan 53 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.

Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 11.

Covered services Care we provide benefits for, as described in this brochure.
Custodial care Custodial care, rest cures, domiciliary or convalescent care is not covered. Custodial care that lasts 90 days or more is sometimes known as Long term care.

Experimental or Investigational services are any treatment, service, procedure, facility, equipment, drug, device or supply (intervention) which is not determined by the Plan or
its designated agent to be a proven treatment.

Group health coverage The Group, including the Employers, who are party to the Group Agreement with UPMC Health Plan.

Medical necessity Services or supplier provided by a Plan Hospital, Facility/ Other Provider, or Professional Provider that UPMC Health Plan determines are:
a. Appropriate for the symptoms and diagnosis or treatment of the Member's condition; and
b. Provided in accordance with standards of good medical practice and consistent in type, frequency and duration of treatment with scientifically based guidelines of
medical, research, or health care coverage organizations or governmental agencies that are accepted by UPMC Health Plan; and
c. Not provided only as a convenience.

Plan allowance Plan allowance is the amount we use to determine our payment to our Plan providers for covered services. Plan providers accept the plan allowance as payment in full.

Us/ We Us and we refer to UPMC Health Plan.
You You refers to the enrollee and each covered family member.

Experimental or investigational services 57.
57 Page 58 59
2003UPMC Health Plan 54 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 about enrolling in the retirement office can answer your questions, and give you a Guide to Federal Employees
FEHB Program Health Benefits Plans, brochures for other plans, and other materials you need to make an informed decision about your FEHB coverage. These materials tell you:

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

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

Types of coverage available Self Only coverage is for you alone. Self and Family coverage is for for you and your family you, your spouse, and your unmarried dependent children up to 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: 58.
58 Page 59 60
2003UPMC Health Plan 55 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 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 premiums start during Open Season, your coverage begins on the first day of your first pay period that
starts on or after January 1. Annuitants' coverage and premiums begin on January 1. If you joined at any other time during the year, your employing office will tell you the
effective date of coverage.

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

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

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

Temporary continuation of coverage (TCC) If you leave Federal service, or if you lose coverage because you no longer qualify as a
family member, you may be eligible for Temporary Continuation of Coverage (TCC). For example, you can receive TCC if you are not able to continue your FEHB enrollment 59.
59 Page 60 61
2003UPMC Health Plan 56 Section 11
after you retire, if you lose your job, if you are a covered dependent child and you turn 22 or marry, etc.
You may not elect TCC if you are fired from your Federal job due to gross misconduct.
Enrolling in TCC. Get the RI 79-27, which describes TCC, and the RI 70-5, the Guide to Federal Employees Health Benefits Plans for Temporary Continuation of Coverage
and Former Spouse Enrollees, from your employing or retirement office or from www. opm. gov/ insure. It explains what you have to do to enroll.

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

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

However, if you are a family member who is losing coverage, the employing or retirement office will not notify you. You must apply in writing to us within 31 days
after you are no longer eligible for coverage.
Your benefits and rates will differ from those under the FEHB Program; however, you will not have to answer questions about your health, and we will not impose a waiting
period or limit your coverage due to pre-existing conditions.
Getting a Certificate of Group Health Plan Coverage
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a Federal law that offers limited Federal protections for health coverage availability and continuity
to people who lose employer group coverage. If you leave the FEHB Program, we will give you a Certificate of Group Health Plan Coverage that indicates how long you have
been enrolled with us. You can use this certificate when getting health insurance or other health care coverage. Your new plan must reduce or eliminate waiting periods,
limitations, or exclusions for health related conditions based on the information in the certificate, as long as you enroll within 63 days of losing coverage under this Plan. If you
have been enrolled with us for less than 12 months, but were previously enrolled in other FEHB plans, you may also request a certificate from those plans. For more information,
get OPM pamphlet RI 79-27, Temporary Continuation of Coverage (TCC) under the FEHB Program. See also the FEHB web site (www. opm. gov/ insure/ health); refer to the
"TCC and HIPAA" frequently asked question. These highlight HIPAA rules, such as the requirement that Federal employees must exhaust any TCC eligibility as one condition
for guaranteed access to individual health coverage under HIPAA, and have information about Federal and State agencies you can contact for more information. 60.
60 Page 61 62
2003 UPMC Health Plan 57 Long Term Care Insurance
Long Term Care Insurance Is Still Available!
. Open Season for Long Term Care Insurance

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

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

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

Find Out More Contact LTC Partners by calling 1-800-LTC-FEDS (1-800-582-3337) (TDD for the hearing impaired: 1-800-843-3557) or visiting www. ltcfeds. com to get more information and to request an application. 61.
61 Page 62 63
2003 UPMC Health Plan 58 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 43 Allergy tests 18
Allogenetic (donor) bone marrow transplant 29 Ambulance 33
Anesthesia 30 Autologous bone marrow transplant 29
Biopsies 26 Blood and blood plasma 32
Breast cancer screening 16 Casts 32
Changes for 2003 8 Chemotherapy 19
Childbirth 17 Chiropractic 24
Cholesterol tests 15 Claims 46
Coinsurance 12 Colorectal cancer screening 15
Congenital anomalies 27 Contraceptive devices and drugs 40
Coordination of benefits 49 Covered charges 53
Covered providers 9 Crutches 23
Deductible 12 Definitions 53
Dental care 43 Diagnostic services 14
Disputed claims review 47 Donor expenses (transplants) 29
Dressings 32 Durable medical equipment (DME) 23
Educational classes and programs 25 Effective date of enrollment 55
Emergency 34 Experimental or investigational 53
Eyeglasses 21 Family planning 17

Fecal occult blood test 15 General Exclusions 45
Hearing services 21 Home health services 24
Hospice care 33 Home nursing care 24
Hospital 31 Immunizations 16
Infertility 18 Inhospital physician care 14
Inpatient Hospital Benefits 31 Insulin 40
Laboratory and pathological services 15
Machine diagnostic tests 15 Magnetic Resonance Imagings
(MRIs) 15 Mail Order Prescription Drugs 40
Mammograms 16 Maternity Benefits 17
Medicaid 52 Medically necessary 53
Medicare 49 Mental Conditions/ Substance
Abuse Benefits 36 Neurological testing 15
Newborn care 17 Non-FEHB Benefits 44
Nursery charges 17 Obstetrical care 17
Occupational therapy 20 Ocular injury 21
Office visits 14 Oral and maxillofacial surgery 28
Orthopedic devices 22 Out-of-pocket expenses 12
Outpatient facility care 32 Oxygen 23

Pap test 15 Physical examination 16
Physical therapy 20 Physician 14
Preventive care, adult 15 Preventive care, children 16
Prescription drugs 38 Preventive services 15
Prostate cancer screening 15 Prosthetic devices 22
Psychologist 36 Psychotherapy 36
Radiation therapy 19 Renal dialysis 19
Room and board 31 Skilled nursing facility care 33
Smoking cessation 25 Speech therapy 20
Splints 32 Sterilization procedures 17
Subrogation 52 Substance abuse 36
Surgery 26 Anesthesia 30
Oral 28 Outpatient 26
Reconstructive 27 Syringes 40
Temporary continuation of coverage 55
Transplants 29 Treatment therapies 19
Vision services 21 Well child care 16
Wheelchairs 23 Workers' compensation 51
X-rays 15 62.
62 Page 63 64
2003 UPMC Health Plan
Summary of benefits for the UPMC Health Plan 2003
Do not rely on this chart alone. All benefits are provided in full unless indicated and are subject to the
definitions, limitations, and exclusions in this brochure. On this page we summarize specific expenses we cover; for more detail, look inside.

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

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

Benefits You Pay Page
Medical services provided by physicians:
Diagnostic and treatment services provided in the office................. Office visit copay: $10 primary care; $10 specialist (referred)/$ 30 self-referred 14

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

Nothing.
Nothing.
31

32
Emergency benefits:
In-area .............................................................................................
Out-of-area ......................................................................................

$50 copay (waived if admitted)
$50 copay (waived if admitted)

34
34
Mental health and substance abuse treatment ..................................... Regular cost sharing. 36
Prescription drugs ................................................................................. Retail: $5 generic/$ 15 preferred brand-name/$ 35 non-preferred brand name

Mail Order: $10 generic/$ 30 preferred brand-name/$ 70 non-preferred brand name
38

Dental Care....................................................................................... Dental Discount Program 44
Vision Care....................................................................................... Nothing for routine eye exam. Once every 24 months for over age 22/ Once every 12 months
for under age 22.
21

Special features:
1. Direct Access to Network Specialists
2. Direct Access to Selected OB/ GYN for Women
3. Assist America (Out-of-Area Travel Assistance)

42 63.
63 Page 64 65
2003 UPMC Health Plan 64.
64 Page 65
2003 UPMC Health Plan
2003 Rate Information for UPMC Health Plan
Non-Postal rates apply to most non-Postal enrollees. If you are in a special enrollment category, refer to the FEHB Guide for that category or contact the agency that maintains your
health benefits enrollment.
Postal rates apply to career Postal Service employees. Most employees should refer to the FEHB Guide for United States Postal Service Employees, RI 70-2. Different postal rates apply
and a special FEHB guide is published for Postal Service Inspectors and Office of Inspector General (OIG) employees (see RI 70-2IN).

Postal rat