Pages 1--104 from Blue Cross and Blue Shield Service Benefit Plan

with a preferred provider organization and a point-of-service product

Sponsored and administered by: The Blue Cross and Blue Shield Association and participating local Blue Cross and Blue Shield Plans
Who may enroll in this Plan: All Federal employees and annuitants who are eligible to enroll in the FEHBP

Enrollment codes for this Plan:
101 High Option -Self Only 102 High Option -Self and Family
104 Standard Option -Self Only 105 Standard Option -Self and Family

RI 71-005 1
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2001 Blue Cross and Blue Shield Service Benefit Plan 2 Table of Contents
Table of Contents
Introduction................................................................................................................................................................. 4
Plain Language............................................................................................................................................................ 4
Section 1. Facts about this fee-for-service Plan ......................................................................................................... 5
Section 2. How we change for 2001 .......................................................................................................................... 7
Section 3. How you receive benefits.......................................................................................................................... 9
Identification cards.................................................................................................................................... 9
Where you get covered care ...................................................................................................................... 9
Covered professional providers ........................................................................................................ 9
Covered facility providers............................................................................................................... 10
What you must do to get covered care .................................................................................................... 11
How to get approval for. ......................................................................................................................... 12
Your hospital stay (precertification) ............................................................................................... 12
Other services ................................................................................................................................. 14
Section 4. Your costs for covered services .............................................................................................................. 15
Copayments .................................................................................................................................... 15
Deductible ....................................................................................................................................... 15
Coinsurance .................................................................................................................................... 16
Differences between our allowance and the bill ............................................................................. 16
Your out-of-pocket maximum................................................................................................................. 17
When government facilities bill us.......................................................................................................... 18
If we overpay you ................................................................................................................................... 18
When you are age 65 or over and you do not have Medicare................................................................. 19
When you have Medicare........................................................................................................................ 20
Section 5. Benefits ................................................................................................................................................... 21
Overview................................................................................................................................................. 21
(a) Medical services and supplies provided by physicians and other health care professionals ............ 22
(b) Surgical and anesthesia services provided by physicians and other health care professionals ........ 40
(c) Services provided by a hospital or other facility, and ambulance services ...................................... 48
(d) Emergency services/ accidents.......................................................................................................... 57
(e) Mental health and substance abuse benefits..................................................................................... 59
(f) Prescription drug benefits ................................................................................................................ 65
(g) Special features ................................................................................................................................ 69
(h) Dental benefits ................................................................................................................................. 70
(i) Non-FEHB benefits available to Plan members............................................................................... 75 2
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2001 Blue Cross and Blue Shield Service Benefit Plan 3 Table of Contents
Section 6. General exclusions -things we don't cover ........................................................................................... 76
Section 7. Filing a claim for covered services........................................................................................................ 77
Section 8. The disputed claims process.................................................................................................................. 80
Section 9. Coordinating benefits with other coverage............................................................................................ 82
When you have other health coverage................................................................................................... 82
The Original Medicare Plan .................................................................................................................. 83
Medicare managed care plan................................................................................................................. 85
TRICARE/ Workers' Compensation..................................................................................................... 85
Medicaid................................................................................................................................................ 86
When other Government agencies are responsible for your care .......................................................... 86
When others are responsible for injuries ............................................................................................... 86
Section 10. Definitions of terms we use in this brochure......................................................................................... 87
Section 11. FEHB facts............................................................................................................................................ 93
Coverage information............................................................................................................................ 93
No pre-existing condition limitation .............................................................................................. 93
Where you get information about enrolling in the FEHB Program ............................................... 93
Types of coverage available for you and your family.................................................................... 93
When benefits and premiums start................................................................................................. 94
Your medical and claims records are confidential ......................................................................... 94
When you retire.............................................................................................................................. 94
When you lose benefits ......................................................................................................................... 94
When FEHB coverage ends ........................................................................................................... 94
Spouse equity coverage.................................................................................................................. 94
Temporary Continuation of Coverage (TCC) ................................................................................ 95
Converting to individual coverage ................................................................................................. 95
Getting a Certificate of Group Health Plan Coverage ........................................................................... 95
Inspector General Advisory................................................................................................................... 96
Department of Defense/ FEHB Program Demonstration Project............................................................................... 97
INDEX...................................................................................................................................................................... 99
Summary of Standard Option benefits .................................................................................................................... 102
Summary of High Option benefits .......................................................................................................................... 103
Rates............................................................................................................................................................ Back cover 3
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2001 Blue Cross and Blue Shield Service Benefit Plan 4 Introduction/ Plain Language
Introduction
Blue Cross and Blue Shield Service Benefit Plan 1310 G Street, NW, Suite 900
Washington, DC 20005
This Plan is underwritten by participating Blue Cross and Blue Shield Plans (Local Plans) that administer this Plan on behalf of the Blue Cross and Blue Shield Association (the Carrier).

This brochure describes the benefits of the Blue Cross and Blue Shield Service Benefit Plan under our contract (CS 1039) with the Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits
(FEHB) 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.

If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled for Self and Family coverage, each eligible family member is also entitled to these benefits. You do not have a right to
benefits that were available before January 1, 2001, unless those benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2001, and are summarized on pages 7 and 8. Rates are shown at the end of this brochure.

Plain Language
The President and Vice President are making the Government's communication more responsive, accessible, and understandable to the public by requiring agencies to use plain language. In response, a team of health plan
representatives and OPM staff worked cooperatively to make this brochure clearer. Except for necessary technical terms, we use common words. "You" means the enrollee or family member; "we" means the Blue Cross and Blue
Shield Service Benefit Plan or the local Blue Cross and Blue Shield Plans that administer it.
The plain language team reorganized the brochure and the way we describe our benefits. When you compare this Plan with other FEHB plans, you will find that the brochures have the same format and similar information to make
comparisons easier.
If you have comments or suggestions about how to improve this brochure, let us know. Visit OPM's "Rate Us" feedback area at www. opm. gov/ insure, or e-mail us at fehbwebcomments@ opm. gov, or write to OPM at the
Insurance Planning and Evaluation Division, P. O. Box 436, Washington, DC 20044-0436. 4
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2001 Blue Cross and Blue Shield Service Benefit Plan 5 Section 1
Section 1. Facts about this fee-for-service plan
This Plan is a fee-for-service (FFS) plan. You can choose your own hospitals, physicians, and other professional health care providers.

We reimburse you or your provider for your covered services, usually based on a percentage of the amount we allow. The type and extent of covered services, and the amount we allow, may be different from other plans. Read brochures
carefully.
We have Preferred Provider Organizations (PPO):
Our fee-for-service plan offers services through a PPO. When you use our PPO providers, you will receive covered services at a reduced cost. Your Local Plan (or for retail pharmacies, PCS Health Systems, Inc.) is solely responsible
for the selection of PPO providers in your area. Contact your Local Plan for the names of PPO providers and to verify their continued participation. You can also go to our web page, which you can reach through the FEHB web site,
www. opm. gov/ insure. Do not call OPM or your agency for our provider directory. Contact your Local Plan to request a PPO directory.

PPO benefits apply only when you use a PPO provider. PPO networks may be more extensive in some areas than in others. We cannot guarantee the availability of every specialty in all areas. If no PPO provider is available, or you do
not use a PPO provider, the standard non-PPO benefits apply.
We also have Point-of-Service (POS) benefits:
In certain areas, our fee-for-service plan offers POS benefits to members who select Standard Option. This means you can get better benefits at less out-of-pocket costs by signing up with us for the POS program, selecting a contracted
POS primary care physician (PCP), and letting the PCP manage your care. In Minnesota and North Dakota, you select a primary care clinic rather than a primary care physician. If you go to another provider without a referral from your
PCP, we will provide only regular Standard Option non-PPO benefits. We offer the POS program in the following areas: Connecticut, Georgia, Kansas, Louisiana (New Orleans area), Massachusetts, Minnesota, New Jersey, New
York (areas served by the Empire Plan), North Dakota (Fargo area), and Oklahoma. You can obtain a brochure addendum from your Local Plan in these areas that describes our POS service areas, benefit levels, and special
requirements.
How we pay professional and facility providers:
We pay benefits when we receive a claim for covered services. Each Local Plan contracts with hospitals and other health care facilities, physicians, and non-physician health care professional providers in its service area, and is
responsible for processing and paying claims for services you receive within that area. Most, but not all, of these contracted providers are in our PPO network.

= PPO providers. PPO providers have agreed to accept a specific negotiated amount as payment in full for services provided to you. We refer to PPO facility and professional providers as "Preferred." They will generally
bill the Local Plan directly, who will then pay them directly. You do not file a claim. Your out-of-pocket costs are generally less when you receive services from PPO providers, and are limited to your applicable deductible,
and coinsurance or copayments, for covered services. We provide benefits for some services (such as a routine physical exam) only when you use PPO providers.

= Participating providers. Some Local Plans also contract with other providers that are not in our PPO network. If they are professionals, we refer to them as "Participating" providers, and if they are facilities, we refer to them
as "Member" facilities. They have agreed to accept a different negotiated amount than our PPO providers as payment in full. They will also generally file your claims for you. They have agreed not to bill you for more
than your applicable deductible, and coinsurance or copayments, for covered services. We pay them directly, but at our non-PPO benefit levels. Your out-of-pocket costs will be greater than if you use PPO providers.

Note: Not all areas have participating providers and/ or member facilities. To verify the status of a provider, please contact the Local Plan serving the area where the services are to be performed. 5
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2001 Blue Cross and Blue Shield Service Benefit Plan 6 Section 1
= Non-participating providers. Providers who are not PPO or Participating providers do not have contracts with us, and may or may not accept our allowance. We refer to them as "Non-participating providers" generally,
although if they are facilities we may refer to them as "Non-member facilities." When you use Non-participating providers, you may have to file your claim with us. We will then pay our benefits to you, and you must pay the
provider.
You must pay any difference between the amount Non-participating providers charge and our allowance, in addition to any applicable coinsurance amounts, copayment amounts, amounts applied to your calendar year
deductible, and amounts for noncovered services. Important: Your out-of-pocket costs may be substantially higher when you use Non-participating providers than when you use PPO or Participating providers.

Note: In Local Plan areas other than those described below, PPO and Participating providers who contract with us will generally accept 100% of the Plan allowance as payment in full for covered services. As a result, you are only
responsible for applicable coinsurance amounts, copayment amounts, amounts applied to the calendar year deductible, and any charges for noncovered services. However, this may not apply when there is another source of payment
besides you and us. When you have other coverage (see Section 9), the following exceptions exist in our arrangements with PPO and Participating professional providers. Contact your Local Plan if you have questions
about the amounts PPO and Participating providers may collect from you.
= In Arizona, when there is any other source of payment (whether we pay primary or secondary), PPO and Participating physicians are not obligated to accept our allowance as payment in full.

= In New York areas served by the Rochester Plan and in West Virginia, except when we pay secondary to other Blue Cross and Blue Shield coverage administered by the same Local Plan, PPO and Participating
physicians may collect the difference between the total payments made by us and the primary carrier and the physician's charge.

= In Pennsylvania and Utah, when we pay secondary, PPO physicians are not obligated to accept our allowance as payment in full unless we make a payment as the secondary payer.
= In Puerto Rico, when we pay secondary, PPO physicians may collect the difference between the total payments made by us and the primary carrier and the physician's charge.
= In Montana, when we pay secondary, PPO and Participating physicians may collect the difference between the total payments made by us and the primary carrier and the physician's charge.
= In Rhode Island, South Carolina, and Vermont, except when we pay secondary to other Blue Cross and Blue Shield coverage, PPO and Participating physicians may collect the difference between the total
payments made by us and the primary carrier and the physician's charge.

Patients' Bill of Rights
OPM requires that all FEHB Plans comply with the Patients' Bill of Rights, recommended by the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry. You may get information
about us, our networks, and providers. You can also find out about care management, including medical practice guidelines, disease management programs, and how we determine if procedures are experimental or investigational.
OPM's website (www. opm. gov/ insure) lists the specific types of information that we must make available to you.
If you want more information about us, call or write to us. Our telephone number and address are shown on the back of your Service Benefit Plan ID card. You may also visit our website at www. fepblue. org. 6
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2001 Blue Cross and Blue Shield Service Benefit Plan 7 Section 2
Section 2. How we change for 2001
Program-wide changes
= The plain language team reorganized the brochure and the way we describe our benefits. We hope this will make it easier for you to compare FEHB Plans.

= This year, the Federal Employees Health Benefits Program is implementing network mental health and substance abuse parity. This means that your coverage for network mental health, substance abuse, medical, surgical, and
hospital services from providers in our PPO network will be the same with regard to deductibles, coinsurance, copayments, and day and visit limitations when you follow a treatment plan that we approve. Previously, we
placed higher patient cost sharing or shorter day or visit limitations on mental health and substance abuse services than we did on services to treat physical illness, injury, or disease.

= Many health care organizations have turned their attention this past year to improving health care quality and patient safety. OPM asked all FEHB Plans to join them in this effort. You can find specific information on our
patient safety activities by calling the telephone number on the back of your Plan ID card, or checking our website www. fepblue. org. You can find out more about patient safety on the OPM website,
www. opm. gov/ insure. To improve your health care, take these five steps:
Speak up if you have questions or concerns.
Keep a list of all the medicines you take.
Make sure you get the results of any test or procedure.
Talk with your doctor and health care team about your options if you need hospital care.
Make sure you understand what will happen if you need surgery.
= We clarified the brochure language to show that anyone who needs a mastectomy may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure.

Previously, the language referenced only women.
= North Dakota is deleted from the list of states designated as medically underserved in 2001. See page 10 for information on medically underserved areas.

Changes to this Plan
= Your share of the non-Postal Standard Option premium will increase by 14. 0% for Self Only or 21. 2% for Self and Family.

= Your share of the non-Postal High Option premium will increase by 5. 8% for Self Only or 3. 7% for Self and Family.
= We have enhanced our Mental Health and Substance Abuse benefits. See Section 5( e).
= Your share for outpatient facility services is now based on coinsurance:
Under Standard Option, you now pay 10% of the Plan allowance at PPO facilities, and 25% of the Plan allowance at Member and Non-member facilities. You also pay any difference between the Plan allowance

and a Non-member facility's actual charge. Previously, your cost share was $25 per day at PPO facilities, $100 per day at Member facilities, and $150 per day at Non-member facilities. See Section 5( c).

Under High Option, you now pay 5% of the Plan allowance at PPO facilities, and 20% of the Plan allowance at Member and Non-member facilities. You also pay any difference between the Plan allowance and a Non-member
facility's actual charge. Previously, your cost share was $10 per day at PPO facilities, $50 per day at Member facilities, and $100 per day at Non-member facilities. See Section 5( c). 7
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2001 Blue Cross and Blue Shield Service Benefit Plan 8 Section 2
= Under Standard Option, your calendar year deductible is now $250 per person/$ 500 per family. Previously, your calendar year deductible was $200 per person/$ 400 per family. See Section 4.
= Under Standard Option, your copayment for PPO home and office visits is now $15. Previously, your copayment was $12. See Sections 5( a), 5( c) and 5( e).
= Under Standard Option, your hospital inpatient per admission copayment is now $100 per admission at PPO hospitals and $300 per admission at Member and Non-member hospitals. Previously, you paid nothing per
admission at Preferred hospitals and $250 per admission at Member and Non-member hospitals. See Section 5( c).

= Under Standard Option, your catastrophic protection out-of-pocket limit is now $3,000 per contract when you use only PPO providers and $5,000 per contract when you use a combination of PPO and non-PPO providers.
Previously, your out-of-pocket limit was $2000 (PPO only) and $3,750 (PPO and non-PPO). See Section 4.
= Your cost sharing (deductibles, coinsurance or copayments) for In-Network (Preferred) mental health and substance abuse services is now included under the catastrophic protection out-of-pocket limit. See Section 4.

= You now pay $15 per visit under Standard Option and $12 per visit under High Option for PPO office visits associated with hepatitis immunizations, and nothing for the immunization. Previously, you paid (subject to
the applicable calendar year deductible) 10% of the Plan allowance under Standard Option and 5% of the Plan allowance under High Option. See Section 5( a).

= We now provide limited benefits under Standard and High Option for audiologists, diabetic educators, dieticians, and nutritionists who bill independently for covered services. See Section 3 and Section 5( a).
= We now provide benefits under Standard and High Option for outpatient cardiac rehabilitation when you obtain prior approval from your Local Plan. See Sections 5( a) and 5( c) for benefits, and Section 3 for prior approval
procedures.
= For your safety, we have placed additional limits on the quantities of prescription drugs you may obtain through the Retail Pharmacy Program and the Mail Service Prescription Drug Program, in accordance with

FDA guidelines.
= We have expanded our benefits for organ/ tissue transplants to include all phagocytic deficiency diseases. See Section 5( b).

= We now provide benefits for inpatient stays in sub-acute units during a medically necessary hospital admission. See Section 5( c).
= Our Standard Option Point-of-Service (POS) program is no longer offered in the Cincinnati area of Ohio.
= Under our Standard Option POS program, you now pay $15 per visit for home, office, and clinic visits, nurse or home health aide visits, and visits for physical, occupational, or speech therapy. Previously, you paid $10 per

visit. See your POS brochure addendum.
= Under our Standard Option POS program, you now pay $50 per hospital emergency room visit and $40 per urgent care center visit. Previously, you paid $35 (ER) and $25 (urgent care) per visit. See your POS brochure

addendum.
= Under our Standard Option POS program, you now pay the lesser of the actual charge, or $10 per generic prescription or $20 per brand name prescription, for drugs obtained from a POS retail pharmacy. Previously,

your copayments were $5 (generic) and $15 (brand name). See your POS brochure addendum. 8
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2001 Blue Cross and Blue Shield Service Benefit Plan 9 Section 3
Section 3. How you receive benefits
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 covered provider, or fill a prescription at a pharmacy participating in our Retail Pharmacy Program.
Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation
letter (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 the Local Plan
serving the area where you reside and ask them to assist you, or write to us directly at: FEP Enrollment Services, 550 12 th Street, SW,
Washington, DC 20065-1463.

Where you get covered care You can get care from any "covered professional provider" or "covered facility provider." How much we pay – and you pay – depends on the
type of covered provider you use. If you use our PPO, Participating, or Member providers, or our point-of-service program, you will pay less.

Covered professional providers We consider the following to be covered professionals when they perform services within the scope of their license or certification:
Physician -Doctors of medicine (M. D.); osteopathy (D. O.); dental surgery (D. D. S.); medical dentistry (D. M. D.); podiatric medicine
(D. P. M.); and optometry (O. D.). Independent Laboratory -A laboratory that is licensed under State
law or, where no licensing requirement exists, that is approved by the Local Plan.
Qualified Clinical Psychologist -A psychologist who (1) is licensed or certified in the state where the services are performed;
(2) has a doctoral degree in psychology (or an allied degree if, in the individual state, the academic licensing/ certification requirement for
clinical psychologist is met by an allied degree) or is approved by the Local Plan; and (3) has met the clinical psychological experience
requirements of the individual State Licensing Board. Nurse Midwife -A person who is certified by the American College
of Nurse Midwives or, if the state requires it, is licensed or certified as a nurse midwife.
Nurse Practitioner/ Clinical Specialist -A person who (1) has an active R. N. license in the United States; (2) has a baccalaureate or
higher degree in nursing; and (3) if the state requires it, is licensed or certified as a nurse practitioner or clinical nurse specialist.
Clinical Social Worker -A social worker who (1) has a master's or doctoral degree in social work; (2) has at least two years of clinical
social work practice; and (3) if the state requires it, is licensed, certified, or registered as a social worker where the services are
performed. Physical, Speech, and Occupational Therapist -A professional
who is licensed where the services are performed or meets the requirements of the Local Plan to provide physical, speech, or
occupational therapy services. 9
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2001 Blue Cross and Blue Shield Service Benefit Plan 10 Section 3
Nursing School Administered Clinic -A clinic that (1) is licensed or certified in the state where services are performed; and (2)
provides ambulatory care in an outpatient setting -primarily in rural or inner-city areas where there is a shortage of physicians. Services
billed for by these clinics are considered outpatient "office" services rather than facility charges.

Audiologist -A professional who, if the state requires it, is licensed, certified, or registered as an audiologist where the services are
performed.
Dietician -A professional who, if the state requires it, is licensed, certified, or registered as a dietician where the services are

performed.
Diabetic educator -A professional who, if the state requires it, is licensed, certified, or registered as a diabetic educator where the

services are performed.
Nutritionist -A professional who, if the state requires it, is licensed, certified, or registered as a nutritionist where the services are

performed.
Other professional providers specifically shown in the benefits descriptions in Section 5.

Medically underserved areas. Note: In medically underserved areas, we cover any licensed medical practitioner for any covered service
performed within the scope of that license in states OPM determines are "medically underserved." For 2001, the states are: Alabama, Idaho,
Kentucky, Louisiana, Mississippi, Missouri, New Mexico, South Carolina, South Dakota, Utah, and Wyoming.

Covered facility providers Covered facilities include:
Hospital -An institution, or a distinct portion of an institution, that:
(1) Primarily provides diagnostic and therapeutic facilities for surgical and medical diagnoses, treatment, and care of injured and sick
persons provided or supervised by a staff of licensed doctors of medicine (M. D.) or licensed doctors of osteopathy (D. O.), for
compensation from its patients, on an inpatient or outpatient basis; (2) Continuously provides 24-hour-a-day professional registered nursing
(R. N.) services; and (3) Is not, other than incidentally, an extended care facility; a nursing
home; a place for rest; an institution for exceptional children, the aged, drug addicts, or alcoholics; or a custodial or domiciliary
institution having as its primary purpose the furnishing of food, shelter, training, or non-medical personal services.

Note: We consider college infirmaries to be Non-member hospitals. In addition, we may, at our discretion, recognize any institution located
outside the 50 states and the District of Columbia as a Non-member hospital.

Freestanding Ambulatory Facility -A freestanding facility, such as an ambulatory surgical center, freestanding surgi-center,
freestanding dialysis center, or freestanding ambulatory medical facility, that: 10
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2001 Blue Cross and Blue Shield Service Benefit Plan 11 Section 3
(1) Provides services in an outpatient setting; (2) Contains permanent amenities and equipment primarily for the
purpose of performing medical, surgical, and/ or renal dialysis procedures;
(3) Provides treatment performed or supervised by doctors and/ or nurses, and may include other ancillary professional services
performed at the facility; and (4) Is not, other than incidentally, an office or clinic for the private
practice of a doctor or other professional.
Note: We may, at our discretion, recognize any other similar facilities, such as birthing centers, as freestanding ambulatory facilities.

Cancer Research Facility -A facility that is:
(1) A National Cooperative Center Cancer Study Group institution that is funded by the National Cancer Institute (NCI) and has been
approved by a Cooperative Group as a bone marrow transplant center;
(2) An NCI-designated Cancer Center; or (3) An institution that has an NCI-funded, peer-reviewed grant to study
allogeneic or autologous bone marrow transplants and blood stem cell transplant support.

Other facilities specifically listed in the benefits descriptions in Section 5( c).
What you must do to It depends on the kind of care you want to receive. You can go to any get covered care provider you want, but in some circumstances, we must approve care in
advance.

Transitional care Specialty Care: If you have a chronic or disabling condition and lose access to PPO benefits for your specialist's services 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;

you may be able to continue to receive PPO benefits for your specialist's services 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 PPO benefits for your specialist's services based on the above
circumstances, you can continue to receive PPO benefits for your specialist's services until the end of your postpartum care, even if it is
beyond the 90 days.

Hospital care Hospital care: If you are in the hospital when your enrollment in our Plan begins, call us immediately. If you have not yet received your
Service Benefit Plan ID card, you can contact your Local Plan at the telephone number listed in your local telephone directory. If you already
have your new Service Benefit Plan ID card, call us at the number on the back of the card. If you are new to the FEHB Program, we will
reimburse you for your covered expenses while in the hospital. 11
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2001 Blue Cross and Blue Shield Service Benefit Plan 12 Section 3
However, 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.
How to get approval for…

Your hospital stay Precertification is the process by which – prior to your inpatient hospital admission – we evaluate the medical necessity of your proposed stay and
the number of days required to treat your condition. Unless we are misled by the information given to us, we will not change our decision on
medical necessity.
In most cases, your physician or hospital will take care of precertification. Because you are still responsible for ensuring that we
are asked to precertify your care, you should always ask your physician or hospital whether they have contacted us.

Warning: We will reduce our benefits for the inpatient hospital stay by $500 if no one contacts us for precertification. If the stay is not medically
necessary, we will not pay any benefits.

How to precertify an admission: You, your representative, your doctor, or your hospital must call us at the telephone number listed on the back of your Service Benefit
Plan ID card any time prior to admission.
= If you have an emergency admission due to a condition that you reasonably believe puts your life in danger or could cause serious
damage to bodily function, you, your representative, your doctor, or your hospital must telephone us within two business days following
the day of the emergency admission, even if you have been discharged from the hospital.

= Provide the following information:
Enrollee's name and Plan identification number;
Patient's name, birth date, and phone number;
Reason for hospitalization, proposed treatment, or surgery;
Name and phone number of admitting doctor;
Name of hospital or facility; and
Number of planned days of confinement.
= We will then tell the doctor and/ or hospital the number of approved inpatient days and we will send written confirmation of our decision
to you, your doctor, and the hospital. 12
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2001 Blue Cross and Blue Shield Service Benefit Plan 13 Section 3
Maternity care You do not need to precertify a maternity admission for a routine delivery. However, if your medical condition requires you to stay more than 48 hours
after a vaginal delivery or 96 hours after a cesarean section, then your physician or the hospital must contact us for precertification of additional
days. Further, if your baby stays after you are discharged, then your physician or the hospital must contact us for precertification of additional
days for your baby.
If your hospital stay If your hospital stay, including for maternity care, needs to be needs to be extended: extended, your doctor or the hospital must ask us to approve the additional
days.
What happens when you When we precertified the admission but you remained in the do not follow the hospital beyond the number of days we approved and
precertification rules did not get the additional days precertified, then:
for the part of the admission that was medically necessary, we will pay inpatient benefits, but

for the part of the admission that was not medically necessary, we will pay only medical services and supplies otherwise payable on
an outpatient basis and we will not pay inpatient benefits.
= If no one contacted us, we will decide whether the hospital stay was medically necessary.

If we determine that the stay was medically necessary, we will pay the inpatient charges, less the $500 penalty.
If we determine that it was not medically necessary for you to be an inpatient, we will not pay inpatient hospital benefits. We will
only pay for any covered medical supplies and services that are otherwise payable on an outpatient basis.

= If we denied the precertification request, we will not pay inpatient hospital benefits or inpatient physician care benefits. We will only
pay for any covered medical supplies and services that are otherwise payable on an outpatient basis.

Exceptions: You do not need precertification in these cases:
= You are admitted to a hospital outside the United States.
= You have another group health insurance policy that is the primary payer for the hospital stay.

= Your Medicare Part A is the primary payer for the hospital stay. Note: If you exhaust your Medicare hospital benefits and do not want
to use your Medicare lifetime reserve days, then we will become the primary payer and you do need precertification. 13
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2001 Blue Cross and Blue Shield Service Benefit Plan 14 Section 3
Other services These services require prior approval:
= Home health care (High Option) -Contact us at the number listed on the back of your ID card before obtaining services. We will
request the medical evidence we need to make our coverage determination and advise you which home health care agencies have
agreements with us.
= Home hospice care -Contact us at the number listed on the back of your ID card before obtaining services. We will request the medical
evidence we need to make our coverage determination and advise you which home hospice care agencies we have approved.

= Partial hospitalization or intensive outpatient treatment for mental health/ substance abuse -Contact us at the number listed on
the back of your ID card for mental health and substance abuse before obtaining services for intensive outpatient treatment or partial
hospitalization. We will request the medical evidence we need to make our coverage determination. We will also consider the
necessary duration of either of these services.
= Organ/ tissue transplants -Contact us at the number listed on the back of your ID card before obtaining services. We will request the
medical evidence we need to make our coverage determination. We will consider whether the facility is approved for the procedure and
whether you meet the facility's criteria.
= Clinical trials for certain organ/ tissue transplants -Contact our Clinical Trials Information Unit at 1-800-225-2268 for information
or to request prior approval before obtaining services. We will request the medical evidence we need to make our coverage
determination. Use this number only for prior approval of clinical trials for bone marrow and peripheral blood stem cell transplant
support procedures for those conditions shown on page 46 as covered only in clinical trials.

= Cardiac rehabilitation -Contact us at the number listed on the back of your ID card prior to starting treatment. We will request the
information we need to make our coverage determination.
= Prescription drugs -Contact our Retail Pharmacy Program at 1-800-624-5060 (TDD: 1-800-624-5077 for the hearing impaired) to
request prior approval, or to obtain an updated list of prescription drugs that require prior approval. We will request the information
we need to make our coverage determination. You must periodically renew prior approval for certain drugs.

Note: Until we approve them, you must pay for these drugs in full when you purchase them at any retail pharmacy, even at Preferred
pharmacies, and submit the expense( s) to us on a claim form. Preferred pharmacies will not file these claims for you. Our Mail
Service Prescription Drug Program also will not fill your prescription until you have prior approval. Merck-Medco Rx
Services, the administrator of the Mail Service Prescription Drug Program, will return your prescription to you along with a Prior
Approval Request Form and a letter explaining the prior approval procedures. 14
14 Page 15 16
2001 Blue Cross and Blue Shield Service Benefit Plan 15 Section 4
Section 4. Your costs for covered services
This is what you will pay out-of-pocket for your covered care:
Copayments A copayment is a fixed amount of money you pay to the provider when you receive certain services.

Example: When you see your PPO physician you pay a copayment of $15 per visit.
We also have a per admission copayment for inpatient hospital stays (except under High Option in Preferred hospitals). This is a fixed
amount of covered hospital room and board expenses you must pay once during each hospital admission before we pay benefits. The per
admission copayment does not apply to Preferred maternity care and High Option Preferred hospitals.

Note: If the billed amount (or the Plan allowance that providers we contract with have agreed to accept as payment in full) is less than your
copayment, you pay the lower amount.
Deductible A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for
them. Copayments do not count toward any deductible. When a covered service or supply is subject to a deductible, only the Plan allowance for
the service or supply that you then pay counts toward meeting your deductible.

We have a calendar year deductible. The calendar year deductible is $250 per person under Standard Option and $150 per person
under High Option. Under a family enrollment, the calendar year deductible for each family member is satisfied and benefits are
payable for all family members when the combined covered expenses of the family reach $500 under Standard Option and $300
under High Option.
Note: If the billed amount (or the Plan allowance that providers we contract with have agreed to accept as payment in full) is less than the
remaining portion of your deductible, you pay the lower amount.
Example: If the billed amount is $100, the provider has an agreement with us to accept $80, and you have not paid any amount toward meeting
your Standard Option calendar year deductible, you must pay $80. We will apply $80 to your deductible. We will begin paying benefits once
the remaining portion of your Standard Option calendar year deductible ($ 170) has been satisfied.

Note: If you change plans during Open Season and the effective date of your new plan is after January 1 of the next year, you do not have to start
a new deductible under your old plan between January 1 and the effective date of your new plan. If you change plans at another time during the
year, you must begin a new deductible under your new plan.
And, if you change options in this Plan during the year, we will credit the amount of covered expenses already applied toward the calendar year
deductible of your old option to the calendar year deductible of your new option. 15
15 Page 16 17
2001 Blue Cross and Blue Shield Service Benefit Plan 16 Section 4
Coinsurance Coinsurance is the percentage of the Plan allowance that you must pay for your care. Coinsurance does not begin until you meet your
deductible.
Example: You pay 20% of the Plan allowance under High Option, or 25% of the Plan allowance under Standard Option, for ambulance
transport services.
Note: Your coinsurance is based on the Plan allowance, or the billed amount, whichever is less.

Note: If your provider routinely waives (does not require you to pay) your deductible, coinsurance or copayments, the provider is misstating
the fee and may be violating the law. In this case, when we calculate our share, we will reduce the provider's fee by the amount waived.

Example: If your physician ordinarily charges $100 for a service but routinely waives your 25% Standard Option coinsurance, the actual
charge is $75. We will pay $56.25 (75% of the actual charge of $75).
Differences between Our "Plan allowance" is the amount we use to calculate our payment for our allowance and covered services. Fee-for-service plans arrive at their allowances in
the bill different ways, so their allowances vary. For information about how we determine our Plan allowance, see the definition of Plan allowance in
Section 10.
Often, the provider's bill is more than a fee-for-service plan's allowance. Whether or not you have to pay the difference between our allowance
and the bill will depend on the provider you use.
= PPO providers agree to limit what they bill you. Because of that,
when you use a PPO provider, your share of covered charges consists only of your deductible and coinsurance or copayment. Here is an

example: You see a PPO physician who charges $150, but our allowance is $100. If you have met your deductible, you are only
responsible for your coinsurance. That is, under Standard Option, you pay just 10% of our $100 allowance ($ 10). Because of the
agreement, your PPO physician will not bill you for the $50 difference between our allowance and his/ her bill. See page 6 for
exceptions.
= Participating providers also agree to limit what they bill you.
Because of that, when you use a Participating provider, your share of covered charges consists only of your deductible and coinsurance or

copayment. Here is an example: You see a Participating physician who charges $150, but the Plan allowance is $100. If you have met
your deductible, you are only responsible for your coinsurance. That is, under Standard Option, you pay just 25% of our $100 allowance
($ 25). Because of the agreement, your Participating physician will not bill you for the $50 difference between our allowance and his/ her
bill. See page 6 for exceptions. 16
16 Page 17 18
2001 Blue Cross and Blue Shield Service Benefit Plan 17 Section 4
= Non-participating providers, on the other hand, have no agreement to
limit what they will bill you. When you use a Non-participating provider, you will pay your deductible and coinsurance -plus any

difference between our allowance and the charges on the bill. For example, you see a Non-participating physician who charges $150.
The Plan allowance is again $100, and you have met your deductible. You are responsible for your coinsurance, so you pay 25% of the $100
Plan allowance or $25. Plus, because there is no agreement between the Non-participating physician and us, the physician can bill you for
the $50 difference between our allowance and his/ her bill.
The following table illustrates this example of how much you have to pay out-of-pocket for services from a PPO physician, a Participating
physician, and a Non-participating physician. The table uses our example of a service for which the physician charges $150 and the Plan
allowance is $100. The table shows the amount you pay if you have met your calendar year deductible.

EXAMPLE PPO physician Participating physician Non-participating physician
Physician's charge $150 $150 $150 Our allowance We set it at: 100 We set it at: 100 We set it at: 100
We pay 90% of our allowance: 90 75% of our allowance: 75 75% of our allowance: 75 You owe:
Coinsurance 10% of our allowance: 10 25% of our allowance: 25 25% of our allowance: 25 +Difference up to
charge? No: 0 No: 0 Yes: 50 TOTAL YOU PAY $10 $25 $75

Note: Had you not met any of your deductible in the above examples, only our allowance ($ 100), which you would pay in full, would count
toward your deductible.
° Overseas providers. We pay overseas claims at PPO benefit levels, using an Overseas Fee Schedule as our Plan allowance. Most overseas

providers are under no obligation to accept our allowance, and you must pay any difference between our payment and the provider's bill.
See Section 5( g) for more information about our overseas benefits.
Note: Under Standard Option, we pay scheduled amounts for routine dental services and you pay any balance. See Section 5( h) for

information about your costs for routine dental services.
Your out-of-pocket maximum If the total amount of out-of-pocket expenses in a calendar year for you for deductibles, coinsurance and your covered family members for deductibles, coinsurance, and
and copayments copayments (other than those indicated on the following page) exceeds $5000 under Standard Option, or $2,700 under High Option, then you
and any covered family members will not have to continue paying them for the remainder of the calendar year.

PPO maximum: If the total amount of these out-of-pocket expenses in a calendar year from using PPO providers for you and your covered family
members exceeds $3,000 under Standard Option, or $1,000 under High Option, then you and any covered family members will not have to pay
them for the remainder of the calendar year when you continue to use PPO providers. You will, however, have to pay them when you use non-PPO
providers, until your out-of-pocket expenses reach $5000 under Standard Option, or $2,700 under High Option, as shown above. 17
17 Page 18 19
2001 Blue Cross and Blue Shield Service Benefit Plan 18 Section 4
The following expenses are not included under this feature. These expenses do not count toward your out-of-pocket maximum, and you
must continue to pay them even after your expenses exceed the limits described on page 17:

= The difference between the Plan allowance and the billed amount. See page 16;
= Expenses for services, drugs, and supplies in excess of our maximum benefit limitations;
= Your 30% coinsurance for inpatient care in a Non-member hospital;
= Your 25% (Standard Option) and 20% (High Option) coinsurance for outpatient care by a Non-member facility;

= Your expenses for mental conditions and substance abuse care by a non-PPO professional or facility provider;

= Your expenses for dental services in excess of our fee schedule payments under Standard Option. See Section 5( h); and
= The $500 penalty for failing to obtain precertification, and any other amounts you pay because we reduce benefits for not complying with
our cost containment requirements.
Note: If you change to another plan during Open Season, we will continue to provide benefits between January 1 and the effective date of
your new plan.
= If you had already paid the out-of-pocket maximum, we will continue to provide benefits as described above until the effective date of your
new plan.
= If you had not yet paid the out-of-pocket maximum, we will apply any expenses you incur in January (before the effective date of your

new plan) to our prior year's out-of-pocket maximum. Once you reach the maximum, you don't need to pay our deductibles,

copayments or coinsurance amounts (except as shown above) from that point until the effective date of your new plan.

Note: Because benefit changes are effective January 1, we will apply our next year's benefits to any expenses you incur in January.
Note: If you change options in this Plan during the year, we will credit the amounts already accumulated toward the PPO and non-PPO out-of-pocket
limits of your old option to the out-of-pocket limits of your new option. If you change from Self Only to Self and Family, or vice versa,
during the calendar year, please contact your Local Plan about your out-of-pocket accumulations and how they carry over.

When government facilities Facilities of the Department of Veterans Affairs, the Department of bill us Defense, and the Indian Health Service are entitled to seek
reimbursement from us for certain services and supplies they provide to you or a family member. They may not seek more than their governing

laws allow.

If we overpay you We will make diligent efforts to recover benefit payments we made in error but in good faith. We may reduce subsequent benefit payments to
offset overpayments.
Note: We will generally first seek recovery from the provider if we paid the provider directly, or from the person (covered family member,
guardian, custodial parent, etc.) to whom we sent our payment. 18
18 Page 19 20
2001 Blue Cross and Blue Shield Service Benefit Plan 19 Section 4
When you are age 65 or over and you do not have Medicare
Under the FEHB law, we must limit our payments for those benefits you would be entitled to if you had Medicare. And, your physician and hospital must follow Medicare rules and cannot bill you for more than they could bill you if
you had Medicare. The following chart has more information about the limits.
If you…
= are age 65 or over, and
= do not have Medicare Part A, Part B, or both; and
= have this Plan as an annuitant, as a former spouse, or as a family member of an annuitant or former spouse; and

= are not employed in a position that gives FEHB coverage. (Your employing office can tell you if this applies.)

Then, for your inpatient hospital care,
= the law requires us to base our payment on an amount -the "equivalent Medicare amount" -set by Medicare's rules for what Medicare will pay and not on the actual charge;

= you are responsible for your applicable deductible and coinsurance or copayments you owe under this Plan;

= you are not responsible for any charges greater than the equivalent Medicare amount; we will show that amount on the explanation of benefits (EOB) form that we send you; and
= the law prohibits a hospital from collecting more than the equivalent Medicare amount.
And, for your physician care, the law requires us to base our payment and your applicable coinsurance on…
= an amount -set by Medicare and called the "Medicare approved amount" or
= the actual charge if it is lower than the Medicare approved amount.

If your physician… Then you are responsible for…

Participates with Medicare or accepts Medicare assignment for the claim and
is in our PPO network
your deductibles, coinsurance, and copayments

Participates with Medicare or accepts Medicare assignment and is not in our
PPO network
your deductibles, coinsurance, and copayments, and any balance up to the Medicare approved
amount
Does not participate with Medicare, and is in our PPO network your deductibles, coinsurance, and copayments, and any balance up to 115% of the Medicare

approved amount
Note: In many cases, your payment will be less because of our PPO agreements. Contact your

Local Plan for information about what your specific PPO provider can collect from you.

Does not participate with Medicare and is not in our PPO network your deductibles, coinsurance, copayments, and any balance up to 115% of the Medicare
approved amount
It is generally to your financial advantage to use a physician who participates with Medicare. Such physicians are only permitted to collect up to the Medicare approved amount.

Our explanation of benefits (EOB) form will tell you how much the physician or hospital can collect from you. If your physician or hospital tries to collect more than allowed by law, ask the physician or hospital to reduce the charges. If
you have paid more than allowed, ask for a refund. If you need further assistance, call us. 19
19 Page 20 21
2001 Blue Cross and Blue Shield Service Benefit Plan 20 Section 4
When you have the We limit our payment to an amount that supplements the benefits that Original Medicare Plan Medicare would pay under Medicare Part A (Hospital Insurance) and
Medicare Part B (Medical Insurance), regardless of whether Medicare pays.

Note: We pay our regular benefits for emergency services to a facility provider, such as a hospital, that does not participate with Medicare and
is not reimbursed by Medicare.
If you are covered by Medicare Part B and it is primary, your out-of-pocket costs for services that both we and Medicare cover depend on
whether your physician accepts Medicare assignment for the claim.
= If your physician accepts Medicare assignment, then you pay nothing
for covered charges.

= If your physician does not accept Medicare assignment, then you pay
the difference between our payment combined with Medicare's payment, and the charge.

Note: The physician who does not accept Medicare assignment may not bill you for more than 115% of the amount Medicare bases its payment
on, called the "limiting charge." The Medicare Summary Notice (MSN) form that you receive from Medicare will have more information about
the limiting charge. If your physician tries to collect more than allowed by law, ask them to reduce their charges. If they do not, report them to
your Medicare carrier who sent you the MSN form. Call us if you need further assistance.

When you have a Medicare A physician may ask you to sign a private contract agreeing that you can Private Contract be billed directly for services ordinarily covered by Medicare. Should
you sign an agreement, Medicare will not pay any portion of the charges, and we will not increase our payment to you or the physician. We will
still limit our payment to the amount we would have paid after Medicare's payment. You will be responsible for paying the difference
between the limiting charge and the amount we paid.
Please see Section 9, Coordinating benefits with other coverage, for more information about how we coordinate benefits with Medicare. 20
20 Page 21 22
2001 Blue Cross and Blue Shield Service Benefit Plan 21 Section 5
Section 5. Benefits -OVERVIEW
(See pages 7-8 for how our benefits changed this year and pages 102-103 for a benefits summary.)

NOTE: This benefits section is divided into subsections. Please read the important things you should keep in mind at the beginning of each subsection. Also read the General exclusions in Section 6; they apply to
the benefits in the following subsections. To obtain claim forms, claims filing advice, or more information about our benefits, contact us at the telephone number on the back of your Service Benefit Plan ID card or
at our website at www. fepblue. org.

(a) Medical services and supplies provided by physicians and other health care professionals...................... 22-39
= 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
= Rehabilitative therapies
= Hearing services (testing, treatment, and
supplies)

= Vision services (testing, treatment, and
supplies) = Foot care

= Orthopedic and prosthetic devices
= Durable medical equipment (DME)
= Medical supplies
= Home health services
= Alternative treatments
= Educational classes and programs

(b) Surgical and anesthesia services provided by physicians and other health care professionals .................. 40-47
= Surgical procedures
= Reconstructive surgery
= Oral and maxillofacial surgery

= Organ/ tissue transplants
= Anesthesia

(c) Services provided by a hospital or other facility, and ambulance services................................................ 48-56
= Inpatient hospital
= Outpatient hospital or ambulatory surgical
center = Extended care benefits/ Skilled nursing

care facility benefits

= Hospice care
= Ambulance
= Home health care

(d) Emergency services/ Accidents .................................................................................................................. 57-58
= Accidental injury
= Medical emergency

= Ambulance

(e) Mental health and substance abuse benefit ................................................................................................ 59-64
(f) Prescription drug benefits .......................................................................................................................... 65-68
(g).. Special features ............................................................................................................................................... 69 Health support programs

= Flexible benefits option
= 24-hour nurse line

= Services for the deaf and hearing impaired
= Travel benefit/ services overseas

(h) Dental benefits ........................................................................................................................................... 70-74
(i) Non-FEHB benefits available to Plan members ............................................................................................. 75

General exclusions ................................................................................................................................................. 76
SUMMARY OF BENEFITS........................................................................................................................... 102-103 21
21 Page 22 23
2001 Blue Cross and Blue Shield Service Benefit Plan 22 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 you should 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.

= The calendar year deductible is: $250 per person ($ 500 per family) under Standard Option and $150 per person ($ 300 per family) under High Option. The calendar year deductible
applies to almost all benefits in this Section. We added "( No deductible)" to show when the calendar year deductible does not apply.

= Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works, with special sections for members who are age 65 or over. Also
read Section 9 about coordinating benefits with other coverage, including Medicare.
= The non-PPO benefits are the standard benefits of this Plan. PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non-PPO benefits apply.

= We base payment on whether a facility or a health care professional bills for the services or supplies. You will find that some benefits are listed in more than one section of the
brochure. This is because how they are paid depends on what type of provider bills for the service. For example, physical therapy is paid differently depending on whether it is billed
by an inpatient facility, a doctor, a physical therapist, or an outpatient facility.

I M
P O
R T
A N
T

Benefit Description You pay After the calendar year deductible…
NOTE: The calendar year deductible applies to almost all benefits in this Section. We say "No deductible" when it does not apply.
Diagnostic and treatment services You pay – Standard Option You pay – High Option
Professional services of physicians:
= Outpatient consultations
= Second surgical opinions
= Office visits
= Home visits

Preferred: $15 copayment for the office visit charge (No
deductible); 10% of the Plan allowance for all other
services (deductible applies)

Participating: 25% of the Plan allowance
Non-participating: 25% of the Plan allowance, plus any
difference between our allowance and the
physician's actual charge

Preferred: $12 copayment for the office visit charge
(No deductible); 5% of the Plan allowance for all
other services (deductible applies)

Participating: 20% of the Plan allowance
Non-participating: 20% of the Plan allowance, plus
any difference between our allowance and the
physician's actual charge

Diagnostic and treatment services – Continued on next page 22
22 Page 23 24
2001 Blue Cross and Blue Shield Service Benefit Plan 23 Section 5( a)
Diagnostic and treatment services -Continued You pay – Standard Option You pay – High Option
Professional services of physicians (cont'd):
= During a hospital stay
= Services for nonsurgical procedures when ordered, provided, and billed by a physician

during a covered inpatient hospital admission
= Medical care by the attending physician (the physician who is primarily responsible for your

care when you are hospitalized) on days we pay Inpatient Hospital Benefits. Note: A consulting
physician employed by the hospital is not the attending physician

= Consultations when requested by the attending physician
= Concurrent care – hospital inpatient care by a physician other than the attending physician for
a condition not related to your primary diagnosis, or because the medical complexity of
your condition requires this additional medical care

= Physical therapy by a physician other than the attending physician
= Initial examination of a newborn needing definitive treatment when covered under a
family enrollment
= Pharmacotherapy (See Section 5( f) for coverage for prescription drugs)

= Neurological testing

Preferred: 10% of the Plan allowance
Participating: 25% of the Plan allowance

Non-participating: 25% of the Plan
allowance, plus any difference between our
allowance and the physician's actual charge

Preferred: 5% of the Plan allowance (No
deductible)
Participating: 20% of the Plan
allowance (No deductible)

Non-participating: 20% of the Plan
allowance (No deductible), plus
any difference between our
allowance and the physician's actual
charge

Diagnostic and treatment services – Continued on next page 23
23 Page 24 25
2001 Blue Cross and Blue Shield Service Benefit Plan 24 Section 5( a)
Diagnostic and treatment services -Continued You pay – Standard Option You pay – High Option
Not covered:
= Routine services except for those Preventive care services described on pages 26-28

= Inpatient private duty nursing
= Standby physicians
= Routine radiological and staff consultations required by hospital rules and regulations

= Inpatient physician care when your hospital admission or portion of an admission is not
covered [( see Section 5( c)]
Note: If we determine that a hospital admission is not covered, we will not provide benefits for

inpatient room and board or inpatient physician care. However, we will provide benefits for
covered services or supplies other than room and board and inhospital physician care at the level
that we would have paid if they had been provided in some other setting.

All charges All charges 24
24 Page 25 26
2001 Blue Cross and Blue Shield Service Benefit Plan 25 Section 5( a)
Lab, X-ray and other diagnostic tests You pay – Standard Option You pay – High Option
Diagnostic tests provided, or ordered and billed by a physician, such as:

= Blood tests
= CT Scans/ MRIs
= EKGs and EEGs
= Laboratory tests
= Pathological services
= Ultrasounds
= Urinalysis
= X-rays
= Fecal occult blood tests*
= Non-routine mammograms*
= Non-routine Pap tests*
= PSA tests*
= Sigmoidoscopies*
Laboratory and pathological services billed by an independent laboratory

Note: If your PPO provider uses a non-PPO laboratory or radiologist, we will pay non-PPO
benefits for any laboratory and X-ray charges.

Preferred: 10% of the Plan allowance; For
services marked with (*), $15 copayment for
associated office visits (No deductible);
nothing for services or tests

Participating: 25% of the Plan allowance

Non-participating: 25% of the Plan allowance,
plus any difference between our allowance
and the physician's actual charge

Preferred: 5% of the Plan allowance; For
services marked with (*), $12 copayment for
associated office visits (No deductible); nothing
for services or tests

Participating: 20% of the Plan allowance

Non-participating: 20% of the Plan allowance,
plus any difference between our allowance
and the physician's actual charge 25
25 Page 26 27
2001 Blue Cross and Blue Shield Service Benefit Plan 26 Section 5( a)
Preventive care, adult You pay – Standard Option You pay – High Option
Home and office visits for routine (screening) physical examinations

= Under age 65 – once every three calendar years
= Age 65 and older – once each calendar year
A routine physical examination may consist of:
= History and risk assessment
= Chest X-ray
= EKG
= Urinalysis
= Basic or comprehensive metabolic panel test

= CBC
= Cholesterol tests (may be done by any independent laboratory)

Note: These benefits do not apply to children. (See benefits under Preventive care, children, this
section.)
Note: When billed by a facility, such as the outpatient department of a hospital, we provide

benefits as shown here, according to the contracting status of the provider.

Note: We provide benefits for adult routine physical examinations only when you receive
these services from a Preferred provider.

Preferred: $15 copayment for
associated office visits (No deductible);
nothing for services or tests

Participating: All charges

Non-participating: All charges

Preferred: $12 copayment for
associated office visits (No
deductible); nothing for services or tests

Participating: All charges

Non-participating: All charges

Preventive care, adult – Continued on next page 26
26 Page 27 28
2001 Blue Cross and Blue Shield Service Benefit Plan 27 Section 5( a)
Preventive care, adult – Continued You pay – Standard Option You pay – High Option
Cancer screening
= Colorectal cancer screening, including:
Fecal occult blood test – one annually starting at age 40 *

Sigmoidoscopy – one every five years starting at age 50 *
= Prostate cancer screening -Prostate Specific Antigen (PSA test) – one annually for males
age 40 and older *
= Cervical cancer screening – one routine Pap test annually for females of any age *

= Breast cancer screening – routine mammograms for females age 35 and older,
as follows*
From age 35 through 39, one during this five-year period

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

* Scheduled limits apply only to Participating and Non-participating providers
Note: We provide benefits in full for preventive (screening) tests and immunizations only when you
receive these services from a Preferred physician on an outpatient basis. If these services are billed
separately from the routine physical examination, you may be responsible to pay an additional
copayment for each office visit billed.
Note: When billed by a facility, such as the outpatient department of a hospital, we provide

benefits as shown here, according to the contracting status of the provider.

Preferred: $15 copayment for
associated office visits (No deductible); nothing
for services or tests
Participating: 25% of the Plan allowance

Non-participating: 25% of the Plan allowance, plus
any difference between our allowance and the
physician's actual charge

Preferred: $12 copayment for
associated office visits (No deductible); nothing
for services or tests
Participating: 20% of the Plan allowance

Non-participating: 20% of the Plan allowance,
plus any difference between our allowance
and the physician's actual charge

Preventive care, adult – Continued on next page. 27
27 Page 28 29
2001 Blue Cross and Blue Shield Service Benefit Plan 28 Section 5( a)
Preventive care, adult -Continued You pay – Standard Option You pay – High Option
Routine immunizations without regard to age, limited to:

= Hepatitis immunizations for patients with increased risk or family history
= Influenza and pneumococcal vaccines, annually
= Lyme disease vaccine
= Tetanus-diphtheria (Td) booster – once every 10 years

Preferred: $15 copayment for
associated office visits (No deductible); nothing for
services or tests
Participating: 25% of the Plan allowance

Non-participating: 25% of the Plan allowance, plus
any difference between our allowance and the
physician's actual charge

Preferred: $12 copayment for
associated office visits (No deductible); nothing
for services or tests
Participating: 20% of the Plan allowance

Non-participating: 20% of the Plan allowance,
plus any difference between our allowance
and the physician's actual charge

Not covered: Office visit charges associated with preventive services and routine
immunizations performed by Participating and Non-participating providers.
All charges All charges

Preventive care, children You pay – Standard Option You pay – High Option
We provide benefits for the following services:
= All healthy newborn visits including routine screening (inpatient or outpatient)

= The following routine services as recommended by the American Academy of
Pediatrics for children up to the age of 22, including children living, traveling, or adopted
from outside the United States:
Routine physical examinations
Routine hearing tests
Laboratory tests
Immunizations
Related office visits
Note: When billed by a facility, such as the outpatient department of a hospital, we provide

benefits as shown here, according to the contracting status of the provider.

Preferred: Nothing (No deductible)
Participating: Nothing (No deductible)
Non-participating: Nothing (No deductible) up to the
Plan allowance. You are responsible only for any
difference between our allowance and the
physician's actual charge

Preferred: Nothing (No deductible)
Participating: Nothing (No deductible)
Non-participating: Nothing (No deductible)
up to the Plan allowance. You are
responsible only for any difference between our
allowance and the physician's actual
charge 28
28 Page 29 30
2001 Blue Cross and Blue Shield Service Benefit Plan 29 Section 5( a)
Maternity care You pay – Standard Option You pay – High Option
Complete maternity (obstetrical) care including related conditions resulting in childbirth or

miscarriage when provided, or ordered and billed by a physician or nurse midwife, such as:

= Prenatal care
= Delivery
= Postpartum care
Note: Here are some things to keep in mind:
= You do not need to precertify your normal delivery; see page 13 for other circumstances,

such as extended stays for you or your baby.
= You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a

cesarean delivery. We will cover an extended stay, if medically necessary, but you must
precertify the extended stay. See Section 3 for information on requesting additional days.

= We cover routine nursery care of the newborn child during the covered portion of the
mother's maternity stay, or if the child is covered under the father's Self and Family
enrollment. We cover other care of a newborn who requires definitive treatment as a patient,
such as circumcision, or incubation for prematurity, only if we cover the newborn
under a Self and Family enrollment.
= We pay assistant surgeon services (delivery) and anesthesia the same as for illness or injury.

See Surgery benefits (Section 5b).
= For inpatient and outpatient facility care related to maternity, we waive the per admission copay

and services are paid in full when you use Preferred providers.

Preferred: Nothing (No deductible)
Participating: 25% of the Plan allowance

Non-participating: 25% of the Plan allowance, plus
any difference between our allowance and the
physician's actual charge

Preferred: Nothing (No deductible)
Participating: 20% of the Plan allowance (No
deductible)
Non-participating: 20% of the Plan allowance
(No deductible), plus any difference between
our allowance and the physician's actual
charge

Not covered:
Procedures, services, drugs and 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.

All charges All charges 29
29 Page 30 31
2001 Blue Cross and Blue Shield Service Benefit Plan 30 Section 5( a)
Family planning You pay – Standard Option You pay – High Option
We provide benefits for:
= Depo-Provera
= Diaphragms
= Intrauterine devices (IUDs)
= Norplant
= Oral contraceptives
= Voluntary sterilization
Note: See Prescription Drugs, Section 5( f), for our coverage for IUDs, Norplant, Depo-Provera,

diaphragms and oral contraceptives obtained from a retail pharmacy. Oral contraceptives may
also be obtained through the Mail Service Prescription Drug Program.

Preferred: 10% of the Plan allowance
Participating: 25% of the Plan allowance

Non-participating: 25% of the Plan allowance, plus any
difference between our allowance and the
physician's actual charge

Preferred: 5% of the Plan allowance (No deductible)
Participating: 20% of the Plan allowance (No
deductible)
Non-participating: 20% of the Plan allowance (No
deductible), plus any difference between our
allowance and the physician's actual charge

Not covered:
= Reversal of voluntary sterilization
= Contraceptive devices not described above

All charges All charges

Infertility services You pay – Standard Option You pay – High Option
Diagnosis and treatment of infertility, except as excluded below

Note: See Section 5( f) for prescription drug coverage.
Preferred: 10% of the Plan allowance

Participating: 25% of the Plan allowance

Non-participating: 25% of the Plan allowance, plus any
difference between our allowance and the
physician's actual charge

Preferred: 5% of the Plan allowance (No deductible)
Participating: 20% of the Plan allowance (No
deductible)
Non-participating: 20% of the Plan allowance (No
deductible), plus any difference between our
allowance and the physician's actual charge

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

artificial insemination (AI)
in vitro fertilization (IVF)
embryo transfer and Gamete Intrafallopian Transfer (GIFT)

intravaginal insemination (IVI)
intra-cervical insemination (ICI)
intrauterine insemination (IUI)
= Services and supplies related to ART procedures, such as sperm banking

All charges All charges 30
30 Page 31 32
2001 Blue Cross and Blue Shield Service Benefit Plan 31 Section 5( a)
Allergy care You pay – Standard Option You pay – High Option
Testing and treatment, including materials (such as allergy serum) and injections Preferred: 10% of the Plan allowance

Participating: 25% of the Plan allowance

Non-participating: 25% of the Plan allowance, plus
any difference between our allowance and the
physician's actual charge

Preferred: 5% of the Plan allowance
Participating: 20% of the Plan allowance

Non-participating: 20% of the Plan allowance,
plus any difference between our allowance
and the physician's actual charge

Not covered:
= Provocative food testing and sublingual allergy desensitization
All charges All charges

Treatment therapies You pay – Standard Option You pay – High Option
= Chemotherapy and radiation therapy
Note: We cover high dose chemotherapy and/ or radiation therapy in connection with bone

marrow transplants, and drugs or medications to stimulate or mobilize stem cells for transplant
procedures, only for those conditions listed as covered under Organ/ tissue transplants in Section
5( b). See also, Services requiring our prior approval, in Section 3.

= Renal dialysis – Hemodialysis and peritoneal dialysis
= Intravenous (IV)/ Infusion therapy – Home IV therapy
Note: Home nursing visits associated with Home IV therapy are covered as shown under Home
health services on page 37.
Outpatient cardiac rehabilitation. (Prior approval is required. See Section 3.)

Preferred: 10% of the Plan allowance
Participating: 25% of the Plan allowance
Non-participating: 25% of the Plan allowance, plus
any difference between our allowance and the
physician's actual charge

Preferred: 5% of the Plan allowance
Participating: 20% of the Plan allowance
Non-participating: 20% of the Plan allowance,
plus any difference between our allowance
and the physician's actual charge 31
31 Page 32 33
2001 Blue Cross and Blue Shield Service Benefit Plan 32 Section 5( a)
Rehabilitative therapies You pay – Standard Option You pay – High Option
Physical therapy, occupational therapy, and speech therapy – when performed by a physical
therapist, occupational therapist, speech therapist or physician

Physical therapy:
= Up to 50 visits for physical therapy per person, per calendar year under Standard

Option
= Up to 75 visits for physical therapy per person, per calendar year under High Option

Acupuncture as a physical therapy modality and for pain management if performed by a physician
or licensed physical therapist
Occupational and Speech therapy:
= Up to 25 visits for occupational therapy, speech therapy, or a combination of both, per

person, per calendar year under both Standard Option and High Option

Note: Visits that you pay for while meeting your calendar year deductible count toward the limits
cited above.
When billed by a skilled nursing facility, nursing home, or extended care facility, we pay benefits

as shown here for professional care, according to the contracting status of the therapist.

Preferred: 10% of the Plan allowance
Participating: 25% of the Plan allowance
Non-participating: 25% of the Plan allowance, plus
any difference between our allowance and the
provider's actual charge

Preferred: 5% of the Plan allowance
Participating: 20% of the Plan allowance
Non-participating: 20% of the Plan allowance,
plus any difference between our allowance
and the provider's actual charge

Not covered:
= Maintenance or palliative rehabilitative therapy
= Exercise programs
= Hippotherapy
= Recreational or educational therapy, and any related diagnostic testing except as provided by a

hospital as part of a covered inpatient stay or through an approved home health care program

All charges All charges 32
32 Page 33 34
2001 Blue Cross and Blue Shield Service Benefit Plan 33 Section 5( a)
Hearing services (testing, treatment, and supplies) You pay – Standard Option You pay – High Option
Hearing tests related to illness or injury Preferred: 10% of the Plan allowance

Participating: 25% of the Plan allowance

Non-participating: 25% of the Plan allowance, plus
any difference between our allowance and the
physician's actual charge

Preferred: 5% of the Plan allowance
Participating: 20% of the Plan allowance

Non-participating: 20% of the Plan allowance,
plus any difference between our allowance
and the physician's actual charge

Not covered:
= Routine hearing tests (except as indicated under Preventive care, children)

= Hearing aids (including implanted bone conduction hearing aids)
= Testing and examinations for the prescribing or fitting of hearing aids

All charges All charges

Vision services (testing, treatment, and supplies) You pay – Standard Option You pay – High Option
= One pair of eyeglasses, replacement lenses, or contact lenses to correct an impairment
directly caused by a single instance of accidental ocular injury or intraocular surgery

Note: This benefit may also be used to obtain one pair of eyeglasses or lenses prescribed in lieu of
surgery when the condition can be corrected by surgery, but surgery is precluded because of age or
medical condition.
= Eye examinations related to a specific medical condition

= Nonsurgical treatment for amblyopia and strabismus, for children from birth through
age 12
Note: See Section 5( b), Surgical procedures, for coverage for surgical treatment of amblyopia and

strabismus.

Preferred: 10% of the Plan allowance
Participating: 25% of the Plan allowance
Non-participating: 25% of the Plan allowance, plus
any difference between our allowance and the
physician's actual charge

Preferred: 5% of the Plan allowance
Participating: 20% of the Plan allowance
Non-participating: 20% of the Plan allowance,
plus any difference between our allowance
and the physician's actual charge

Vision services – Continued on next page 33
33 Page 34 35
2001 Blue Cross and Blue Shield Service Benefit Plan 34 Section 5( a)
Vision services (testing, treatment, and supplies) -
Continued
You pay – Standard Option You pay – High Option

Not covered:
= Eyeglasses, contact lenses, routine eye examinations or vision testing for the

prescribing or fitting of eyeglasses or contact lenses, except as described on page 33

= Eye exercises, visual training or orthoptics, except for nonsurgical treatment of
amblyopia and strabismus as described on page 33

= Radial keratotomy and other refractive services

All charges All charges

Foot care You pay – Standard Option You pay – High Option
Routine foot care when you are under active treatment for a metabolic or peripheral vascular
disease, such as diabetes
Note: See orthopedic and prosthetic devices for information on podiatric shoe inserts.

Preferred: $15 copayment for the office visit (No
deductible); 10% of the Plan allowance for all other
services (deductible applies)

Participating: 25% of the Plan allowance
Non-participating: 25% of the Plan allowance, plus any
difference between our allowance and the physician's
actual charge

Preferred: $12 copayment for the office visit (No
deductible); 5% of the Plan allowance for all
other services (deductible applies)

Participating: 20% of the Plan allowance
Non-participating: 20% of the Plan allowance, plus
any difference between our allowance and the
physician's actual charge

Not covered:
= Routine foot care, such as 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

All charges All charges 34
34 Page 35 36
2001 Blue Cross and Blue Shield Service Benefit Plan 35 Section 5( a)
Orthopedic and prosthetic devices You pay – Standard Option You pay – High Option
Orthopedic braces and prosthetic appliances such as:

= Artificial limbs and eyes
= Functional foot orthotics when prescribed by a physician

= Rigid devices attached to the foot or a brace, or placed in a shoe
= Replacement, repair and adjustment of covered devices
= Following a mastectomy, externally worn breast prostheses and surgical bras, including
necessary replacements
Note: A prosthetic appliance is a device that is surgically inserted or physically attached to the

body to restore a bodily function or replace a physical portion of the body.

We provide hospital benefits for internal prosthetic devices, such as artificial joints,
pacemakers, cochlear implants, and surgically implanted breast implants following mastectomy;
see Section 5( c) for payment information. Insertion of the device is paid as surgery; see
Section 5( b).

Preferred: 10% of the Plan allowance
Participating: 25% of the Plan allowance
Non-participating: 25% of the Plan allowance, plus
any difference between our allowance and the
provider's actual charge

Preferred: 5% of the Plan allowance
Participating: 20% of the Plan allowance
Non-participating: 20% of the Plan allowance,
plus any difference between our allowance
and the provider's actual charge

Not covered:
= Shoes and over-the-counter orthotics
= Arch supports
= Heel pads and heel cups
= Penile implants
= Wigs
= Implanted bone conduction hearing aids

All charges All charges 35
35 Page 36 37
2001 Blue Cross and Blue Shield Service Benefit Plan 36 Section 5( a)
Durable medical equipment (DME) You pay – Standard Option You pay – High Option
Durable medical equipment (DME) is equipment and supplies that:

1. Are prescribed by your attending physician (i. e., the physician who is treating your illness or
injury);
2. Are medically necessary;
3. Are primarily and customarily used only for a medical purpose;

4. Are generally useful only to a person with an illness or injury;
5. Are designed for prolonged use; and
6. Serve a specific therapeutic purpose in the treatment of an illness or injury.

We cover rental or purchase, at our option, including repair and adjustment, of durable medical equipment,
such as oxygen and home dialysis equipment. Under this benefit, we also cover:

= Hospital beds
= Wheelchairs
= Crutches
= Walkers
= Other items that we determine to be DME

Preferred: 10% of the Plan allowance
Participating: 25% of the Plan allowance

Non-participating: 25% of the Plan allowance, plus
any difference between our allowance and the
provider's actual charge

Preferred: 5% of the Plan allowance
Participating: 20% of the Plan allowance

Non-participating: 20% of the Plan allowance,
plus any difference between our allowance
and the provider's actual charge

Not covered:
= Exercise and bathroom equipment
= Lifts, such as seat, chair or van lifts
= Car seats
= Air conditioners, humidifiers, dehumidifiers and purifiers

= Breast pumps
= Computer "story boards" or "light talkers" for communication-impaired individuals

= Equipment for cosmetic purposes

All charges All charges 36
36 Page 37 38
2001 Blue Cross and Blue Shield Service Benefit Plan 37 Section 5( a)
Medical supplies You pay – Standard Option You pay – High Option
= Medical foods for children with inborn errors of amino acid metabolism

= Ostomy and catheter supplies
= Oxygen, regardless of the provider
= Blood and blood plasma except when donated or replaced, and blood plasma expanders

Preferred: 10% of the Plan allowance
Participating: 25% of the Plan allowance

Non-participating: 25% of the Plan allowance, plus
any difference between our allowance and the
provider's actual charge

Preferred: 5% of the Plan allowance
Participating: 20% of the Plan allowance

Non-participating: 20% of the Plan allowance,
plus any difference between our allowance
and the provider's actual charge

Home health services You pay – Standard Option You pay – High Option
Home nursing care for two (2) hours per day, up to 25 visits per calendar year under Standard Option

and 50 visits per calendar year under High Option, when:

= A registered nurse (R. N.) or licensed practical nurse (L. P. N.) provides the services; and
= A physician orders the care
Note: Visits that you pay for while meeting your calendar year deductible count toward the limits cited

above.

Preferred: 10% of the Plan allowance
Participating: 25% of the Plan allowance

Non-participating: 25% of the Plan allowance, plus
any difference between our allowance and the
provider's actual charge

Preferred: 5% of the Plan allowance
Participating: 20% of the Plan allowance

Non-participating: 20% of the Plan allowance,
plus any difference between our allowance
and the provider's actual charge

Not covered:
= Nursing care requested by, or for the convenience of, the patient or the patient's family

= Nursing care primarily for bathing, feeding, exercising, moving the patient, homemaking,
giving medication, or acting as a companion or sitter

All charges All charges 37
37 Page 38 39
2001 Blue Cross and Blue Shield Service Benefit Plan 38 Section 5( a)
Alternative treatments You pay – Standard Option You pay – High Option
Acupuncture – when performed and billed by a physician or licensed physical therapist, for:

= pain relief, and
= as a modality of physical therapy

Note: See page 32 for limitations.
Note: We may also cover services of certain alternative treatment providers in medically

underserved areas. See page 10 for additional information.

Preferred: 10% of the Plan allowance
Participating: 25% of the Plan allowance

Non-participating: 25% of the Plan allowance, plus
any difference between our allowance and the
provider's actual charge

Preferred: 5% of the Plan allowance
Participating: 20% of the Plan allowance

Non-participating: 20% of the Plan allowance,
plus any difference between our allowance
and the provider's actual charge

Not covered:
Services you receive from non-covered providers such as:

chiropractors
naturopaths
hypnotherapists
= Biofeedback (or other forms of self-care or self-help training)

All charges All charges

Educational classes and programs You pay – Standard Option You pay – High Option
Coverage is limited to:
= Smoking cessation— enrollment in one smoking cessation program per member per

lifetime
Note: Services may be provided by any covered provider or by a smoking cessation clinic.

See Section 5( f) for our coverage for smoking cessation drugs

You pay all charges after we pay $100 per member, per
lifetime (calendar year deductible applies)
You pay all charges after we pay $100 per member, per
lifetime (calendar year deductible applies)

= Diabetic education when billed by a covered provider
Note: We cover diabetic educators, dieticians, and nutritionists who bill independently only as part of a
covered diabetic education program.

Preferred: 10% of the Plan allowance
Participating: 25% of the Plan allowance
Non-participating: 25% of the Plan allowance, plus any
difference between our allowance and the physician's
actual charge

Preferred: 5% of the Plan allowance
Participating: 20% of the Plan allowance
Non-participating: 20% of the Plan allowance, plus any
difference between our allowance and the
physician's actual charge
Educational classes and programs – Continued on next page 38
38 Page 39 40
2001 Blue Cross and Blue Shield Service Benefit Plan 39 Section 5( a)
Educational classes and programs -
Continued
You pay – Standard Option You pay – High Option

Not covered:
= Marital, family, educational or other counseling or training services when performed as part of an

educational class or program
= Premenstrual (PMS), lactation, headache, eating disorder and other educational clinics

= Recreational or educational therapy, and any related diagnostic testing except as provided by a
hospital as part of a covered inpatient stay or through an approved home health care program

= Services performed or billed by a school or halfway house or a member of its staff

All charges All charges 39
39 Page 40 41
2001 Blue Cross and Blue Shield Service Benefit Plan 40 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

Here are some important things you should 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.

= The calendar year deductible is: $250 per person ($ 500 per family) under Standard Option and $150 per person ($ 300 per family) under High Option. The Calendar Year deductible
applies to almost all benefits under Standard Option in this Section. We added "( No deductible)" to show when the calendar year deductible does not apply.

= Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works, with special sections for members who are age 65 or over. Also
read Section 9 about coordinating benefits with other coverage, including Medicare.
= The amounts listed below are for the charges billed by a physician or other health care professional for your surgical care. Look in Section 5( c) for charges associated with the

facility (i. e., hospital, surgical center, etc.).
= YOU MUST GET PRIOR APPROVAL for all organ transplant surgical procedures; and if your surgical procedure requires an inpatient admission, YOU MUST GET

PRECERTIFICATION. Please refer to the prior approval and precertification information shown in Section 3 to be sure which services require prior approval or
precertification.
= The non-PPO benefits are the standard benefits of this Plan. PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non-PPO benefits apply.

I M
P O
R T
A N
T

Benefit Description You pay After the calendar year deductible…
NOTE: The calendar year deductible applies to almost all benefits in this Section. We say "No deductible" when it does not apply.

Surgical procedures You pay – Standard Option You pay – High Option
We pay for the following services provided, or ordered, and billed by a physician:

= Operative procedures
= Treatment of fractures and dislocations, 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 on page 42)

= Treatment of burns

Preferred: 10% of the Plan allowance
Participating: 25% of the Plan allowance

Non-participating: 25% of the Plan allowance, plus any
difference between our allowance and the physician's
actual charge

Preferred: 5% of the Plan allowance
(No deductible)
Participating: 20% of the Plan allowance (No

deductible)

Non-participating: 20% of the Plan allowance (No
deductible), plus any difference between our
allowance and the physician's actual charge

Surgical procedures – Continued on next page 40
40 Page 41 42
2001 Blue Cross and Blue Shield Service Benefit Plan 41 Section 5( b)
Surgical procedures – Continued You pay – Standard Option You pay – High Option
= Insertion of internal prosthetic devices. See Section 5( a) – Orthopedic and prosthetic devices,

and Section 5( c) – Other hospital services and supplies – for our coverage for the device.

= Voluntary sterilization, Norplant (a surgically implanted contraceptive), and intrauterine devices
(IUDs)
= Assistant surgeons/ surgical assistance by a physician if required because of the complexity

of the surgical procedures
= Gastric bypass surgery or gastric stapling procedures for morbid obesity – a condition in

which an individual weighs 100 pounds over, or 100% over, his or her normal weight according to
current underwriting standards; eligible members must be age 18 or over

When multiple surgical procedures that add time or complexity to patient care are performed during the
same operative session, the Local Plan determines our allowance for the combination of multiple, bilateral,
or incidental surgical procedures. Generally, we will allow a reduced amount for procedures other than the
primary procedure.
Note: We do not pay extra for "incidental" procedures (those that do not add time or

complexity to patient care).
Note: When unusual circumstances require the removal of casts or sutures by a physician other than

the one who applied them, the Local Plan may determine that a separate allowance is payable.

Preferred: 10% of the Plan allowance
Participating: 25% of the Plan allowance

Non-participating: 25% of the Plan allowance, plus any
difference between our allowance and the
physician's actual charge

Preferred: 5% of the Plan allowance (No
deductible)
Participating: 20% of the Plan allowance (No

deductible)
Non-participating: 20% of the Plan allowance (No
deductible), plus any difference between our
allowance and the physician's actual charge

Not covered:
= Reversal of voluntary sterilization
= Services of a standby physician
= Routine surgical treatment of conditions of the foot (see Section 5( a) – Foot care)

= Cosmetic surgery
= Radial Keratotomy and other refractive surgery

All charges All charges 41
41 Page 42 43
2001 Blue Cross and Blue Shield Service Benefit Plan 42 Section 5( b)
Reconstructive surgery You pay – Standard Option You pay – High Option
= Surgery to correct a functional defect
= Surgery to correct a congenital anomaly – 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; and webbed fingers and
toes.
Note: Congenital anomalies do not include conditions related to the teeth or intra-oral

structures supporting the teeth.
= Treatment to restore the mouth to a pre-cancer state

= 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

Note: Internal breast prostheses are paid as medical services and supplies [see Section 5( a)], or hospital
services [see Section 5( c)].
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.

Preferred: 10% of the Plan allowance
Participating: 25% of the Plan allowance
Non-participating: 25% of the Plan allowance, plus any
difference between our allowance and the
physician's actual charge

Preferred: 5% of the Plan allowance
(No deductible)
Participating: 20% of the Plan allowance (No
deductible)
Non-participating: 20% of the Plan allowance (No
deductible), plus any difference between our
allowance and the physician's actual charge

Not covered:
= Cosmetic surgery – any operative procedure or any portion of a procedure performed primarily to

improve physical appearance through change in bodily form –unless required for a congenital
anomaly or to restore or correct a part of the body that has been altered as a result of accidental
injury, disease or surgery (does not include anomalies related to the teeth or structures
supporting the teeth)
= Surgeries related to sex transformation, sexual dysfunction or sexual inadequacy

All charges All charges 42
42 Page 43 44
2001 Blue Cross and Blue Shield Service Benefit Plan 43 Section 5( b)
Oral and maxillofacial surgery You pay – Standard Option You pay – High Option
Oral surgical procedures, limited to:
= Excision of tumors and cysts of the jaws, cheeks, lips, tongue, roof and floor of mouth when

pathological examination is necessary
= Surgery needed to correct accidental injuries (see Definitions) to jaws, cheeks, lips, tongue, roof and

floor of mouth
= Excision of exostoses of jaws and hard palate
= External incision and drainage of cellulitis
= Incision and surgical treatment of accessory sinuses, salivary glands or ducts

= Reduction of dislocations and excision of temporomandibular joints
= Removal of impacted teeth

Preferred: 10% of the Plan allowance
Participating: 25% of the Plan allowance

Non-participating: 25% of the Plan allowance, plus any
difference between our allowance and the
physician's actual charge

Preferred: 5% of the Plan allowance (No deductible)
Participating: 20% of the Plan allowance (No
deductible)
Non-participating: 20% of the Plan allowance (No
deductible), plus any difference between our
allowance and the physician's actual charge

Not covered:
= Oral implants and transplants
= Surgical procedures that involve the teeth or their supporting structures (such as the

periodontal membrane, gingiva, and alveolar bone), except as shown above and in Section
5( h)
= Surgical procedures involving orthodontic care, dental implants or preparation of the

mouth for the fitting or the continued use of dentures, except as specifically shown above
and in Section 5( h)

All charges All charges

Organ/ tissue transplants You pay – Standard Option You pay – High Option
= Cornea
= Heart
= Heart-lung
= Kidney

= Liver
= Pancreas
= Small bowel

Preferred: 10% of the Plan allowance
Participating: 25% of the Plan allowance
Preferred: 5% of the Plan allowance (No deductible)
Participating: 20% of the Plan allowance (No
deductible)
= Single or double lung: only for the following end-stage pulmonary diseases: pulmonary

fibrosis, primary pulmonary hypertension, and emphysema

= Double lung: only for patients with end-stage cystic fibrosis

Non-participating: 25% of the Plan allowance, plus any
difference between our allowance and the
physician's actual charge

Non-participating: 20% of the Plan allowance (No
deductible), plus any difference between our
allowance and the physician's actual charge

Organ/ tissue transplants – Continued on next page 43
43 Page 44 45
2001 Blue Cross and Blue Shield Service Benefit Plan 44 Section 5( b)
Organ/ tissue transplants – Continued You pay – Standard Option You pay – High Option
Bone marrow and stem cell transplants, limited to:
= Allogeneic bone marrow transplants and allogeneic cord blood stem cell transplants (from related or

unrelated donors) for:
Advanced neuroblastoma
Infantile malignant osteopetrosis
Severe combined immunodeficiency
Wiskott-Aldrich syndrome
Mucopolysaccharidosis (e. g., Hunter, Hurler's, Sanfilippo, Maroteaux-Lamy variants)

Mucolipidosis (e. g., Gaucher's disease, metachromatic leukodystrophy,
adrenoleukodystrophy)
Severe or very severe aplastic anemia
Thalassemia major (homozygous beta-thalassemia)

Sickle cell anemia
Phagocytic deficiency diseases
= Allogeneic bone marrow transplants, allogeneic cord blood stem cell transplants (from related or

unrelated donors) and allogeneic peripheral blood stem cell transplants for:

Acute lymphocytic or non-lymphocytic (i. e., myelogenous) leukemia
Advanced Hodgkin's lymphoma
Advanced non-Hodgkin's lymphoma
Chronic myelogenous leukemia
Advanced forms of myelodysplastic syndromes
= Autologous bone marrow transplants and autologous peripheral blood stem cell transplants

(collectively referred to as autologous stem cell support) for:

Acute lymphocytic or nonlymphocytic (i. e., myelogenous) leukemia
Advanced Hodgkin's lymphoma
Advanced non-Hodgkin's lymphoma
Advanced neuroblastoma
Testicular, Mediastinal, Retroperitoneal and Ovarian germ cell tumors

Multiple myeloma

Preferred: 10% of the Plan allowance
Participating: 25% of the Plan allowance

Non-participating: 25% of the Plan allowance, plus any
difference between our allowance and the physician's
actual charge

Preferred: 5% of the Plan allowance (No deductible)
Participating: 20% of the Plan allowance (No
deductible)
Non-participating: 20% of the Plan allowance (No

deductible), plus any difference between our
allowance and the physician's actual charge

Organ/ tissue transplants – Continued on next page 44
44 Page 45 46
2001 Blue Cross and Blue Shield Service Benefit Plan 45 Section 5( b)
Organ/ tissue transplants – Continued You pay – Standard Option You pay – High Option
= Extraction or reinfusion of bone marrow, blood stem cells, or cord blood as a source of stem cells

as part of a covered allogeneic or autologous bone marrow transplant or blood stem cell transplant
support procedure
= Marrow harvesting in anticipation of a covered autologous bone marrow transplant, for patients

diagnosed at the time of harvesting with one of the conditions listed above

= Collection, processing, storage and distribution of cord blood only when performed by a cord blood
bank approved by the FDA
= Storage of harvested bone marrow, blood stem cells, or cord blood as a source of stem cells, only

when a covered transplant has already been scheduled

= Related medical and hospital expenses of the donor, as part of a covered transplant procedure
= Related services or supplies provided to the recipient
Note: See Section 5( a) for coverage for related services, such as chemotherapy and/ or radiation therapy and drugs

administered to stimulate or mobilize stem cells for covered transplant procedures.

Limitations
(1) You must obtain prior approval (see page 14) from the Local Plan, for both the procedure and the facility, for

the following transplant procedures:
= Bone marrow, cord blood stem cell and peripheral blood stem cell transplant support

procedures
= Heart
= Heart-lung
= Liver
= Lung (single/ double)
= Pancreas
= Small bowel

See page 44 See page 44

Organ/ tissue transplants – Continued on next page 45
45 Page 46 47
2001 Blue Cross and Blue Shield Service Benefit Plan 46 Section 5( b)
Organ/ tissue transplants ---Continued You pay – Standard Option You pay – High Option
(2) For the following procedures, we provide benefits only when conducted at a Cancer Research Facility

and performed as part of a clinical trial that meets the requirements shown below:

= Allogeneic bone marrow transplants, syngeneic bone marrow transplants, and allogeneic
peripheral blood stem cell transplants for:
Multiple myeloma
Chronic lymphocytic leukemia
Early stage (indolent or non-advanced) small cell lymphocytic lymphoma

= Autologous bone marrow transplants and autologous peripheral blood stem cell transplants
(collectively referred to as autologous stem cell support) for:

Breast cancer
Epithelial ovarian cancer
Chronic myelogenous leukemia
Chronic lymphocytic leukemia
Early stage (indolent or non-advanced) small cell lymphocytic lymphoma

For these bone marrow transplant procedures and related services or supplies covered only through
clinical trials:
1. You must contact our Clinical Trials Information Unit at 1-800-225-2268 for prior approval (see

page 14);
2. The clinical trial must be reviewed and approved by the Institutional Review Board of the Cancer

Research Facility where the procedure is to be delivered; and

3. The patient must be properly and lawfully registered in the clinical trial, meeting all the
eligibility requirements of the trial.
If a non-randomized clinical trial meeting these requirements is not available at a Cancer Research

Facility where you are eligible, we will arrange for the transplant to be provided at another Plan-designated
transplant facility.

See page 44 See page 44

Organ/ tissue transplants – Continued on next page 46
46 Page 47 48
2001 Blue Cross and Blue Shield Service Benefit Plan 47 Section 5( b)
Organ/ tissue transplants -Continued You pay – Standard Option You pay – High Option
Not covered:
= Transplants for any diagnosis not listed as covered

= Donor screening tests and donor search expenses, except those performed for the actual donor

All charges All charges

Anesthesia You pay – Standard Option You pay – High Option
Anesthesia (including acupuncture) for covered surgical services when requested by the attending

physician and performed by:
= a certified registered nurse anesthetist (CRNA), or

= a physician other than the operating physician (surgeon) or the assistant
Professional services provided in –
= Hospital (inpatient)
= Hospital outpatient department
= Skilled nursing facility
= Ambulatory surgical center
= Office
Anesthesia services consist of administration by injection or inhalation of a drug or other anesthetic

agent (including acupuncture) to obtain muscular relaxation, loss of sensation, or loss of consciousness.

Note: See Section 5( c) for anesthesia services billed by a facility.

Preferred: 10% of the Plan allowance
Participating: 25% of the Plan allowance

Non-participating: 25% of the Plan allowance, plus any
difference between our allowance and the physician's
actual charge

Preferred: 5% of the Plan allowance (No deductible)
Participating: 20% of the Plan allowance (No
deductible)

Non-participating: 20% of the Plan allowance (No
deductible), plus any difference between our
allowance and the physician's actual charge 47
47 Page 48 49
2001 Blue Cross and Blue Shield Service Benefit Plan 48 Section 5( c)
Section 5( c). Services provided by a hospital or other facility, and ambulance services
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Here are some important things you should 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.

= Unlike Sections 5( a) and (b), in this Section the calendar year deductible applies to only a few benefits. In that case, we added "( calendar year deductible applies)" when it applies.
= Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works, with special sections for members who are age 65 or over. Also read
Section 9 about coordinating benefits with other coverage, including Medicare.
= The amounts listed below are for the charges billed by the facility (i. e., hospital or surgical center) or ambulance service for your inpatient surgery or care. Any costs associated with the

professional charge (i. e., physicians, etc.) are listed in Section 5( a) or (b).
= YOU MUST GET PRECERTIFICATION OF HOSPITAL STAYS; FAILURE TO DO SO WILL RESULT IN A $500 PENALTY. Please refer to the precertification information

listed in Section 3 to be sure which services require precertification.
= You should be aware that some PPO hospitals may have Non-PPO professional providers on staff. If you use a PPO facility, we may still pay Non-PPO benefits if you receive treatment

from a radiologist, pathologist, anesthesiologist, assistant surgeon, or other provider who is not a PPO provider.

= We base payment on whether the facility or a health care professional bills for the services or supplies. You will find that some benefits are listed in more than one section of the brochure.
This is because how they are paid depends on what type provider bills for the service. For example, physical therapy is paid differently depending on whether it is billed by an inpatient
facility, a doctor, a physical therapist, or an outpatient facility.
= The non-PPO benefits are the standard benefits of this Plan. PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non-PPO benefits apply.

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Benefit Description You pay
NOTE: The calendar year deductible applies ONLY when we say below: "calendar year deductible applies."
Inpatient hospital You pay – Standard Option You pay – High Option Room and board, such as:

= semiprivate or intensive care accommodations
= general nursing care
= meals and special diets
Note: We cover a private room only when you must be isolated to prevent contagion, when your

isolation is required by law, or when a Preferred or Member hospital only has private rooms.
Otherwise, we will pay the hospital's average daily rate for semiprivate rooms as determined
by the Local Plan. If a Non-member hospital only has private rooms, we base our payment on
the average daily rate as determined by the Local Plan.

Preferred: $100 per admission copayment for
unlimited days
Member: $300 per admission copayment
for unlimited days
Non-member: $300 per admission copayment
plus 30% of the Plan allowance, and any
remaining balance after our payment

Note: You pay nothing for facilities outside of
the United States and Puerto Rico

Preferred: Nothing for unlimited days
Member: $100 per admission copayment for
unlimited days
Non-member: $100 per admission copayment
plus 30% of the Plan allowance, and any
remaining balance after our payment

Note: You pay nothing for facilities outside of
the United States and Puerto Rico
Inpatient hospital – Continued on next page. 48
48 Page 49 50
2001 Blue Cross and Blue Shield Service Benefit Plan 49 Section 5( c)
Inpatient hospital – Continued You pay – Standard Option You pay – High Option
Other hospital services and supplies, such as:

= Operating, recovery, maternity and other treatment rooms

= Prescribed drugs
= Diagnostic laboratory tests, pathology services, MRIs, machine diagnostic tests and X-rays

= Administration of blood or blood plasma
= Dressings, splints, casts and sterile tray services
= Internal prosthetic devices
= Other medical supplies and equipment, including oxygen

= Anesthetics and anesthesia services
= Take-home items
= Pre-admission testing recognized as part of the hospital admissions process

Note: Here are some things to keep in mind:
= We base payment on whether the facility or a health care professional bills for the services or supplies.
You will find that some benefits are listed in more than one section of the brochure. This is because
how they are paid depends on what type of provider bills for the service. For example, physical therapy
is paid differently depending on whether it is billed by an inpatient facility, a doctor, a physical
therapist, or an outpatient facility.
= You do not need to precertify your normal delivery; see page 13 for other circumstances, such as
extended stays for you or your baby.
= If you need to stay longer in the hospital than initially planned, we will cover an extended stay
if it is medically necessary. However, you must precertify the extended stay. See Section 3 for
information on requesting additional days.
We pay Inpatient hospital benefits for an admission in connection with dental procedures only when a

non-dental physical impairment exists that makes hospitalization necessary to safeguard the health of
the patient. We provide benefits for dental procedures as shown in Section 5( h).

Note: See page 29 for covered maternity services.
Note: See page 37 for coverage of blood and blood products.

See page 48 See page 48

Inpatient hospital – Continued on next page. 49
49 Page 50 51
2001 Blue Cross and Blue Shield Service Benefit Plan 50 Section 5( c)
Inpatient hospital – Continued You pay – Standard Option You pay – High Option
Not covered:
Hospital room and board expenses when in our judgement, a hospital admission or portion of an

admission is:
= Custodial care
= Convalescent care or a rest cure
= Domiciliary care provided because care in the home is not available or unsuitable

= Not medically necessary, such as when services did not require the acute/ subacute
hospital inpatient (overnight) setting but could have been provided safely and adequately in a
physician's office, the outpatient department of a hospital, or some other setting, without
adversely affecting your condition or the quality of medical care you receive. Some
examples are:
Admissions for or consisting primarily of observation and/ or evaluation that could

have been provided safely and adequately in some other setting (such as a
physician's office)
Admissions primarily for diagnostic studies, laboratory and pathological services, X-rays,

MRIs, or machine diagnostic tests that could have been provided safely and adequately in
some other setting (such as the outpatient department of a hospital or a physician's
office)
Note: If we determine that a hospital admission is one of the types listed above, we will not provide

benefits for inpatient room and board or inhospital physician care. However, we will provide benefits
for covered services or supplies other than room and board and inhospital physician care at the level that
we would have paid if they had been provided in some other setting.

= Admission to non-covered facilities, such as nursing homes, extended care facilities,
schools, residential treatment centers
= Personal comfort items, such as guest meals and beds, telephone, television, beauty and

barber services
= Inpatient private duty nursing

All charges All charges 50
50 Page 51 52
2001 Blue Cross and Blue Shield Service Benefit Plan 51 Section 5( c)
Outpatient hospital or ambulatory surgical center You pay – Standard Option You pay – High Option
Outpatient medical services performed and billed for by a hospital or freestanding ambulatory
facility, such as:
= Operating, recovery and other treatment rooms

= Prescribed drugs
= Diagnostic tests, such as laboratory and pathology services, MRIs, machine diagnostic

tests and X-rays
= Administration of blood, blood plasma and other biologicals

= Blood and blood plasma, if not donated or replaced
= Dressings, splints, casts and sterile tray services
= Other medical supplies, including oxygen
= Renal dialysis
Note: See pages 26-28 for covered preventive services for adults and children.

Preferred facilities: 10% of the Plan
allowance (calendar year deductible
applies)

Member facilities: 25% of the Plan allowance
(calendar year deductible applies)

Non-member facilities: 25% of the Plan
allowance (calendar year deductible applies), plus
any difference between our allowance and the
provider's actual charge

Note: You pay nothing for facilities outside the
United States and Puerto Rico.

Preferred facilities: 5% of the Plan
allowance (calendar year deductible
applies)

Member facilities: 20% of the Plan allowance
(calendar year deductible applies)

Non-member facilities: 20% of the Plan
allowance (calendar year deductible
applies), plus any difference between our
allowance and the provider's actual
charge

Note: You pay nothing for facilities outside the
United States and Puerto Rico.

Outpatient hospital or ambulatory surgical center – Continued on next page 51
51 Page 52 53
2001 Blue Cross and Blue Shield Service Benefit Plan 52 Section 5( c)
Outpatient hospital or ambulatory surgical center – Continued You pay – Standard Option You pay – High Option
Outpatient surgery and related services performed and billed for by a hospital or
freestanding ambulatory facility, such as:
= Operating, recovery and other treatment rooms

= Prescribed drugs
= Pre-surgical testing performed within one business day of the covered surgical services

= Facility supplies for hemophilia home care
= Diagnostic tests, such as laboratory and pathology services, MRIs, machine diagnostic

tests and X-rays
= Administration of blood, blood plasma and other biologicals

= Blood and blood plasma, if not donated or replaced
= Dressings, splints, casts and sterile tray services
= Other medical supplies, including oxygen
Note: We cover outpatient hospital services and supplies related to dental procedures only when a

non-dental physical impairment exists that makes the hospital setting necessary to safeguard the
health of the patient. See Section 5( h), Dental benefits, for additional benefit information.

Note: See page 29 for covered maternity services.

Preferred facilities: 10% of the Plan
allowance (No deductible)

Member facilities: 25% of the Plan allowance
(No deductible)

Non-member facilities: 25% of the Plan
allowance (No deductible), plus any
difference between our allowance and the
provider's actual charge

Note: You pay nothing for facilities outside the
United States and Puerto Rico.

Preferred facilities: 5% of the Plan allowance
(No deductible)

Member facilities: 20% of the Plan allowance
(No deductible)

Non-member facilities: 20% of the Plan
allowance (No deductible), plus any
difference between our allowance and the
provider's actual charge

Note: You pay nothing for facilities outside the
United States and Puerto Rico. 52
52 Page 53 54
2001 Blue Cross and Blue Shield Service Benefit Plan 53 Section 5( c)
Extended care benefits/ Skilled nursing care facility benefits You pay – Standard Option You pay – High Option
Limited to the following benefits for Medicare Part A copayments:
When Medicare Part A is the primary payer (meaning that it pays first) and has made payment, Standard
and High Options provide limited secondary benefits.
We pay the applicable Medicare Part A copayments incurred in full during the first through the 30 th day of

confinement for each benefit period (as defined by Medicare) in a qualified skilled nursing facility. A
qualified skilled nursing facility is a facility that specializes in skilled nursing care performed by or
under the supervision of licensed nurses, skilled rehabilitation services, and other related care and
meets Medicare's special qualifying criteria, but is not an institution that primarily cares for and treats mental
diseases.
If Medicare pays the first 20 days in full, Plan benefits will begin on the 21 st day (when Medicare Part A

copayments begin) and will end on the 30 th day.
Note: See page 32 for benefits provided for outpatient speech, occupational and physical therapy

when billed by a skilled nursing facility. See Section 5( f) for benefits for prescription drugs.

If you do not have Medicare Part A, we do not provide benefits for skilled nursing facility care.

Preferred: Nothing
Participating/ Member: Nothing

Non-participating/ Non-member: Nothing
Note: You pay all charges not paid by Medicare after
the 30 th day.

Preferred: Nothing
Participating/ Member: Nothing

Non-participating/ Non-member: Nothing

Note: You pay all charges not paid by
Medicare after the 30 th day. 53
53 Page 54 55
2001 Blue Cross and Blue Shield Service Benefit Plan 54 Section 5( c)
Hospice care You pay – Standard Option You pay – High Option
Hospice care is an integrated set of services and supplies designed to provide palliative and supportive

care to terminally ill patients in their homes.
We provide the following home hospice care benefits for members with a life expectancy of six months or

less when prior approval is obtained from the Local Plan and the home hospice agency is approved
by the Local Plan:
= Physician visits
= Nursing care
= Medical social services
= Physical therapy
= Services of home health aides
= Durable medical equipment rental
= Prescription drugs
= Medical supplies

Nothing Nothing

Inpatient hospice for members receiving home hospice care benefits:
Benefits are provided for up to five (5) consecutive days in a hospital or a freestanding hospice inpatient
facility.
Each inpatient stay must be separated by at least 21 days.

These covered inpatient hospice benefits are available only when inpatient services are necessary to:
control pain and manage the patient's symptoms; or
provide an interval of relief (respite) to the family.
Note: You are responsible for making sure that the home hospice care provider has received prior

approval from the Local Plan (see page 14 for instructions). Please check with your Local Plan
and/ or your PPO directory for listings of approved agencies.

Preferred: $100 per admission copayment
Member: $300 per admission copayment
Non-member: $300 per admission copayment plus
30% of the Plan allowance, and any remaining balance
after our payment

Preferred: Nothing (No deductible)
Member: $100 per admission copayment
Non-member: $100 per admission copayment plus
30% of the Plan allowance, and any remaining balance
after our payment

Not covered:
= Homemaker or bereavement services
All charges All charges 54
54 Page 55 56
2001 Blue Cross and Blue Shield Service Benefit Plan 55 Section 5( c)
Ambulance You pay – Standard Option You pay – High Option
Local professional ambulance transport services to or from the nearest hospital equipped to

adequately treat your condition, when medically appropriate, and:

= Associated with covered hospital inpatient care
= Related to and within 72 hours after an accidental injury or medical emergency
= During covered home health care

Preferred: 10% of the Plan allowance (calendar
year deductible applies)

Participating: 25% of the Plan allowance
(calendar year deductible applies)

Non-participating: 25% of the Plan allowance
(calendar year deductible applies),
plus any difference between our allowance
and the provider's actual charge

Preferred: 5% of the Plan allowance
(calendar year deductible applies)

Participating: 20% of the Plan allowance
(calendar year deductible applies)

Non-participating: 20% of the Plan allowance
(calendar year deductible applies),
plus any difference between our allowance
and the provider's actual charge 55
55 Page 56 57
2001 Blue Cross and Blue Shield Service Benefit Plan 56 Section 5( c)
Home Health Care You pay – Standard Option You pay – High Option
Under High Option only, for up to 90 days per calendar year, the covered Home health care services

listed below if:
1) The services you receive are billed by a home health care agency (such as the hospital or a
visiting nurse association) that has a written agreement with the Local Plan to provide home
health care services, and
2) Prior approval is obtained from the Local Plan. If prior approval is not obtained, benefits will be
provided as applicable under Section 5( a), Medical services and supplies.

Note: You are responsible for making sure that the home health care provider has received prior
approval from the Local Plan (see page14 for instructions). Please check with your Local Plan
and/ or your PPO directory for listings of approved agencies.

Covered services:
= Nursing care such as dressing changes, injections, and monitoring of vital signs

= Physical therapy
= Respiratory or inhalation therapy
= Prescription drugs
= Medical supplies that serve a specific therapeutic or diagnostic purpose

= Infusion therapy
= Other medically necessary services or supplies that would have been provided by

a hospital if you were hospitalized
Note: See Section 5( a) for High Option coverage for physician home visits while receiving covered home

health care services, and for Standard Option coverage for home nursing visits.

All charges
See Section 5( a) for coverage of Home health
services.

Nothing (No deductible)

Not covered:
= Home health care services for routine maternity care, for routine monitoring of a

condition, for intermittent care of a stable condition, or for initial evaluation of the
patient to determine whether or not home health care is appropriate

= Homemaking services, including housekeeping, preparing meals, or acting
as a companion or sitter 56
56 Page 57 58
2001 Blue Cross and Blue Shield Service Benefit Plan 57 Section 5( d)
Section 5 (d). Emergency services/ accidents
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Here are some important things to keep in mind about these benefits:
= Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure.

= The calendar year deductible is: $250 per person ($ 500 per family) under Standard Option and $150 per person ($ 300 per family) under High Option. The calendar year deductible
applies to almost all benefits in this Section. We added "( No deductible)" to show when the calendar year deductible does not apply.

= Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works, with special sections for members who are age 65 or over. Also
read Section 9 about coordinating benefits with other coverage, including Medicare.
= The non-PPO benefits are the standard benefits of this Plan. PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non-PPO benefits apply.

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What is an accidental injury? An accidental injury is an injury caused by an external force or element such as a blow or fall and which requires immediate medical attention, including animal bites and poisonings. (See Section 5( h) for dental
care for accidental injury.)

Benefit Description You pay After the calendar year deductible…
NOTE: The calendar year deductible applies to almost all benefits in this Section. We say "No deductible" when it does not apply.
Accidental injury You pay – Standard Option You pay – High Option
If you receive care in connection with, and within 72 hours after an accidental injury, we

cover:
= Physician services in the office or hospital outpatient department including

X-rays, MRIs, laboratory and pathological services, and machine
diagnostic tests
= Related outpatient hospital services and supplies, including X-rays, MRIs,

laboratory, pathological and machine diagnostic tests

Note: For services received after 72 hours, please see Section 5( a), Medical services and
supplies, and Section 5( c), Outpatient hospital, for the benefits we provide. We
pay Inpatient hospital benefits if you are admitted [see Section 5( c)]. See Section 5( h)
for dental benefits for accidental injuries.

Preferred: Nothing (No deductible)
Participating: Nothing (No deductible)
Non-participating: Any difference
between the Plan allowance and the
billed amount (No deductible)

Preferred: Nothing (No deductible)
Participating: Nothing (No deductible)
Non-participating: Any difference between the Plan
allowance and the billed amount (No deductible)

Accidental injury – Continued on next page 57
57 Page 58 59
2001 Blue Cross and Blue Shield Service Benefit Plan 58 Section 5( d)
Accidental injury – Continued You pay – Standard Option You pay – High Option
Not covered:
= Oral surgery except as shown in Section 5( b)
= Injury to the teeth while eating

All charges All charges

Medical emergency You pay – Standard Option You pay – High Option
For medical emergency services, other than those services performed within 72 hours after

an accidental injury for which we pay under Accidental injury above, see the following
benefits sections:
= Section 5( a), Medical services and supplies
= Section 5( b), Surgical procedures
= Section 5( c), Outpatient hospital
= Section 5( c), Inpatient hospital
Note: We pay Inpatient hospital benefits if you are admitted as a result of a medical emergency

(see Section 5( c), Inpatient hospital).
Please refer to Section 3 for information about precertifying emergency hospital admissions.

Same as for illness (Regular benefits) Same as for illness (Regular benefits)

Ambulance You pay – Standard Option You pay – High Option
Local professional ambulance transport services to or from the nearest hospital equipped to

adequately treat the patient's condition, when medically appropriate, and:

= Associated with covered hospital inpatient care
= Related to and within 72 hours after an accidental injury or medical emergency
= During covered home health care
Note: See Section 5( c) for non-emergency ambulance services.

Preferred: 10% of the Plan allowance
Participating: 25% of the Plan allowance
Non-participating: 25% of the Plan allowance,
plus any difference between our allowance
and the provider's actual charge

Preferred: 5% of the Plan allowance
Participating: 20% of the Plan allowance
Non-participating: 20% of the Plan allowance,
plus any difference between our allowance
and the provider's actual charge 58
58 Page 59 60
2001 Blue Cross and Blue Shield Service Benefit Plan 59 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
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Beginning in 2001, all FEHB plans' mental health and substance abuse benefits will achieve "parity" with other benefits. This means that we will provide mental health and substance abuse benefits differently than
in the past.
You may choose to get care from Non-preferred providers (same as before) or from Preferred providers (new in 2001). When you receive care from Preferred providers, generally your cost sharing for your
mental health and substance abuse benefits will be no greater than for similar benefits for other illnesses and conditions.

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

= The calendar year deductible or, for facility care, the inpatient per admission copay, applies to almost all benefits in this Section. We added "( No deductible)" to show when a deductible does not apply.
= There is a maximum of 25 visits per year under Standard Option and 50 visits per year under High Option for office visits, partial hospitalization, intensive outpatient treatment, and other hospital
outpatient treatment. The first 25 visits under Standard Option and 50 visits under High Option each calendar year by Preferred providers and Non-preferred providers count toward this maximum. This
maximum may be waived for services received from Preferred providers.
= Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works, with special sections for members who are age 65 or over. Also read Section 9 about

coordinating benefits with other coverage, including Medicare.
= YOU MUST GET PRECERTIFICATION OF HOSPITAL STAYS: FAILURE TO DO SO WILL RESULT IN A $500 PENALTY. Please refer to the precertification information listed in

Section 3. Some other services also require prior approval. See the instructions after the benefits descriptions below.

= Preferred mental health and substance abuse benefits are presented below. Non-preferred benefits begin on page 62.
= The non-PPO benefits are the standard benefits of this Plan. PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non-PPO benefits apply.

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Benefit Description You pay After the calendar year deductible…
NOTE: The calendar year deductible applies to almost all benefits in this Section. We say "No deductible" when it does not apply.

Preferred (In-Network) benefits You pay – Standard Option You pay – High Option
All diagnostic and treatment services contained in a treatment plan that we approve. The treatment plan
may include services, drugs, and supplies described elsewhere in this brochure.

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

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

Preferred benefits – Continued on next page 59
59 Page 60 61
2001 Blue Cross and Blue Shield Service Benefit Plan 60 Section 5( e)
Preferred benefits – Continued You pay – Standard Option You pay – High Option
Professional services, including individual or group therapy by providers such as psychiatrists,
psychologists, clinical social workers or psychiatric nurses

Note: Additional licensed provider types may be available to you for mental health and substance abuse
services. Consult your PPO directory or contact your Local Plan at the mental health phone number on the
back of your ID card.
= Office and home visits
= Medication management
= Psychological testing

$15 copayment for the visit, up to two hours per visit (No
deductible); 10% of the Plan allowance for all other
services (deductible applies)

$12 copayment for the visit, up to two hours per
visit (No deductible); 5% of the Plan allowance for
all other services (deductible applies)

= Inpatient visits
= Intensive outpatient treatment – not limited to two hours per visit but you must obtain prior

approval
= Outpatient diagnostic tests

10% of the Plan allowance 5% of the Plan allowance (No
deductible for inpatient visits)

Inpatient services provided and billed by a hospital or other covered facility
= Room and board, such as semiprivate or intensive accommodations, general nursing care,
meals and special diets and other hospital services

= Diagnostic tests
Note: You must get precertification of inpatient hospital stays; failure to do so will result in a $500

penalty.

$100 per admission copayment for medically
necessary days (No deductible)
Nothing for medically necessary days (No
deductible)

Outpatient services provided and billed by a hospital or other covered facility
= Diagnostic tests
= Services in the following approved treatment programs (must be prior approved):

partial hospitalization
facility-based intensive outpatient treatment

10% of the Plan allowance 5% of the Plan allowance

Preferred benefits – Continued on next page 60
60 Page 61 62
2001 Blue Cross and Blue Shield Service Benefit Plan 61 Section 5( e)
Preferred benefits – Continued You pay – Standard Option You pay – High Option
Not covered:
= Services we have not approved
= Educational or training services
= Psychoanalysis or psychotherapy credited toward earning a degree or furtherance of education or

training regardless of diagnosis or symptoms that may be present

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 All charges

Authorization Procedures To be eligible to receive enhanced mental health and substance abuse benefits you must see a Preferred provider, follow your treatment plan and
follow the applicable authorization processes.
To locate a Preferred provider, please refer to your PPO directory, visit our website at www. fepblue. org or contact the Local Plan at the mental health

and substance abuse phone number shown on the back of your ID card.
Precertification You must get precertification of inpatient hospital stays; failure to do so will result in a $500 penalty. Please refer to the precertification information

listed in Section 3 for additional information.

Prior Approval Prior approval is required for partial hospitalization and intensive outpatient treatment programs. Prior to starting treatment, you, someone acting on
your behalf, your physician or your hospital must call the Local Plan at the mental health and substance abuse phone number on the back of your ID
card. We will not pay for partial hospitalization or intensive outpatient treatment programs, even in-network, until you obtain prior approval.

Treatment Plans In order to maximize your benefits, your provider must submit a treatment plan to the Local Plan prior to your ninth outpatient visit. When the
Local Plan approves the treatment plan, your provider will be given authorization for additional visits. The number of additional visits will
depend on the treatment plan. Subsequent treatment plans may be requested by the Local Plan. If a treatment plan is not submitted or not approved, we
will provide only Non-preferred (out-of-network) benefits. If you change providers, a new treatment plan must be submitted. We will be flexible in
allowing additional visits while your treatment plan is being prepared or under review.

Preferred limitation If you do not obtain and follow an approved treatment plan, we will provide only Non-preferred (out-of-network) benefits. 61
61 Page 62 63
2001 Blue Cross and Blue Shield Service Benefit Plan 62 Section 5( e)
Non-preferred benefits You pay – Standard Option You pay – High Option
Professional services, including individual or group therapy, by providers such as psychiatrists,
psychologists, clinical social workers or psychiatric nurses, limited to 25 outpatient visits* per calendar
year under Standard Option, or 50 outpatient visits* per calendar year under High Option, for:

= Office and home visits
= Psychological testing
= In a hospital outpatient department (except for emergency rooms)

*The visit limit is a combined maximum for all outpatient professional care, partial hospitalization
and outpatient facility care, whether performed by Preferred or Non-preferred providers, or applied to
your calendar year deductible.

40% of the Plan allowance for up to two hours per visit; all
charges after 25 visits*
30% of the Plan allowance for up to two hours per visit; all
charges after 50 visits*

Inpatient visits, limited to 100 days per calendar year under Standard Option, and 120 days per calendar
year under High Option
40% of the Plan allowance; all charges after 100 days 30% of the Plan allowance; all charges after 120 days

Non-preferred benefits – Continued on next page 62
62 Page 63 64
2001 Blue Cross and Blue Shield Service Benefit Plan 63 Section 5( e)
Non-preferred benefits – Continued You pay–StandardOption You pay – High Option
Inpatient services provided and billed by a hospital or other covered facility; limited to 100
days per calendar year under Standard Option or 120 days per calendar year under High Option

= Room and board, such as semiprivate or intensive accommodations, general nursing
care, meals and special diets and other hospital services

You must get precertification of inpatient hospital stays; failure to do so will result in a $500 penalty.

$400 copayment per day (No deductible); all charges after
100 days
$300 copayment per day (No deductible); all charges after
120 days

Outpatient services provided and billed by a hospital or other covered facility
= Psychological testing
25% of the Plan allowance, plus any difference between
the Plan allowance and the provider's actual charge
20% of the Plan allowance, plus any difference between
the Plan allowance and the provider's actual charge

Partial hospitalization, for up to 25 visits* per calendar year under Standard Option and 50
visits* per calendar year under High Option
Note: Visits that you pay for while meeting your deductible count toward the limits cited above.

*The visit limit is a combined maximum for all outpatient professional care, partial hospitalization
and outpatient facility care, whether performed by Preferred or Non-preferred providers, or applied
to your calendar year deductible.

25% of the Plan allowance, plus any difference between
the Plan allowance and the provider's actual charge; all
charges after 25 visits*

20% of the Plan allowance, plus any difference between
the Plan allowance and the provider's actual charge; all
charges after 50 visits*

Non-preferred benefits – Continued on next page 63
63 Page 64 65
2001 Blue Cross and Blue Shield Service Benefit Plan 64 Section 5( e)
Non-preferred benefits – Continued You pay – Standard Option You pay – High Option
Inpatient care to treat substance abuse includes room and board and ancillary charges for
confinements in a treatment facility for rehabilitative treatment of alcoholism or
substance abuse
Note: Non-preferred inpatient care for the treatment of substance abuse is limited to one

treatment program (28-day maximum) per lifetime under Standard and High Options.

Non-preferred facility: $400 copayment per day
(No deductible); all charges after 28 days per lifetime

Non-preferred professional: 40% of the Plan allowance;
all charges after 28 days per lifetime

Non-preferred facility: $300 copayment per day
(No deductible); all charges after 28 days per
lifetime
Non-preferred professional: 20% of the

Plan allowance; all charges after 28 days per
lifetime

Not covered :
= == = Marital, family, educational, or other counseling or training services

= == = Services performed by a non-covered provider
= == = Testing and treatment for learning disabilities and mental retardation

= == = Services performed or billed by schools, residential treatment centers, halfway houses, or members of
their staffs
= == = Psychoanalysis or psychotherapy credited toward earning a degree or furtherance of education or

training regardless of diagnosis or symptoms that may be present

= == = Home health care services related to the treatment of mental health and substance abuse

All charges All charges

Lifetime maximum Non-preferred inpatient care for the treatment of substance abuse is limited to one treatment program (28-day maximum) per lifetime under Standard and
High Options.

Precertification You must get precertification of the medical necessity of your admission to a hospital or other covered facility. Report emergency admissions within
two business days following the day of admission, even if you have been discharged. Otherwise, we will reduce the benefits payable by $500. See
Section 3 for more information on precertification.
See these sections of the brochure for more valuable information about these benefits:
= Section 4, Your costs for covered services, for information about catastrophic protection for mental health and substance abuse benefits.

= Section 7, Filing a claim for covered services, for information about submitting Non-preferred claims. 64
64 Page 65 66
2001 Blue Cross and Blue Shield Service Benefit Plan 65 Section 5( f)
Section 5 (f). Prescription drug benefits
I M
P O
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A N
T

Here are some important things to keep in mind about these benefits:
= We cover prescription drugs and supplies, 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.

= The calendar year deductible does not apply to prescriptions filled through the Retail Pharmacy Program or Mail Service Prescription Drug Program. We added "( calendar year deductible
applies)" when it applies.
= YOU MUST GET PRIOR APPROVAL FOR CERTAIN DRUGS, and prior approval must be renewed periodically. Please refer to the prior approval information shown in

Section 3.
= Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works, with special sections for members who are age 65 or over. Also read

Section 9 about coordinating benefits with other coverage, including Medicare.
= The non-PPO benefits are the standard benefits of this Plan. PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non-PPO benefits apply.

I M
P O
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T

We will send each new enrollee a description of our prescription drug program, a combined prescription drug/ Plan identification card, a mail order form/ patient profile, and a preaddressed reply envelope.
= Who can write your prescriptions. A physician or dentist licensed in the United States or Puerto Rico, or a nurse practitioner in states that permit it, must write your prescriptions.
= Where you can obtain them. You may fill prescriptions at a Preferred retail pharmacy, at a Non-preferred retail pharmacy, and through our Mail Service Prescription Drug Program. We pay a higher level of benefits when you
use a Preferred retail pharmacy or our Mail Service Prescription Drug Program.
= We use an open formulary. This is a list of preferred name brand drugs selected to meet patient needs at a lower cost to us. If your physician believes a name brand drug is necessary or there is no generic equivalent available,

ask your physician to prescribe a name brand drug from our formulary list. We may ask your doctor to substitute a formulary drug in order to help achieve the best clinical outcome while at the same time help control costs. We
cover drugs that require a prescription (whether or not they are on our formulary list). There is no penalty to you if you do not choose a drug from our formulary. However, your cooperation with our cost-savings efforts helps keep
your premium affordable. You can view our formulary on our website at www. fepblue. org or request a copy by mail by calling 1-800-624-5060 (TDD: 1-800-624-5077). Any savings we receive on the cost of drugs purchased
under this Plan from drug manufacturers are credited to the reserves held for this Plan.
= Generic equivalents. By submitting your prescription (or those of family members covered by the Plan) to your retail pharmacy or the Mail Service Prescription Drug Program, you authorize them to substitute any available

Federally approved generic equivalent, unless you or your physician specifically request a name brand drug.
= Disclosure of information. As part of our administration of prescription drug benefits, we may disclose information about your prescription drug utilization, including the names of your prescribing physicians, to any

treating physicians or dispensing pharmacies.
= These are the dispensing limitations. You may purchase up to a 90-day supply of covered drugs and supplies through the Retail Pharmacy Program. You may purchase a supply of more than 21 days up to 90 days through the

Mail Service Prescription Drug Program. Certain drugs such as narcotics may have additional FDA limits on the quantities that a pharmacy may dispense. In most cases, refills cannot be obtained until 75% of the prescription
has been used. Call the Retail Pharmacy Program or the Mail Service Prescription Drug Program at the numbers shown below for exceptions to this policy, and further information about dispensing limits for specific drugs.

= Important phone numbers. Retail Pharmacy Program: 1-800-624-5060 (TDD: 1-800-624-5077) Mail Service Prescription Drug Program: 1-800-262-7890 (TDD: 1-800-446-7292)
Prescription drug benefits -Continued on next page 65
65 Page 66 67
2001 Blue Cross and Blue Shield Service Benefit Plan 66 Section 5( f)
Covered medications and supplies You pay – Standard Option You pay – High Option
= Drugs, vitamins and minerals, and nutritional supplements that by Federal law of the United

States require a prescription for their purchase
= Insulin
= Needles and disposable syringes for the administration of covered medications

= Drugs to aid smoking cessation that require a prescription by Federal law (limited to one course
of treatment per calendar year)
= Contraceptive drugs and devices, limited to:
Depo-Provera *
Diaphragms *
Intrauterine Device (IUD) *
Norplant *
Oral contraceptives
*available only through retail pharmacies

Here is how to obtain your prescription drugs:
Retail Pharmacy Program
= You must present your Plan ID card at the time of purchase at a Preferred retail

pharmacy.
= If you use a Non-preferred retail pharmacy, or your prescription requires prior approval, you
must pay the full cost of the drug or supply at the time of purchase and file a claim with the
Retail Pharmacy Program to be reimbursed. Please refer to Section 7 for instructions on
how to file prescription drug claims.
Note: For prescription drugs billed for by a skilled nursing facility, nursing home, or extended care
facility, we provide benefits as shown above for retail pharmacy-obtained drugs, according to the
Preferred or Non-preferred status of the pharmacy supplying the drugs to the facility. For a list of
our Preferred Network Long Term Care pharmacies that service nursing homes, call 1-800-
624-5060 (TDD: 1-800-624-5077) or visit our web site at www. fepblue. org.

Note: For coordination of benefits purposes, if you need a statement of Preferred retail pharmacy
benefits in order to file claims with your other coverage when this Plan is the primary payer, call
the Retail Pharmacy Program at 1-800-624-5060 (TDD: 1-800-624-5077).

Preferred Retail Pharmacy: 25% of the Plan allowance
Non-preferred Retail Pharmacy: 45% of the Plan
allowance, plus any difference between our
allowance and the billed amount

Preferred Retail Pharmacy: 15% of the Plan allowance
Non-preferred Retail Pharmacy: 35% of the Plan
allowance, plus any difference between our
allowance and the billed amount

Covered medications and supplies – Continued on next page 66
66 Page 67 68
2001 Blue Cross and Blue Shield Service Benefit Plan 67 Section 5( f)
Covered medications and supplies – Continued You pay – Standard Option You pay – High Option
Mail Service Prescription Drug Program
If your doctor orders more than a 21-day supply of covered drugs or supplies, up to a 90-day

supply, you can use this service for your prescriptions and refills.

Please refer to Section 7 for instructions on how to use the Mail Service Prescription Drug
Program.
Note: Not all drugs are available through the Mail Service Prescription Drug Program.

Mail Service Program: $12 generic
$20 brand-name
Note: If there is no generic equivalent available, you must
still pay the brand-name copayment when you receive a
brand-name drug.
Note: If the cost of your prescription is less than your
copayment, you pay only the cost of your prescription.
The Mail Service Prescription Drug Program will charge you
the lesser of the prescription cost or the copayment when
you place your order. If you have already sent in your
copayment, they will credit your account with any
difference.

Mail Service Program: $8 generic
$14 brand-name
Note: If there is no generic equivalent available, you
must still pay the brand-name copayment when you
receive a brand-name drug.
Note: If the cost of your prescription is less than
your copayment, you pay only the cost of your
prescription. The Mail Service Prescription Drug
Program will charge you the lesser of the prescription
cost or the copayment when you place your order. If you
have already sent in your copayment, they will credit
your account with any difference.

Drugs from other sources
= Covered prescription drugs and supplies not obtained at a retail pharmacy or through the
Mail Service Prescription Drug Program.
Note: Drugs purchased overseas must be the equivalent to drugs that by Federal law of the
United States require a prescription.
Note: For covered prescription drugs and supplies purchased outside of the United States and Puerto
Rico, please submit claims on an Overseas Claim Form. See Section 7 for information on how to
file claims for overseas services.
= Please refer to Sections 5( a) and 5( c) for additional benefit information when you
purchase drugs from a:
Hospital (inpatient or outpatient)
Hospice agency
Home health care agency
Physician's office

Preferred: 10% of the Plan allowance (calendar year
deductible applies)

Participating/ Member: 25% of the Plan allowance (calendar
year deductible applies)

Non-participating/ Non-member: 25% of the Plan allowance
(calendar year deductible applies), plus any difference
between our allowance and the billed amount

Preferred: 5% of the Plan allowance (calendar year
deductible applies)

Participating/ Member: 20% of the Plan allowance
(calendar year deductible applies)

Non-participating/ Non-member: 20% of the Plan
allowance (calendar year deductible applies), plus any
difference between our allowance and the billed
amount

Covered medications and supplies – Continued on next page 67
67 Page 68 69
2001 Blue Cross and Blue Shield Service Benefit Plan 68 Section 5( f)
Covered medications and supplies – Continued You pay – Standard Option You pay – High Option
Prior Approval
= You must request and receive prior approval for certain prescription drugs and supplies,

whether you choose to fill your prescription with a Preferred retail pharmacy, a Non-preferred
retail pharmacy, or the Mail Service Prescription Drug Program. Prior
approval must be renewed periodically. To obtain a list of prescription drugs and
supplies requiring prior approval and to obtain prior approval request forms, call the
Retail Pharmacy Program at 1-800-624-5060 (TDD: 1-800-624-5077). You can also
obtain the list through our web site at www. fepblue. org.

= Please read Section 3 for more information about prior approval.

------

Not covered:
= Medical supplies such as dressings and antiseptics

= Drugs and supplies for cosmetic purposes
= Drugs and supplies for weight loss
= Drugs for orthodontic care, dental implants, and periodontal disease

= Medication that does not require a prescription under Federal law even if your
doctor prescribes it or a prescription is required under your State law

= Drugs for which prior approval has been denied or not obtained

All charges All charges 68
68 Page 69 70
2001 Blue Cross and Blue Shield Service Benefit Plan 69 Section 5( g)
Section 5 (g). Special features
Special features Description
Health support programs The Service Benefit Plan is developing and may offer patient support programs for certain diagnoses in select locations on a pilot basis. We
will notify you about programs available in your area.
Flexible benefits option Under the flexible benefits option (also referred to as case management), we determine the most effective way to provide services.

= We may identify medically appropriate alternatives to traditional care and/ or direct the provision of Plan benefits to a less costly
alternative benefit.
= Alternative benefits are subject to ongoing review by the Local Plan.
= By approving an alternative benefit, we cannot guarantee you will receive 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.

24-hour nurse line Help with health concerns is available 24 hours a day, 365 days a year, by calling a toll-free telephone number, 1-888-258-3432, or by accessing our
Internet web site, www. fepblue. org. The service, called Blue Health Connection, offers health advice or health information and counseling by

registered nurses. Also available is the AudioHealth Library with hundreds of tapes, ranging from first aid to infectious diseases to general health
issues. You can get information about health care resources to help you find local doctors, hospitals or other health care services affiliated with the
Blue Cross and Blue Shield Service Benefit Plan. Contact us at the number above or visit our web site for more information.

Services for the deaf and hearing impaired All Blue Cross and Blue Shield Plans provide TDD access for the hearing impaired to access information and receive answers to their
questions.

Travel benefit/ services overseas Members located overseas who need assistance locating providers who accept our Plan allowance for overseas services, should contact the
Worldwide Assistance Center (provided by World Access Service Corporation), at 1-804-673-1678. Members in the United States, Puerto

Rico or the Virgin Islands should call 1-800-699-4337. World Access Service Corporation offers emergency evacuation services, translation
services and conversion of foreign medical bills to U. S. currency. You may contact World Access Service Corporation 24 hours per day, 365 days per
year.
We pay overseas claims at Preferred benefit levels. See Sections 5( a)-5( f). This payment arrangement is based on an Overseas Fee Schedule. You
must pay any difference between our payment and the provider's bill, in addition to any applicable deductible, coinsurance, or copayment amounts. 69
69 Page 70 71
2001 Blue Cross and Blue Shield Service Benefit Plan 70 Section 5( h)
Section 5 (h). Dental benefits
I M
P O
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A N
T

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

= The calendar year deductible applies only to the accidental injury benefit below. We added "calendar year deductible applies" when it applies.
= Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works, with special sections for members who are age 65 or over. Also
read Section 9 about coordinating benefits with other coverage, including Medicare.
= Note: We cover hospitalization for dental procedures only when a non-dental physical impairment exists that makes hospitalization necessary to safeguard the health of the patient

(even if the dental procedure itself is not covered).

I M
P O
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A N
T

Accidental injury benefit You pay-Standard Option You pay – High Option
We provide benefits for services, supplies or appliances for dental care necessary to
promptly repair injury to sound natural teeth required as a result of, and directly related to,
an accidental injury.
Note: An accidental injury is an injury caused by an external force or element such as

a blow or fall and that requires immediate attention. Injuries to the teeth while eating are
not considered accidental injuries.
Note: A sound natural tooth is a tooth that is whole or properly restored (restoration with

amalgams only); is without impairment, periodontal or other conditions; and is not in
need of the treatment provided for any reason other than an accidental injury. For purposes
of this Plan, a tooth with a crown is not considered a sound natural tooth.

Note: Under Standard Option, we first provide benefits as shown in the Schedule of Dental
Allowances on the following pages. We then pay benefits as shown here for any balances.

Preferred: 10% of the Plan allowance
(calendar year deductible applies)

Participating: 25% of the Plan allowance
(calendar year deductible applies)

Non-participating: 25% of the Plan
allowance (calendar year deductible
applies), plus any difference between
our allowance and the physician's actual
charge

Preferred: 5% of the Plan allowance
(calendar year deductible applies)

Participating: 20% of the Plan allowance
(calendar year deductible applies)

Non-participating: 20% of the Plan
allowance (calendar year deductible
applies), plus any difference between
our allowance and the physician's
actual charge

Dental benefits – Continued on next page. 70
70 Page 71 72
2001 Blue Cross and Blue Shield Service Benefit Plan 71 Section 5( h)
What is Covered
Under Standard Option only, we pay billed charges for the following services, up to the amounts shown per service as listed in the following Schedule of Dental Allowances on the following pages below. This is a complete list of dental
services covered under this benefit for Standard Option. There are no deductibles, copayments or coinsurance. You pay all charges in excess of our listed fee schedule amounts. These benefits are not available under High Option.

Note: See Section 5( b) for our benefits for Oral and maxillofacial surgery, and Section 5( c) for our benefits for hospital services (inpatient/ outpatient) in connection with dental services, available under both Standard Option and High Option.

Preferred Dental Network
All Local Plans contract with Preferred dentists who are available in most areas. Preferred dentists agree to accept a negotiated, discounted amount called the Maximum Allowable Charge (MAC) as payment in full for the following
services. They will also file your dental claims for you. You are responsible, as an out-of-pocket expense, for the difference between the amount specified in this Schedule of Dental Allowances and the MAC. To find a Preferred
dentist near you or to obtain a copy of the applicable MAC listing, refer to the Preferred provider directory, our web site, or contact your Local Plan.

Note: These dentists may not be Preferred for other services covered by this Plan under other benefit provisions (such as oral and maxillofacial surgery).

Dental benefits Standard Option Only
Service
ADA Code

We pay You pay

Clinical oral evaluations
0120 Periodic oral evaluation*
0140 Limited oral evaluation
0150 Comprehensive oral evaluation
0160 Detailed and extensive oral evaluation
* Limited to two per person per calendar year

To age 13
$12
$14
$14
$14

Age 13 and over
$8
$9
$9
$9

Radiographs
0210 Intraoral complete series
0220 Intraoral periapical first film
0230 Intraoral periapical each additional film
0240 Intraoral occlusal film
0250 Extraoral first film
0260 Extraoral each additional film
0270 Bitewing – single film
0272 Bitewings – two films
0274 Bitewings – four films

$36
$7
$4
$12
$16
$6
$9
$14
$19

$22
$5
$3
$7
$10
$4
$6
$9
$12

All charges in excess of the scheduled amounts
listed to the left

Standard Option dental benefits— Continued on next page 71
71 Page 72 73
2001 Blue Cross and Blue Shield Service Benefit Plan 72 Section 5( h)
Dental benefits --Continued Standard Option Only
Service
ADA Code
We pay You pay

Radiographs – continued
0277 Bitewings – vertical
0290 Posterior-anterior or lateral skull and facial bone survey film

0330 Panoramic film

To age 13
$12
$45

$36

Age 13 and over
$7
$28

$23
Tests and laboratory exams
0460 Pulp vitality tests $11 $7

Palliative treatment
9110 Palliative (emergency) treatment of dental pain – minor procedure

2940 Sedative filling
$24
$24
$15
$15

Preventive
1120 Prophylaxis – child*
1110 Prophylaxis – adult*
1201 Topical application of flouride (including prophylaxis) – child*

1203 Topical application of flouride (prophylaxis not included) – child
1205 Topical application of flouride (including prophylaxis) – adult*
1204 Topical application of flouride (prophylaxis not included) – adult

* Limited to two per person per calendar year

$22
---

$35
$13
---

---

$14
$16

$22
$8
$24

$8

Space maintenance (passive appliances)
1510 Space maintainer – fixed – unilateral
1515 Space maintainer – fixed -bilateral
1520 Space maintainer – removable – unilateral

1525 Space maintainer – removable – bilateral
1550 Recementation of space maintainer

$94
$139

$94
$139
$22

$59
$87

$59
$87
$14

All charges in excess of the scheduled amounts
listed to the left

Dental benefits – Continued on next page. 72
72 Page 73 74
2001 Blue Cross and Blue Shield Service Benefit Plan 73 Section 5( h)
Dental benefits --Continued Standard Option Only
Service
ADA Code
We pay You pay

Amalgam restorations (including polishing)
2110 Amalgam – one surface, primary
2120 Amalgam – two surfaces, primary
2130 Amalgam – three surfaces, primary
2131 Amalgam – four or more surfaces, primary
2140 Amalgam – one surface, permanent
2150 Amalgam – two surfaces, permanent
2160 Amalgam – three surfaces, permanent
2161 Amalgam – four or more surfaces, permanent

To age 13
$22
$31
$40
$49
$25
$37
$50
$56

Age 13 and over
$14
$20
$25
$31
$16
$23
$31
$35

Filled or unfilled resin restorations
2330 Resin – one surface, anterior
2331 Resin – two surfaces, anterior
2332 Resin – three surfaces, anterior
2335 Resin – four or more surfaces or involving incisal angle (anterior)

2380 Resin – one surface, posterior-primary
2381 Resin – two surfaces, posterior-primary
2382 Resin – three or more surfaces, posterior-primary

2385 Resin – one surface, posterior-permanent
2386 Resin – two surfaces, posterior-permanent
2387 Resin – three surfaces, posterior-permanent

2388 Resin – four or more surfaces, posterior-permanent

$25
$37
$50

$56
$22
$31

$40
$25
$37
$50

$50

$16
$23
$31

$35
$14
$20

$25
$16
$23
$31

$31
Inlay restorations
2510 Inlay – metallic – one surface
2520 Inlay – metallic – two surfaces
2530 Inlay – metallic – three or more surfaces
2610 Inlay – porcelain/ ceramic – one surface
2620 Inlay – porcelain/ ceramic – two surfaces
2630 Inlay – porcelain/ ceramic – three or more surfaces

$25
$37
$50
$25
$37

$50

$16
$23
$31
$16
$23

$31

All charges in excess of the scheduled amounts
listed to the left

Dental benefits – Continued on next page. 73
73 Page 74 75
2001 Blue Cross and Blue Shield Service Benefit Plan 74 Section 5( h)
Dental benefits --Continued Standard Option Only
Service
ADA Code
We pay You pay

Inlay restorations – Continued
2650 Inlay – composite/ resin – one surface

2651 Inlay – composite/ resin – two surfaces
2652 Inlay – composite/ resin – three or more surfaces

To age 13
$25
$37

$50

Age 13 and over
$16
$23

$31

Other restorative services
2951 Pin retention – per tooth, in addition to restoration $13 $8

Extractions – includes local anesthesia and routine post-operative
care
7110 Single tooth
7120 Each additional tooth
7130 Root removal – exposed roots
7210 Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap

and removal of bone and/ or section of tooth

7250 Surgical removal of residual tooth roots (cutting procedure)
9220 General anesthesia in connection with covered extractions

$30
$27
$71

$43
$71

$43

$19
$17
$45

$27
$45

$27

All charges in excess of the scheduled amounts
listed to the left

Not covered:
Any service not specifically listed above
Nothing All charges 74
74 Page 75 76
2001 Blue Cross and Blue Shield Service Benefit Plan 75 Section 5( i)
Section 5 (i). Non-FEHB benefits available to Plan members The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB dispute
regarding these benefits. Fees you pay for these services do not count toward FEHB deductibles or out-of-pocket maximums.
Vision Care Program
Service Benefit Plan members may obtain eye exams and eyewear at substantial savings from EyeMed* Vision

Care providers. EyeMed Vision Care operates a national provider network consisting of over 7,000 providers,
including LensCrafters locations and doctors located next to LensCrafters, independent optometrists,
ophthalmologists, and opticians. The names, addresses, and telephone numbers of EyeMed providers are
available by calling 1-800-551-3337. Location information is available 24-hours a day; customer service
is available from 8: 00 a. m. to 11: 00 p. m. EST, Monday through Saturday, and from 11: 00 a. m. to 8: 00 p. m. EST
on Sunday. Or, visit www. fepblue. org for a complete description of the program and provider locations.

You may also obtain contact lenses through the Advantage Program. Contact one of the participating
optometrists next to a LensCrafters for information on how to enroll in this program. You can also save 15% of
the retail price on Lasik or PRK vision correction procedures provided by the U. S. Laser Network. Simply
call 1-877-552-7376 for the nearest laser facility and to receive authorization for the discount.

There are no enrollment fees and no additional paperwork or claim forms to be filed in this program. All charges for
eye exams and eyewear are handled directly between you and the EyeMed provider.

Complementary and Alternative Medicine
Service Benefit Plan members now have access to a national network of chiropractors, acupuncturists, and

massage therapists at discounted rates, through American Specialty Health (ASH)*. The program is simple to use.
Members may call providers directly and schedule appointments; no physician referral is required. There are
no enrollment fees and no additional paperwork or claim forms for this program. All charges for health services are
handled directly between you and the ASH provider.
For more information, visit our website at www. fepblue. org or call ASH Member Services at 1-877-258-7283. This

discount provider network is available to members nationwide, unless prohibited by state law or regulation.

Through ASH, members may also purchase health and wellness products at discounted prices including vitamins,
minerals, herbal supplements, homeopathic remedies, sports nutrition products, books, videotapes, and skin care
products. Shipping is free to Service Benefit Plan members. You may order products online at www. fepblue. org or
request a free catalog by calling American Specialty Health (ASH) at 1-877-258-7283.

ASH Customer Service hours are from 8: 00 a. m. to 11: 00 p. m. EST, Monday through Friday, and from 9: 00 a. m. to
6: 00 p. m. EST on Saturday.

Federal DentalBlue (Standard Option Only)
Federal DentalBlue is an optional dental product with an additional premium that supplements the dental benefits

included in your Standard Option coverage. To apply for Federal DentalBlue, you must be enrolled in
Standard Option and reside in a Plan area listed below. To purchase this additional coverage, complete and sign
the Federal DentalBlue enrollment form, which you can obtain from your Local Plan.

Federal DentalBlue is available in only the following Plan areas: Alabama, Massachusetts, Oklahoma, and
Washington State (only counties served by Regence BlueShield).

Many other Blue Cross and Blue Shield Plans offer dental insurance to FEP members for an additional
premium. If interested, contact your Local Plan about the availability of a non-FEHB dental program in your area.

Medicare Prepaid Plan Enrollment
Some local Blue Cross and Blue Shield Plans offer Medicare recipients the opportunity to enroll in a Medicare

prepaid plan without payment of an FEHB premium. Contact your local Blue Cross and Blue Shield Plan to find
out if a Medicare prepaid plan is available in your area and the cost, if any, of that enrollment.

* The Blue Cross and Blue Shield Association and participating Local Plans will receive remuneration from EyeMed and ASH to cover their administrative costs for offering these programs, and for other purposes. 75
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2001 Blue Cross and Blue Shield Service Benefit Plan 76 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 we determine it is medically necessary to prevent, diagnose, or treat your illness,
disease, injury, or condition.
We do not cover the following:
= 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 in the United States;

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

= Services, drugs, or supplies related to sex transformations, sexual dysfunction, or sexual inadequacy;
= Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program;
= Services, drugs, or supplies you would not be charged for if you had no health insurance coverage;
= Services, drugs, or supplies you receive without charge while in active military service; or that you require as a result of an act of war within the United States, its territories, or possessions; or during combat;

= Amounts charged that neither you nor we are legally obligated to pay, such as amounts over the Medicare limiting charge or equivalent Medicare amount as described in Section 4 under Your costs for covered services,
or State premium taxes, however applied;
= Services, drugs, or supplies you receive from immediate relatives or household members, such as spouse, parent, child, brother, or sister, by blood, marriage, or adoption;

= Services or supplies (except for medically necessary prescription drugs) that you receive from a noncovered facility, such as an extended care facility or nursing home, except as specifically described in Section 5( c);
= Services, drugs, or supplies you receive from noncovered providers such as chiropractors, except in medically underserved areas as specifically described on page 10;
= Services, drugs, or supplies you receive for cosmetic purposes;
= Services, drugs, or supplies for the treatment of obesity, weight reduction, or dietary control, except for gastric bypass surgery or gastric stapling procedures;

= Any dental or oral surgical procedures or drugs involving orthodontic care, the teeth, dental implants, periodontal disease, or preparing the mouth for the fitting or continued use of dentures, except as specifically described in
Section 5( h), Dental benefits, and Section 5( b) under Oral and maxillofacial surgery;
= Orthodontic care for temporomandibular joint (TMJ) syndrome;
= Services of standby physicians;
= Self-care or self-help training;
= Custodial care;
= Personal comfort items such as beauty and barber services, radio, television, or telephone;
= Routine services, such as periodic physical exams; screening examinations; immunizations; and services or tests not related to a specific diagnosis, illness, injury, set of symptoms, or maternity care, except for those preventive

services specifically covered under Preventive care, adult and child in Sections 5( a) and 5( c); or
= Services not specifically listed as covered. 76
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2001 Blue Cross and Blue Shield Service Benefit Plan 77 Section 7
Section 7. Filing a claim for covered services
How to claim benefits To obtain claim forms or other claims filing advice, or answers about our benefits, contact us at the telephone number on the back of your
Service Benefit Plan ID card, or at our website at www. fepblue. org.
In most cases, physicians and facilities file claims for you. Just present your Service Benefit Plan ID card when you receive services. Your
physician must file on the HCFA-1500, Health Insurance Claim Form. Your facility will file on the UB-92 form.

When you must file a claim -such as for overseas claims or when another group health plan is primary -submit it on the HCFA-1500 or a
claim form that includes the information shown below. Use a separate claim form for each family member. For long or continuing hospital
stays, or other long-term care, you should submit claims at least every 30 days. Bills and receipts should be itemized and show:

= Name of patient and relationship to enrollee;
= Plan identification number of enrollee;
= Name and address of person or firm providing the service or supply;

= Dates that services or supplies were furnished;
= Diagnosis;
= Type of each service or supply; and
= The charge for each service or supply.
Note: Canceled checks, cash register receipts, or balance due statements are not acceptable substitutes for itemized bills.

In addition:
= You must send a copy of the explanation of benefits (EOB) form from any primary payer (such as the Medicare Summary Notice
[MSN]) with your claim.
= Bills for home nursing care must show that the nurse is a registered or licensed practical nurse.

= Claims for rental or purchase of durable medical equipment, private duty nursing; and physical, occupational, and speech
therapy, require a written statement from the physician specifying the medical necessity for the service or supply and the length of
time needed. 77
77 Page 78 79
2001 Blue Cross and Blue Shield Service Benefit Plan 78 Section 7
= Claims for prescription drugs and supplies that are not received from the Retail Pharmacy Program or through the Mail Service
Prescription Drug Program must include receipts that include the prescription number, name of drug or supply, prescribing
physician's name, date, and charge. (See below for information on how to obtain benefits from the Retail Pharmacy Program and the
Mail Service Prescription Drug Program.)
= We will provide translation and currency conversion services for claims for overseas (foreign) services.

Prescription drug claims Mail Service Prescription Drug Program -We will send you information on our Mail Service Prescription Drug Program, including
an initial mail order form. To use this program:
. 1) Complete the initial mail order form;
2) Enclose your prescription and copayment;
3) Mail your order to Merck-Medco Rx Services, P. O. Box 30492, Tampa, FL 33633-0144; and

4) Allow approximately two weeks for delivery.
Alternatively, your physician may call in your initial prescription at 1-800-262-7890 (TDD: 1-800-446-7292). You will be billed later for
the copayment.
After that, to order refills either call the same number or access our website at www. fepblue. org and either charge your copayment to your
credit card or have it billed to you later. Allow approximately one week for delivery on refills.

Retail Pharmacy Program – When you use Preferred retail pharmacies, show your Service Benefit Plan ID card. Preferred retail
pharmacies will file your claims for you. We reimburse the pharmacy for your covered drugs. You pay the applicable coinsurance.

When you use Non-preferred retail pharmacies, you should use a retail prescription drug claim form to claim benefits. You may obtain these
forms from your Local Plan, or by calling 1-800-624-5060. Hearing-impaired members with TDD equipment may call1-800-624-5077.
Follow the instructions on the prescription drug claim form and submit the completed form to: Blue Cross and Blue Shield Service Benefit
Plan Retail Pharmacy Program, P. O. Box 52057, Phoenix, AZ 85072-2057.

Note: Even if you use Preferred pharmacies, you will have to file a paper claim form to obtain reimbursement if:
= you do not have a valid Service Benefit Plan ID card;
= you do not show your valid Service Benefit Plan ID card at the time of purchase; or

= you failed to obtain prior approval when required (see page 14). 78
78 Page 79 80
2001 Blue Cross and Blue Shield Service Benefit Plan 79 Section 7
Records Keep a separate record of the medical expenses of each covered family member, because deductibles and benefit maximums (such as those for
smoking cessation treatment and outpatient physical therapy), apply separately to each person. Save copies of all medical bills, including
those you accumulate to satisfy a deductible. In most instances they will serve as evidence of your claim. We will not provide duplicate or
year-end statements.

Deadline for filing your claim Send us your claim and appropriate documentation 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
you submitted the claim as soon as reasonably possible. If we return a claim or part of a claim for additional information, you must resubmit it
within 90 days, or before the timely filing period expires, whichever is later.

Note: Once we pay benefits, there is a three-year limitation on the reissuance of uncashed checks.

Overseas claims For covered services you receive in hospitals outside the United States and Puerto Rico and performed by physicians outside the United States
and Puerto Rico, send a completed Overseas Claim Form and the itemized bills to: FEP Overseas Claims Section, CareFirst Blue Cross
and Blue Shield, 550 12 th Street, SW, Washington, DC 20065-8473. Send any written inquiries concerning the processing of overseas
claims to this address or call us at 1-888-999-9862. You may also obtain Overseas Claim Forms from this address, or from your Local
Plan.

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. 79
79 Page 80 81
2001 Blue Cross and Blue Shield Service Benefit Plan 80 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 precertification or prior approval:

Step Description
1 Ask us in writing to reconsider our initial decision. Write to us at the address shown on your explanation of benefits (EOB) form. You must:
(a) Write to us within 6 months from the date of our decision; and
(b) Send your request to us at the address shown on your explanation of benefits (EOB) form for the Local Plan that processed the claim (or, for Prescription drug benefits, our Retail Pharmacy Program or Mail

Service Prescription Drug Program); 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, precertify your hospital stay or grant your request for prior approval for
a service, drug, or supply); 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 -if we did not send you a decision within 30 days after we received the additional information.
Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Contracts Division I, P. O. Box 436, Washington, D. C. 20044-0436.
The disputed claims process – Continued on next page 80
80 Page 81 82
2001 Blue Cross and Blue Shield Service Benefit Plan 81 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 different claims, you must clearly identify which documents apply to which claim.

Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representative, such as medical providers, must provide 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 determine if we correctly applied the terms of our contract when we denied your claim or request for service. OPM will send you a final decision within 60
days. There are no other administrative appeals.

6 If you do not agree with OPM's decision, your only recourse is to sue. If you decide to sue, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services, drugs, or supplies. This is the only deadline that may not be extended.
OPM may disclose the information it collects during the review process to support their disputed claims decision. This information will become part of the court record.
You may not sue until you have completed the disputed claims process. Further, Federal law governs your lawsuit, benefits, and payment of benefits. The Federal court will base its review on the record that was
before OPM when OPM decided to uphold or overturn our decision. You may recover only the amount of benefits in dispute.

Note: If you have a serious or life-threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and
(a) We have not responded yet to your initial claim or request for precertification/ prior approval, then call us at the telephone number on the back of your Service Benefit Plan ID card and we will expedite our review;
or
(b) We denied your initial claim or request for precertification/ prior approval, then:
If we expedite our review and maintain our denial, we will inform OPM so that they can give your claim expedited treatment too; or

You can call OPM's Health Benefits Contracts Division I at 1-202-606-0727 between 8 a. m. and 5 p. m., eastern time. 81
81 Page 82 83
2001 Blue Cross and Blue Shield Service Benefit Plan 82 Section 9
Section 9. Coordinating benefits with other coverage
When you have other health coverage You must tell us if you are covered or a family member is covered under another group health plan or has 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. For example:
= If you are an annuitant under our Plan and also are actively employed, any group health insurance you have from your
employer will pay primary and we will pay secondary.
= When you are entitled to the payment of health care expenses under automobile insurance, including no-fault insurance and other
insurance that pays without regard to fault, your automobile insurance is the primary payer and we are the secondary payer.

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. For example, we will generally only make up the difference between
the primary payer's benefits payment and 100% of the Plan allowance, subject to our applicable deductible and coinsurance or copayment
amounts, except when Medicare is the primary payer (see Section 4). Thus, it is possible that the combined payments from both plans may
not equal the entire amount billed by the provider.
Note: When we pay secondary to primary coverage you have from a prepaid plan (HMO), we base our benefits on your out-of-pocket
liability under the prepaid plan (generally, the prepaid plan's copayments), subject to our deductible and coinsurance or copayment
amounts.
In certain circumstances when we are secondary and there is no adverse effect on you (that is, you do not pay any more), we may also take
advantage of any provider discount arrangements your primary plan may have and only make up the difference between the primary plan's
payment and the amount the provider has agreed to accept as payment in full from the primary plan.

Remember: Even if you do not file a claim with your other plan, you must still tell us that you have double coverage, and you must also send
us documents about your other coverage if we ask for them.

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) 82
82 Page 83 84
2001 Blue Cross and Blue Shield Service Benefit Plan 83 Section 9
Medicare has two parts:
Part A (Hospital Insurance). Most people do not have to pay for Part A.
Part B (Medical Insurance). Most people pay monthly for Part B.
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+ Choice plan you have.

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

When you are enrolled in this Plan and the Original Medicare Plan, you still need to follow the rules in this brochure for us to cover your care.
For example, you must continue to obtain prior approval for some prescription drugs and organ/ tissue transplants before we will pay
benefits. However, you do not have to precertify inpatient hospital stays when Medicare Part A is primary (see page 13 for exception).

Claims process – You probably will never have to file a claim form when you have both our Plan and Medicare.
= When we are the primary payer, we process the claim first.
= When the Original Medicare Plan is the primary payer, Medicare processes your claim first. In most cases, your claims will be

coordinated automatically and we will pay the balance of the covered charges. You will not need to do anything. To find out if

you need to do something about filing your claims, call us at the number on the back of your Service Benefit Plan ID card or visit
our web site at www. fepblue. org.
We waive some costs when you have Medicare: When Medicare is the primary payer, we will waive some out-of-pocket costs, as follows:

When Medicare Part A is primary, we will waive our:
= == = Inpatient hospital per-admission copayments; = == = Inpatient Non-member hospital coinsurance; and

= == = Non-PPO inpatient per-day copayments for mental conditions/ substance abuse care.
Note: Once you have exhausted your Medicare Part A benefits, we become primary. You must then pay any difference between our
allowance and the billed amount at Non-member hospitals.
When Medicare Part B is primary, we will waive our:
= == = Calendar year deductible; = == = Coinsurance for care by physicians and other health care

professionals (inpatient and outpatient, including mental conditions/ substance abuse care);

= == = PPO physician office visit copayments;
= == = PPO physician and facility copayments for routine physical examinations and preventive (screening) services; and 83
83 Page 84 85
2001 Blue Cross and Blue Shield Service Benefit Plan 84 Section 9
= Outpatient facility coinsurance for medical, surgical, preventive, and mental conditions/ substance abuse care.
Note: We do not waive benefit limitations, such as the 25-visit limit on occupational and speech therapy visits.
You must tell us about your or your covered family members' Medicare coverage, and let us obtain information about services denied or paid under Medicare if we ask. You must also tell us about other coverage you or your
covered family members may have, as this coverage may affect the primary/ secondary status of this Plan and Medicare.

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

Original Medicare This Plan

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

3) Are a re-employed 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……..…..…..…..…....……...…..…..……. 84
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2001 Blue Cross and Blue Shield Service Benefit Plan 85 Section 9
Medicare managed care plan If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare managed care plan. These are
health care choices (like HMOs) in some areas of the country. In most Medicare managed care plans, you can only go to doctors, specialists,
or hospitals that are part of the plan. Medicare managed care plans cover all Medicare Part A and Medicare Part B benefits. 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, but we will not waive any of our copayments, coinsurance, or deductibles if you receive services
from providers who do not participate in the Medicare managed care plan.

Suspended FEHB coverage and enrollment in a Medicare managed care plan: If you are an annuitant or former spouse, you can suspend
your FEHB coverage and enroll in a Medicare managed care plan, eliminating your FEHB 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.

Private contract A physician may ask you to sign a private contract agreeing that you can be billed directly for services ordinarily covered by the Original
Medicare Plan. Should you sign an agreement, Medicare will not pay any portion of the charges, and we will not increase our payment. We
will still limit our payment to the amount we would have paid after the Original Medicare Plan's payment.

Enrollment in Medicare Part B Note: We cannot require you to enroll in Medicare. If you choose not to enroll in Medicare Part B, you can still be covered under the FEHB
Program.

TRICARE TRICARE is the health care program for eligible dependents of military persons and retirees of the military. TRICARE includes the
CHAMPUS program. If both TRICARE and this Plan cover you, we pay first. See your TRICARE Health Benefits Advisor if you have
questions about TRICARE coverage.

Workers' Compensation We do not cover services that:
= You need because of a workplace-related disease or injury that the
Office of Workers' Compensation Programs (OWCP) or a similar Federal or State agency determines they must provide; or

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

Once OWCP or a similar agency pays its maximum benefits for your treatment, we will cover your benefits. 85
85 Page 86 87
2001 Blue Cross and Blue Shield Service Benefit Plan 86 Section 9
Medicaid When you have this Plan and Medicaid, we pay first.
When other Government agencies We do not cover services and supplies when a local, State, are responsible for your care or Federal Government agency directly or indirectly pays for them.

When others are responsible If another person or entity, through an act or omission, causes you to for injuries suffer an injury or illness, and if we pay benefits for that injury or
illness, you must agree to the following:

= All recoveries you obtain (whether by lawsuit, settlement, or otherwise), no matter how described or designated, must be used to
reimburse us in full for benefits we paid. Our share of any recovery extends only to the amount of benefits we have paid or
will pay to you or, if applicable, to your heirs, administrators, successors, or assignees.
= We will not reduce our share of any recovery unless we agree in writing to a reduction, (1) because you do not receive the full
amount of damages that you claimed or (2) because you had to pay attorneys' fees. This is our right of recovery.
= If you do not seek damages for your illness or injury, you must permit us to initiate recovery on your behalf (including the right to
bring suit in your name). This is called subrogation.
= If we pursue a recovery of the benefits we have paid, you must cooperate in doing what is reasonably necessary to assist us. You

must not take any action that may prejudice our rights to recover.

You must tell us promptly if you have a claim against another party for a condition that we have paid or may pay benefits for, and you must tell
us about any recoveries you obtain, whether in or out of court. We may seek a lien on the proceeds of your claim in order to reimburse
ourselves to the full amount of benefits we have paid or will pay.
We may request that you assign to us (1) your right to bring an action or (2) your right to the proceeds of a claim for your illness or injury.
We may delay processing of your claims until you provide the assignment.

Note: We will pay the costs of any covered services you receive that are in excess of any recoveries made.
The following are examples of circumstances in which we may subrogate or assert a right of recovery:
= When you or your dependent are injured on premises owned by a third party; or
= When you or your dependent are injured and benefits are available to you or your dependent, under any law or under any type of
insurance, including, but not limited to:
Personal injury protection benefits Uninsured and underinsured motorist coverage (does not
include no-fault automobile insurance) Workers' compensation benefits
Medical reimbursement coverage
Contact us if you need more information about subrogation. 86
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2001 Blue Cross and Blue Shield Service Benefit Plan 87 Section 10
Section 10. Definitions of terms we use in this brochure
Accidental injury An injury caused by an external force or element such as a blow or fall that requires immediate medical attention, including animal bites and
poisonings. Note: Injuries to the teeth while eating are not considered accidental injuries. Dental care for accidental injury is limited to dental
treatment necessary to repair sound natural teeth.

Admission The period from entry (admission) as an inpatient into a hospital (or other covered facility) until discharge. In counting days of inpatient
care, the date of entry and the date of discharge count as the same day.

Assignment An authorization by the enrollee or spouse for us to issue payment of benefits directly to the provider. We reserve the right to pay you, the
enrollee, directly for all covered services.

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.

Carrier The Blue Cross and Blue Shield Association, on behalf of the local Blue Cross and Blue Shield Plans.

Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. You may also be responsible for additional amounts. See
page 16.

Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 15.

Cosmetic surgery Any surgical procedure or any portion of a procedure performed primarily to improve physical appearance through change in bodily
form, except for repair of accidental injury, or to restore or correct a part of the body that has been altered as a result of disease or surgery or
to correct a congenital anomaly.

Covered services Services we provide benefits for, as described in this brochure.
Custodial care Treatment or services, regardless of who recommends them or where they are provided, that a person not medically skilled could perform
safely and reasonably, or that mainly assist the patient with daily living activities, such as:
1. Personal care including help in walking, getting in and out of bed, bathing, eating (by spoon, tube, or gastrostomy), exercising, or
dressing; 2. Homemaking, such as preparing meals or special diets;
3. Moving the patient; 87
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2001 Blue Cross and Blue Shield Service Benefit Plan 88 Section 10
4. Acting as companion or sitter; 5. Supervising medication that can usually be self-administered; or
6. Treatment or services that any person can perform with minimal instruction, such as recording pulse, temperature, and respiration;
or administration and monitoring of feeding systems.

Deductible A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies in a calendar year before we start
paying benefits for those services. See page 15.

Durable medical equipment Equipment and supplies that: 1. Are prescribed by your physician (i. e., the physician who is
treating your illness or injury); 2. Are medically necessary;
3. Are primarily and customarily used only for a medical purpose; 4. Are generally useful only to a person with an illness or injury;
5. Are designed for prolonged use; and 6. Serve a specific therapeutic purpose in the treatment of an illness
or injury.
Experimental or A drug, device, or biological product is experimental or investigational investigational services if the drug, device, or biological product cannot be lawfully marketed
without approval of the U. S. Food and Drug Administration (FDA); and, approval for marketing has not been given at the time it is

furnished. Note: Approval means all forms of acceptance by the FDA.
A medical treatment or procedure, or a drug, device, or biological product, is experimental or investigational if:

1. Reliable evidence shows that it is the subject of ongoing phase I, II, or III clinical trials or under study to determine its maximum
tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis; or

2. Reliable evidence shows that the consensus of opinion among experts regarding the drug, device, or biological product or
medical treatment or procedure, is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its
toxicity, its safety, its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis.

Reliable evidence shall mean only:
= published reports and articles in the authoritative medical and scientific literature;
= the written protocol or protocols used by the treating facility or the protocol( s) of another facility studying substantially the
same drug, device, or biological product or medical treatment or procedure; or
= the written informed consent used by the treating facility or by another facility studying substantially the same drug,
device, or medical treatment or procedure.
Each Local Plan has a Medical Review department that determines whether a claimed service is experimental or investigational after
consulting with internal or external experts or nationally recognized guidelines in a particular field or specialty. 88
88 Page 89 90
2001 Blue Cross and Blue Shield Service Benefit Plan 89 Section 10
For more detailed information, contact your Local Plan at the telephone number located on the back of your Plan identification card.
Group health coverage Health care coverage that you are eligible for based on your employment, or your membership in or connection with a particular
organization or group, that provides payment for medical services or supplies, or that pays a specific amount of more than $200 per day for
hospitalization (including extension of any of these benefits through COBRA).

Intensive outpatient care A comprehensive, structured outpatient treatment program that includes extended periods of individual or group therapy sessions designed to
assist members with mental health and/ or substance abuse conditions. It is an intermediate setting between traditional outpatient therapy and
partial hospitalization, typically performed in an outpatient facility or outpatient professional office setting. Program sessions may occur
more than one day per week. Timeframes and frequency will vary based upon diagnosis and severity of illness.

Lifetime maximum The maximum amount the Plan will pay on your behalf for covered services you receive while you are enrolled in your option. Benefit
amounts accrued under Standard Option and High Option are accumulated in a permanent record regardless of the number of
enrollment changes.

Local Plan A Blue Cross and/ or Blue Shield Plan that serves a specific geographic area.

Medical necessity We determine whether services, drugs, supplies, or equipment provided by a hospital or other covered provider are:
1. Appropriate to prevent, diagnose, or treat your condition, illness, or injury;
2. Consistent with standards of good medical practice in the United States;
3. Not primarily for the personal comfort or convenience of the patient, the family, or the provider;
4. Not part of or associated with scholastic education or vocational training of the patient; and
5. In the case of inpatient care, cannot be provided safely on an outpatient basis.

The fact that one of our covered providers has prescribed, recommended, or approved a service or supply does not, in itself, make
it medically necessary or covered under this Plan. 89
89 Page 90 91
2001 Blue Cross and Blue Shield Service Benefit Plan 90 Section 10
Mental conditions/ Conditions and diseases listed in the most recent edition of the substance abuse International Classification of Diseases (ICD) as psychoses, neurotic
disorders, or personality disorders; other nonpsychotic mental disorders listed in the ICD; or disorders listed in the ICD requiring treatment for
abuse of or dependence upon substances such as alcohol, narcotics, or hallucinogens.

Partial hospitalization An intensive facility-based treatment program during which an interdisciplinary team provides care related to mental health and/ or
substance abuse conditions. Program sessions may occur more than one day per week and may be full or half days, evenings, and/ or
weekends. The duration of care per session is less than 24 hours. Timeframes and frequency will vary based upon diagnosis and severity
of illness.

Plan allowance Our Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. Fee-for-service plans determine
their allowances in different ways . If the amount your provider bills for covered services is less than our allowance, we base our payment,
and your share (coinsurance, deductible, and/ or copayments), on the billed amount. We determine our allowance as follows:

= PPO providers – Our allowance (which we may refer to as the "PPA" for "Preferred Provider Allowance") is the negotiated
amount that most Preferred providers (hospitals and other facilities, physicians, and non-physician professional providers that
contract with each local Blue Cross and Blue Shield Plan, and retail pharmacies that contract with PCS Health Systems, Inc.)
have agreed to accept as payment in full, when we pay primary benefits (see page 6 for exceptions).

Our PPO allowance includes any known discounts that can be accurately calculated at the time your claim is processed. For PPO
facilities, we sometimes refer to our allowance as the "Preferred rate". The Preferred rate may be subject to a periodic adjustment
after your claim is processed that may decrease or increase the amount of our payment that is due to the facility. However, your
cost sharing (if any) does not change. If our payment amount is decreased, we credit the amount of the decrease to the reserves of
this Plan. If our payment amount is increased, we pay that cost on your behalf. (See page 71 for special information about limits on
the amounts Preferred dentists can charge you.)
= Participating providers – Our allowance (which we may refer to as the "PAR" for "Participating Provider Allowance") is the
negotiated amount that these providers (hospitals and other facilities, physicians, and non-physician professional providers that
contract with some local Blue Cross and Blue Shield Plans) have agreed to accept as payment in full, when we pay primary benefits
(see page 6 for exceptions). For facilities, we sometimes refer to our allowance as the "Member rate". The member rate includes
any known discounts that can be accurately calculated at the time your claim is processed, and may be subject to a periodic
adjustment after your claim is processed that may decrease or increase the amount of our payment that is due to the facility.
However, your cost sharing (if any) does not change. If our payment amount is decreased, we credit the amount of the
decrease to the reserves of this Plan. If our payment amount is increased, we pay that cost on your behalf. 90
90 Page 91 92
2001 Blue Cross and Blue Shield Service Benefit Plan 91 Section 10
= Non-participating providers – Since we have no agreements with these providers, we use:
= For inpatient services by hospitals and other facilities that do not contract with your Local Blue Cross and Blue Shield Plan,
our allowance is the average semiprivate room rate charged for inpatient care by similar institutions in the same area, as
determined by your Local Plan;
= For outpatient services by hospitals and other facilities that do not contract with your Local Blue Cross and Blue Shield Plan,

our allowance is the billed amount (minus any amounts for non-covered services);

= For physicians and non-physician professional providers that do not contract with your local Blue Cross and Blue Shield
Plan, our allowance is equal to the greater of 1) the Medicare participating fee schedule amount for the service or supply in
the geographic area in which it was performed or obtained (or 60% of the billed charge if there is no equivalent Medicare fee
schedule amount) or 2) 80% of the 2001 Usual, Customary, and Reasonable (UCR) amount for the service or supply in the
geographic area in which it was performed or obtained. Local Plans determine the UCR amount in different ways. Contact
your Local Plan if you need more information. We may refer to our allowance for Non-participating providers as the "NPA"
(for "Non-participating Provider Allowance");
= For prescription drugs furnished by retail pharmacies that do not contract with PCS Health Systems, Inc., our allowance is

the average wholesale price (" AWP") of a drug on the date it is dispensed, as set forth in the most current version of First
DataBank's National Drug Data File;
= For services you receive outside of the United States and Puerto Rico from providers that do not contract with us or

with World Access, Inc., our allowance is an Overseas Fee Schedule that is based on amounts comparable to what
Participating providers in the Washington, DC, area have agreed to accept.

Non-participating providers are under no obligation to accept our allowance as payment in full. If you use Non-participating
providers, you will be responsible for any difference between our payment and the provider's charge, including any applicable
copayments, coinsurance, or deductibles.
For more information, see Section 4, Your costs for covered services. For more information about how we pay providers overseas, see pages

17 and 69.

Precertification The requirement to contact the Local Blue Cross and Blue Shield Plan serving the area where the services will be performed before being
admitted to the hospital for inpatient care, or within two business days following an emergency admission. 91
91 Page 92 93
2001 Blue Cross and Blue Shield Service Benefit Plan 92 Section 10
Preferred provider organization An arrangement between Local Plans and physicians, hospitals, health (PPO) arrangement care institutions, and other health care professionals (or for retail
pharmacies, between pharmacies and PCS Health Systems, Inc.) to provide services to you at a reduced cost. The PPO provides you with
an opportunity to reduce your out-of-pocket expenses for care by selecting your facilities and providers from among a specific group.
PPO providers are available in most locations; using them whenever possible helps contain health care costs and reduces your out-of-pocket
costs. The selection of PPO providers is solely the Local Plan's (or for pharmacies, PCS Health Systems, Inc. 's) responsibility. We cannot
guarantee that any specific provider will continue to participate in these PPO arrangements.

Prior approval Written assurance that benefits will be provided from:
1. The Local Plan where the services will be performed; 2. The Retail Pharmacy Program or Mail Service Prescription Drug
Program for prescription drugs; or 3. The Blue Cross and Blue Shield Association Clinical Trials
Information Unit for certain organ/ tissue transplants we cover only in clinical trials. See Section 5( b).

Home health care, home hospice care, certain prescription drugs, certain organ/ tissue transplants, and cardiac rehabilitation require prior
approval. For more information, see the benefit descriptions in Section 5 and How to get approval for… other services on page 14. See Section
5( e) for special authorization requirements for mental health and substance abuse benefits.

Routine services Services that are not related to a specific illness, injury, set of symptoms, or maternity care.
Us/ We "Us" and "we" refer to the Blue Cross and Blue Shield Service Benefit Plan, and the Local Blue Cross and Blue Shield Plans that administer it.
You "You" refers to the enrollee (the contract holder eligible for enrollment and coverage under the Federal Employees Health Benefits Program
and enrolled in the Plan) and each covered family member. 92
92 Page 93 94
2001 Blue Cross and Blue Shield Service Benefit Plan 93 Section 11
Section 11. FEHB facts
No pre-existing condition We will not refuse to cover the treatment of a condition that you had limitation before you enrolled in this Plan solely because you had the condition
before you enrolled.

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

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

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

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

If you have a Self Only enrollment, you may change to a Self and Family enrollment if you marry, give birth, or add a child to your
family. You may change your enrollment 31 days before to 60 days after that event. The Self and Family enrollment begins on the first day
of the pay period in which the child is born or becomes an eligible family member. When you change to Self and Family because you
marry, the change is effective on the first day of the pay period that begins after your employing office receives your enrollment form;
benefits will not be available to your spouse until you marry.
Your employing or retirement office will not notify you when a family member is no longer eligible to receive health benefits, nor will we.
Please tell us immediately when you add or remove family members from your coverage for any reason, including divorce, or when your
child under age 22 marries or turns 22.
If you or one of your family members are enrolled in one FEHB plan, that person may not be enrolled in or covered as a family member by
another FEHB plan. 93
93 Page 94 95
2001 Blue Cross and Blue Shield Service Benefit Plan 94 Section 11
When benefits and The benefits in this brochure are effective on January 1. If you are new premiums start to this Plan, your coverage and premiums begin on the first day of your
first pay period that starts on or after January 1. Annuitants' premiums begin on January 1.

Your medical and claims We will keep your medical and claims information confidential. Only records are confidential the following will have access to it:
= OPM, this Plan, and subcontractors when they administer this contract;
= This Plan, and appropriate third parties, such as other insurance plans and the Office of Workers' Compensation Programs (OWCP),
when coordinating benefit payments and subrogating claims;
= Law enforcement officials when investigating and/ or prosecuting alleged civil or criminal actions;

= OPM and the General Accounting Office when conducting audits;
= Individuals involved in bona fide medical research or education that does not disclose your identity; or

= OPM, when reviewing a disputed claim or defending litigation about a claim.

Note: As part of our administration of this contract, we may disclose your medical and claims information (including your prescription drug
utilization) to any treating physicians or dispensing pharmacies.

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 coverage If you are divorced from a Federal employee or annuitant, you may not continue to get benefits under your former spouse's enrollment. But,
you may be eligible for your own FEHB coverage under the spouse equity law. 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. 94
94 Page 95 96
2001 Blue Cross and Blue Shield Service Benefit Plan 95 Section 11
Temporary Continuation If you leave Federal service, or if you lose coverage because you no of Coverage (TCC) longer qualify as a family member, you may be eligible for Temporary
Continuation of Coverage (TCC). For example, you can receive TCC if you are not able to continue your FEHB enrollment after you retire.

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

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 If you leave the FEHB Program, we will give you a Certificate of Group Health Plan Coverage 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. 95
95 Page 96 97
2001 Blue Cross and Blue Shield Service Benefit Plan 96 Section 11
Inspector General Advisory Stop health care fraud! Fraud increases the cost of health care for everyone. If you suspect that a physician, pharmacy, or hospital 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 the number on the back of your Service Benefit Plan ID card and explain the

situation.
= If we do not resolve the issue, call THE HEALTH CARE FRAUD HOTLINE— 1-202-418-3300 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.

Penalties for Fraud Anyone who falsifies a claim to obtain FEHB Program benefits can be prosecuted for fraud. Also, the Inspector General may investigate
anyone who uses an ID card if the person tries to obtain services for someone who is not an eligible family member, or is no longer enrolled
in the Plan and tries to obtain benefits. Your agency may also take administrative action against you. 96
96 Page 97 98
2001 Blue Cross and Blue Shield Service Benefit Plan 97 DoD/ FEHB Demonstration Project
Department of Defense/ FEHB Demonstration Project
What is it? The Department of Defense/ FEHB Demonstration Project allows some active and retired uniformed service members and their dependents to enroll in the
FEHB Program. The demonstration will last for three years and began with the 1999 Open Season for the year 2000. Open Season enrollments will be effective
January 1, 2001. DoD and OPM have set up some special procedures to implement the Demonstration Project, noted below. Otherwise, the provisions
described in this brochure apply.

Who is eligible DoD determines who is eligible to enroll in the FEHB Program. Generally, you may enroll if:

= You are an active or retired uniformed service member and are eligible for Medicare;
= You are a dependent of an active or retired uniformed service member and are eligible for Medicare;
= You are a qualified former spouse of an active or retired uniformed service member and you have not remarried; or
= You are a survivor dependent of a deceased active or retired uniformed service member; and
= You live in one of the geographic demonstration areas.
If you are eligible to enroll in a plan under the regular Federal Employees Health Benefits Program, you are not eligible to enroll under the DoD/ FEHB
Demonstration Project.

The demonstration areas Dover AFB, DE Commonwealth of Puerto Rico = Fort Knox, KY Greensboro/ Winston Salem/ High Point, NC
= Dallas, TX Humboldt County, CA area
= New Orleans, LA Naval Hospital, Camp Pendleton, CA = Adair County, IA area Coffee County, GA area

When you can join You may enroll under the DoD/ FEHB Demonstration Project during the 2000 Open Season, November 13, 2000, through December 11, 2000. Your coverage
will begin January 1, 2001. DoD has set up an Information Processing Center (IPC) in Iowa to provide you with information about how to enroll. IPC staff
will verify your eligibility and provide you with FEHB Program information, plan brochures, enrollment instructions, and forms. The toll-free phone number
for the IPC is 1-877-DOD-FEHB (1-877-363-3342).
You may select coverage for yourself (Self Only) or for you and your family (Self and Family) during the 2000 and 2001 Open Seasons. Your coverage will
begin January 1 of the year following the Open Season during which you enrolled. 97
97 Page 98 99
2001 Blue Cross and Blue Shield Service Benefit Plan 98 DoD/ FEHB Demonstration Project
If you become eligible for the DoD/ FEHB Demonstration Project outside of Open Season, contact the IPC to find out how to enroll and when your coverage
will begin.
DoD has a web site devoted to the Demonstration Project. You can view information such as their marketing/ beneficiary education plan, frequently asked
questions, demonstration area locations, and zip code lists at www. tricare. osd. mil/ fehbp. You can also view information about the
demonstration project, including "The 2001 Guide to Federal Employees Health Benefits Plans Participating in the DoD/ FEHB Demonstration Project," on the
OPM web site at www. opm. gov.

TCC eligibility See Section 11, FEHB Facts; it explains Temporary Continuation of Coverage (TCC). Under this DoD/ FEHB Demonstration Project the only individual
eligible for TCC is one who ceases to be eligible as a "member of family" under your self and family enrollment. This occurs when a child turns 22, for
example, or if you divorce and your spouse does not qualify to enroll as an unremarried former spouse under title 10, United States Code. For these
individuals, TCC begins the day after their enrollment in the DoD/ FEHB Demonstration Project ends. TCC enrollment terminates after 36 months or the
end of the Demonstration Project, whichever occurs first. You, your child, or another person must notify the IPC when a family member loses eligibility for
coverage under the DoD/ FEHB Demonstration Project.
TCC is not available if you move out of a DoD/ FEHB Demonstration Project area, you cancel your coverage, or your coverage is terminated for any reason.
TCC is not available when the Demonstration Project ends.

Other features The 31-day extension of coverage and right to convert do not apply to the DoD/ FEHB Demonstration Project. 98
98 Page 99 100
2001 Blue Cross and Blue Shield Service Benefit Plan 99 Index
Index Do not rely on this page; it is for your convenience and is not an official statement of benefits.
Accidental injury 43, 57, 58, 70 Allergy tests 31
Alternative treatment 38 Ambulance 55, 58
Anesthesia 29, 40, 47, 49, 74 Biopsies 40
Birthing centers 11 Blood and blood plasma 37, 49,
51-52 Bone marrow transplant
(Allogeneic/ Autologous) 11,14,31,44-46
Breast cancer screening 27 Carryover 18
Case management 69 Casts 40,41,49, 51-52
Catastrophic protection 8, 17-18 Certificate of group plan
coverage 95 Changes for 2001 7-8
Chemotherapy 31, 45 Childbirth 29
Cholesterol tests 26 Circumcision 29
Claims and claim filing 77-79 Coinsurance 16, 87
Colorectal cancer screening 27 Confidentiality 94
Congenital anomalies 40,42, 87 Contraceptive devices, drugs 30,
41, 66 Coordination of benefits 66, 82
Covered providers 9-11 Deductible 15, 88
Definitions 87-92 Dental care 49, 57, 70-74
Department of Defense facilities (MTFs) 18
Diagnostic services 22-25, 51-52
Disputed claims process 80-81 Donor expenses (transplants)
45, 47 Dressings 49, 51-52
Durable medical equipment 36,54, 77, 88
Educational classes/ programs 38-39
Emergency 12, 55, 57-58 Enrollment questions 9,85, 93
Experimental or investigational 6, 76, 88
Eyeglasses 33-34 Family planning 30
Fecal occult blood test 25, 27 Flexible benefits option 69
Foot care 34, 41 Freestanding ambulatory
facilities 10-11, 51-52

General Exclusions 76 Hearing services 28, 33
Home health services 14,31,37, 56, 64
Home nursing care 31,37, 56, 77 Hospice care 14, 54, 92
Hospital 10, 48-52 Immunizations 27-28,76
Independent laboratories 9,25 Infertility 30
Inhospital physician care 23 Inpatient hospital benefits 48-50
Insulin 66 Laboratory and pathological
services 25,49,50, 51-52, 57 Lifetime maximum 64, 89
Machine diagnostic tests 25, 49, 50, 51-52, 57
Magnetic Resonance Imaging (MRIs) 25,49,50,51-52, 57
Mail Service Prescription Drugs 14, 65, 67, 78
Mammograms 25, 27 Maternity benefits 29, 49
Medicaid 86 Medically necessary 76, 89
Medically underserved areas 10 Medicare 19-20, 53, 75, 82-85
Mental conditions/ substance abuse benefits 7, 14, 18,
59-64,89, 90 Neurological testing 23
Newborn care 23, 28-29 Non-FEHB benefits 75
Nurse 9, 29,37,47,56,60,62 Nurse help line (Blue Health
Connection) 69 Nursery charges 29
Nursing School Administered Clinic 10
Obstetrical care 29 Occupational therapy 8,32,77
Ocular injury 33 Office visits 8, 22, 25-28, 57,
59, 60, 62 Oral and maxillofacial surgery
43 Oral statements 4
Orthopedic devices 35 Ostomy and catheter supplies 37
Out-of-pocket expenses 8,17-18 Outpatient facility care 51-52,
60, 62, 63 Overpayments 18
Overseas claims 17, 67, 69, 79 Oxygen 36, 37,49, 51-52
Pap test 25, 27 Parity (mental health and
substance abuse) 7, 59 Patients' Bill of Rights 6

Pharmacotherapy 23 Physical examination 26-28,83
Physical therapy 8, 23, 32, 38, 54, 56, 77
Physician 5-6, 9 Plan allowance 16, 90-91
Pre-admission testing 49 Precertification 12-13, 40, 48, 59,
60,61,63, 64-65, 91 Preferred Provider Organization
(PPO) 5-6,16,90, 92 Prescription drugs 65-68
Preventive care, adult 26-28 Preventive care, children 28
Prior approval 14, 40, 45, 46, 54, 56,60, 61, 65,66,68,92
Prostate cancer screening 27 Prosthetic devices 35,41,49
Psychologist 9, 60, 62 Psychotherapy 60-64
Radiation therapy 31, 45 Reconsideration 80-81
Rehabilitative therapies 32 Renal dialysis 11, 31 51
Room and board 15, 48, 50, 60, 63-64
Second surgical opinion 22 Skilled nursing facility care 53
Smoking cessation 38, 66 Social Worker 9, 60, 62
Speech therapy 8, 32, 77, 84 Special features 69
Splints 49, 51-52 Stem cell transplant support
11,14, 31, 44-46 Sterilization procedures 30, 41
Subrogation 86 Substance abuse 7, 14, 18, 59-
64, 89-90 Surgery 40-47, 52, 87
= Assistant surgeon 29,41,47
= Multiple procedures 41 = Outpatient 40-47,52

= Reconstructive 42 Syringes 66

Temporary Continuation of Coverage 94-95, 98
Transplants 11, 14, 31, 43-47 Treatment therapies 31
VA facilities 18 Vision services 33-34
Weight control 41,68, 76 Well child care 28
Wheelchairs 36 Workers' compensation 84-86
X-rays 25-26, 49-52, 57 99
99 Page 100 101
2001 Blue Cross and Blue Shield Service Benefit Plan 100
Notes 100
100 Page 101 102
2001 Blue Cross and Blue Shield Service Benefit Plan 101
Notes 101
101 Page 102 103
2001 Blue Cross and Blue Shield Service Benefit Plan 102 Standard Option Summary
Summary of benefits for the Blue Cross and Blue Shield Service Benefit Plan Standard Option -2001
= Do not rely on this chart alone. All benefits 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.
= Below, an asterisk (*) means the item is subject to the $250 per person ($ 500 per family) calendar year deductible. If you use a Non-PPO physician or other health care professional, you generally pay any difference
between our allowance and the billed amount.
Benefits You Pay Page

Medical services provided by physicians:
= Diagnostic and treatment services provided in the office...................................................... PPO: 10%* of our allowance; $15 per office visit Non-PPO: 25%* of our allowance 22

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

= Outpatient ........................................................

PPO: $100 per admission Non-PPO: $300 per admission
PPO: 10%* of our allowance (no deductible for surgery) Non-PPO: 25%* of our allowance (no deductible for
surgery)

48-50
51-52
Emergency benefits:
= Accidental injury .............................................

. . . Medical emergency..........................................

PPO: Nothing for outpatient hospital and physician services within 72 hours; regular benefits thereafter
Non-PPO: Any difference between our payment and the billed amount within 72 hours; regular benefits thereafter
Regular benefits

57-58
58
Mental health and substance abuse treatment ....... In-Network (PPO): Regular cost sharing, such as $15 office visit copay; $100 per hospital admission

Out-of-Network (Non-PPO): Benefits are limited
59-64

Prescription drugs ................................................. Retail Pharmacy Program:
= PPO: 25% of our allowance = Non-PPO: 45% Average Wholesale Price (AWP)

Mail Service Prescription Drug Program: $12 generic/$ 20 brand-name per prescription
65-68

Dental care ............................................................ Scheduled allowances for diagnostic and preventive services, fillings, and extractions; regular benefits for
dental services required due to accidental injury and covered oral and maxillofacial surgery
43, 70-74

Special features: Health support programs; flexible benefits option; 24-hour nurse line; services for deaf and hearing impaired; and travel benefit/ services overseas 69
Point of Service benefits – Yes, in some Plan areas 5
Protection against catastrophic costs (your out-of-pocket maximum)............................. Nothing after $3,000 (PPO) or $5,000 (combined PPO/ Non-PPO) per contract per year; some costs do not
count toward this protection 17-18 102
102 Page 103 104
2001 Blue Cross and Blue Shield Service Benefit Plan 103 High Option Summary
Summary of benefits for the Blue Cross and Blue Shield Service Benefit Plan High Option – 2001
= Do not rely on this chart alone. All benefits 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.
= Below, an asterisk (*) means the item is subject to the $150 per person ($ 300 per family) calendar year deductible. If you use a Non-PPO physician or other health care professional, you generally pay any difference
between our allowance and the billed amount.
Benefits You Pay Page

Medical services provided by physicians:
= Diagnostic and treatment services provided in the office.................................................... PPO: 5%* of our allowance; $12 per office visit Non-PPO: 20%* of our allowance 22

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

= Outpatient ........................................................

PPO: Nothing Non-PPO: $100 per admission
PPO: 5%* of our allowance (no deductible for surgery) Non-PPO: 20% * of our allowance (no deductible for
surgery)

48-50
51-52
Emergency benefits:
= Accidental injury .............................................

= Medical emergency..........................................

PPO: Nothing for outpatient hospital and physician services within 72 hours; regular benefits thereafter
Non-PPO: Any difference between our payment and the billed amount within 72 hours; regular benefits thereafter
Regular benefits

57-58
58
Mental health and substance abuse treatment ....... In-Network (PPO): Regular cost sharing, such as $12 office visit copay; nothing per hospital admission

Out-of-Network (Non-PPO): Benefits are limited
59-64

Prescription drugs ................................................. Retail Pharmacy Program:
= PPO: 15% of our allowance = Non-PPO: 35% Average Wholesale Price (AWP)

Mail Service Prescription Drug Program:
= $8 generic/$ 14 brand-name per prescription

65-68

Dental Care ........................................................... Regular benefits, limited to dental services required due to accidental injury and covered oral and maxillofacial
surgery
43, 70

Special features: Health support programs; flexible benefits option; 24-hour nurse line; services for deaf and hearing impaired; and travel benefit/ services overseas 69
Protection against catastrophic costs (your out-of-pocket maximum)............................. Nothing after $1,000 (PPO) or $2,700 (combined PPO/ Non-PPO) per contract per year; some costs do not
count toward this protection 17-18 103
103 Page 104
2001 Rate Information for Blue Cross and Blue Shield Service Benefit 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 special FEHB
guides are published for Postal Service Nurses and Tool & Die employees (see RI 70-2B); and for Postal Service Inspectors and Office of Inspector General (OIG) employees (see RI 70-2IN).

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

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

High Option
Self Only 101 $86.59 $70.14 $187.61 $151.97 $102.22 $54.51

High Option
Self and Family 102 $195.82 $139.32 $424.28 $301.86 $231.17 $103.97

Standard Option
Self Only 104 $86.59 $34.26 $187.61 $74.23 $102.22 $18.63

Standard Option
Self and Family 105 $195.82 $80.91 $424.28 $175.30 $231.17 $45.56 104

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