Pages 1--52 from PacifiCare Asia Pacific

Enrollment in this Plan is limited; see page 3 for requirements.

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

Standard Option
JK3 Self Only
JK5 Self and Family

RI 73-776

http:// www. pacificare. com/ asiapacific
For changes in benef its,
see page
5 1
1 Page 2 3
2
2 Page 3 4
1
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Plain Language . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Section 1. Facts about this HMO plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
How we pay providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Patients' Bill of Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Service Area. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Section 2. How we change for 2001 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Program-wide changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Changes to this Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Section 3. How you get care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Identification cards. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Where you get covered care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
° Plan providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
° Plan facilities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
What you must do to get covered care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
° Primary care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
° Specialty care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
° Hospital care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Circumstances beyond our control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Services requiring our prior approval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Section 4. Your costs for covered services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
° Copayments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
° Deductible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
° Coinsurance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Your out-of-pocket maximum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Section 5. Benefits
Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
(a) Medical services and supplies provided by physicians and other health care professionals . . . . . 11
(b) Surgical and anesthesia services provided by physicians and other health care professionals . . . 18
(c) Services provided by a hospital or other facility, and ambulance services . . . . . . . . . . . . . . . . . 22
(d) Emergency services/ accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
(e) Mental health and substance abuse benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
(f) Prescription drug benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
(g) Special features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
(h) Dental benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
(i) Non-FEHB benefits available to Plan members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Section 6. General exclusions Ð things we don't cover. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

2001 PacifiCare Asia Pacific Table of Contents

Table of Contents 3
3 Page 4 5
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Section 7. Filing a claim for covered services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Section 8. The disputed claims process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Section 9. Coordinating benefits with other coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
° When you have É
° Other health coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
° Original Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
° Medicare managed care plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
° TRICARE/ Workers' Compensation/ Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
° Other Government agencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
° When others are responsible for injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Section 10. Definitions of terms we use in this brochure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Section 11. FEHB facts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
° Coverage information
° No pre-existing condition limitation
° Where you get information about enrolling in the FEHB Program
° Types of coverage available for you and your family
° When benefits and premiums start
° Your medical and claims records are confidential
° When you retire
When you lose benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
° When FEHB coverage ends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
° Spouse equity coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
° TCC (Temporary Continuation of Coverage) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
° Converting to individual coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
° Getting a Certificate of Group Health Plan Coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Inspector General Advisory: Stop care fraud! . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Summary of Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Rates. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

2001 PacifiCare Asia Pacific Table of Contents 4
4 Page 5 6
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PacifiCare Health Insurance Company Micronesia
DBA PacifiCare Asia Pacific owned by PacifiCare Health Plans
231 Guerro Drive
Tamuning, Guam 96911

This brochure describes the benefits of PacifiCare Health Plans under our contract (CS 2825) with the Office of
Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. 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 page 5. Rates are shown at the end of this brochure.

2001 PacifiCare Asia Pacific Introduction/ Plain Language

Introduction
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 PacifiCare Asia Pacific.

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 Insurance
Planning and Evaluation Division, P. O. Box 436, Washington, DC 20044-0436.

Plain Language 5
5 Page 6 7
4
This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and other
providers that contract with us. These Plan providers coordinate your health care services.

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

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

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

How we pay providers
We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure. These
Plan providers accept a negotiated payment from us, and you will only be responsible for your copayments or
coinsurance.

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, providers, and facilities. OPM's FEHB website (www. opm. gov/ insure) lists the specific types of information
that we must make available to you. Some of the required information is listed below.

° PHICM, dba PacifiCare Asia Pacific, has met all the licensing requirements needed on Guam, in the CNMI and the Republic of Belau to conduct business as an insurance company
° PacifiCare has been operating on Guam for 27 years ° We are a for-profit organization

If you want more information about us, call 1-671-647-3526 or write to PacifiCare at 231 Guerrero Drive Tamuning,
Guam 96911. You may also contact us by fax at 1-671-646-6923or visit our website at www. pacificare. com.

Service Area
To enroll with us, you must live in our service area. This is where our providers practice.
Our service area is:
The Territory of Guam, the Commonwealth of the Northern Mariana Islands and the Republic of Palau.
Ordinarily, you must get your care from providers who contract with us. If you receive care outside our service area, we
will only pay for emergency care. We will not pay for any other health care services.

2001 PacifiCare Asia Pacific Section 1

Section 1. Facts about this HMO plan 6
6 Page 7 8
5
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 plans.

° This year, the Federal Employees Health Benefits Program is implementing network mental health and substance abuse parity. This means that your coverage for mental health, substance abuse, medical, surgical, and hospital
services from providers in our plan network will be the same with regard to deductibles, coinsurance, copays, and
day and visit limitations when you follow a treatment plan that we approve. Previously, we placed 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 healthcare organizations have turned their attention this past year to improving healthcare 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 PacifiCare Asia Pacific Customer Service Department at 1-671-647-3526 or checking
our website www. pacificare. com You can find out more about patient safety on the OPM website,
www. opm. gov/ insure. To improve your healthcare, 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 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.
Changes to this Plan
° Your share of the Standard Option non-postal premium will increase by 15.1% for Self Only coverage and 1.7% for Self and Family coverage.
° Your share of the High Option non-postal premium will increase by 8.9% for Self Only coverage and 32.3% for Self and Family coverage.

° Prescription drug benefit Ð Diabetic lancets are covered. ° Chiropractic Services Ð We cover up to 10 visits to a participating Chiropractor per calendar year. You pay nothing
up to $25 per visit.
° Vision Services Ð We cover annual eye refractions. Under the Standard Option you pay a $15 copayment per visit, under High Option you pay a $10 copayment per visit.

° Visions Services Ð When you purchase prescription eyewear at a Plan provider, you will receive a $100 credit towards the cost per calendar year.

2001 PacifiCare Asia Pacific Section 2

Section 2. How we change for 2001 7
7 Page 8 9
6
Identification cards We will send you an identification (ID) card. You should carry your ID card with you at all times. You must show it whenever you receive services from a Plan
provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card,
use your copy of the Health Benefits Election Form, SF-2809, your health
benefits enrollment confirmation (for annuitants), or your Employee Express
confirmation letter.

If you do not receive your ID card within 30 days after the effective date of your
enrollment, or if you need replacement cards, call us at 1-671-647-3526.

Where you get covered care You get care from "Plan providers" and "Plan facilities." You will only pay copayments, and/ or deductibles, and you will not have to file claim.

° Plan providers Plan providers are physicians and other health care professionals in our service
area that we contract with to provide covered services to our members. We
credential Plan providers according to national standards.

We list Plan providers in the provider directory, which we update periodically.
The list is also on our website, which you can also access @
www. pacificare. com/ asia pacific.

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

What you must do to get It depends on the type of care you need. First, you and each family member must covered care choose a primary care physician. This decision is important since your primary

care physician provides or arranges for most of your health care. In selecting a
primary care physician, call the PacifiCare Asia Pacific Customer Service
Department at 1-671-647-3526. You may have different primary care physician
for each member of the family. You may also change your primary care
physician as often as once a month and any changes made will be made effective
on the first of the following month.

° Primary care Your primary care physician can be a family practitioner, internist, General
Practitioner or pediatrician for children under 18 years of age. Your primary
care physician will provide most of your health care, or give you a referral to see
a specialist.

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

° Specialty care Your primary care physician will refer you to a specialist for needed care. For
well-woman care, no referrals are needed and you may contact an OB/ GYN
directly for an appointment

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

2001 PacifiCare Asia Pacific Section 3

Section 3. How you get care 8
8 Page 9 10
7
° If you are seeing a specialist when you enroll in our Plan, talk to your
primary care physician. Your primary care physician will decide what
treatment you need. If he or she decides to refer you to a specialist, ask if
you can see your current specialist. If your current specialist does not
participate with us, you must receive treatment from a specialist who does.
Generally, we will not pay for you to see a specialist who does not
participate with our Plan.

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

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

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

°° reduce our service area and you enroll in another FEHB Plan,
you may be able to continue seeing your specialist for up to 90 days after
you receive notice of the change. Contact us at 1-671-647-3526 or, if we
drop out of the Program, contact your new plan.

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

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

If you are in the hospital when your enrollment in our Plan begins, call our
Customer Service Department immediately at 1-671-647-3526. If you are new to
the FEHB Program, we will arrange for you to receive care.

If you changed from another FEHB plan to us, your former plan will pay for the
hospital stay until:

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

These provisions apply only to the hospital benefit of the hospitalized person

2001 PacifiCare Asia Pacific Section 3 9
9 Page 10 11
8
Circumstances beyond our control Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In that case,
we will make all reasonable efforts to provide you with the necessary care.
Services requiring our prior approval Your primary care physician has authority to refer you for most services. For

certain services, however, your physician must obtain approval from us. Before
giving approval, we consider if the service is covered, medically necessary, and
follows generally accepted medical practice.

We call this the approval process. Your physician must obtain approval for
services such as but not limited to:

° Hospitalization
° CT scans
° Growth Hormone Therapy (GHT)
° MRIs
° Off-island referrals

2001 PacifiCare Asia Pacific Section 3 10
10 Page 11 12
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You must share the cost of some services. You are responsible for:
° Copayments A copayment is a fixed amount of money you pay to the provider when you
receive services.

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

° Deductible We do not have a deductible.
° Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care.
Example: When you are referred for specialty care off-island, under the Standard
Option, you pay 20% of the first $5,000 charges, then you are covered 100%
thereafter up to the plan maximum of $95,000.

Your out-of-pocket maximum After your copayments total $1,000 per person or $3,000 per family enrollment in any calendar year, you do not have to pay any more for covered services.

However, copayments for the following services do not count toward your out-of-pocket
maximum, and you must continue to pay copayments for these services:

° Prescription Drugs
° Dental Services
° Vision Hardware
° Chiropractic Services
° Hospital emergency room copays

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

2001 PacifiCare Asia Pacific Section 4

Section 4. Your costs for covered services 11
11 Page 12 13
10
NOTE: This benefits section is divided into subsections. Please read the important things you should keep in mind at
the beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the
following subsections. To obtain claims forms, claims filing advice, or more information about our benefits, contact
us at 1-671-647-3526 or at our website at www. pacificare. com/ asia pacific.

(a) Medical services and supplies provided by physicians and other health care professionals . . . . . . . . . . . . . . . . . 11-17

(b) Surgical and anesthesia services provided by physicians and other health care professionals . . . . . . . . . . . . . . . 18-21
(c) Services provided by a hospital or other facility, and ambulance services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22-24

(d) Emergency services/ accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25-26
° Medical emergency ° Ambulance

(e) Mental health and substance abuse benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27-28
(f) Prescription drug benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29-30
(g) Special features. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
° FHP urgent care center

° Out of area primary care

(h) Dental benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
(i) Non-FEHB benefits available to Plan members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Summary of benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

° Inpatient hospital
° Outpatient hospital or ambulatory surgical
center

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

° Surgical procedures
° Reconstructive surgery
° Oral and maxillofacial surgery
° Organ/ tissue transplants
° Anesthesia

° 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)
° Home health services
° Alternative treatments
° Educational classes and programs

2001 PacifiCare Asia Pacific Section 5

Section 5. Benefits --OVERVIEW
(See page 5 for how our benefits changed this year and page 47 for a benefits summary.) 12
12 Page 13 14
Diagnostic and treatment services You pay -Standard Option You pay -High Option
Professional services of physicians $15 per office visit $10 per office visit
° In physician's office
° In an urgent care center
° Office medical consultations
° Second surgical opinion
° During a hospital stay
° In a skilled nursing facility
° Initial examination of a newborn child covered under a family enrollment

At home doctors house calls or visits by nurses and Nothing Nothing
health aides

Not covered: All charges All charges
Off-island care without prior authorization, except in
the case of emergency or eligible reciprocity benefits.
Blood products not replaced by the member.

Lab, X-ray and other diagnostic tests
Tests, such as:
° Blood tests
° Urinalysis
° Non-routine pap tests
° Pathology
° X-rays
° Non-routine Mammograms
° Cat Scans/ MRI
° Ultrasound
° Electrocardiogram and EEG

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

Nothing if you receive
these services during
your office visit;
otherwise, $15 per
office visit

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

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

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

approved by the PacifiCare Medical Management Department.

2001 PacifiCare Asia Pacific Section 5a

Section 5 (a). Medical services and supplies provided by physicians and
other health care professionals

Benefit Description You pay 13
13 Page 14 15
12
Preventive care, adult You pay Ð Standard Option You pay Ð High Option
Routine screenings, such as: $15 per office visit $10 per office visit
° Blood lead level Ð One annually
° Total Blood Cholesterol Ð once every three years, ages 19 through 64

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

Prostate Specific Antigen (PSA test) Ð one $15 per office visit $10 per office visit
annually for men age 40 and older

Routine pap test $15 per office visit $10 per office visit
Note: The office visit is covered if pap test is
received on the same day; see Diagnostic and
Treatment Services above.

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

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

° From age 40 through 64, one every 2 years
° At age 65 and older, one every two consecutive calendar years

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

Routine Immunizations, limited to: $15 per office visit $10 per office visit
° Tetanus-diphtheria (Td) booster Ð once every 10 years, ages 19 and over (except as provided for

under Childhood immunizations)
° Influenza/ Pneumococcal vaccines, annually, age 65 and over

Preventive care, children
° Childhood immunizations recommended by the $15 per office visit $10 per office visit American Academy of Pediatrics

° Examinations, such as: $15 per office visit $10 per office visit
°° Eye exams through age 17 to determine the need for vision correction

°° Ear exams through age 17 to determine the need for hearing correction
°° Examinations done on the day of immunizations (through age 22)
° Well-child care charges for routine examinations, immunizations and care (through age 22)

2001 PacifiCare Asia Pacific Section 5a 14
14 Page 15 16
13
Maternity care You pay Ð Standard Option You pay Ð High Option
Complete maternity (obstetrical) care, such as:
° Prenatal care
° Delivery
° Postnatal care

Note: Here are some things to keep in mind:
° You do not need to precertify your normal delivery; see page 22 for other circumstances,

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

cesarean delivery. We will extend your inpatient
stay if medically necessary.

° We cover routine nursery care of the newborn child during the covered portion of the mother's

maternity stay. We will cover other care of an
infant who requires non-routine treatment only if
we cover the infant under a Self and Family
enrollment.

° We pay hospitalization and surgeon services (delivery) the same as for illness and injury.

See Hospital benefits (Section 5c) and Surgery
benefits (Section 5b).

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

Family planning
° Voluntary sterilization $15 per office visit $10 per office visit
° Surgically implanted contraceptives
° Injectable contraceptive drugs
° Intrauterine devices (IUDs)
° Norplant

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

Infertility services
Diagnosis and treatment of infertility, such as: 50% of charges $10 per office visit
° Artificial insemination
°° intravaginal insemination (IVI)
°° intracervical insemination (ICI)
° Injectable fertility drugs
Note: We cover oral fertility drugs under the
prescription drug benefit.

A single $10 copayment
for the entire pregnancy
A single $15 copayment
for the entire pregnancy

2001 PacifiCare Asia Pacific Section 5a 15
15 Page 16 17
14
Infertility services (Continued) You pay Ð Standard Option You pay Ð High Option
Not covered: All charges All charges
° Assisted reproductive technology (ART) procedures, such as:

°° in vitro fertilization
°° embryo transfer and GIFT
°° intrauterine insemination (IUI)
° Other services and supplies related to ART procedures

° Cost of donor sperm
Allergy care
Testing and treatment $15 per office visit $10 per office visit
Allergy injection

Allergy serum Nothing Nothing
Not covered: provocative food testing and sublingual
allergy desensitization

Treatment therapies
° Chemotherapy and radiation therapy $15 per office visit $10 per office visit
Note: High dose chemotherapy in association with
autologous bone marrow transplants are limited to
those transplants listed under Organ/ Tissue
Transplants on page 20.

° Respiratory and inhalation therapy
° Dialysis Ð Hemodialysis and peritoneal dialysis
° Intravenous (IV)/ Infusion Therapy Ð Home IV and antibiotic therapy

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

2001 PacifiCare Asia Pacific Section 5a 16
16 Page 17 18
15
Rehabilitative therapies You pay Ð Standard Option You pay Ð High Option
Physical therapy, occupational therapy and
speech therapy Ð

° 90 visits per condition for the services of each of the following:

°° qualified physical therapists;
°° speech therapists; and
°° occupational therapists.

° Cardiac rehabilitation following a heart 50% of charges $10 per office visit transplant, bypass surgery or a myocardial
infarction, is provided for up to 90 days
Not covered: All charges All charges
° long-term rehabilitative therapy
° exercise programs

Hearing services (testing, treatment,
and supplies)

° First hearing aid and testing only when $15 per office visit $10 per office visit necessitated by accidental injury

° Hearing testing for children through age 17 (see Preventive care, children)

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

Vision services (testing, treatment,
and supplies)

Medical and surgical benefits for the diagnosis and $15 per office visit $10 per office visit
treatment of diseases of the eye

°Prescription Eyeglasses or prescription contact All charges after $100 at All charges after $100 at lenses participating providers participating providers

°Eye exam to determine the need for vision $15 per office visit $10 per office visit correction for children through age 17 (see
preventive care)
°Annual eye refractions

Not covered: All charges All charges
° Eye exercises and orthoptics
° Radial keratotomy and other refractive surgery

$10 per office visit,
nothing for home visits

Nothing for inpatient services

$15 per office visit,
nothing for home visits

20% for inpatient services

2001 PacifiCare Asia Pacific Section 5a 17
17 Page 18 19
16
Foot care You pay Ð Standard Option You pay Ð High Option
Routine foot care when you are under active $15 per office visit $10 per office visit
treatment for a metabolic or peripheral vascular
disease, such as diabetes.

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

Not covered: All charges All charges
° Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine

treatment of conditions of the foot, except as
stated above

° Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or

sublaxation of the foot (unless the treatment is by
open cutting surgery)

Orthopedic and prosthetic devices
° Artificial limbs and eyes; stump hose $15 per office visit $10 per office visit
° Externally worn breast prostheses and surgical bras, including necessary replacements, following

a mastectomy.
° Orthopedic devices, such as braces Benefits are not available for the $10 per office visit
° foot orthotics Standard Option

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

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

Durable medical equipment (DME)
Rental or purchase, at our option, including repair Benefits are not available for the Member is responsible for any
and adjustment, of durable medical equipment Standard Option deposit required.
prescribed by your Plan physician. Under this benefit,
we cover:

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

2001 PacifiCare Asia Pacific Section 5a 18
18 Page 19 20
17
Durable medical equipment (DME) You pay Ð Standard Option You pay Ð High Option
(Continued)

Not covered: All charges. All charges.
° Motorized wheel chairs
° Glucose monitors
° Insulin pumps

Home health services
° Home health care ordered by a Plan physician and Nothing Nothing provided by a registered nurse (R. N.), licensed

practical nurse (L. P. N.), licensed vocational
nurse (L. V. N.), or home health aide.

° Services include oxygen therapy, intravenous therapy and medications.

Not covered: All charges All charges
° Nursing care requested by, or for the convenience of, the patient or the patient's family;

° Nursing care primarily for hygiene, feeding, exercising, moving the patient, homemaking,
companionship or giving oral medication.
Alternative treatments
° Chiropractic services Ð You may self refer to a All charges above $25 All charges above $25 participating chiropractor for up to 10 visits per

calendar year.
Not covered: All charges All charges
° Acupuncture services
° Naturopathic services
° Hypnotherapy
° Biofeedback

Educational classes and programs
Coverage is limited to:
° Smoking Cessation
° Diabetes management classes
° Taking Charge of Your Heart Health

Nothing
(Note: There is a $20
Prescription Drug copayment
for nicotine replacement
prescription)

Nothing
(Note: There is a $20
Prescription Drug copayment
for nicotine replacement
prescription)

2001 PacifiCare Asia Pacific Section 5a 19
19 Page 20 21
Surgical procedures You pay -Standard Option You pay Ð High Option
° Treatment of fractures, including casting
° Normal pre-and post-operative care by the surgeon

° Correction of amblyopia and strabismis
° Endoscopy procedure
° Biopsy procedure
° Removal of tumors and cysts
° Correction of congenital anomalies (see Reconstructive surgery)

° Surgical treatment of morbid obesity
° Insertion of internal prosthetic devices. See 5( a) Ð Orthopedic braces and prosthetic devices for

device coverage information.

° Voluntary sterilization $15 per office visit $10 per office visit
° Norplant (a surgically implanted contraceptive) and intrauterine devices (IUDs) Note: Devices are

covered under 5( a).
° Treatment of burns
Note: Generally, we pay for internal prostheses
(devices) according to where the procedure is done.
For example, we pay Hospital benefits for a
pacemaker and Surgery benefits for insertion of the
pacemaker.

$10 per office visit; nothing for
outpatient or inpatient surgery
$15 per office visit; nothing for
outpatient or inpatient surgery

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

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

coverage, including with Medicare.
° The amounts listed below are for the charges billed by a physician or other health care professional for your surgical care. Look in Section 5( c) for charges associated with the

facility (i. e. hospital, surgical center, etc.).
° YOU MUST GET PRECERTIFICATION OF SOME SURGICAL PROCEDURES. Please refer to the precertification information shown in Section 3 to be sure which

services require precertification and identify which surgeries require precertification.
° Referrals to doctors or facilities not on Guam can only be made to those under contract to provide service off-island. A written referral must be made by a Plan provider and

approved by the PacifiCare Medical Management Department.

2001 PacifiCare Asia Pacific Section 5b

Section 5 (b). Surgical and anesthesia services provided by physicians and
other health care professionals

Benefit Description You pay

Surgical procedures Ð Continued on next page. 20
20 Page 21 22
19
Surgical procedures You pay -Standard Option You pay Ð High Option
Not covered: All charges All charges
° Reversal of voluntary sterilization
° Routine treatment of conditions of the foot; see Foot care.

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

°° the condition produced a major effect on the member's appearance and
°° the condition can reasonably be expected to be corrected by such surgery
° Surgery to correct a condition that existed at or from birth and is a significant deviation from the
common form or norm. Some examples of
congenital anomalies are: protruding ear
deformities; cleft lip; cleft palate; birth marks;
webbed fingers; and webbed toes.

° All stages of breast reconstruction surgery following a mastectomy, such as:

°° surgery to produce a symmetrical appearance on the other breast;
°° treatment of any physical complications, such as lymphedemas;
°° breast prostheses and surgical bras and replacements (see Prosthetic devices)
Note: If you need a mastectomy, you may choose to,
have the procedure performed on an inpatient basis
and remain in the hospital up to 48 hours after the
procedure.

Not covered: All charges All charges
° Cosmetic surgery Ð any surgical procedure (or any portion of a procedure) performed primarily

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

° Surgeries related to sex transformation

$10 per office visit; nothing for
hospital visits
$15 per office visit; nothing for
hospital visits

2001 PacifiCare Asia Pacific Section 5b 21
21 Page 22 23
20
Oral and maxillofacial surgery You pay Ð Standard Option You pay Ð High Option
Oral surgical procedures, limited to:
° Reduction of fractures of the jaws or facial bones;
° Surgical correction of cleft lip, cleft palate or severe functional malocclusion;

° Removal of stones from salivary ducts;
° Excision of leukoplakia or malignancies;
° Excision of cysts and incision of abscesses when done as independent procedures; and

° Other surgical procedures that do not involve the teeth or their supporting structures.

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

membrane, gingiva, and alveolar bone)
Organ/ tissue transplants

Limited to:
° Cornea
° Heart
° Heart/ lung
° Kidney
° Liver
° Allogeneic (donor) bone marrow transplants
° Autologous bone marrow transplants (autologous stem cell and peripheral stem cell support) for the

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

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

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

Nothing Nothing
$10 per office visit; nothing for
hospital visits
$15 per office visit; nothing for
hospital visits

2001 PacifiCare Asia Pacific Section 5b
Organ/ tissue transplants Ð continued on next page 22
22 Page 23 24
21
Organ/ tissue transplants You pay Ð Standard Option You pay Ð High Option
Not covered: All charges All charges
° Donor screening tests and donor search expenses, except those performed for the actual donor

° Implants of artificial organs
° Transplants not listed as covered

Anesthesia
Professional services provided in Ð Nothing Nothing
° Hospital (inpatient)

Professional services provided in Ð $15 per office visit $10 per office visit
° Hospital outpatient department
° Skilled nursing facility
° Ambulatory surgical center
° Office

2001 PacifiCare Asia Pacific Section 5b 23
23 Page 24 25
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Here are some important things to remember about these benefits:
° Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

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

the professional charge (i. e., physicians, etc.) are covered in Section 5( a) or (b).
° Referrals to doctors or facilities not on Guam can only be made to those under contract to provide service off-island. A written referral must be made by a Plan provider and

approved by the PacifiCare Medical Management Department.

2001 PacifiCare Asia Pacific Section 5c

Section 5 (c). Services provided by a hospital or other facility,
and ambulance services

Benefit Description You pay

Inpatient hospital continued on next page
Inpatient hospital You pay -Standard Option You pay -High Option
Room and board, such as:
° ward, semiprivate, or intensive care accommodations

° general nursing care; and
° meals and special diets.
NOTE: If you want a private room when it is not
medically necessary, you pay the additional charge
above the semiprivate room rate.

Other hospital services and supplies, such as: Nothing Nothing
° Operating, recovery, maternity, and other treatment rooms

° Prescribed drugs and medicines
° Diagnostic laboratory tests and X-rays
° Administration of blood and blood products
° Blood or blood plasma, if not donated or replaced
° Dressings, splints, casts, and sterile tray services
° Medical supplies and equipment, including oxygen

° Anesthetics, including nurse anesthetist services
° Take-home items
° Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use

at home

Nothing $150 per admission 24
24 Page 25 26
23
Inpatient hospital (Continued) You pay -Standard Option You pay -High Option
Not covered: All charges All charges
° Custodial care
° Non-covered facilities, such as nursing homes, extended care facilities, schools

° Personal comfort items, such as telephone, television, barber services, guest meals and beds
° Private duty nursing car
Outpatient hospital or ambulatory
surgical center

° Operating, recovery, and other treatment rooms
° Diagnostic laboratory tests, X-rays, and pathology services

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

Not covered: blood and blood derivatives not All charges All charges
replaced by the member.

Extended care benefits/ skilled nursing care
facility benefits

Extended care benefit: The Plan provides a Nothing Nothing
comprehensive range of benefits when full-time
skilled nursing care and confinement in a skilled
nursing facility is medically appropriate as determined
by a Plan doctor and approved by the Plan.

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

nursing facility when prescribed by a Plan doctor.
Not covered: blood and blood derivatives not All charges All charges
replaced by the member.

Nothing Nothing

2001 PacifiCare Asia Pacific Section 5c 25
25 Page 26 27
24
Hospice care You pay -Standard Option You pay -High Option
Supportive and palliative care for a terminally ill Nothing Nothing
member is covered in the home or hospice facility
when approved by the Plan's Medical Management
Department. Services are provided under the
direction of a Plan doctor who certifies that the
patient is in the terminal stages of illness, with a life
expectancy of approximately six months or less.

Services include
° inpatient and outpatient care
° family counseling

Not covered: services such as independent nursing All charges All charges
and homemaker services

Ambulance
° Local professional ambulance service when Nothing Nothing medically appropriate

2001 PacifiCare Asia Pacific Section 5c 26
26 Page 27 28
What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your
life or could result in serious injury or disability, and requires immediate medical or surgical care. Some problems are
emergencies because, if not treated promptly, they might become more serious; examples include deep cuts and broken
bones. Others are emergencies because they are potentially life-threatening, such as heart attacks, strokes, poisonings,
gunshot wounds, or sudden inability to breathe. There are many other acute conditions that we may determine are
medical emergencies Ð what they all have in common is the need for quick action.

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

Emergencies within our service area: If you receive emergency care and are in our service area, notify your PCP on
the first business day following your admission, so that he or she can coordinate any follow-up treatment.

When you need urgent care while you're in our service area, call your primary care physician. All physician offices
have a 24-hour answering service that will contact your PCP or his or her on-call partner. Your physician can assess the
situation and decide what type of care you need. Ask your PCP about after-hours and "on-call" procedures now, before
you need these services.

Emergencies outside our service area: If you receive emergency or urgent care outside our service area, contact
PacifiCare Customer Service within 48 hours, unless it was not reasonably possible to do so, to let us know what has
happened and where you went for care.

We also cover follow-up treatment to emergency care up to $400 per person per calendar year when that care is
delivered outside our service area.

° When you have to file a claim. Please refer to Section 7 for information on how to file a pharmacy claim, or contact our
Customer Service Department at 1-800-562-6223.

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

Prescription drug benefits begin on the next page.

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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.

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

2001 PacifiCare Asia Pacific Section 5d

Section 5 (d). Emergency services/ accidents 27
27 Page 28 29
26 2001 PacifiCare Asia Pacific Section 5d
Emergency within our service area You pay -Standard Option You pay -High Option
Emergency care at a doctor's office $15 per office visit $10 per office visit
Emergency care as an outpatient at a hospital,
including doctor's services.

° During normal business hours $15 per visit

$10 per visit
Emergency outside our service area
°Emergency care at a doctor's office $15 per office visit $25 per visit
°Emergency care at an urgent care center 20% of charges $25 per hospital emergency room visit

°Emergency care as an outpatient or inpatient Note: Copay waived if admitted If emergency results in at a hospital, including doctors' services in the hospital admission to a hospital, the
emergency care copay is
waived

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

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

service area
Ambulance

Professional ambulance service when medically Nothing Nothing
appropriate.

See 5( c) for non-emergency service.

Not covered: air ambulance All charges All charges

$25 per emergency room visit
and all charges after $500

Note: You pay nothing if you
are admitted to the hospital

$25 per emergency room visit
and all charges after $500

Note: You pay nothing if you
are admitted to the hospital

Benefit Description You pay 28
28 Page 29 30
Mental health and substance abuse benefits You pay -Standard Option You pay -High Option
Diagnostic and treatment services recommended by a
Plan provider and contained in a treatment plan that we
approve. The treatment plan may include services, drugs,
and supplies described elsewhere in this brochure.

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

° Professional services, including individual or $15 per office visit $10 per office visit. group therapy by providers such as psychiatrists,
psychologists, or clinical social workers
° Medication management

° Diagnostic tests Nothing Nothing
° Services provided by a hospital or other facility $150 per admission Nothing
° Services in approved alternative care settings such as partial hospitalization, half-way house,

residential treatment, full-day hospitalization,
facility based intensive outpatient treatment

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

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

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Parity
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.

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

Here are some important things to keep in mind about these benefits:
° All benefits are subject to the definitions, limitations, and exclusions in this brochure.
° Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other

coverage, including with Medicare.
° YOU MUST GET PREAUTHORIZATION OF THESE SERVICES. See the instructions after the benefits description below.

° Referrals to doctors or facilities not on Guam can only be made to those under contract to provide service off-island. A written referral must be made by a Plan provider and
approved by the PacifiCare Medical Management Department.

2001 PacifiCare Asia Pacific Section 5e

Section 5 (e). Mental health and substance abuse benefits
Benefit Description You pay

Network mental health and substance abuse benefits Ð Continued on next page 29
29 Page 30 31
28
Mental health and substance abuse You pay Ð Standard Option You pay Ð High Option
benefits (Continued)

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

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

Special transitional benefit If a mental health or substance abuse professional provider is treating you under our plan as of January 1, 2001, you will be eligible for continued coverage with
your provider for up to 90 days if your mental health or substance abuse
professional provider with whom you are currently in treatment leaves the plan at
our request for other than cause.

If this condition applies to you, we will allow you reasonable time to transfer your
care to a Plan mental health or substance abuse professional provider. During the
transitional period, you may continue to see your treating provider and will not pay
any more out-of-pocket than you did in the year 2000 for services. This transitional
period will begin with our notice to you of the change in coverage and will end 90
days after you receive our notice. If we write to you before October 1, 2000, the
90-day period ends before January 1 and this transitional benefit does not apply.

Network limitation We may limit your benefits if you do not follow your treatment plan.
How to submit network claims If you have out-of-pocket expenses for covered services, PacifiCare will reimburse you for those allowable charges, minus any applicable copayments. You should
contact the PacifiCare Customer Service Department at 1/ 671-647-3526 and
provide PacifiCare with a copy of your bill, your proof of payment and a brief
description of what happened.

2001 PacifiCare Asia Pacific Section 5e 30
30 Page 31 32
There are important features you should be aware of. These include:
° Who can write your prescription. A Plan physician must write the prescription Ð or Ð A plan physician or licensed dentist
must write the prescription.

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

° These are the dispensing limitations. Prescription drugs will be dispensed for up to a 30-day supply or one commercially
prepared unit (i. e., one inhaler, one vial of ophthalmic medication, one tube of ointment, one vial of insulin). For drugs that
could be habit forming, the prescription unit is set at a smaller quantity for the protection and safety of our member.

° When you have to file a claim. Please refer to Section 7 for information on how to file a pharmacy claim, or contact our
Customer Service Department at 1-800-562-6223.

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Here are some important things to keep in mind about these benefits:
° We cover prescribed drugs and medications, as described in the chart beginning on the next page.

° All benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.
° Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other
coverage, including with Medicare.

2001 PacifiCare Asia Pacific Section 5f

Section 5 (f). Prescription drug benefits
Prescription drug benefits begin on the next page. 31
31 Page 32 33
30 2001 PacifiCare Asia Pacific Section 5f
Covered medications and supplies You pay -Standard Option You pay -High Option
We cover the following medications and supplies
prescribed by a Plan physician and obtained from a
Plan pharmacy or through our mail-order program:

° Drugs and medications that by Federal law of the United States require a physician's prescription for

their purchase, except as excluded below.
° Insulin, copay charged to each vial
° Disposable needles and syringes for the administration of covered medications; lancets

° Oral contraceptive drugs; contraceptive diaphragms and cervical caps. (Injectable and
implantable contraceptive drugs are covered under
section 5( a) Family Services)

° Oral medications to treat infertility. (Injectable infertility drugs are covered under Section 5( a)

Infertility Services)

Limited benefits
° Drugs for sexual dysfunction are covered when Plan's medical criteria is met. Contact plan for

dose limits. You pay 50% per prescription unit
or refill up to the dosage limits.

Here are some things to keep in mind about our
prescription drug program:

° A generic equivalent will be dispensed if it is available, unless your physician specifically

requires a name brand. If you receive a name
brand drug when a Federally-approved generic
drug is available, and your physician has not
specified Dispense as Written for the name
brand drug, you have to pay the difference in
cost between the name brand drug and the generic.

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

° Non-prescription medicines
° Medical supplies such as dressings and antiseptics
° Appetite suppressants
° Drugs to enhance athletic performance

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

$20 for each non-formulary
prescription unit

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

$20 for each non-formulary
prescription unit

Benefit Description You pay 32
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31 2001 PacifiCare Asia Pacific Section 5g
Extended care hours are available to Plan members. If your Primary Care Doctor's
clinic is closed, you may seek treatment from the FHP Clinic's Urgent Care
services.

Members may receive primary care services from out-of-area primary care
providers. Out-of-area coverage is limited to the providers or geographic areas
listed below. Primary care providers are limited to General and Family
Practitioners and Internists. Other services must be treated by, or referred to a
specialist by, your Plan primary care doctor.

United States (refer to your provider directory for participating providers in the
U. S.) Ð You pay a nothing per office visit for High Option and all charges for the
Standard Option.

Hawaii (refer to your provider directory for participating providers in Hawaii) Ð
you pay nothing for High or Standard Option

Philippines (refer to your provider directory for participating providers in the
Philippines) Ð You pay nothing for High or Standard Option

Pacific Rim (Australia, Hong Kong, Japan, Korea, Singapore and Taiwan) Ð You
pay 20% for High or Standard Option

For eligible services, which includes primary care physician visits, diagnostic
laboratory and x-rays and routine immunizations, the Plan will pay up to the
covered reasonable and customary charge.

You pay nothing for the following PacifiCare Programs:
Managing your Heart Health, Managing Diabetes, Smoking Cessation*.
*Smoking Cessation nicotine replacement require a $20 copayment.

Section 5 (g). Special features
Feature Description
FHP Urgent Care Center

Out-of-area Primary Care

Health Improvement Programs 33
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32 2001 PacifiCare Asia Pacific Section 5h
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Here are some important things to keep in mind about these benefits:
° Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically

necessary.
° Plan dentists must provide or arrange your care.
° We cover hospitalization for dental procedures only when a non-dental physical impairment exists which makes hospitalization necessary to safeguard the health of the

patient; we do not cover the dental procedure unless it is described below.
° Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other

coverage, including with Medicare.

Section 5 (h). Dental benefits

Accidental injury benefit
We cover restorative services and supplies necessary to promptly repair You pay a $10 copayment
(but not replace) sound natural teeth. The need for these services must
result from an accidental injury.

If you are outside of the service area, we will reimburse you up to $100
for these services, if they are provided by a non plan dentist.

Benefit Description You pay

OFFICE VISIT
X-rays, including bitewings and panoramic (once a Nothing Nothing
year); oral examination and treatment plan, vitality
test; and oral cancer exam

PREVENTIVE SERVICES
Prophylaxis (once every 6 months); sealants; annual Nothing Nothing
topical application of fluoride (up to age 12);
preventive dental instructions

RESTORATIVE DENTISTRY
Amalgam Ð one, two or three surfaces; plastic or Nothing Nothing
composite Ð one or two surfaces

ORAL SURGERY
Post-operative treatment; simple extraction Nothing Nothing

PROSTHETICS
Full and partial dentures; crowns and bridges; repair; Nothing Nothing
relining and/ or reconstruction of dentures

Dental Benefits
Service You pay -Standard Option You pay -High Option 34
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33
The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed claim about
them. Fees you pay for these services do not count toward FEHB deductibles or out-of-pocket maximums.

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

YOU PAY
Diagnostic Services Nothing
Preventive Services Nothing
Restorative Services Nothing
Oral Surgery Nothing
Endodontics 50% of covered charges
Periodontics 50% of covered charges
Prosthetics 50% of covered charges
Orthodontics
The supplemental dental plan will cover orthodontic treatment for dependent children at participating orthodontic providers up
to $1000 per member per lifetime.

Dental Plan Premium
The supplemental dental plan will pay a maximum of $1500 per member per calendar year.

For details on the cost of the supplemental dental plan and how to enroll, call 1/ 671-647-3526.

2001 PacifiCare Asia Pacific Section 5i

Section 5 (i). Non-FEHB benefits available to Plan members 35
35 Page 36 37
34
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not cover it
unless your Plan doctor determines it is medically necessary to prevent, diagnose, or treat your illness, disease, injury or
condition and we agree, as discussed under What Services Require Our Prior Approval on page 8.

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

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

2001 PacifiCare Asia Pacific Section 6

Section 6. General exclusions Ñ things we don't cover 36
36 Page 37 38
35
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at Plan
pharmacies, you will not have to file claims. Just present your identification card and pay your copayment, coinsurance, or
deductible.

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

Medical, hospital and In most cases, providers and facilities file claims for you. Physicians must file on pharmacy benefits the form HCFA-1500, Health Insurance Claim Form. Facilities will file on the
UB-92 form. For claims questions and assistance, call us at 1/ 617-647-3526.
When you must file a claim Ñ such as for out-of-area care Ñ submit it on the
HCFA-1500 or a claim form that includes the information shown below. Bills and
receipts should be itemized and show:

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

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

° Receipts, if you paid for your services.
Submit your claims to: PacifiCare Asia Pacific
231 Guerrero Drive
Tamuning, Guam 96911

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

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

2001 PacifiCare Asia Pacific Section 7

Section 7. Filing a claim for covered services 37
37 Page 38 39
36
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 Ð including a request for preauthorization:

Step Description
1 Ask us in writing to reconsider our initial decision. You must:
(a) Write to us within 6 months from the date of our decision; and

(b) Send your request to us at: 231 Guerrero Drive, Tamuning, Guam 96911; and
(c) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in
this brochure; and

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

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

(b) Write to you and maintain our denial Ñ 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 requestÑ
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 Ñ if we did not answer that request in some way within 30 days;
or
° 120 days after we asked for additional information.
Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Contracts Division III,
P. O. Box 436, Washington, D. C. 20044-0436.

2001 PacifiCare Asia Pacific Section 8

Section 8. The disputed claims process 38
38 Page 39 40
37
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 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 claim decision. This
information will become part of the court record.

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

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

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

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

°° You can call OPM's Health Benefits Contracts Division III at 202/ 606-0737 between 8 a. m. and 5 p. m. eastern time.

2001 PacifiCare Asia Pacific Section 8 39
39 Page 40 41
38
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 have automobile insurance that pays health care expenses
without regard to fault. This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in full as the
primary payer and the other plan pays a reduced benefit as the secondary payer.
We, like other insurers, determine which coverage is primary according to the
National Association of Insurance Commissioners' guidelines.

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

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

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

Medicare has two parts:
° Part A (Hospital Insurance). Most people do not have to pay for Part A.
° 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
healthcare. Medicare + Choice is the term used to describe the various health plan
choices available to Medicare beneficiaries. The information in the next few pages
shows how we coordinate benefits with Medicare, depending on the type of
Medicare managed care plan you have.

° The Original Medicare Plan The Original Medicare Plan 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 Original Medicare, like
prescription drugs.

When you are enrolled in this Plan and Original Medicare, you still need to follow
the rules in this brochure for us to cover your care. Your care must continue to be
coordinated by your Plan PCP, and preauthorization rules still apply.

We will not waive any of our copayments, coinsurance, and deductibles.
(Primary payer chart begins on next page.)

2001 PacifiCare Asia Pacific Section 9

Section 9. Coordinating benefits with other coverage 40
40 Page 41 42
39 2001 PacifiCare Asia Pacific Section 9
The following chart illustrates whether Original Medicare or this Plan should be the primary payer for you according to your
employment status and other factors determined by Medicare. It is critical that you tell us if you or a covered family member
has Medicare coverage so we can administer these requirements correctly.

1) Are 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 reemployed annuitant with the Federal government whenÉ
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 (except for claims
unable to return to duty, related to Workers'
Compensation.)

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,

1) Are eligible for Medicare based on disability, and
a) Are an annuitant, or . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
b) Are an active employee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Primary Payer Chart
A. When either you Ð or your covered spouse Ð are age 65 or over and É

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

C. When you or a covered family member have FEHB andÉ

Then the primary payer isÉ
Original Medicare This Plan

If your Plan physician does not participate in Medicare, you will have to file claims directly with Medicare. 41
41 Page 42 43
40
Claims process Ð 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 Original Medicare is the primary payer, Medicare processes your claim first. In most cases, your claims will be coordinated automatically and we will
pay the balance of covered charges. You will not need to do anything. To find out
if you need to do something about filing your claims, call us at 1-671-647-3526.

°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 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, but we will not waive any of our copayments, coinsurance, or deductibles.

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

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

TRICARE TRICARE is the health care program for members, 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 similar agency pays its maximum benefits for your treatment, we
will cover your benefits. You must use our providers.

2001 PacifiCare Asia Pacific Section 9 42
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41
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, or Federal Government are responsible for your care agency directly or indirectly pays for them.

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

If you do not seek damages you must agree to let us try. This is called subrogation.
If you need more information, contact us for our subrogation procedures.

2001 PacifiCare Asia Pacific Section 9 43
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Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on December 31 of
the same year.
Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 9.

Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. See page 9.
Covered services Care we provide benefits for, as described in this brochure.
Custodial Care Day to day care that can be provided by a non-medical individual.
Deductible A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for those services.
See page 9.
Experimental or investigational Services Our National and Regional Medical Committees determine whether or not
treatments, procedures and drugs are no longer considered experimental or
investigational. Our determinations are based on the safety and efficacy of new
medical procedures, technologies, devices and drugs.

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

° Rendered for the treatment or diagnosis of an injury or illness; and
° Appropriate for the symptoms, consistent with diagnosis, and otherwise in
accordance with sufficient scientific evidence and professionally recognized
standards; and

° Not furnished primarily for the convenience of the Member, the attending
physician, or other provider of service; and

° Furnished in the most economically efficient manner which may be provided
safely and effectively to the Member.

Plan allowance Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. Plans determine their allowances in different
ways. We determine our allowance by our contracted rate with the participating
provider.

Us/ We Us and we refer to PacifiCare Asia Pacific.
Yo u You refers to the enrollee and each covered family member.

2001 PacifiCare Asia Pacific Section 10

Section 10. Definitions of terms we use in this brochure 44
44 Page 45 46
43
No pre-existing condition We will not refuse to cover the treatment of a condition that you had before you limitation enrolled in this Plan solely because you had the condition before you enrolled.
Where you can get See www. opm. gov/ insure. Also, your employing or retirement office can answer information about enrolling your questions, and give you a Guide to Federal Employees Health Benefits Plans,
in the FEHB Program 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 you, your for you and your family spouse, and your unmarried dependent children under age 22, including any foster
children or stepchildren your employing or retirement office authorizes coverage
for. Under certain circumstances, you may also continue coverage for a disabled
child 22 years of age or older who is incapable of self-support.

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

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

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

2001 PacifiCare Asia Pacific Section 11

Section 11. FEHB facts 45
45 Page 46 47
44
When benefits and The benefits in this brochure are effective on January 1. If you are new to this premiums start 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 the records are confidential 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.
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.

° TCC If you leave Federal service, or if you lose coverage because you no longer qualify as a family member, you may be eligible for Temporary Continuation of Coverage
(TCC). For example, you can receive TCC if you are not able to continue your
FEHB enrollment 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.

2001 PacifiCare Asia Pacific Section 11 46
46 Page 47 48
45
° 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 Group Health Plan Coverage 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.

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 1/ 671-647-3526 and
explain the situation.
° If we do not resolve the issue, call THE HEALTH CARE FRAUD HOTLINEÑ 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.

2001 PacifiCare Asia Pacific Section 11 47
47 Page 48 49
46 2001 PacifiCare Asia Pacific Index
Index
Do not rely on this page; it is for your convenience and does not explain your benefit coverage.

Accidental injury 15, 19, 32
Allergy tests 14
Alternative treatment 17
Ambulance 24, 26
Anesthesia 21, 22, 23
Autologous bone marrow transplant 14, 20
Biopsies 18
Blood and blood plasma 22, 23
Breast cancer screening 12
Casts 18
Catastrophic protection 9
Changes for 2001 5
Chemotherapy 14
Childbirth 13, 22
Cholesterol tests 12
Circumcision 13
Claims 35
Coinsurance 9
Congenital anomalies 18, 19
Contraceptive devices and drugs 13, 18, 30
Coordination of benefits 38
Covered charges 4, 9
Covered providers 4, 6
Crutches 16
Deductible 9
Definitions 42
Dental care 32
Diagnostic services 11
Disputed claims review 36
Donor expenses (transplants) 14, 20, 21
Dressings 22, 23
Durable medical equipment (DME) 16, 17
Educational classes and programs 17
Effective date of enrollment 6, 42
Emergency 25
Experimental or investigational 34, 42
Eyeglasses 15
Family planning 13
Fecal occult blood test 12

General Exclusions 34
Hearing services 12, 15
Home health services 17
Home nursing care 17
Hospice care 24
Hospital 6
Immunizations 12, 31
Infertility 13
Inhospital physician care 22
Insulin 17, 29, 30
Laboratory and pathological services 11, 22,
23, 31
Machine diagnostic tests 8, 11
Magnetic Resonance Imagings (MRI) 11
Mail Order Prescription Drugs 30
Mammograms 11, 12
Maternity Benefits 13
Medicaid 40
Medically necessary 8
Medicare 38
Mental Conditions/ Substance Abuse
Benefits 27-28
Neurological testing 27-28
Newborn care 11, 13
Non-FEHB Benefits 33
Nurse
Licensed Practical Nurse 17
Nurse Anesthetist 18
Registered Nurse 17
Nursery charges 13
Obstetrical care 13
Occupational therapy 15
Office visits 4
Oral and maxillofacial surgery 20
Orthopedic devices 15, 16
Out-of-pocket expenses 9
Outpatient facility care 23
Oxygen 17, 22, 23
Pap test 11, 12

Physical examination 4
Physical therapy 15
Physician 4
Precertification 28
Preventive care, adult 12
Preventive care, children 12
Prescription drugs 29-30
Preventive services 12
Prior approval 28
Prosthetic devices 16
Psychologist 27
Psychotherapy 27
Radiation therapy 14
Rehabilitation therapies 15
Renal dialysis 38, 39
Room and board 22
Second surgical opinion 11
Skilled nursing facility care 7, 23
Smoking cessation 17, 31
Speech therapy 15
Sterilization procedures 13, 18
Substance abuse 27
Surgery 18
° Anesthesia 18 ° Oral 20

° Outpatient 23 ° Reconstructive 19
Syringes 30
Temporary continuation of
coverage 44
Transplants 14, 15
Treatment therapies 14
Vision services 5
Wheelchairs 16
Workers' compensation 40
X-rays 11 48
48 Page 49 50
47 2001 PacifiCare Asia Pacific Summary of Benefits
Summary of benefits for the PacifiCare Asia Pacific Ð 2001
° Do not rely on this chart alone. All benefits are provided in full unless indicated and are subject to the definitions, limitations, and exclusions in this brochure. On this page we summarize specific expenses we cover; for more detail, look
inside.
° If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on your enrollment form.

° We only cover services provided or arranged by Plan physicians, except in emergencies.
Benefits You Pay Ð Standard Option Page
Medical services provided by physicians: Office visit copay: $15 primary care; 11
° Diagnostic and treatment services provided in the office. . . . . . $15 specialist for standard

Services provided by a hospital:
° Inpatient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $150 copay for standard option 22
° Outpatient. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Outpatient services are covered at 23 your office visit copay

Emergency benefits:
° In-area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $25 copay per emergency visit and 26 all charges over $500

° Out-of-area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20% copayment for standard option 26
Mental health and substance abuse treatment . . . . . . . . . . . . . . . . . . Same as any other illness or condition 27
Prescription drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $5 copay for formulary prescriptions 30
$20 for non-formulary prescriptions

Dental Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Not covered 32
Vision Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Office visit copay: $15 for standard 15
Special features: Health improvement programs 31
Protection against catastrophic costs Nothing after $1,000/ Self Only or 9
(your out-of-pocket maximum) . . . . . . . . . . . . . . . . . . . . . . . . . . . . $3,000/ Family enrollment per year

Some costs do not count toward this
protection 49
49 Page 50 51
48 2001 PacifiCare Asia Pacific Summary of Benefits
Benefits You Pay Ð High Option Page
Medical services provided by physicians: Office visit copay: $10 primary care; 11
° Diagnostic and treatment services provided in the office. . . . . . $10 specialist for standard

Services provided by a hospital:
° Inpatient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nothing per admission for high option 22
° Outpatient. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Outpatient services are covered at 23 your office visit copay

Emergency benefits:
° In-area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $25 copay per emergency visit and 26 all charges over $500

° Out-of-area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $25 per emergency room visit 26
Mental health and substance abuse treatment . . . . . . . . . . . . . . . . . . Regular benefits 27
Prescription drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $5 copay for formulary prescriptions 30
$20 for non-formulary prescriptions

Dental Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nothing for preventive services; 32
scheduled allowance for other services
high option only

Vision Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Office visit copay: $10 for high option 15
Special features: Health improvement programs 31
Protection against catastrophic costs Nothing after $1,000/ Self Only or 9
(your out-of-pocket maximum) . . . . . . . . . . . . . . . . . . . . . . . . . . . . $3,000/ Family enrollment per year

Some costs do not count toward this
protection 50
50 Page 51 52
Guam/ N. Mariana Islands/ Palau
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 contract 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.

2001 Rate Information for
PacifiCare Asia Pacific

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

High Option
Self and Family

JK1
JK2
$81.81
$195.82
$27.27
$90.78
$177.26
$424.28
$59.08
$196.69
$96.81
$231.17
$12.27
$55.43
Standard Option
Self Only

Standard Option
Self and Family

JK4
JK5
$53.85
$142.19
$17.95
$47.39
$116.68
$308.07
$38.89
$102.69
$63.72
$168.25
$8.08
$21.33

49 2001 PacifiCare Asia Pacific Summary of Benefits 51
51 Page 52
52

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