Inspector General Advisory
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 1-800-FEP-8440 and explain
the situation.
If we do not resolve the issue, call or write:

THE HEALTH CARE FRAUD HOTLINE
202/ 418-3300 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.

Stop health care fraud! 5
5 Page 6 7

2002 Blue Cross and Blue Shield
Service Benefit Plan 6 Section 1

Section 1. Facts about this fee-for-service Plan
This Plan is a fee-for-service (FFS) plan. You can choose your own hospitals, physicians, and other professional health care
providers.

We reimburse you or your provider for your covered services, usually based on a percentage of the amount we allow. The type and
extent of covered services, and the amount we allow, may be different from other plans. Read brochures carefully.

We have Preferred Provider Organizations (PPO):
Our fee-for-service plan offers services through a PPO. When you use our PPO (Preferred) providers, you will receive covered
services at a reduced cost. Your Local Plan (or, for retail pharmacies, AdvancePCS) is solely responsible for the selection of PPO
providers in your area. Contact your Local Plan for the names of PPO (Preferred) providers and to verify their continued
participation. You can also go to our web page, which you can reach through the FEHB website, www. opm. gov/ insure. Do not call
OPM or your agency for our provider directory. Contact your Local Plan to request a PPO directory.

Under Standard Option, non-PPO (Non-preferred) benefits are the standard benefits. PPO (Preferred) benefits apply only when
you use a PPO (Preferred) provider. PPO networks may be more extensive in some areas than in others. We cannot guarantee the
availability of every specialty in all areas. If no PPO (Preferred) provider is available, or you do not use a PPO (Preferred) provider,
the standard non-PPO (Non-preferred) benefits apply.

Under Basic Option, you must use Preferred providers in order to receive benefits. See page 11 for the exceptions to this
requirement.

How we pay professional and facility providers:
We pay benefits when we receive a claim for covered services. Each Local Plan contracts with hospitals and other health care
facilities, physicians, and other health care professionals in its service area, and is responsible for processing and paying claims for
services you receive within that area. Many, but not all, of these contracted providers are in our PPO (Preferred) network.

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

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

Note: Not all areas have Participating providers and/ or Member facilities. To verify the status of a provider, please contact the
Local Plan serving the area where the services are to be performed.

Non-participating providers. Providers who are not Preferred or Participating providers do not have contracts with us, and may or may not accept our allowance. We refer to them as "Non-participating providers" generally, although if they are
facilities we refer to them as "Non-member facilities." When you use Non-participating providers, you may have to file your
claim with us. We will then pay our benefits to you, and you must pay the provider. 6
6 Page 7 8

2002 Blue Cross and Blue Shield
Service Benefit Plan 7 Section 1

You must pay any difference between the amount Non-participating providers charge and our allowance, in addition to any
applicable coinsurance amounts, copayment amounts, amounts applied to your calendar year deductible, and amounts for
noncovered services. Important: Under Standard Option, your out-of-pocket costs may be substantially higher when you
use Non-participating providers than when you use Preferred or Participating providers. Under Basic Option, you must
use Preferred providers to receive benefits. See page 11 for the exceptions to this requirement.

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

In Arizona, when there is any other source of payment (whether we pay primary or secondary), Preferred and Participating physicians are not obligated to accept our allowance as payment in full.

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

In Pennsylvania and Utah, when we pay secondary, Preferred physicians are not obligated to accept our allowance as payment in full unless we make a payment as the secondary payer.

In Montana, when we pay secondary, Preferred and Participating physicians may collect the difference between the total payments made by us and the primary carrier and the billed amount.
In South Carolina, except when we pay secondary to other Blue Cross and Blue Shield coverage, Preferred and Participating physicians may collect the difference between the total payments made by us and the primary carrier and the billed amount.

Your Rights
OPM requires that all FEHB Plans provide certain information to their FEHB members. You may get information about us, our
networks, and providers. You can also find out about care management, including medical practice guidelines, disease management
programs, and how we determine if procedures are experimental or investigational. OPM's FEHB website (www. opm. gov/ insure)
lists the specific types of information that we must make available to you.

If you want more information about us, call or write to us. Our telephone number and address are shown on the back of your
Service Benefit Plan ID card. You may also visit our website at www. fepblue. org. 7
7 Page 8 9

2002 Blue Cross and Blue Shield
Service Benefit Plan 8 Section 2

Section 2. How we change for 2002
Do not rely only on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5 (Benefits).
Also, we edited and clarified language throughout the brochure; any language change not shown here is a clarification that does not
change benefits.

Program-wide changes
We clarified the brochure to show why we think you should use generic drugs whenever possible. We moved other language around within the Prescription drugs section but didn't change its meaning. (Section 5( f))

We changed the address for sending disputed claims to OPM. (Section 8)
Georgia, Montana, North Dakota, and Texas are added to and Louisiana is deleted from the list of states designated as medically underserved in 2002. (Section 3)

Changes to this Plan
Your share of the non-Postal Standard Option premium will increase by 20.0% for Self Only or 17.2% for Self and Family.
We have merged our High Option into Standard Option. High Option is no longer available.
We have added a new option called Basic Option.
You pay no deductible under Basic Option.
You must use Preferred providers in order to receive benefits (see page 11 for the exceptions to this requirement).
Please carefully review this brochure, including Section 5 (Benefits), to understand Basic Option benefits. If you have any questions about Basic Option, please call us at the customer service telephone number on the back of your Service Benefit

Plan ID card.
We have discontinued our Point of Service (POS) pilot program.
Under Standard Option, your catastrophic protection out-of-pocket limit is now $4,000 per contract when you use only Preferred providers and $6,000 per contract when you use a combination of Preferred and Non-preferred providers. Previously, your

catastrophic protection out-of-pocket limit was $3,000 (Preferred only) and $5,000 (Preferred and Non-preferred). (Section 4)
We now provide benefits at Preferred benefit levels for covered services performed by certain other covered health care professionals (for example, nurse practitioners, audiologists, nurse anesthetists, etc.) that contract with Local Plans. (Section 3)

We now provide benefits at Preferred benefit levels for covered services performed in Preferred facilities by covered Non-preferred radiologists, anesthesiologists, certified registered nurse anesthetists (CRNAs), pathologists, and emergency room
physicians. (Sections 5( a) and 5( b))
We now provide benefits for routine screening for chlamydial infection. (Section 5( a))
We now provide benefits for organ/ tissue transplants to include autologous stem cell support for amyloidosis. (Section 5( b))
We now provide benefits for organ/ tissue transplants in clinical trials to include nonmyeloablative allogeneic stem cell transplants for chronic myelogenous leukemia, acute lymphocytic or non-lymphocytic (i. e., myelogenous) leukemia, advanced Hodgkin's

lymphoma, advanced non-Hodgkin's lymphoma, advanced forms of myelodysplastic syndromes, multiple myeloma, chronic
lymphocytic leukemia, early stage (indolent or non-advanced) small cell lymphocytic lymphoma, and renal cell carcinoma.
(Section 5( b))

Under Standard Option, we now provide benefits in full for ambulance services provided in connection with, and within 72 hours after, an accidental injury. (Section 5( d))

We now provide benefits for dental accidental injury only when treatment is started promptly and completed within 12 months of the accident. (Section 5( h))
Under Standard Option, your Mail Service Prescription Drug Program copayments have changed: for generic drugs the copayment has decreased to $10 and for brand-name drugs the copayment has increased to $35. Previously, the Mail Service
Prescription Drug Program copayments were $12 for generic drugs and $20 for brand-name drugs. (Section 5( f))
We now treat smoking cessation services the same as other medical or mental health/ substance abuse services. Previously, under Standard Option, smoking cessation services were limited to $100 of coverage per lifetime. In addition, we no longer limit

smoking cessation drugs to one course of treatment per year; additional courses of treatment do require prior approval and
participation in a smoking cessation program. (Sections 3, 5( a), 5( e), and 5( f)) 8
8 Page 9 10

2002 Blue Cross and Blue Shield
Service Benefit Plan 9 Section 3

Section 3. How you receive benefits
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You will need it whenever you receive services from a
covered provider, or fill a prescription through a Preferred retail or internet pharmacy.
Until you receive your ID card, use your copy of the Health Benefits Election Form,
SF-2809, your health benefits enrollment confirmation letter (for annuitants), or your
Employee Express confirmation letter.

If you do not receive your ID card within 30 days after the effective date of your
enrollment, or if you need replacement cards, call the Local Plan serving the area where
you reside and ask them to assist you, or write to us directly at: FEP Enrollment
Services, 550 12 th Street, SW, Washington, DC 20065-1463.

Where you get covered care Under Standard Option, you can get care from any "covered professional provider" or "covered facility provider." How much we pay – and you pay – depends on the type
of covered provider you use. If you use our Preferred, Participating, or Member
providers, you will pay less.

Under Basic Option, you must use those "covered professional providers" or "covered facility providers" that are Preferred providers for Basic Option in order to receive

benefits. Please refer to page 11 for the exceptions to this requirement. Refer to page 6
for more information about Preferred providers.

Covered professional providers We consider the following to be covered professionals when they perform services within the scope of their license or certification.

Physicians – Doctors of medicine (M. D.); osteopathy (D. O.); dental surgery (D. D. S.);
medical dentistry (D. M. D.); podiatric medicine (D. P. M.); and optometry (O. D.). For
Basic Option, the term "primary care provider" includes family practitioners, general
practitioners, medical internists, pediatricians, and obstetricians/ gynecologists.

Other Covered Health Care Professionals – Professionals who provide additional
covered services and meet the state's applicable licensing or certification requirements
and the requirements of the Local Plan. Other covered health care professionals
include:

Clinical Psychologist – A psychologist who (1) is licensed or certified in the state where the services are performed; (2) has a doctoral degree in psychology (or an

allied degree if, in the individual state, the academic licensing/ certification
requirement for clinical psychologist is met by an allied degree) or is approved by
the Local Plan; and (3) has met the clinical psychological experience requirements
of the individual State Licensing Board.

Clinical Social Worker – A social worker who (1) has a master's or doctoral degree in social work; (2) has at least two years of clinical social work practice;

and (3) if the state requires it, is licensed, certified, or registered as a social worker
where the services are performed.

Independent Laboratory – A laboratory that is licensed under state law or, where no licensing requirement exists, that is approved by the Local Plan.

Nurse Midwife – A person who is certified by the American College of Nurse Midwives or, if the state requires it, is licensed or certified as a nurse midwife.
Nurse Practitioner/ Clinical Specialist – A person who (1) has an active R. N. license in the United States; (2) has a baccalaureate or higher degree in nursing;
and (3) if the state requires it, is licensed or certified as a nurse practitioner or
clinical nurse specialist. 9
9 Page 10 11

2002 Blue Cross and Blue Shield
Service Benefit Plan 10 Section 3

Physical, Speech, and Occupational Therapist – A professional who is licensed where the services are performed or meets the requirements of the Local Plan to
provide physical, speech, or occupational therapy services.
Nursing School Administered Clinic – A clinic that (1) is licensed or certified in the state where services are performed; and (2) provides ambulatory care in an

outpatient setting – primarily in rural or inner-city areas where there is a shortage
of physicians. Services billed for by these clinics are considered outpatient
"office" services rather than facility charges.

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

Dietician – A professional who, if the state requires it, is licensed, certified, or registered as a dietician where the services are performed.
Diabetic educator – A professional who, if the state requires it, is licensed, certified, or registered as a diabetic educator where the services are performed.
Nutritionist – A professional who, if the state requires it, is licensed, certified, or registered as a nutritionist where the services are performed.
Other professional providers specifically shown in the benefit descriptions in Section 5.

Medically underserved areas. In states that OPM determines are "medically
underserved":

Under Standard Option, we cover any licensed medical practitioner for any
covered service performed within the scope of that license.

Under Basic Option, we cover any licensed medical practitioner who is Preferred
for any covered service performed within the scope of that license.

For 2002, the states are: Alabama, Georgia, Idaho, Kentucky, Mississippi, Missouri,
Montana, New Mexico, North Dakota, South Carolina, South Dakota, Texas, Utah, and
Wyoming.

Covered facility providers Covered facilities include those listed below, when they meet the state's applicable licensing or certification requirements.

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

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

Freestanding Ambulatory Facility – A freestanding facility, such as an ambulatory surgical center, freestanding surgi-center, freestanding dialysis center,
or freestanding ambulatory medical facility, that:
(1) Provides services in an outpatient setting;
(2) Contains permanent amenities and equipment primarily for the purpose of
performing medical, surgical, and/ or renal dialysis procedures; 10
10 Page 11 12

2002 Blue Cross and Blue Shield
Service Benefit Plan 11 Section 3

(3) Provides treatment performed or supervised by doctors and/ or nurses, and may
include other professional services performed at the facility; and
(4) Is not, other than incidentally, an office or clinic for the private practice of a doctor
or other professional.

Note: We may, at our discretion, recognize any other similar facilities, such as birthing
centers, as freestanding ambulatory facilities.

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

Other facilities specifically listed in the benefits descriptions in Section 5( c).
What you must do to get covered care Under Standard Option, you can go to any covered provider you want, but in some circumstances, we must approve your care in advance.
Under Basic Option, you must use Preferred providers in order to receive benefits,
except under the special situations listed below. In addition, we must approve certain
types of care in advance. Please refer to Section 4, Your costs for covered services, for
related benefits information.

(1) Medical emergency or accidental injury care in a hospital emergency room and
related ambulance transport as described in Section 5( d), Emergency
services/ accidents;
(2) Professional care provided by certain Non-preferred providers (radiologists,
anesthesiologists, certified registered nurse anesthetists (CRNAs), pathologists,
emergency room physicians, and assistant surgeons) at Preferred facilities;
(3) Laboratory and pathology services, X-rays, and diagnostic tests billed by Non-preferred
laboratories, radiologists, and outpatient facilities;
(4) Services of assistant surgeons;
(5) Special provider access situations (contact your Local Plan for more information);
or
(6) Care received outside the United States and Puerto Rico.

Unless otherwise noted in Section 5, when services of Non-preferred providers are covered in a special exception, benefits will be provided based on the Plan allowance.
You are responsible for the applicable coinsurance or copayment, and may also be responsible for any difference between our allowance and the billed amount.

Transitional care: Specialty Care: If you have a chronic or disabling condition and
lose access to your specialist because we drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB plan, or

lose access to your Preferred specialist because we terminate our contract with your specialist for other than cause,
you may be able to continue seeing your specialist and receiving any Preferred benefits
for up to 90 days after you receive notice of the change. Contact us or, if we drop out
of the Program, contact your new plan. 11
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2002 Blue Cross and Blue Shield
Service Benefit Plan 12 Section 3

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 and
any Preferred benefits will continue until the end of your postpartum care, even if it is
beyond the 90 days.

Hospital care: If you are in the hospital when your enrollment in our Plan begins, call us immediately. If you have not yet received your Service Benefit Plan ID card, you can contact your
Local Plan at the telephone number listed in your local telephone directory. If you
already have your new Service Benefit Plan ID card, call us at the number on the back
of the card. If you are new to the FEHB Program, we will reimburse you for your
covered expenses while in the hospital.

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

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

These provisions apply only to the benefits of the hospitalized person.
How to get approval for…

Your hospital stay Precertification is the process by which – prior to your inpatient hospital admission – we evaluate the medical necessity of your proposed stay and the number of days required to
treat your condition. Unless we are misled by the information given to us, we will not
change our decision on medical necessity.

In most cases, your physician or hospital will take care of precertification. Because you
are still responsible for ensuring that we are asked to precertify your care, you should
always ask your physician or hospital whether they have contacted us.

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

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

representative, your doctor, or your hospital must telephone us within two business
days following the day of the emergency admission, even if you have been
discharged from the hospital.

Provide the following information:
Enrollee's name and Plan identification number;
Patient's name, birth date, and phone number;
Reason for hospitalization, proposed treatment, or surgery;
Name and phone number of admitting doctor;
Name of hospital or facility; and
Number of planned days of confinement.
We will then tell the doctor and/ or hospital the number of approved inpatient days and we will send written confirmation of our decision to you, your doctor, and the

hospital. 12
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2002 Blue Cross and Blue Shield
Service Benefit Plan 13 Section 3

Maternity care You do not need to precertify a maternity admission for a routine delivery. However, if your medical condition requires you to stay more than 48 hours after a vaginal delivery
or 96 hours after a cesarean section, then your physician or the hospital must contact us
for precertification of additional days. Further, if your baby stays after you are
discharged, then your physician or the hospital must contact us for precertification of
additional days for your baby.

If your hospital stay If your hospital stay – including for maternity care – needs to be extended, you, your
needs to be extended: representative, your doctor, or the hospital must ask us to approve the additional days.

What happens when you When we precertified the admission but you remained in the hospital beyond the do not follow the number of days we approved and you did not get the additional days precertified,
precertification rules then:
for the part of the admission that was medically necessary, we will pay inpatient benefits, but

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

If we determine that the stay was medically necessary, we will pay the inpatient charges, less the $500 penalty. [See Section 5( c) for payment information.]
If we determine that it was not medically necessary for you to be an inpatient, we will not pay inpatient hospital benefits. We will only pay for any covered
medical supplies and services that are otherwise payable on an outpatient basis.
If we denied the precertification request, we will not pay inpatient hospital benefits or inpatient physician care benefits. We will only pay for any covered medical supplies

and services that are otherwise payable on an outpatient basis.
Exceptions: You do not need precertification in these cases:
You are admitted to a hospital outside the United States.
You have another group health insurance policy that is the primary payer for the hospital stay.

Your Medicare Part A is the primary payer for the hospital stay.
Note: If you exhaust your Medicare hospital benefits and do not want to use your
Medicare lifetime reserve days, then we will become the primary payer and you do
need precertification.

Other services These services require prior approval under both Standard and Basic Option:
Home hospice care – Contact us at the customer service number listed on the back of your ID card before obtaining services. We will request the medical evidence we
need to make our coverage determination and advise you which home hospice care
agencies we have approved.

Partial hospitalization or intensive outpatient treatment for mental health/ substance abuse – Contact us at the mental health and substance abuse

number listed on the back of your ID card before obtaining services for intensive
outpatient treatment or partial hospitalization. We will request the medical evidence
we need to make our coverage determination. We will also consider the necessary
duration of either of these services. 13
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2002 Blue Cross and Blue Shield
Service Benefit Plan 14 Section 3

Organ/ tissue transplants – Contact us at the customer service number listed on the back of your ID card before obtaining services. We will request the medical
evidence we need to make our coverage determination. We will consider whether
the facility is approved for the procedure and whether you meet the facility's
criteria.

Clinical trials for certain organ/ tissue transplants – Contact our Clinical Trials Information Unit at 1-800-225-2268 for information or to request prior approval

before obtaining services. We will request the medical evidence we need to make
our coverage determination. Use this number only for prior approval of clinical
trials for bone marrow and peripheral blood stem cell transplant support procedures
for those conditions shown on page 52 as covered only in clinical trials.

Cardiac rehabilitation – Contact us at the customer service number listed on the back of your ID card prior to starting treatment. We will request the information we

need to make our coverage determination.
Prescription drugs – Certain prescription drugs require prior approval. Contact our Retail Pharmacy Program at 1-800-624-5060 (TDD: 1-800-624-5077 for the hearing

impaired) to request prior approval, or to obtain an updated list of prescription drugs
that require prior approval. We will request the information we need to make our
coverage determination. You must periodically renew prior approval for certain
drugs. See page 83 for more about our prescription drug prior approval program,
which is part of our Patient Safety and Quality Monitoring (PSQM) program.

Note: Benefits for drugs to aid smoking cessation that require a prescription by
Federal law are limited to one course of treatment per calendar year. Prior approval
is required before benefits will be provided for additional medication. To obtain
approval, the physician must certify the patient is participating in a smoking
cessation program that provides clinical treatment, including counseling and
behavioral therapies.

Note: Until we approve them, you must pay for these drugs in full when you
purchase them – even if you purchase them at a Preferred retail pharmacy or
through an internet pharmacy – and submit the expense( s) to us on a claim form.
Preferred pharmacies will not file these claims for you.

Under Standard Option, members may use our Mail Service Prescription Drug
Program to fill their prescriptions. However, the Mail Service Prescription Drug
Program also will not fill your prescription until you have obtained prior approval.
Merck-Medco Rx Services, the administrator of the Mail Service Prescription Drug
Program, will return your prescription to you along with a Prior Approval Request
Form and a letter explaining the prior approval procedures.

The Mail Service Prescription Drug Program is not available under Basic Option.

In addition to the types of care listed above, these services also require prior approval under Basic Option:

Outpatient mental health and substance abuse treatment – You must call us at the number listed on the back of your ID card for mental health and substance abuse
before receiving any outpatient professional or facility care. We will then
provide you with the names and phone numbers of several Preferred providers to
choose from and tell you how many visits we are initially approving. 14
14 Page 15 16
2002 Blue Cross and Blue Shield
Service Benefit Plan 15 Section 4

Section 4. Your costs for covered services
This is what you will pay out-of-pocket for your covered care:
Copayments A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive certain services.

Example: Under Standard Option, when you see your Preferred physician, you pay a
copayment of $15 per visit and when you go in a Preferred hospital, you pay $100 per
admission. We then pay the remainder of the bill for covered services.

Note: If the billed amount (or the Plan allowance that providers we contract with have
agreed to accept as payment in full) is less than your copayment, you pay the lower
amount.

Deductible A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for them. Copayments do not
count toward your deductible. When a covered service or supply is subject to a
deductible, only the Plan allowance for the service or supply that you then pay counts
toward meeting your deductible.

Under Standard Option, the calendar year deductible is $250 per person. Under a
family enrollment, the calendar year deductible for each family member is satisfied and
benefits are payable for all family members when the combined covered expenses of
the family reach $500.

Note: If the billed amount (or the Plan allowance that providers we contract with have
agreed to accept as payment in full) is less than the remaining portion of your
deductible, you pay the lower amount.

Example: If the billed amount is $100, the provider has an agreement with us to accept
$80, and you have not paid any amount toward meeting your Standard Option calendar
year deductible, you must pay $80. We will apply $80 to your deductible. We will
begin paying benefits once the remaining portion of your Standard Option calendar year
deductible ($ 170) has been satisfied.

Note: If you change plans during Open Season and the effective date of your new plan
is after January 1 of the next year, you do not have to start a new deductible under your
old plan between January 1 and the effective date of your new plan. If you change
plans at another time during the year, you must begin a new deductible under your new
plan.

Under Basic Option, there is no calendar year deductible.

Coinsurance Coinsurance is the percentage of the Plan allowance that you must pay for your care. Your coinsurance is based on the Plan allowance, or billed amount, whichever is less.
Under Standard Option only, coinsurance does not begin until you meet your deductible.

Example: You pay 10% of the Plan allowance under Standard Option for durable
medical equipment obtained from a Preferred provider, after meeting your $250
calendar year deductible.

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

Example: If your physician ordinarily charges $100 for a service but routinely waives
your 25% Standard Option coinsurance, the actual charge is $75. We will pay $56.25
(75% of the actual charge of $75). 15
15 Page 16 17

2002 Blue Cross and Blue Shield
Service Benefit Plan 16 Section 4

Waivers In some instances, a Preferred, Participating, or Member provider may ask you to sign a "waiver" prior to receiving care. This waiver may state that you accept responsibility
for the total charge for any care that is not covered by your health plan. If you sign
such a waiver, whether you are responsible for the total charge depends on the content
of the contracts that the Local Plan has with its providers. If you are asked to sign this
type of waiver, please be aware that, if benefits are denied for the services, you could
be legally liable for the related expenses. If you would like more information about
waivers, please contact us at the customer service number on the back of your ID card.

Differences between Our "Plan allowance" is the amount we use to calculate our payment for certain types our allowance and of covered services. Fee-for-service plans arrive at their allowances in different ways,
the bill so allowances vary. For information about how we determine our Plan allowance, see
the definition of Plan allowance in Section 10.

Often, the provider's bill is more than a fee-for-service plan's allowance. Whether or
not you have to pay the difference between our allowance and the bill will depend on
the type of provider you use. In this Plan, we have the following types of providers:

Preferred providers. These types of providers have agreements with the Local
Plan to limit what they bill our members. Because of that, when you use a Preferred
provider, your share of the provider's bill for covered care is limited.

Under Standard Option, your share consists only of your deductible and
coinsurance or copayment. Here is an example of coinsurance: You see a Preferred
physician who charges $150, but our allowance is $100. If you have met your
deductible, you are only responsible for your coinsurance. That is, under Standard
Option, you pay just 10% of our $100 allowance ($ 10). Because of the agreement,
your Preferred physician will not bill you for the $50 difference between our
allowance and his/ her bill. See page 7 for exceptions.

Under Basic Option, your share consists only of your copayment or coinsurance
amount, since there is no calendar year deductible. Here is an example involving a
copayment: You see a Preferred physician who charges $150 for covered services
subject to a $20 copayment. Even though our allowance may be $100, you still pay
just the $20 copayment. Because of the agreement, your Preferred physician will
not bill you for the $130 difference between your copayment and his/ her bill.

Remember, under Basic Option, you must use Preferred providers in order to
receive benefits. See page 11 for the exceptions to this requirement.

Participating providers. These types of Non-preferred providers have
agreements with the Local Plan to limit what they bill our Standard Option
members.

Under Standard Option, when you use a Participating provider, your share of
covered charges consists only of your deductible and coinsurance or copayment.
Here is an example: You see a Participating physician who charges $150, but the
Plan allowance is $100. If you have met your deductible, you are only responsible
for your coinsurance. That is, under Standard Option, you pay just 25% of our $100
allowance ($ 25). Because of the agreement, your Participating physician will not
bill you for the $50 difference between our allowance and his/ her bill. See page 7
for exceptions.

Under Basic Option, there are no benefits for care performed by Participating
providers; you pay all charges. See page 11 for the exceptions to this
requirement. 16
16 Page 17 18

2002 Blue Cross and Blue Shield
Service Benefit Plan 17 Section 4

Non-participating providers. These Non-preferred providers have no agreement to
limit what they will bill you.

Under Standard Option, when you use a Non-participating provider, you will pay
your deductible and coinsurance – plus any difference between our allowance and the
charges on the bill. For example, you see a Non-participating physician who charges
$150. The Plan allowance is again $100, and you have met your deductible. You are
responsible for your coinsurance, so you pay 25% of the $100 Plan allowance or $25.
Plus, because there is no agreement between the Non-participating physician and us,
the physician can bill you for the $50 difference between our allowance and his/ her
bill.

Under Basic Option, there are no benefits for care performed by Non-participating providers; you pay all charges. See page 11 for the exceptions to

this requirement.
The following table illustrates examples of how much you have to pay out-of-pocket
for services from a Preferred physician, a Participating physician, and a Non-participating
physician. The table uses our example of a service for which the
physician charges $150 and the Plan allowance is $100. For Standard Option, the table
shows the amount you pay if you have met your calendar year deductible.

EXAMPLE
Preferred
physician
Standard Option

Preferred
physician
Basic Option

Participating
physician (Standard Option*)
Non-participating
physician (Standard Option*)

Physician's charge $150 $150 $150 $150
Our allowance We set it at: 100 We set it at: 100 We set it at: 100 We set it at: 100

We pay 90% of our allowance: 90 Our allowance less copay: 80 75% of our allowance: 75 75% of our allowance: 75
You owe:
Coinsurance
10% of our
allowance: 10 Not applicable
25% of our
allowance: 25
25% of our
allowance: 25

You owe:
Copayment Not applicable 20 Not applicable Not applicable

+Difference up to
charge? No: 0 No: 0 No: 0 Yes: 50

TOTAL YOU PAY $10 $20 $25 $75

*Under Basic Option, there are no benefits for care performed by Participating and
Non-participating physicians. You must use Preferred providers in order to receive benefits. See page 11 for the exceptions to this requirement.

Note: Under Standard Option, had you not met any of your deductible in the above
examples, only our allowance ($ 100), which you would pay in full, would count toward
your deductible.

Overseas providers. We pay overseas claims at Preferred benefit levels, using an Overseas Fee Schedule as our Plan allowance. Most overseas professional providers

are under no obligation to accept our allowance, and you must pay any difference
between our payment and the provider's bill. For facility care you receive overseas,
we provide benefits in full after you pay the applicable copayment or coinsurance.
See Section 5( g) for more information about our overseas benefits. 17
17 Page 18 19

2002 Blue Cross and Blue Shield
Service Benefit Plan 18 Section 4

Dental care. Under Standard Option, we pay scheduled amounts for routine dental services and you pay any balance. Under Basic Option, you pay $20 for any
covered evaluation and we pay the balance for covered services. See Section 5( h) for
a listing of covered dental services.

Hospital care. You pay the coinsurance or copayment amounts listed in Section 5( c). Under Standard Option, you must meet your deductible before we begin

providing benefits for certain hospital-billed services. Under Basic Option, you
must use Preferred facilities in order to receive benefits. See page 11 for the
exceptions to this requirement.

Your catastrophic protection out-of-pocket maximum If the total amount of out-of-pocket expenses in a calendar year for you and your covered family members for deductibles (Standard Option only), coinsurance, and
copayments (other than those listed below) exceeds $6,000 under Standard Option, or
$5, 000 under Basic Option, then you and any covered family members will not have to
continue paying them for the remainder of the calendar year.

Standard Option Preferred maximum: If the total amount of these out-of-pocket
expenses from using Preferred providers for you and your covered family members
exceeds $4,000 in a calendar year under Standard Option, then you and any covered
family members will not have to pay these expenses for the remainder of the calendar
year when you continue to use Preferred providers. You will, however, have to pay
them when you use Non-preferred providers, until your out-of-pocket expenses (for the
services of both Preferred and Non-preferred providers) reach $6,000 under Standard
Option, as shown above.

Basic Option maximum: If the total amount of these out-of-pocket expenses from
using Preferred providers for you and your covered family members exceeds $5,000 in
a calendar year under Basic Option, then you and any covered family members will not
have to pay these expenses for the remainder of the calendar year.

The following expenses are not included under this feature. These expenses do not count toward your catastrophic protection out-of-pocket maximum, and you must

continue to pay them even after your expenses exceed the limits described above.
The difference between the Plan allowance and the billed amount. See pages 16-17;

Expenses for services, drugs, and supplies in excess of our maximum benefit limitations;
Under Standard Option, your 30% coinsurance for inpatient care in a Non-member hospital;
Under Standard Option, your 25% coinsurance for outpatient care by a Non-member facility;
Your expenses for mental conditions and substance abuse care by a Non-preferred professional or facility provider;
Your expenses for dental services in excess of our fee schedule payments under Standard Option. See Section 5( h);
The $500 penalty for failing to obtain precertification, and any other amounts you pay because we reduce benefits for not complying with our cost containment
requirements;
Under Basic Option, coinsurance you pay for non-formulary brand-name drugs; and

Under Basic Option, your expenses for care received from Participating/ Non-participating professional providers or Member/ Non-member facilities, except for
coinsurance and copayments you pay in those special situations where we do pay
for care provided by Non-preferred providers. Please see page 11 for the
exceptions to the requirement to use Preferred providers.

Note: If you change to another plan during Open Season, we will continue to provide
benefits between January 1 and the effective date of your new plan. 18
18 Page 19 20

2002 Blue Cross and Blue Shield
Service Benefit Plan 19 Section 4

If you had already paid the out-of- pocket maximum, we will continue to provide benefits as described on page 18 until the effective date of your new plan.
If you had not yet paid the out-of- pocket maximum, we will apply any expenses you incur in January (before the effective date of your new plan) to our prior
year's out-of-pocket maximum. Once you reach the maximum, you don't need to
pay our deductibles, copayments or coinsurance amounts (except as shown on
page 18) from that point until the effective date of your new plan.

Note: Because benefit changes are effective January 1, we will apply our next year's
benefits to any expenses you incur in January.

Note: If you change options in this Plan during the year, we will credit the amounts
already accumulated toward the catastrophic protection out-of-pocket limit of your old
option to the catastrophic protection out-of-pocket limit of your new option. If you
change from Self Only to Self and Family, or vice versa, during the calendar year,
please call us about your out-of-pocket accumulations and how they carry over.

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

If we overpay you We will make diligent efforts to recover benefit payments we made in error but in good faith. We may reduce subsequent benefit payments to offset overpayments.

Note: We will generally first seek recovery from the provider if we paid the provider
directly, or from the person (covered family member, guardian, custodial parent, etc.) to
whom we sent our payment. 19
19 Page 20 21
2002 Blue Cross and Blue Shield
Service Benefit Plan 20 Section 4

When you are age 65 or over and you do not have Medicare
Under the FEHB law, we must limit our payments for those benefits you would be entitled to if you had Medicare. And, your
physician and hospital must follow Medicare rules and cannot bill you for more than they could bill you if you had Medicare. The
following chart has more information about the limits.

If you…
are age 65 or over; and
do not have Medicare Part A, Part B, or both; and
have this Plan as an annuitant, as a former spouse, or as a family member of an annuitant or former spouse; and
are not employed in a position that gives FEHB coverage. (Your employing office can tell you if this applies.)

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

you are responsible for your deductible (Standard Option only), coinsurance, or copayments you owe under this Plan;
you are not responsible for any charges greater than the equivalent Medicare amount; we will show that amount on the explanation of benefits (EOB) form that we send you; and

the law prohibits a hospital from collecting more than the equivalent Medicare amount.
And, for your physician care, the law requires us to base our payment and your applicable coinsurance or copayment on…
an amount set by Medicare and called the "Medicare approved amount" or
the actual charge if it is lower than the Medicare approved amount.

If your physician… Then you are responsible for…

Standard Option: your deductibles, coinsurance, and copayments Participates with Medicare or accepts Medicare assignment for the claim and is in our Preferred
network Basic Option: your copayments and coinsurance

Standard Option: your deductibles, coinsurance, and copayments, and any balance up to the Medicare approved amount Participates with Medicare or accepts Medicare
assignment and is not in our Preferred network Basic Option: all charges

Standard Option: your deductibles, coinsurance, and copayments, and any balance up to 115% of the Medicare approved amount
Basic Option: your copayments and coinsurance Does not participate with Medicare, and is in
our Preferred network Note: In many cases, your payment will be less because
of our Preferred agreements. Contact your Local Plan
for information about what your specific Preferred
provider can collect from you.

Standard Option: your deductibles, coinsurance, copayments, and any balance up to 115% of the Medicare approved amount Does not participate with Medicare and is not in
our Preferred network Basic Option: all charges

It is generally to your financial advantage to use a physician who participates with Medicare. Such physicians are permitted to collect
only up to the Medicare approved amount.

Our explanation of benefits (EOB) form will tell you how much the physician or hospital can collect from you. If your physician or
hospital tries to collect more than allowed by law, ask the physician or hospital to reduce the charges. If you have paid more than
allowed, ask for a refund. If you need further assistance, call us. 20
20 Page 21 22

2002 Blue Cross and Blue Shield
Service Benefit Plan 21 Section 4

When you have the We limit our payment to an amount that supplements the benefits that Medicare Original Medicare Plan would pay under Medicare Part A (Hospital Insurance) and Medicare Part B (Medical
(Part A, Part B, or both) Insurance), regardless of whether Medicare pays.
Note: We pay our regular benefits for emergency services to a facility provider, such as
a hospital, that does not participate with Medicare and is not reimbursed by Medicare.

If you are covered by Medicare Part B and it is primary, your out-of-pocket costs for
services that both Medicare Part B and we cover depend on whether your physician
accepts Medicare assignment for the claim.

If your physician accepts Medicare assignment, then you pay nothing for covered
charges.

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

Note: Under Basic Option, you must see Preferred providers in order to receive
benefits. See page 11 for the exceptions to this requirement.

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

When you have a Medicare Private Contract A physician may ask you to sign a private contract agreeing that you can be billed directly for services Medicare ordinarily covers. Should you sign an agreement,
Medicare will not pay any portion of the charges, and we will not increase our payment
to you or the physician. We will still limit our payment to the amount we would have
paid after Medicare's payment. You will be responsible for paying the difference
between the limiting charge and the amount we paid.

Please see Section 9, Coordinating benefits with other coverage, for more information about how we coordinate benefits with Medicare. 21
21 Page 22 23

2002 Blue Cross and Blue Shield
Service Benefit Plan 22 Section 5

Section 5. Benefits --OVERVIEW
(See page 8 for how our benefits changed this year and pages 118-119 for a benefits summary.)

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

(a) Medical services and supplies provided by physicians and other health care professionals..................................................... 23-43
Diagnostic and treatment services
Lab, X-ray, and other diagnostic tests
Preventive care, adult
Preventive care, children
Maternity care
Family planning
Infertility services
Allergy care
Treatment therapies
Physical therapy
Occupational and speech therapies

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

(b) Surgical and anesthesia services provided by physicians and other health care professionals................................................. 44-54
Surgical procedures
Reconstructive surgery
Oral and maxillofacial surgery

Organ/ tissue transplants
Anesthesia

(c) Services provided by a hospital or other facility, and ambulance services............................................................................... 55-64
Inpatient hospital
Outpatient hospital or ambulatory surgical center
Extended care benefits/ Skilled nursing care facility
benefits

Hospice care
Ambulance

(d) Emergency services/ Accidents ................................................................................................................................................. 65-69
Medical emergency
Accidental injury
Ambulance

(e) Mental health and substance abuse benefits ............................................................................................................................. 70-76
(f) Prescription drug benefits......................................................................................................................................................... 77-84
(g) Special features.............................................................................................................................................................................. 85

Flexible benefits option
24-hour nurse line
Services for the deaf and hearing impaired
Travel benefit/ services overseas
Health support programs
(h) Dental benefits.......................................................................................................................................................................... 86-91
(i) Non-FEHB benefits available to Plan members............................................................................................................................ 92
SUMMARY OF BENEFITS ......................................................................................................................................................... 118-119 22
22 Page 23 24

2002 Blue Cross and Blue Shield
Service Benefit Plan 23 Section 5( a)

Section 5 (a). Medical services and supplies provided by physicians and other health care professionals
I M
P O
R T
A N
T

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

Under Standard Option, the calendar year deductible is $250 per person ($ 500 per family). The calendar year deductible applies to almost all benefits in this Section. We added "( No deductible)"
to show when the calendar year deductible does not apply.
Under Basic Option, there is no calendar year deductible.
Under Basic Option, you must use Preferred providers in order to receive benefits. See page 11 for the exceptions to this requirement.

Please refer to Section 3, How you receive benefits, for a list of providers we consider to be primary care providers (under Basic Option) and other health care professionals.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works, with special sections for members who are age 65 or over. Also read Section 9
about coordinating benefits with other coverage, including Medicare.
We base payment on whether a facility or a health care professional bills for the services or supplies. You will find that some benefits are listed in more than one section of the brochure.

This is because how they are paid depends on what type of provider bills for the service. For
example, physical therapy is paid differently depending on whether it is billed by an inpatient
facility, a doctor, a physical therapist, or an outpatient facility.

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

or other outpatient facility, etc.).
The non-PPO benefits are the standard benefits for Standard Option. PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non-PPO benefits apply.

I M
P O
R T
A N
T

Benefit Description You Pay
NOTE: The calendar year deductible applies to almost all Standard Option benefits in this Section. We say "( No deductible)" when the Standard Option deductible does not apply.
There is no calendar year deductible under Basic Option.
Diagnostic and treatment services You Pay – Standard Option You Pay – Basic Option
Professional services of physicians and other health
care professionals:

Outpatient consultations
Outpatient second surgical opinions
Office visits
Home visits
Initial examination of a newborn needing definitive treatment when covered under a family enrollment

Preferred: $15 copayment for
the office visit charge (No
deductible)

Participating: 25% of the Plan
allowance

Non-participating: 25% of the
Plan allowance, plus any
difference between our
allowance and the billed
amount

Preferred primary care
provider or other health care
professional: $20 copayment
per visit

Preferred specialist: $30
copayment per visit

Participating/ Non-participating:
You pay all
charges

Diagnostic and treatment services – continued on next page 23
23 Page 24 25

2002 Blue Cross and Blue Shield
Service Benefit Plan 24 Section 5( a)

NOTE: The calendar year deductible applies to almost all Standard Option benefits in this Section.
We say "( No deductible)" when the Standard Option deductible does not apply.
There is no calendar year deductible under Basic Option.

Diagnostic and treatment services (continued) You Pay – Standard Option You Pay – Basic Option

Outpatient professional services:
Pharmacotherapy [see Section 5( f) for prescription drug coverage]

Neurological testing

Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Preferred primary care
provider or other health care
professional: $20 copayment
per visit

Preferred specialist: $30
copayment per visit

Participating/ Non-participating:
You pay all
charges

Inpatient professional services:
During a hospital stay
Services for nonsurgical procedures when ordered, provided, and billed by a physician during a

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

care when you are hospitalized) on days we pay
inpatient hospital benefits

Note: A consulting physician employed by the
hospital is not the attending physician.

Consultations when requested by the attending physician

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

Physical therapy by a physician other than the attending physician

Initial examination of a newborn needing definitive treatment when covered under a family
enrollment
Pharmacotherapy [see Section 5( c) for prescription drug coverage]

Neurological testing
Second surgical opinion

Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Note: We provide benefits at
90% of the Plan allowance
for services provided in
Preferred facilities by Non-preferred
radiologists,
anesthesiologists, certified
registered nurse anesthetists
(CRNAs), pathologists, and
emergency room physicians.
You are responsible for any
difference between our
allowance and the billed
amount.

Preferred: Nothing
Participating/ Non-participating:
You pay all
charges

Note: We provide benefits at
100% of the Plan allowance
for services provided in
Preferred facilities by Non-preferred
radiologists,
anesthesiologists, certified
registered nurse anesthetists
(CRNAs), pathologists,
emergency room physicians,
and assistant surgeons. You
are responsible for any
difference between our
allowance and the billed
amount.

Diagnostic and treatment services – continued on next page 24
24 Page 25 26

2002 Blue Cross and Blue Shield
Service Benefit Plan 25 Section 5( a)

NOTE: The calendar year deductible applies to almost all Standard Option benefits in this Section.
We say "( No deductible)" when the Standard Option deductible does not apply.
There is no calendar year deductible under Basic Option.

Diagnostic and treatment services (continued) You Pay – Standard Option You Pay – Basic Option

Not covered:
Routine services except for those Preventive care services described on pages 27-30

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

Inpatient physician care when your hospital admission or portion of an admission is not
covered [see Section 5( c)]
Note: If we determine that a hospital admission
is not covered, we will not provide benefits for
inpatient room and board or inpatient physician
care. However, we will provide benefits for
covered services or supplies other than room
and board and inpatient physician care at the
level that we would have paid if they had been
provided in some other setting.

All charges All charges 25
25 Page 26 27

2002 Blue Cross and Blue Shield
Service Benefit Plan 26 Section 5( a)

NOTE: The calendar year deductible applies to almost all Standard Option benefits in this Section.
We say "( No deductible)" when the Standard Option deductible does not apply.
There is no calendar year deductible under Basic Option.

Lab, X-ray, and other diagnostic tests You Pay – Standard Option You Pay – Basic Option
Diagnostic tests provided, or ordered and billed
by a physician, such as:

Blood tests
CT scans/ MRIs
EKGs and EEGs
Laboratory tests
Pathology services
Ultrasounds
Urinalysis
X-rays
Laboratory and pathology services billed by an
independent laboratory

Note: See Section 5( c) for services billed for by
a facility, such as the outpatient department of a
hospital.

Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

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

Preferred primary care
provider or other health care
professional: $20 copayment
per visit

Preferred specialist: $30
copayment per visit

Participating/ Non-participating:
You pay all
charges

Note: For services billed by
Participating and Non-participating
laboratories or
radiologists, you pay a
separate $20 copayment, plus
any difference between our
allowance and the billed
amount.

Other diagnostic tests provided, or ordered and
billed by a physician, such as:

Fecal occult blood tests
Non-routine mammograms
Non-routine Pap tests
Prostate Specific Antigen (PSA) tests
Sigmoidoscopies
Note: See Section 5( c) for services billed for by
a facility, such as the outpatient department of a
hospital.

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

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

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

Preferred primary care
provider or other health care
professional: $20 copayment
per visit

Preferred specialist: $30
copayment per visit

Participating/ Non-participating:
You pay all
charges

Note: For services billed by
Participating and Non-participating
laboratories or
radiologists, you pay a
separate $20 copayment, plus
any difference between our
allowance and the billed
amount. 26
26 Page 27 28

2002 Blue Cross and Blue Shield
Service Benefit Plan 27 Section 5( a)

NOTE: The calendar year deductible applies to almost all Standard Option benefits in this Section.
We say "( No deductible)" when the Standard Option deductible does not apply.
There is no calendar year deductible under Basic Option.

Preventive care, adult You Pay – Standard Option You Pay – Basic Option
Home and office visits for routine (screening)
physical examinations

Under Standard Option, benefits are limited
to the following services when performed as
part of a routine physical examination:

History and risk assessment
Chest X-ray
EKG
Urinalysis
Basic or comprehensive metabolic panel test
CBC
Cholesterol tests (may be done by any independent laboratory)

Chlamydial infection test
Under Basic Option, benefits are provided for
all of the services listed above and for other
appropriate screening tests and services.

Note: These benefits do not apply to children
up to age 22. (See benefits under Preventive
care, children, this section.)

Preferred: $15 copayment for
the examination (No
deductible); nothing for
services or tests

Note: We cover one routine
physical examination every
three calendar years for
members under age 65 and
one each calendar year for
members age 65 and older.

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

Participating:
You pay all charges

Non-participating:
You pay all charges

Note: When billed by a
facility, such as the
outpatient department of a
hospital, we provide benefits
as shown here, according to
the contracting status of the
facility.

Preferred primary care
provider or other health care
professional: $20 copayment
per visit

Preferred specialist: $30
copayment per visit

Participating/ Non-participating:
You pay all
charges

Note: For services billed by
Participating and Non-participating
laboratories or
radiologists, you pay a
separate $20 copayment, plus
any difference between our
allowance and the billed
amount.

Note: See Section 5( c) for
our payment levels for these
services when billed for by a
facility, such as the
outpatient department of a
hospital.

Preventive care, adult – continued on next page 27
27 Page 28 29

2002 Blue Cross and Blue Shield
Service Benefit Plan 28 Section 5( a)

NOTE: The calendar year deductible applies to almost all Standard Option benefits in this Section.
We say "( No deductible)" when the Standard Option deductible does not apply.
There is no calendar year deductible under Basic Option.

Preventive care, adult (continued) You Pay – Standard Option You Pay – Basic Option

Cancer screening
Colorectal cancer screening, including:
Fecal occult blood test
Sigmoidoscopy
Prostate cancer screening – Prostate Specific Antigen (PSA) test

Cervical cancer screening
Breast cancer screening (routine mammograms)

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

Note: We provide benefits in
full for preventive
(screening) tests and
immunizations only when
you receive these services
from a Preferred provider
on an outpatient basis. If
these services are billed
separately from the routine
physical examination, you
may be responsible for
paying an additional
copayment for each office
visit billed.

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Note: When billed by a
facility, such as the
outpatient department of a
hospital, we provide benefits
as shown here, according to
the contracting status of the
facility.

Preferred primary care
provider or other health care
professional: $20 copayment
per visit

Preferred specialist: $30
copayment per visit

Participating/ Non-participating:
You pay all
charges

Note: For services billed by
Participating and Non-participating
laboratories or
radiologists, you pay a
separate $20 copayment, plus
any difference between our
allowance and the billed
amount.

Note: See Section 5( c) for
our payment levels for these
services when billed for by a
facility, such as the
outpatient department of a
hospital.

Preventive care, adult – continued on next page 28
28 Page 29 30

2002 Blue Cross and Blue Shield
Service Benefit Plan 29 Section 5( a)

NOTE: The calendar year deductible applies to almost all Standard Option benefits in this Section.
We say "( No deductible)" when the Standard Option deductible does not apply. There is no calendar year deductible under Basic Option.

Preventive care, adult (continued) You Pay – Standard Option You Pay – Basic Option
Cancer screening (continued) Note: If you go to a
Participating or Non-participating
provider for
these services, the following
limits apply:

Fecal occult blood test – one annually starting at age

40
Sigmoidoscopy – one every five years starting at

age 50
Prostate Specific Antigen (PSA) test – one annually

for males age 40 and older
Cervical cancer screening – one routine Pap test

annually for females of any
age

Breast cancer screening – routine mammograms for

females age 35 and older,
as follows

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

period
From age 40 through 64, one annually

At age 65 and older, one every two consecutive
calendar years
Note: When billed by a
facility, such as the
outpatient department of a
hospital, we provide benefits
as shown here, according to
the contracting status of the
facility.

See page 28

Preventive care, adult – continued on next page 29
29 Page 30 31

2002 Blue Cross and Blue Shield
Service Benefit Plan 30 Section 5( a)

NOTE: The calendar year deductible applies to almost all Standard Option benefits in this Section.
We say "( No deductible)" when the Standard Option deductible does not apply. There is no calendar year deductible under Basic Option.

Preventive care, adult (continued) You Pay – Standard Option You Pay – Basic Option
Routine immunizations without regard to age,
limited to:

Hepatitis immunizations (Types A and B) for patients with increased risk or family history

Influenza and pneumococcal vaccines, annually
Lyme disease vaccine
Tetanus-diphtheria (Td) booster – once every 10 years

Preferred: $15 copayment for
associated office visits (No
deductible); nothing for
immunizations

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Preferred primary care
provider or other health care
professional: $20 copayment
for associated office visits;
nothing for immunizations

Preferred specialist: $30
copayment for associated
office visits; nothing for
immunizations

Participating/ Non-participating:
You pay all
charges

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

All charges All charges

Preventive care, children
We provide benefits for the following services:
All healthy newborn visits including routine screening (inpatient or outpatient)

The following routine services as recommended by the American Academy of
Pediatrics for children up to the age of 22,
including children living, traveling, or
adopted from outside the United States:

Routine physical examinations
Routine hearing tests
Laboratory tests
Immunizations
Related office visits

Preferred: Nothing (No
deductible)

Participating: Nothing (No
deductible)

Non-participating: Nothing
(No deductible) up to the
Plan allowance. You are
responsible only for any
difference between our
allowance and the billed
amount.

Note: When billed by a
facility, such as the outpatient
department of a hospital, we
provide benefits as shown
here, according to the
contracting status of the
facility.

Preferred primary care
provider or other health care
professional: $20 copayment
per visit; you pay nothing for
inpatient visits

Preferred specialist: $30
copayment per visit; you pay
nothing for inpatient visits

Participating/ Non-participating:
You pay all
charges

Note: For services billed by
Participating and Non-participating
laboratories or
radiologists, you pay a
separate $20 copayment, plus
any difference between our
allowance and the billed
amount.

Note: See Section 5( c) for
our payment levels for these
services when billed for by a
facility, such as the outpatient
department of a hospital. 30
30 Page 31 32

2002 Blue Cross and Blue Shield
Service Benefit Plan 31 Section 5( a)

NOTE: The calendar year deductible applies to almost all Standard Option benefits in this Section.
We say "( No deductible)" when the Standard Option deductible does not apply. There is no calendar year deductible under Basic Option.

Maternity care You Pay – Standard Option You Pay – Basic Option
Complete maternity (obstetrical) care including
related conditions resulting in childbirth or
miscarriage when provided, or ordered and
billed by a physician or nurse midwife, such as:

Prenatal care
Delivery
Postpartum care
Note: Here are some things to keep in mind:

You do not need to precertify your normal delivery; see page 13 for other circumstances,

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

after a cesarean delivery. We will cover an
extended stay, if medically necessary, but
you, your representative, your doctor, or your
hospital must precertify the extended stay.
See Section 3 for information on requesting
additional days.

We cover routine nursery care of the newborn child during the covered portion of the

mother's maternity stay, or if the child is
covered under the father's Self and Family
enrollment.

Preferred: Nothing (No
deductible)

Note: For facility care related
to maternity, including care
at birthing facilities, we
waive the per admission
copayment and pay for
covered services in full when
you use Preferred providers.

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Preferred: $100 copayment
for the delivery; nothing for
prenatal and postpartum care

Note: For facility care related
to maternity, including care
at birthing facilities, see
Section 5( c).

Participating/ Non-participating:
You pay all
charges

Note: For services billed by
Participating and Non-participating
laboratories and
radiologists, you are
responsible only for any
difference between our
allowance and the billed
amount.

Note: When a newborn requires definitive
treatment including incubation charges by
reason of prematurity or evaluation for medical
or surgical reasons during or after the mother's
confinement, the newborn is considered a
patient in his or her own right. Expenses of the
newborn including circumcision are eligible for
benefits only if the child is covered by a Self
and Family enrollment.

Note: We pay assistant surgeon services
(delivery) and anesthesia the same as for illness
or injury. See Surgical and anesthesia
benefits in Section 5( b).

Not covered: Procedures, services, drugs, and
supplies related to abortions except when the
life of the mother would be endangered if the
fetus were carried to term or when the
pregnancy is the result of an act of rape or
incest

All charges All charges 31
31 Page 32 33

2002 Blue Cross and Blue Shield
Service Benefit Plan 32 Section 5( a)

NOTE: The calendar year deductible applies to almost all Standard Option benefits in this Section.
We say "( No deductible)" when the Standard Option deductible does not apply. There is no calendar year deductible under Basic Option.

Family planning You Pay – Standard Option You Pay – Basic Option
A broad range of voluntary family planning
services, limited to:

Depo-Provera
Diaphragms
Intrauterine devices (IUDs)
Norplant
Oral contraceptives
Voluntary sterilization
Note: See Section 5( f) for prescription drug
coverage.

Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Preferred primary care
provider or other health care
professional: $20 copayment
per visit

Preferred specialist: $30
copayment per visit

Note: You pay $100 for
related surgical procedures.
See Section 5( b) for our
coverage for related surgical
procedures.

Participating/ Non-participating:
You pay all
charges

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

All charges All charges

Infertility services
Diagnosis and treatment of infertility, except as
shown in Not Covered

Note: See Section 5( f) for prescription drug
coverage.

Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Preferred primary care
provider or other health care
professional: $20 copayment
per visit

Preferred specialist: $30
copayment per visit

Participating/ Non-participating:
You pay all
charges

Note: For services billed by
Participating and Non-participating
laboratories or
radiologists, you pay a
separate $20 copayment, plus
any difference between our
allowance and the billed
amount.

Infertility services – continued on next page 32
32 Page 33 34
2002 Blue Cross and Blue Shield
Service Benefit Plan 33 Section 5( a)

NOTE: The calendar year deductible applies to almost all Standard Option benefits in this Section.
We say "( No deductible)" when the Standard Option deductible does not apply.
There is no calendar year deductible under Basic Option.

Infertility services (continued) You Pay – Standard Option You Pay – Basic Option
Not covered:
Assisted reproductive technology (ART) procedures, such as:

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

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

All charges All charges

Allergy care
Testing and treatment, including materials (such as allergy serum)

Allergy injections

Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Preferred primary care
provider or other health care
professional: $20 copayment
per visit; nothing for
injections

Preferred specialist: $30
copayment per visit; nothing
for injections

Participating/ Non-participating:
You pay all
charges

Note: For services billed by
Participating and Non-participating
laboratories or
radiologists, you pay a
separate $20 copayment, plus
any difference between our
allowance and the billed
amount.

Not covered: Provocative food testing and
sublingual allergy desensitization
All charges All charges 33
33 Page 34 35

2002 Blue Cross and Blue Shield
Service Benefit Plan 34 Section 5( a)

NOTE: The calendar year deductible applies to almost all Standard Option benefits in this Section.
We say "( No deductible)" when the Standard Option deductible does not apply.
There is no calendar year deductible under Basic Option.

Treatment therapies You Pay – Standard Option You Pay – Basic Option
Outpatient treatment therapies:
Chemotherapy and radiation therapy
Note: We cover high dose chemotherapy
and/ or radiation therapy in connection with
bone marrow transplants, and drugs or
medications to stimulate or mobilize stem
cells for transplant procedures, only for those
conditions listed as covered under
Organ/ tissue transplants in Section 5( b). See
also, Services requiring our prior approval, in
Section 3.

Renal dialysis – Hemodialysis and peritoneal dialysis

Intravenous (IV)/ infusion therapy – Home IV or infusion therapy
Note: Home nursing visits associated with
Home IV/ infusion therapy are covered as
shown under Home health services on page
41.

Pharmacotherapy [see Section 5( f) for prescription drug coverage]

Outpatient cardiac rehabilitation (Prior approval is required. See Section 3.)
Note: See Section 5( c) for our payment levels
for treatment therapies billed for by the
outpatient department of a hospital.

Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Preferred primary care
provider or other health care
professional: $20 copayment
per visit

Preferred specialist: $30
copayment per visit

Participating/ Non-participating:
You pay all
charges

Note: You pay 30% of the
Plan allowance for drugs and
supplies related to outpatient
treatment therapies.

Inpatient treatment therapies:
Chemotherapy and radiation therapy
Note: We cover high dose chemotherapy
and/ or radiation therapy in connection with
bone marrow transplants, and drugs or
medications to stimulate or mobilize stem
cells for transplant procedures, only for those
conditions listed as covered under
Organ/ tissue transplants in Section 5( b). See
also, Services requiring our prior approval, in
Section 3.

Renal dialysis – Hemodialysis and peritoneal dialysis

Pharmacotherapy [see Section 5( f) for prescription drug coverage]

Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of the
Plan allowance, plus any
difference between our
allowance and the billed
amount

Note: We provide benefits at
90% of the Plan allowance for
services provided in Preferred
facilities by Non-preferred
radiologists,
anesthesiologists, certified
registered nurse anesthetists
(CRNAs), pathologists, and
emergency room physicians.
You are responsible for any
difference between our
allowance and the billed
amount.

Preferred: Nothing
Participating/ Non-participating:
You pay all
charges

Note: We provide benefits at
100% of the Plan allowance
for services provided in
Preferred facilities by Non-preferred
radiologists,
anesthesiologists, certified
registered nurse anesthetists
(CRNAs), pathologists,
emergency room physicians,
and assistant surgeons. You
are responsible for any
difference between our
allowance and the billed
amount. 34
34 Page 35 36

2002 Blue Cross and Blue Shield
Service Benefit Plan 35 Section 5( a)

NOTE: The calendar year deductible applies to almost all Standard Option benefits in this Section.
We say "( No deductible)" when the Standard Option deductible does not apply. There is no calendar year deductible under Basic Option.

Physical therapy You Pay – Standard Option You Pay – Basic Option
When performed by a physical therapist or
physician:

Physical therapy
Acupuncture as a physical therapy modality and for pain management

Note: See Section 5( c) for our payment levels
for physical therapy performed in and billed by
the outpatient department of a hospital.

Note: When billed by a skilled nursing facility,
nursing home, or extended care facility, we pay
benefits as shown here for professional care,
according to the contracting status of the
therapist.

Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Note: Benefits are limited to
50 visits per person, per
calendar year.

Note: Visits that you pay for
while meeting your calendar
year deductible count toward
the limit cited above.

Preferred primary care
provider or other health care
professional: $20 copayment
per visit

Preferred specialist: $30
copayment per visit

Note: Benefits are limited to
50 visits per person, per
calendar year for physical,
occupational, or speech
therapy, or a combination of
all three.

Participating/ Non-participating:
You pay all
charges

Not covered:
Recreational or educational therapy, and any related diagnostic testing except as provided

by a hospital as part of a covered inpatient
stay

Maintenance or palliative rehabilitative therapy

Exercise programs
Hippotherapy (exercise on horseback)

All charges All charges 35
35 Page 36 37

2002 Blue Cross and Blue Shield
Service Benefit Plan 36 Section 5( a)

NOTE: The calendar year deductible applies to almost all Standard Option benefits in this Section.
We say "( No deductible)" when the Standard Option deductible does not apply.
There is no calendar year deductible under Basic Option.

Occupational and speech therapies You Pay – Standard Option You Pay – Basic Option
Occupational and speech therapy when
performed by an occupational therapist, speech
therapist, or physician

Note: See Section 5( c) for our payment levels
for occupational and speech therapy performed
in and billed by the outpatient department of a
hospital.

Note: When billed by a skilled nursing facility,
nursing home, or extended care facility, we pay
benefits as shown here for professional care,
according to the contracting status of the
therapist.

Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Note: Benefits are limited to
25 visits per person, per
calendar year for
occupational therapy or
speech therapy, or a
combination of both.

Note: Visits that you pay for
while meeting your calendar
year deductible count toward
the limit cited above.

Preferred primary care
provider or other health care
professional: $20 copayment
per visit

Preferred specialist: $30
copayment per visit

Note: Benefits are limited to
50 visits per person, per
calendar year for physical,
occupational, or speech
therapy, or a combination of
all three.

Participating/ Non-participating:
You pay all
charges

Not covered:
Recreational or educational therapy, and any related diagnostic testing except as provided

by a hospital as part of a covered inpatient
stay

Maintenance or palliative rehabilitative therapy

Exercise programs

All charges All charges 36
36 Page 37 38

2002 Blue Cross and Blue Shield
Service Benefit Plan 37 Section 5( a)

NOTE: The calendar year deductible applies to almost all Standard Option benefits in this Section.
We say "( No deductible)" when the Standard Option deductible does not apply.
There is no calendar year deductible under Basic Option.

Hearing services (testing, treatment, and supplies) You Pay – Standard Option You Pay – Basic Option

Hearing tests related to illness or injury Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Preferred primary care
provider or other health care
professional: $20 copayment
per visit

Preferred specialist: $30
copayment per visit

Participating/ Non-participating:
You pay all
charges

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

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

All charges All charges

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

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

Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Preferred: 30% of the Plan
allowance

Participating/ Non-participating:
You pay all
charges

Eye examinations related to a specific medical condition
Nonsurgical treatment for amblyopia and strabismus, for children from birth through
age 12
Note: See Section 5( b), Surgical procedures,
for coverage for surgical treatment of
amblyopia and strabismus.

Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Preferred primary care
provider or other health care
professional: $20 copayment
per visit

Preferred specialist: $30
copayment per visit

Participating/ Non-participating:
You pay all
charges

Vision services (testing, treatment, and supplies) – continued on next page 37
37 Page 38 39

2002 Blue Cross and Blue Shield
Service Benefit Plan 38 Section 5( a)

NOTE: The calendar year deductible applies to almost all Standard Option benefits in this Section.
We say "( No deductible)" when the Standard Option deductible does not apply.
There is no calendar year deductible under Basic Option.

Vision services (testing, treatment, and supplies) (continued) You Pay – Standard Option You Pay – Basic Option

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

prescribing or fitting of eyeglasses or contact
lenses, except as described on page 37

Eye exercises, visual training, or orthoptics, except for nonsurgical treatment of amblyopia

and strabismus as described on page 37
LASIK, radial keratotomy, and other refractive services

All charges All charges

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

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

Note: See Section 5( b) for our coverage for
surgical procedures.

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

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Preferred primary care
provider or other health care
professional: $20 copayment
per visit

Preferred specialist: $30
copayment per visit

Participating/ Non-participating:
You pay all
charges

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

All charges All charges 38
38 Page 39 40

2002 Blue Cross and Blue Shield
Service Benefit Plan 39 Section 5( a)

NOTE: The calendar year deductible applies to almost all Standard Option benefits in this Section.
We say "( No deductible)" when the Standard Option deductible does not apply.
There is no calendar year deductible under Basic Option.

Orthopedic and prosthetic devices You Pay – Standard Option You Pay – Basic Option
Orthopedic braces and prosthetic appliances
such as:

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

Rigid devices attached to the foot or a brace, or placed in a shoe
Replacement, repair, and adjustment of covered devices
Following a mastectomy, breast prostheses and surgical bras, including necessary
replacements
Note: A prosthetic appliance is a device that is
surgically inserted or physically attached to the
body to restore a bodily function or replace a
physical portion of the body.

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

Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Preferred: 30% of the Plan
allowance

Participating/ Non-participating:
You pay all
charges

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

All charges All charges 39
39 Page 40 41
2002 Blue Cross and Blue Shield
Service Benefit Plan 40 Section 5( a)

NOTE: The calendar year deductible applies to almost all Standard Option benefits in this Section.
We say "( No deductible)" when the Standard Option deductible does not apply.
There is no calendar year deductible under Basic Option.

Durable medical equipment (DME) You Pay – Standard Option You Pay – Basic Option
Durable medical equipment (DME) is equipment
and supplies that:

1. Are prescribed by your attending physician
(i. e., the physician who is treating your
illness or injury);

2. Are medically necessary;
3. Are primarily and customarily used only for
a medical purpose;

4. Are generally useful only to a person with
an illness or injury;

5. Are designed for prolonged use; and
6. Serve a specific therapeutic purpose in the
treatment of an illness or injury.

We cover rental or purchase, at our option,
including repair and adjustment, of durable
medical equipment. Under this benefit, we
cover:

Home dialysis equipment
Oxygen equipment
Hospital beds
Wheelchairs
Crutches
Walkers
Other items that we determine to be DME

Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Preferred: 30% of the Plan
allowance

Participating/ Non-participating:
You pay all
charges

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

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

Equipment for cosmetic purposes

All charges All charges 40
40 Page 41 42
2002 Blue Cross and Blue Shield
Service Benefit Plan 41 Section 5( a)

NOTE: The calendar year deductible applies to almost all Standard Option benefits in this Section.
We say "( No deductible)" when the Standard Option deductible does not apply.
There is no calendar year deductible under Basic Option.

Medical supplies You Pay – Standard Option You Pay – Basic Option

Medical foods for children with inborn errors of amino acid metabolism

Medical foods and nutritional supplements when administered by catheter or nasogastric
tubes
Ostomy and catheter supplies
Oxygen, regardless of the provider
Blood and blood plasma except when donated or replaced, and blood plasma expanders

Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Preferred: 30% of the Plan
allowance

Participating/ Non-participating:
You pay all
charges

Home health services
Home nursing care for two (2) hours per day,
up to 25 visits per calendar year, when:

A registered nurse (R. N.) or licensed practical nurse (L. P. N.) provides the services; and

A physician orders the care

Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Note: Visits that you pay for
while meeting your calendar
year deductible count toward
the annual visit limit.

Preferred: $20 copayment per
visit

Participating/ Non-participating:
You pay all
charges

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

family
Services primarily for bathing, feeding, exercising, moving the patient, homemaking,

giving medication, or acting as a companion
or sitter

All charges All charges 41
41 Page 42 43

2002 Blue Cross and Blue Shield
Service Benefit Plan 42 Section 5( a)

NOTE: The calendar year deductible applies to almost all Standard Option benefits in this Section.
We say "( No deductible)" when the Standard Option deductible does not apply.
There is no calendar year deductible under Basic Option.

Chiropractic You Pay – Standard Option You Pay – Basic Option

Initial office visit
Spinal manipulations
Initial set of X-rays

All charges
Note: Benefits may be
available for covered
services you receive from
chiropractors in medically
underserved areas. See page
10 for additional
information.

Preferred: $20 copayment per
visit, up to 20 manipulations
per calendar year

Participating/ Non-participating:
You pay all
charges

Alternative treatments
Acupuncture – when performed and billed by a
physician or physical therapist, for:

pain relief, and
as a modality of physical therapy
Note: See page 35 for limitations.
Note: We may also cover services of certain
alternative treatment providers in medically
underserved areas. See page 10 for additional
information.

Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Preferred primary care
provider or other health care
professional: $20 copayment
per visit

Preferred specialist: $30
copayment per visit

Participating/ Non-participating:
You pay all
charges

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

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

All charges All charges 42
42 Page 43 44

2002 Blue Cross and Blue Shield
Service Benefit Plan 43 Section 5( a)

NOTE: The calendar year deductible applies to almost all Standard Option benefits in this Section.
We say "( No deductible)" when the Standard Option deductible does not apply.
There is no calendar year deductible under Basic Option.

Educational classes and programs You Pay – Standard Option You Pay – Basic Option

Smoking cessation
Note: See Section 5( e) for our coverage of
individual and group psychotherapy for
smoking cessation and Section 5( f) for our
coverage of smoking cessation drugs.

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

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Preferred primary care
provider or other health care
professional: $20 copayment
per visit

Preferred specialist: $30
copayment per visit

Participating/ Non-participating:
You pay all
charges

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

Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Preferred primary care
provider or other health care
professional: $20 copayment
per visit

Preferred specialist: $30
copayment per visit

Participating/ Non-participating:
You pay all
charges

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

performed as part of an educational class or
program

Premenstrual (PMS), lactation, headache, eating disorder, and other educational clinics

Recreational or educational therapy, and any related diagnostic testing except as provided
by a hospital as part of a covered inpatient
stay

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

All charges All charges 43
43 Page 44 45

2002 Blue Cross and Blue Shield
Service Benefit Plan 44 Section 5( b)

Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
I M
P O
R T
A N
T

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

Under Standard Option, the calendar year deductible is $250 per person ($ 500 per family). The calendar year deductible applies to almost all Standard Option benefits in this Section. We say "( No
deductible)" to show when the calendar year deductible does not apply.
Under Basic Option, there is no calendar year deductible.
Under Basic Option, you must use Preferred providers in order to receive benefits. See page 11 for the exceptions to this requirement.

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works, with special sections for members who are age 65 or over. Also read Section 9 about
coordinating benefits with other coverage, including Medicare.
We base payment on whether a facility or a health care professional bills for the services or supplies. You will find that some benefits are listed in more than one section of the brochure. This is because how they

are paid depends on what type of provider bills for the service.
The amounts listed below are for the charges billed by a physician or other health care professional for your surgical care. Look in Section 5( c) for charges associated with the facility (i. e., hospital, surgical

center, etc.).
YOU MUST GET PRIOR APPROVAL for all organ transplant surgical procedures; and if your surgical procedure requires an inpatient admission, YOU MUST GET PRECERTIFICATION. Please

refer to the prior approval and precertification information shown in Section 3 to be sure which services require prior approval or precertification.

The non-PPO benefits are the standard benefits for Standard Option. PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non-PPO benefits apply.

I M
P O
R T
A N
T

Benefit Description You pay
NOTE: The calendar year deductible applies to almost all Standard Option benefits in this Section.
We say "( No deductible)" when the Standard Option deductible does not apply.
There is no calendar year deductible under Basic Option.

Surgical procedures You pay – Standard Option You pay – Basic Option
A comprehensive range of services provided, or
ordered and billed by a physician, such as:

Operative procedures
Treatment of fractures and dislocations, including casting

Normal pre-and post-operative care by the surgeon
Correction of amblyopia and strabismus
Endoscopy procedures
Biopsy procedures
Removal of tumors and cysts
Correction of congenital anomalies (see Reconstructive surgery on page 46)

Treatment of burns

Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Preferred: $100 copayment
per performing surgeon

Note: If you receive the
services of a co-surgeon, you
pay a second $100
copayment for those services.
No additional copayment
applies to the services of
assistant surgeons.

Participating/ Non-participating:
You pay all
charges

Surgical procedures – continued on next page 44
44 Page 45 46

2002 Blue Cross and Blue Shield
Service Benefit Plan 45 Section 5( b)

NOTE: The calendar year deductible applies to almost all Standard Option benefits in this Section.
We say "( No deductible)" when the Standard Option deductible does not apply. There is no calendar year deductible under Basic Option.

Surgical procedures (continued) You pay – Standard Option You pay – Basic Option
Insertion of internal prosthetic devices. See Section 5( a) – Orthopedic and prosthetic
devices, and Section 5( c) – Other hospital
services and supplies – for our coverage for
the device.

Voluntary sterilization, Norplant (a surgically implanted contraceptive), and intrauterine

devices (IUDs)
Assistant surgeons/ surgical assistance by a physician if required because of the

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

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

Note: When multiple surgical procedures that
add time or complexity to patient care are
performed during the same operative session,
the Local Plan determines our allowance for the
combination of multiple, bilateral, or incidental
surgical procedures. Generally, we will allow a
reduced amount for procedures other than the
primary procedure.

Note: We do not pay extra for "incidental"
procedures (those that do not add time or
complexity to patient care).

Note: When unusual circumstances require the
removal of casts or sutures by a physician other
than the one who applied them, the Local Plan
may determine that a separate allowance is
payable.

Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Note: We provide benefits at
90% of the Plan allowance
for services provided in
Preferred facilities by Non-preferred
radiologists,
anesthesiologists, certified
registered nurse anesthetists
(CRNAs), pathologists, and
emergency room physicians.
You are responsible for any
difference between our
allowance and the billed
amount.

Preferred: $100 copayment
per performing surgeon

Note: If you receive the
services of a co-surgeon, you
pay a second $100
copayment for those services.
No additional copayment
applies to the services of
assistant surgeons.

Participating/ Non-participating:
You pay all
charges

Note: We provide benefits at
100% of the Plan allowance
for services provided in
Preferred facilities by Non-preferred
radiologists,
anesthesiologists, certified
registered nurse anesthetists
(CRNAs), pathologists,
emergency room physicians,
and assistant surgeons
(including assistant surgeons
in a physician's office). You
are responsible for any
difference between our
allowance and the billed
amount.

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

Cosmetic surgery
LASIK, radial keratotomy, and other refractive surgery

All charges All charges 45
45 Page 46 47

2002 Blue Cross and Blue Shield
Service Benefit Plan 46 Section 5( b)

NOTE: The calendar year deductible applies to almost all Standard Option benefits in this Section.
We say "( No deductible)" when the Standard Option deductible does not apply.
There is no calendar year deductible under Basic Option.

Reconstructive surgery You pay – Standard Option You pay – Basic Option

Surgery to correct a functional defect
Surgery to correct a congenital anomaly – a condition that existed at or from birth and is a

significant deviation from the common form
or norm. Examples of congenital anomalies
are: protruding ear deformities; cleft lip; cleft
palate; birth marks; and webbed fingers and
toes.

Note: Congenital anomalies do not include
conditions related to the teeth or intra-oral
structures supporting the teeth.

Treatment to restore the mouth to a pre-cancer state

All stages of breast reconstruction surgery following a mastectomy, such as:
surgery to produce a symmetrical appearance on the other breast
treatment of any physical complications, such as lymphedemas
Note: Internal breast prostheses are paid as
Medical services and supplies [see Section
5( a)], or Other hospital services and supplies
[see Section 5( c)].

Note: If you need a mastectomy, you may
choose to have the procedure performed on an
inpatient basis and remain in the hospital up
to 48 hours after the procedure.

Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Note: We provide benefits at
90% of the Plan allowance
for services provided in
Preferred facilities by Non-preferred
radiologists,
anesthesiologists, certified
registered nurse anesthetists
(CRNAs), pathologists, and
emergency room physicians.
You are responsible for any
difference between our
allowance and the billed
amount.

Preferred: $100 copayment
per performing surgeon

Note: If you receive the
services of a co-surgeon, you
pay a second $100
copayment for those services.
No additional copayment
applies to the services of
assistant surgeons.

Participating/ Non-participating:
You pay all
charges

Note: We provide benefits at
100% of the Plan allowance
for services provided in
Preferred facilities by Non-preferred
radiologists,
anesthesiologists, certified
registered nurse anesthetists
(CRNAs), pathologists,
emergency room physicians,
and assistant surgeons
(including assistant surgeons
in a physician's office). You
are responsible for any
difference between our
allowance and the billed
amount.

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

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

Surgeries related to sex transformation, sexual dysfunction, or sexual inadequacy

All charges All charges 46
46 Page 47 48

2002 Blue Cross and Blue Shield
Service Benefit Plan 47 Section 5( b)

NOTE: The calendar year deductible applies to almost all Standard Option benefits in this Section.
We say "( No deductible)" when the Standard Option deductible does not apply.
There is no calendar year deductible under Basic Option.

Oral and maxillofacial surgery You pay – Standard Option You pay – Basic Option
Oral surgical procedures, limited to:
Excision of tumors and cysts of the jaws, cheeks, lips, tongue, roof and floor of mouth

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

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

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

Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Note: We provide benefits at
90% of the Plan allowance
for services provided in
Preferred facilities by Non-preferred
radiologists,
anesthesiologists, certified
registered nurse anesthetists
(CRNAs), pathologists, and
emergency room physicians.
You are responsible for any
difference between our
allowance and the billed
amount.

Preferred: $100 copayment
per performing surgeon

Note: If you receive the
services of a co-surgeon, you
pay a second $100
copayment for those services.
No additional copayment
applies to the services of
assistant surgeons.

Participating/ Non-participating:
You pay all
charges

Note: We provide benefits at
100% of the Plan allowance
for services provided in
Preferred facilities by Non-preferred
radiologists,
anesthesiologists, certified
registered nurse anesthetists
(CRNAs), pathologists,
emergency room physicians,
and assistant surgeons
(including assistant surgeons
in a physician's office). You
are responsible for any
difference between our
allowance and the billed
amount.

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

periodontal membrane, gingiva, and alveolar
bone), except as shown above and in Section
5( h)

Surgical procedures involving orthodontic care, dental implants, or preparation of the

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

All charges All charges 47
47 Page 48 49
2002 Blue Cross and Blue Shield
Service Benefit Plan 48 Section 5( b)

NOTE: The calendar year deductible applies to almost all Standard Option benefits in this Section.
We say "( No deductible)" when the Standard Option deductible does not apply.
There is no calendar year deductible under Basic Option.

Organ/ tissue transplants You pay – Standard Option You pay – Basic Option

Cornea
Heart
Heart-lung

Kidney
Liver
Pancreas

Single or double lung: only for the following end-stage pulmonary diseases: pulmonary

fibrosis, primary pulmonary hypertension, and
emphysema

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

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

Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Note: We provide benefits at
90% of the Plan allowance
for services provided in
Preferred facilities by Non-preferred
radiologists,
anesthesiologists, certified
registered nurse anesthetists
(CRNAs), pathologists, and
emergency room physicians.
You are responsible for any
difference between our
allowance and the billed
amount.

Preferred: $100 copayment
per performing surgeon

Note: If you receive the
services of a co-surgeon, you
pay a second $100
copayment for those services.
No additional copayment
applies to the services of
assistant surgeons.

Participating/ Non-participating:
You pay all
charges

Note: We provide benefits at
100% of the Plan allowance
for services provided in
Preferred facilities by Non-preferred
radiologists,
anesthesiologists, certified
registered nurse anesthetists
(CRNAs), pathologists,
emergency room physicians,
and assistant surgeons
(including assistant surgeons
in a physician's office). You
are responsible for any
difference between our
allowance and the billed
amount.

Organ/ tissue transplants – continued on next page 48
48 Page 49 50
2002 Blue Cross and Blue Shield
Service Benefit Plan 49 Section 5( b)

NOTE: The calendar year deductible applies to almost all Standard Option benefits in this Section.
We say "( No deductible)" when the Standard Option deductible does not apply.
There is no calendar year deductible under Basic Option.

Organ/ tissue transplants (continued) You pay – Standard Option You pay – Basic Option
Bone marrow and stem cell transplants, limited
to:

Allogeneic bone marrow transplants and allogeneic cord blood stem cell transplants

(from related or unrelated donors) for:
Advanced neuroblastoma
Infantile malignant osteopetrosis
Severe combined immunodeficiency
Mucopolysaccharidosis (e. g., Hunter, Hurler's, Sanfilippo, Maroteaux-Lamy

variants)
Mucolipidosis (e. g., Gaucher's disease, metachromatic leukodystrophy,

adrenoleukodystrophy)
Severe or very severe aplastic anemia
Thalassemia major (homozygous beta-thalassemia)

Sickle cell anemia
Phagocytic deficiency diseases (e. g., Wiskott-Aldrich syndrome)

Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Note: We provide benefits at
90% of the Plan allowance
for services provided in
Preferred facilities by Non-preferred
radiologists,
anesthesiologists, certified
registered nurse anesthetists
(CRNAs), pathologists, and
emergency room physicians.
You are responsible for any
difference between our
allowance and the billed
amount.

Preferred: $100 copayment
per performing surgeon

Note: If you receive the
services of a co-surgeon, you
pay a second $100
copayment for those services.
No additional copayment
applies to the services of
assistant surgeons.

Participating/ Non-participating:
You pay all
charges

Note: We provide benefits at
100% of the Plan allowance
for services provided in
Preferred facilities by Non-preferred
radiologists,
anesthesiologists, certified
registered nurse anesthetists
(CRNAs), pathologists,
emergency room physicians,
and assistant surgeons
(including assistant surgeons
in a physician's office). You
are responsible for any
difference between our
allowance and the billed
amount.

Organ/ tissue transplants – continued on next page 49
49 Page 50 51
2002 Blue Cross and Blue Shield
Service Benefit Plan 50 Section 5( b)

NOTE: The calendar year deductible applies to almost all Standard Option benefits in this Section.
We say "( No deductible)" when the Standard Option deductible does not apply.
There is no calendar year deductible under Basic Option.

Organ/ tissue transplants (continued) You pay – Standard Option You pay – Basic Option
Bone marrow and stem cell transplants, limited
to: (continued)

Allogeneic bone marrow transplants, allogeneic cord blood stem cell transplants

(from related or unrelated donors) and
allogeneic peripheral blood stem cell
transplants for:

Acute lymphocytic or non-lymphocytic (i. e., myelogenous) leukemia

Advanced Hodgkin's lymphoma
Advanced non-Hodgkin's lymphoma
Chronic myelogenous leukemia
Advanced forms of myelodysplastic syndromes

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

Acute lymphocytic or nonlymphocytic (i. e., myelogenous) leukemia

Advanced Hodgkin's lymphoma
Advanced non-Hodgkin's lymphoma
Advanced neuroblastoma
Amyloidosis
Testicular, Mediastinal, Retroperitoneal, and Ovarian germ cell tumors

Multiple myeloma

Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Note: We provide benefits at
90% of the Plan allowance
for services provided in
Preferred facilities by Non-preferred
radiologists,
anesthesiologists, certified
registered nurse anesthetists
(CRNAs), pathologists, and
emergency room physicians.
You are responsible for any
difference between our
allowance and the billed
amount.

Preferred: $100 copayment
per performing surgeon

Note: If you receive the
services of a co-surgeon, you
pay a second $100
copayment for those
services. No additional
copayment applies to the
services of assistant
surgeons.

Participating/ Non-participating:
You pay all
charges

Note: We provide benefits at
100% of the Plan allowance
for services provided in
Preferred facilities by Non-preferred
radiologists,
anesthesiologists, certified
registered nurse anesthetists
(CRNAs), pathologists,
emergency room physicians,
and assistant surgeons
(including assistant surgeons
in a physician's office). You
are responsible for any
difference between our
allowance and the billed
amount.

Organ/ tissue transplants – continued on next page 50
50 Page 51 52

2002 Blue Cross and Blue Shield
Service Benefit Plan 51 Section 5( b)

NOTE: The calendar year deductible applies to almost all Standard Option benefits in this Section.
We say "( No deductible)" when the Standard Option deductible does not apply.
There is no calendar year deductible under Basic Option.

Organ/ tissue transplants (continued) You pay – Standard Option You pay – Basic Option
Extraction or reinfusion of bone marrow, blood stem cells, or cord blood as a source of

stem cells as part of a covered allogeneic or
autologous bone marrow transplant or blood
stem cell transplant support procedure

Marrow harvesting in anticipation of a covered autologous bone marrow transplant,

for patients diagnosed at the time of
harvesting with one of the conditions listed on
page 49 or 50

Collection, processing, storage, and distribution of cord blood only when

performed by a cord blood bank approved by
the FDA

Storage of harvested bone marrow, blood stem cells, or cord blood as a source of stem

cells, only when a covered transplant has
already been scheduled

Related medical and hospital expenses of the donor, as part of a covered transplant

procedure
Related services or supplies provided to the recipient

Note: See Section 5( a) for coverage for related
services, such as chemotherapy and/ or radiation
therapy and drugs administered to stimulate or
mobilize stem cells for covered transplant
procedures.

Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Note: We provide benefits at
90% of the Plan allowance
for services provided in
Preferred facilities by Non-preferred
radiologists,
anesthesiologists, certified
registered nurse anesthetists
(CRNAs), pathologists, and
emergency room physicians.
You are responsible for any
difference between our
allowance and the billed
amount.

Preferred: $100 copayment
per performing surgeon

Note: If you receive the
services of a co-surgeon, you
pay a second $100
copayment for those
services. No additional
copayment applies to the
services of assistant
surgeons.

Participating/ Non-participating:
You pay all
charges

Note: We provide benefits at
100% of the Plan allowance
for services provided in
Preferred facilities by Non-preferred
radiologists,
anesthesiologists, certified
registered nurse anesthetists
(CRNAs), pathologists,
emergency room physicians,
and assistant surgeons
(including assistant surgeons
in a physician's office). You
are responsible for any
difference between our
allowance and the billed
amount.

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

Bone marrow, cord blood stem cell, and peripheral blood stem cell transplant

support procedures
Heart
Heart-lung
Liver
Lung (single/ double)
Pancreas
Intestinal transplants (small intestine with or without other organs)

Organ/ tissue transplants – continued on next page 51
51 Page 52 53

2002 Blue Cross and Blue Shield
Service Benefit Plan 52 Section 5( b)

NOTE: The calendar year deductible applies to almost all Standard Option benefits in this Section.
We say "( No deductible)" when the Standard Option deductible does not apply.
There is no calendar year deductible under Basic Option.

Organ/ tissue transplants (continued) You pay – Standard Option You pay – Basic Option
(2) For the following procedures, we provide
benefits only when conducted at a Cancer
Research Facility (see page 11) and
performed as part of a clinical trial that
meets the requirements shown below:

Allogeneic bone marrow transplants, syngeneic bone marrow transplants, and

allogeneic peripheral blood stem cell
transplants for:

Multiple myeloma
Chronic lymphocytic leukemia
Early stage (indolent or non-advanced) small cell lymphocytic lymphoma

Nonmyeloablative allogeneic stem cell transplants for:
Chronic myelogenous leukemia
Acute lymphocytic or non-lymphocytic (i. e., myelogenous) leukemia

Advanced Hodgkin's lymphoma
Advanced non-Hodgkin's lymphoma
Advanced forms of myelodysplastic syndromes

Multiple myeloma
Chronic lymphocytic leukemia
Early stage (indolent or non-advanced) small cell lymphocytic lymphoma

Renal cell carcinoma
Autologous bone marrow transplants and autologous peripheral blood stem cell

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

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

Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Note: We provide benefits at
90% of the Plan allowance
for services provided in
Preferred facilities by Non-preferred
radiologists,
anesthesiologists, certified
registered nurse anesthetists
(CRNAs), pathologists, and
emergency room physicians.
You are responsible for any
difference between our
allowance and the billed
amount.

Preferred: $100 copayment
per performing surgeon

Note: If you receive the
services of a co-surgeon, you
pay a second $100
copayment for those
services. No additional
copayment applies to the
services of assistant
surgeons.

Participating/ Non-participating:
You pay all
charges

Note: We provide benefits at
100% of the Plan allowance
for services provided in
Preferred facilities by Non-preferred
radiologists,
anesthesiologists, certified
registered nurse anesthetists
(CRNAs), pathologists,
emergency room physicians,
and assistant surgeons
(including assistant surgeons
in a physician's office). You
are responsible for any
difference between our
allowance and the billed
amount.

Organ/ tissue transplants – continued on next page 52
52 Page 53 54

2002 Blue Cross and Blue Shield
Service Benefit Plan 53 Section 5( b)

NOTE: The calendar year deductible applies to almost all Standard Option benefits in this Section.
We say "( No deductible)" when the Standard Option deductible does not apply.
There is no calendar year deductible under Basic Option.

Organ/ tissue transplants (continued) You pay – Standard Option You pay – Basic Option

For these bone marrow transplant procedures
and related services or supplies covered only
through clinical trials:

1. You must contact our Clinical Trials
Information Unit at 1-800-225-2268 for
prior approval (see page 14);

2. The clinical trial must be reviewed and
approved by the Institutional Review
Board of the Cancer Research Facility
where the procedure is to be delivered; and

3. The patient must be properly and lawfully
registered in the clinical trial, meeting all
the eligibility requirements of the trial.

If a non-randomized clinical trial meeting
these requirements is not available at a Cancer
Research Facility where you are eligible, we
will arrange for the transplant to be provided
at another Plan-designated transplant facility.

Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Note: We provide benefits at
90% of the Plan allowance
for services provided in
Preferred facilities by Non-preferred
radiologists,
anesthesiologists, certified
registered nurse anesthetists
(CRNAs), pathologists, and
emergency room physicians.
You are responsible for any
difference between our
allowance and the billed
amount.

Preferred: $100 copayment
per performing surgeon

Note: If you receive the
services of a co-surgeon, you
pay a second $100
copayment for those services.
No additional copayment
applies to the services of
assistant surgeons.

Participating/ Non-participating:
You pay all
charges

Note: We provide benefits at
100% of the Plan allowance
for services provided in
Preferred facilities by Non-preferred
radiologists,
anesthesiologists, certified
registered nurse anesthetists
(CRNAs), pathologists,
emergency room physicians,
and assistant surgeons
(including assistant surgeons
in a physician's office). You
are responsible for any
difference between our
allowance and the billed
amount.

Not covered:
Transplants for any diagnosis not listed as covered

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

All charges All charges 53
53 Page 54 55

2002 Blue Cross and Blue Shield
Service Benefit Plan 54 Section 5( b)

NOTE: The calendar year deductible applies to almost all Standard Option benefits in this Section.
We say "( No deductible)" when the Standard Option deductible does not apply.
There is no calendar year deductible under Basic Option.

Anesthesia You pay – Standard Option You pay – Basic Option
Anesthesia (including acupuncture) for covered
surgical services when requested by the
attending physician and performed by:

a certified registered nurse anesthetist (CRNA), or

a physician other than the operating physician (surgeon) or the assistant
Professional services provided in:
Hospital (inpatient)
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center
Office
Anesthesia services consist of administration by
injection or inhalation of a drug or other
anesthetic agent (including acupuncture) to
obtain muscular relaxation, loss of sensation, or
loss of consciousness.

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

Preferred: 10% of the Plan
allowance

Participating: 25% of the
Plan allowance

Non-participating: 25% of
the Plan allowance, plus any
difference between our
allowance and the billed
amount

Note: We provide benefits at
90% of the Plan allowance
for services provided in
Preferred facilities by Non-preferred
anesthesiologists
and certified registered nurse
anesthetists (CRNAs). You
are responsible for any
difference between our
allowance and the billed
amount.

Preferred: Nothing
Participating/ Non-participating:
You pay all
charges

Note: We provide benefits at
100% of the Plan allowance
for services provided in
Preferred facilities by Non-preferred
anesthesiologists
and certified registered nurse
anesthetists (CRNAs). You
are responsible for any
difference between our
allowance and the billed
amount. 54
54 Page 55 56

2002 Blue Cross and Blue Shield
Service Benefit Plan 55 Section 5( c)

Section 5 (c). Services provided by a hospital or other facility, and ambulance services
I M
P O
R T
A N
T

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

Unlike Sections 5( a) and 5( b), in this Section 5( c) the Standard Option calendar year deductible applies to only a few benefits. In that case, we added "( calendar year deductible applies)" when it applies. The
calendar year deductible is $250 per person ($ 500 per family) under Standard Option.
Under Basic Option, there is no calendar year deductible.
Under Basic Option, you must use Preferred providers in order to receive benefits. See page 11 for the exceptions to this requirement.

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works, with special sections for members who are age 65 or over. Also read Section 9 about
coordinating benefits with other coverage, including Medicare.
YOU MUST GET PRECERTIFICATION OF HOSPITAL STAYS; FAILURE TO DO SO WILL RESULT IN A $500 PENALTY. Please refer to the precertification information listed in Section 3 to

be sure which services require precertification.
You should be aware that some PPO hospitals may have non-PPO professional providers on staff.
We base payment on whether the facility or a health care professional bills for the services or supplies. You will find that some benefits are listed in more than one section of the brochure. This is because how

they are paid depends on what type of provider bills for the service. For example, physical therapy is
paid differently depending on whether it is billed by an inpatient facility, a doctor, a physical therapist, or
an outpatient facility.

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

(i. e., physicians, etc.) are listed in Sections 5( a) or (b).
The non-PPO benefits are the standard benefits for Standard Option. PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non-PPO benefits apply.

I M
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T 55
55 Page 56 57

2002 Blue Cross and Blue Shield
Service Benefit Plan 56 Section 5( c)

Benefit Description You pay
NOTE: The Standard Option calendar year deductible applies ONLY when we say below:
"( calendar year deductible applies) ." There is no calendar year deductible under Basic Option.

Inpatient hospital You pay – Standard Option You pay – Basic Option
Room and board, such as:
semiprivate or intensive care accommodations
general nursing care
meals and special diets
Note: We cover a private room only when you
must be isolated to prevent contagion, when
your isolation is required by law, or when a
Preferred or Member hospital only has private
rooms. Otherwise, we will pay the hospital's
average daily rate for semiprivate rooms as
determined by the Local Plan. If a Non-member
hospital only has private rooms, we
base our payment on the average daily rate as
determined by the Local Plan.

Preferred: $100 per
admission copayment for
unlimited days

Member: $300 per admission
copayment for unlimited
days

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

Note: You pay nothing for
facilities outside of the
United States and Puerto
Rico. See Section 5( g) for
more information about
benefits for services received
overseas. See Section 7,
Filing a claim for covered
services, for instructions on
filing claims for overseas
care.

Preferred: $100 per day
copayment up to $500 per
admission for unlimited days

Member/ Non-member: You
pay all charges

Note: You pay a $100 per
day copayment up to $500
per admission for facilities
outside of the United States
and Puerto Rico. See
Section 5( g) for more
information about benefits
for services received
overseas. See Section 7,
Filing a claim for covered
services, for instructions on
filing claims for overseas
care.

Inpatient hospital – continued on next page 56
56 Page 57 58

2002 Blue Cross and Blue Shield
Service Benefit Plan 57 Section 5( c)

NOTE: The Standard Option calendar year deductible applies ONLY when we say below:
"( calendar year deductible applies) ." There is no calendar year deductible under Basic Option.

Inpatient hospital (continued) You pay – Standard Option You pay – Basic Option
Other hospital services and supplies, such as:
Operating, recovery, maternity, and other treatment rooms

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

X-rays
Administration of blood or blood plasma
Dressings, splints, casts, and sterile tray services

Internal prosthetic devices
Other medical supplies and equipment, including oxygen

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

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

such as extended stays for you or your baby.
If you need to stay longer in the hospital than initially planned, we will cover an extended

stay if it is medically necessary. However,
you must precertify the extended stay. See
Section 3 for information on requesting
additional days.

We pay inpatient hospital benefits for an admission in connection with dental

procedures only when a non-dental physical impairment exists that makes hospitalization
necessary to safeguard the health of the patient. We provide benefits for dental
procedures as shown in Section 5( h).
Note: See page 31 for covered maternity
services.

Note: See page 41 for coverage of blood and
blood products.

Preferred: $100 per
admission copayment for
unlimited days

Member: $300 per admission
copayment for unlimited
days

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

Note: You pay nothing for
facilities outside of the
United States and Puerto
Rico. See Section 5( g) for
more information about
benefits for services received
overseas. See Section 7,
Filing a claim for covered
services, for instructions on
filing claims for overseas
care.

Preferred: $100 per day
copayment up to $500 per
admission for unlimited days

Member/ Non-member: You
pay all charges

Note: You pay a $100 per
day copayment up to $500
per admission for facilities
outside of the United States
and Puerto Rico. See Section
5( g) for more information
about benefits for services
received overseas. See
Section 7, Filing a claim for
covered services, for
instructions on filing claims
for overseas care.

Inpatient hospital – continued on next page 57
57 Page 58 59
2002 Blue Cross and Blue Shield
Service Benefit Plan 58 Section 5( c)

NOTE: The Standard Option calendar year deductible applies ONLY when we say below:
"( calendar year deductible applies) ." There is no calendar year deductible under Basic Option.

Inpatient hospital (continued) You pay – Standard Option You pay – Basic Option
Not covered:
Hospital room and board expenses when in our
judgement, a hospital admission or portion of
an admission is:

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

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

Admissions for, or consisting primarily of, observation and/ or
evaluation that could have been
provided safely and adequately in
some other setting (such as a
physician's office)

Admissions primarily for diagnostic studies, laboratory and pathology services, X-rays,
MRIs, or machine diagnostic tests that
could have been provided safely and
adequately in some other setting (such as
the outpatient department of a hospital or a
physician's office)

Note: If we determine that a hospital admission
is one of the types listed above, we will not
provide benefits for inpatient room and board
or inpatient physician care. However, we will
provide benefits for covered services or supplies
other than room and board and inpatient
physician care at the level that we would have
paid if they had been provided in some other
setting.

Admission to non-covered facilities, such as nursing homes, extended care facilities,

schools, residential treatment centers
Personal comfort items, such as guest meals and beds, telephone, television, beauty and

barber services
Inpatient private duty nursing

All charges All charges 58
58 Page 59 60

2002 Blue Cross and Blue Shield
Service Benefit Plan 59 Section 5( c)

NOTE: The Standard Option calendar year deductible applies ONLY when we say below:
"( calendar year deductible applies) ." There is no calendar year deductible under Basic Option.

Outpatient hospital or ambulatory surgical center You pay – Standard Option You pay – Basic Option

Outpatient medical services performed and
billed for by a hospital or freestanding
ambulatory facility, such as:

Use of special treatment rooms
Diagnostic tests, such as laboratory and pathology services, MRIs, machine diagnostic

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

Cardiac rehabilitation (Prior approval is required. See Section 3.)
Renal dialysis
Note: See pages 27-30 for covered preventive
services for adults and children.

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

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

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

Note: You pay nothing for
facilities outside the United
States and Puerto Rico. See
Section 5( g) for more
information about benefits
for services received
overseas. See Section 7,
Filing a claim for covered
services, for instructions on
filing claims for overseas
care.

Preferred: $30 copayment
per day per facility

Member/ Non-member: You
pay all charges

Note: For outpatient
diagnostic tests billed for by
a Member or Non-member
facility, you pay a $30
copayment, plus any
difference between our
allowance and the billed
amount.

Note: You pay a $30 per day
copayment per facility for
outpatient services provided
by facilities outside the
United States and Puerto
Rico. See Section 5( g) for
more information about
benefits for services
received overseas. See
Section 7, Filing a claim for
covered services, for
instructions on filing claims
for overseas care.

Outpatient hospital or ambulatory surgical center – continued on next page 59
59 Page 60 61

2002 Blue Cross and Blue Shield
Service Benefit Plan 60 Section 5( c)

NOTE: The Standard Option calendar year deductible applies ONLY when we say below:
"( calendar year deductible applies) ." There is no calendar year deductible under Basic Option.

Outpatient hospital or ambulatory surgical center (continued) You pay – Standard Option You pay – Basic Option

Outpatient surgery and related services
performed and billed for by a hospital or
freestanding ambulatory facility, such as:

Operating, recovery, and other treatment rooms

Pre-surgical testing performed within one business day of the covered surgical services
Facility supplies for hemophilia home care
Diagnostic tests, such as laboratory and pathology services, MRIs, machine diagnostic

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

Note: We cover outpatient hospital services and
supplies related to dental procedures only when
a non-dental physical impairment exists that
makes the hospital setting necessary to
safeguard the health of the patient. See Section
5( h), Dental benefits, for additional benefit
information.

Note: See page 31 for covered maternity services.

Preferred facilities: 10% of
the Plan allowance

Member facilities: 25% of
the Plan allowance

Non-member facilities: 25%
of the Plan allowance, plus
any difference between our
allowance and the billed
amount

Note: You pay nothing for
facilities outside the United
States and Puerto Rico. See
Section 5( g) for more
information about benefits
for services received
overseas. See Section 7,
Filing a claim for covered
services, for instructions on
filing claims for overseas
care.

Preferred: $30 copayment per
day per facility

Member/ Non-member: You
pay all charges

Note: For outpatient
diagnostic tests billed for by
a Member or Non-member
facility, you pay a $30
copayment, plus any
difference between our
allowance and the billed
amount.

Note: You pay a $30
copayment per day per
facility for outpatient
services provided by
facilities outside the United
States and Puerto Rico. See
Section 5( g) for more
information about benefits
for services received
overseas. See Section 7,
Filing a claim for covered
services, for instructions on
filing claims for overseas
care.

Outpatient hospital or ambulatory surgical center – continued on next page 60
60 Page 61 62

2002 Blue Cross and Blue Shield
Service Benefit Plan 61 Section 5( c)

NOTE: The Standard Option calendar year deductible applies ONLY when we say below:
"( calendar year deductible applies) ." There is no calendar year deductible under Basic Option.

Outpatient hospital or ambulatory surgical center (continued) You pay – Standard Option You pay – Basic Option

Outpatient drugs and supplies billed for by a
hospital or freestanding ambulatory facility,
such as:

Prescribed drugs
Blood and blood plasma, if not donated or replaced

Dressings, splints, casts, and sterile tray services
Other medical supplies, including oxygen

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

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

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

Note: You pay nothing for
facilities outside the United
States and Puerto Rico. See
Section 5( g) for more
information about benefits
for services received
overseas. See Section 7,
Filing a claim for covered
services, for instructions on
filing claims for overseas
care.

Preferred: 30% of the Plan
allowance

Note: You may also be
responsible for paying a $30
copayment per day per
facility for outpatient
services.

Member/ Non-member: You
pay all charges

Note: You pay 30% of the
Plan allowance for outpatient
drugs and supplies provided
by facilities outside the
United States and Puerto
Rico. See Section 5( g) for
more information about
benefits for services received
overseas. See Section 7,
Filing a claim for covered
services, for instructions on
filing claims for overseas
care. 61
61 Page 62 63

2002 Blue Cross and Blue Shield
Service Benefit Plan 62 Section 5( c)

NOTE: The Standard Option calendar year deductible applies ONLY when we say below:
"( calendar year deductible applies) ." There is no calendar year deductible under Basic Option.

Extended care benefits/ Skilled nursing care facility benefits You pay – Standard Option You pay – Basic Option

Limited to the following benefits for Medicare
Part A copayments:

When Medicare Part A is the primary payer
(meaning that it pays first) and has made
payment, Standard Option provides limited
secondary benefits.

We pay the applicable Medicare Part A
copayments incurred in full during the first
through the 30 th day of confinement for each
benefit period (as defined by Medicare) in a
qualified skilled nursing facility. A qualified
skilled nursing facility is a facility that
specializes in skilled nursing care performed by
or under the supervision of licensed nurses,
skilled rehabilitation services, and other related
care, and meets Medicare's special qualifying
criteria, but is not an institution that primarily
cares for and treats mental diseases.

If Medicare pays the first 20 days in full, Plan
benefits will begin on the 21 st day (when
Medicare Part A copayments begin) and will
end on the 30 th day.

Note: See pages 35 and 36 for benefits provided
for outpatient physical, occupational, and
speech therapy when billed by a skilled nursing
facility. See Section 5( f) for benefits for
prescription drugs.

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

Preferred: Nothing
Participating/ Member:
Nothing

Non-participating/ Non-member:
Nothing

Note: You pay all charges
not paid by Medicare after
the 30 th day.

All charges 62
62 Page 63 64

2002 Blue Cross and Blue Shield
Service Benefit Plan 63 Section 5( c)

NOTE: The Standard Option calendar year deductible applies ONLY when we say below:
"( calendar year deductible applies) ." There is no calendar year deductible under Basic Option.

Hospice care You pay – Standard Option You pay – Basic Option
Hospice care is an integrated set of services and supplies designed to provide palliative and

supportive care to terminally ill patients in their
homes.

We provide the following home hospice care
benefits for members with a life expectancy of
six months or less when prior approval is
obtained from the Local Plan and the home
hospice agency is approved by the Local Plan:

Physician visits
Nursing care
Medical social services
Physical therapy
Services of home health aides
Durable medical equipment rental
Prescription drugs
Medical supplies

Nothing Nothing

Inpatient hospice for members receiving home
hospice care benefits:

Benefits are provided for up to five (5)
consecutive days in a hospital or a freestanding
hospice inpatient facility.

Each inpatient stay must be separated by at least
21 days.

These covered inpatient hospice benefits are
available only when inpatient services are
necessary to:

control pain and manage the patient's symptoms; or

provide an interval of relief (respite) to the family
Note: You are responsible for making sure
that the home hospice care provider has received prior approval from the Local Plan

(see page 13 for instructions). Please check
with your Local Plan and/ or your PPO directory
for listings of approved agencies.

Preferred: $100 per
admission copayment

Member: $300 per admission
copayment