Pages 1--60 from PacifiCare of Colorado

Enrollment codes for this Plan:
High Option
D61 Self Only
D62 Self and Family

Standard Option
D64 Self Only
D65 Self and Family

RI 73-049

http:// www. pacificare. com/ colorado
For changes in benefits,
see page
6

This plan has Commendable accreditation
from the NCQA. See the 2002 Guide for
more information on accreditation. 1
1 Page 2 3
1
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Plain Language . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Inspector General Advisory. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Section 1. Facts about this HMO plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
How we pay providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Patients Bill of Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Your Rights. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Service Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Section 2. How we change for 2002. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Program-wide changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Changes to this Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Section 3. How you get care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Identification cards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Where you get covered care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Plan providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Plan facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
What you must do to get covered care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Primary care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Specialty care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Hospital care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Circumstances beyond our control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Services requiring our prior approval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Section 4. Your costs for covered services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Copayments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Deductible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Coinsurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Your out-of-pocket maximum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Section 5. Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
(a) Medical services and supplies provided by physicians and other health care professionals . . . . . . . . . . . . . . 12
(b) Surgical and anesthesia services provided by physicians and other health care professionals . . . . . . . . . . . . 21
(c) Services provided by a hospital or other facility, and ambulance services. . . . . . . . . . . . . . . . . . . . . . . . . . . 25
(d) Emergency services/ accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
(e) Mental health and substance abuse benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

2002 PacifiCare of Colorado Table of Contents

Table of Contents 2
2 Page 3 4
2
(f) Prescription drug benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
(g) Special features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Services for deaf and hearing impaired . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Healthy Pregnancy Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Diabetes Management Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Congestive Heart Failure Program. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
(h) Dental benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
(i) Non-FEHB benefits available to Plan members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Section 6. General exclusions things we don t cover. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Section 7. Filing a claim for covered services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Section 8. The disputed claims process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Section 9. Coordinating benefits with other coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
When you have
Other health coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Original Medicare. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Medicare managed care plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
TRICARE/ Workers Compensation/ Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Other Government agencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
When others are responsible for injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Section 10. Definitions of terms we use in this brochure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Section 11. FEHB facts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Coverage information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
No pre-existing condition limitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Where you get information about enrolling in the FEHB Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Types of coverage available for you and your family . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
When benefits and premiums start . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Your medical and claims records are confidential . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
When you retire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
When you lose benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
When FEHB coverage ends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Spouse equity coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Temporary Continuation of Coverage (TCC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Converting to individual coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Getting a Certificate of Group Health Plan Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Long term care insurance is coming later in 2002 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Summary of benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Back cover

2002 PacifiCare of Colorado Table of Contents 3
3 Page 4 5
3
PacifiCare of Colorado
6455 South Yosemite Street
Greenwood Village, CO 80111

This brochure describes the benefits of PacifiCare of Colorado under our contract (CS 1761) with the Office of Personnel
Management (OPM), as authorized by the Federal Employees Health Benefits law. This brochure is the official statement of
benefits. No oral statement can modify or otherwise affect the benefits, limitations, and exclusions of this brochure.

If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled for Self and
Family coverage, each eligible family member is also entitled to these benefits. You do not have a right to benefits that were
available before January 1, 2002, unless those benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2002, and changes are
summarized on page 6. Rates are shown at the end of this brochure.

2002 PacifiCare of Colorado Introduction/ Plain Language/ Advisory

Introduction
Teams of Government and health plans staff worked on all FEHB brochures to make them responsive, acessible, and
understandable to the public. For instance,

Except for necessary technical terms, we use common words. For instance, "you" means the enrollee or family member;
"we" means PacifiCare of Colorado.

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

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

Plain Language 4
4 Page 5 6
4 2002 PacifiCare of Colorado Introduction/ Plain Language/ Advisory
Stop health care fraud! Fraud increases the cost of health care for everyone. If you suspect that a physician, pharmacy,
or hospital has charged you for services you did not receive, billed you twice for the same
service, or misrepresented any information, do the following:

Call the provider and ask for an explanation. There may be an error.
If the provider does not resolve the matter, call us at 800/ 877-9777, or 303/ 714-5800 when
calling from 303 or 720 area codes and explain the situation.
If we do not resolve the issue, call or write:

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.

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

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

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

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

How we pay providers
We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure. These Plan
providers accept a negotiated payment from us, and you will only be responsible for your copayments or coinsurance. These
payment arrangements include capitation, discounted fee-for-service and case rates, as well as additional financial incentives
including bonuses and withholds.

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

Years in existence — PacifiCare of Colorado (and its predecessors) began offering health care coverage in
Colorado in 1974.
Profit status — For Profit.

If you want more information about us, call 800/ 877-9777, or 303/ 714-5800 when calling from 303 or 720 area codes, or write
to 6455 South Yosemite Street, Greenwood Village, CO 80111. You may also contact us by fax at 303/ 714-3977 or visit our
website at www. pacificare. com/ colorado.

Service Area
To enroll in this Plan, you must live in our Service Area. This is where our providers practice. Our service area is: the
Colorado counties of Adams, Arapahoe, Boulder, Clear Creek, Denver, Douglas, Elbert, El Paso, Gilpin, Jefferson, Larimer,
Morgan, Park, Teller and Weld.

Ordinarily, you must get your care from providers who contract with us. If you receive care outside our service area, we will
pay only for emergency care benefits. We will not pay for any other health care services received outside the service area
unless the services have prior plan approval.

If you or a covered family member move outside of our service area, you can enroll in another plan. If your dependents live
out of the area (for example, if your child goes to college in another state), you should consider enrolling in a fee-for-service
plan or an HMO that has agreements with affiliates in other areas. If you or a family member move, you do not have to wait
until Open Season to change plans. Contact your employing or retirement office.

2002 PacifiCare of Colorado Section 1

Section 1. Facts about this HMO plan 6
6 Page 7 8
6
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5, Benefits.
Also, we edited and clarified language throughout the brochure; any language change not shown here is a clarification that does
not change benefits.

Program-wide changes
We increased speech therapy benefits by removing the requirement that services must be required to restore functional
speech. (Section 5( a))

Changes to this Plan
Your share of the Standard Option non-postal premium will increase by 0.0% for Self Only coverage and 0.0% for Self
and Family coverage.
Your share of the High Option non-postal premium will increase by 27.0% for Self Only coverage and 68.9% for Self and
Family coverage.
We now cover certain intestinal transplants. (Section 5( b))
Emergency room — the copayment will be $100 per visit inside or outside the service area under Standard Option and High
Option.
MRIs, CT and PET scans — a $75 copayment will apply per test under Standard and High Options.
Dental benefits — the High Option dental benefit changes to a dental indemnity plan. A $50 deductible applies under Self-only
coverage, and $150 per family (the deductible is waived for preventive services). Members pay up to 50% for
covered services. The Standard Option dental benefits do not change.
Orthodontic — the fixed fee for orthodontic treatment will increase from $1,950 to $2,150 for members under age 19, and
from $2,200 to $2,500 for members 19 years or older.
Mammography — we clarified the benefit to show mammograms are available once a year from ages 40 through 64.

2002 PacifiCare of Colorado Section 2

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

If you do not receive your ID card within 30 days after the effective date of your
enrollment, or if you need replacement cards, call us at 800/ 877-9777, or 303/ 714-
5800 when calling from 303 or 720 area codes.

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

Plan providers Plan providers are physicians and other health care professionals in our 15-county
service area that we contract with to provide covered services to our members. We
credential Plan providers according to national standards.

The physicians that we contract with are either in private practice in their own
office, or participating in medical groups, practicing in conveniently located group
practice centers.

We list Plan providers in the provider directory, which we update periodically.
The list of primary care physicians is also on our website at
www. pacificare. com/ colorado.

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

What you must do to get It depends on the type of care you need. First, you and each family member must covered care choose a primary care physician (PCP). This decision is important since your PCP
provides or arranges for most of your health care.
Some of our participating physicians are organized into groups of primary care
physicians and specialists who have joined together to provide services. For
physicians affiliated in this manner, PCPs belong to just one group, but some
specialists may have more than one affiliation. When you need specialty care, your
PCP will most likely refer you to a specialist with whom he or she is affiliated.
PCPs typically have established relationships with other doctors to whom they'll
most likely refer patients when specialized care is needed. Referring to specialists
your PCP is familiar with makes it easy for your PCP to communicate with both
you and your specialist and coordinate your care. Our policy is to encourage PCPs
to consider patients' input in care decisions.

Primary care Your primary care physician can be a family practitioner, internist or pediatrician.
Your primary care physician will provide most of your health care, or give you a
referral to see a specialist. We contract with approximately 1,385 primary care
physicians.

2002 PacifiCare of Colorado Section 3

Section 3. How you get care 8
8 Page 9 10
8
If you want to change primary care physicians or if your primary care physician
leaves the Plan, call us. We will help you select a new one.

Specialty care Your primary care physician will refer you to a specialist for needed care.
However, you may access care for the following benefits without a referral from
your PCP:
mental health and substance abuse benefits — refer to Section 5( e) for
information on how to access these benefits.
vision care — contact Vision Service Plan (VSP) at 888/ 426-4877.
chiropractic care — go directly to a participating American Specialty Health
Networks provider.
obstetrical or gynecological care — access care through your primary care
physician or go directly to a participating OB/ GYN physician.

We contract with over 3,000 referral specialists.
Here are other things you should know about specialty care:
If you need to see a specialist frequently because of a chronic, complex, or
serious medical condition, your primary care physician will develop a
treatment plan that allows you to see your specialist for a certain number of
visits without additional referrals. Your primary care physician will use our
criteria when creating your treatment plan (the physician may have to get an
authorization or approval beforehand).

If you are seeing a specialist when you enroll in our Plan, talk to your primary
care physician. Your primary care physician will decide what treatment you
need. If he or she decides to refer you to a specialist, you may discuss whether
or not it is appropriate to continue to see your current specialist. If your
current specialist does not participate with us, you must receive treatment
from a specialist who does. Generally, we will not pay for you to see a
specialist who does not participate with our Plan.

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

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

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

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

2002 PacifiCare of Colorado Section 3 9
9 Page 10 11
9
If you are in the second or third trimester of pregnancy and you lose access to your
specialist based on the above circumstances, you can continue to see your
specialist until the end of your postpartum care, even if it is beyond the 90 days.

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

If you are in the hospital when your enrollment in our Plan begins, call our
customer service department immediately at 800/ 877-9777, or 303/ 714-5800 when
calling from 303 or 720 area codes. If you are new to the FEHB Program, we will
arrange for you to receive care.

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

You are discharged, not merely moved to an alternative care center; or
The day your benefits from your former plan run out; or
The 92nd day after you become a member of this Plan, whichever happens first.
These provisions apply only to the benefits of the hospitalized person.
Circumstances beyond our control Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In that case, we will
make all reasonable efforts to provide you with the necessary care.
Services requiring our prior approval Your primary care physician has authority to refer you for most services. For
certain services, however, your physician must obtain approval from us. Before
giving approval, we consider if the service is covered, medically necessary, and
follows generally accepted medical practice.

We call this review and approval process preauthorization. Your physician must
obtain preauthorization for services such as:
Septoplasty
Hysterectomy
MRIs and CTs and PET scans
Angiography
Upper GI endoscopy
Colonoscopy
Knee arthroscopy

PacifiCare of Colorado may determine medical necessity by using preauthorization
programs and criteria. Our criteria are written guidelines established by us to
determine medical necessity and/ or coverage for certain procedures and treatments.
Our criteria are based on research of scientific literature, collaboration with
physician specialists and compliance with federal and national regulatory agency
guidelines. Criteria are approved by the PacifiCare Health Care Standards and
Education Committee and are reviewed and revised on a regular basis. Criteria are
available for review by the member's participating physician, the member or the
member's representative.

2002 PacifiCare of Colorado Section 3 10
10 Page 11 12
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You must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay to the provider, facility,
pharmacy, etc., when you receive services.

Example: When you see your primary care physician you pay a copayment of $10
(High Option) or $15 (Standard Option) per office visit.

Deductible A deductible is a fixed expense you must incur for certain covered services and
supplies before we start paying benefits for them. Copayments do not count toward
any deductible.

We do not have any deductibles under the High Option.
Under the Standard Option, you must pay a $300 deductible per person, or a
$500 maximum deductible per family for inpatient hospital services each
calendar year. (See Section 5c)

Coinsurance Coinsurance is the percentage of our negotiated fee that you must pay for your care.
Example: In our Plan, you pay 50% of our allowance for infertility services, or
drugs for the treatment of sexual dysfunction.

Your catastrophic protection After your copayments, coinsurance or deductibles total $3,600 per person or out-of-pocket maximum $10,000 per family enrollment in any calendar year, you do not have to pay any
more for covered services. However, your out-of-pocket expenses for the following
services do not count toward your out-of-pocket maximum, and you must continue
to pay copayments for these services:

Prescription drugs
Dental services
Non-authorized/ non-covered services
Be sure to keep accurate records of your copayments, coinsurance and deductibles
since you are responsible for informing us when you reach the maximum.

2002 PacifiCare of Colorado Section 4

Section 4. Your costs for covered services 11
11 Page 12 13
11
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
subsection. To obtain claims forms, claims filing advice, or more information about our benefits, contact us at 800/ 877-9777,
or 303/ 714-5800 when calling from 303 or 720 area codes, or at our website at www. pacificare. com/ colorado.

(a) Medical services and supplies provided by physicians and other health care professionals. . . . . . . . . . . . . . . . . . . . . . 12-20

(b) Surgical and anesthesia services provided by physicians and other health care professionals . . . . . . . . . . . . . . . . . . . . 21-24
(c) Services provided by a hospital or other facility, and ambulance services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25-28

(d) Emergency services/ accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29-30
Medical emergency Ambulance

(e) Mental health and substance abuse benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31-32
(f) Prescription drug benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33-35
(g) Special features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

(h) Dental benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37-42
(i) Non-FEHB benefits available to Plan members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Summary of benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

Services for deaf and hearing impaired
Healthy Pregnancy Program
Diabetes Management Program
Congestive Heart Failure Program

Inpatient hospital
Outpatient hospital or ambulatory surgical
center

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

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

Diagnostic and treatment services
Lab, X-ray and other diagnostic tests
Preventive care, adult
Preventive care, children
Maternity care
Family planning
Infertility services
Allergy care
Treatment therapies
Physical and occupational therapy
Speech therapy

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

2002 PacifiCare of Colorado Section 5

Section 5. Benefits OVERVIEW
(See page 6 for how our benefits changed this year and page 58 for a benefits summary.) 12
12 Page 13 14
Diagnostic and treatment services You pay -Standard Option You pay -High Option
Professional services of physicians
In physician's office $15 per office visit $10 per office visit
Office medical consultations
Second surgical opinion

Professional services of physicians Nothing Nothing
In an urgent care center
During a hospital stay
In a skilled nursing facility
At home when medically necessary

Not covered:
Physical examinations that are not medically All charges All charges
necessary, such as those required for obtaining
or continuing employment or insurance,
attending school or camp, or travel

Obesity treatment, except for surgical treatment
of morbid obesity

Total Parenteral Nutrition (TPN)

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

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

2002 PacifiCare of Colorado Section 5a

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

Benefit Description You pay 13
13 Page 14 15
13
Lab, X-ray and other diagnostic tests You pay — Standard Option You pay — High Option
Tests, such as: Nothing Nothing
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
Ultrasound
Electrocardiogram and EFG
MRIs, CT and PET scans $75 copay per test $75 copay per test

Preventive care, adult

We cover periodic health appraisals for adults. These $15 per office visit $10 per office visit
visits include coverage for routine screenings, such as:

Total Blood Cholesterol
Colorectal Cancer Screening, including:
Fecal occult blood test
Sigmoidoscopy, screening
Prostate Specific Antigen (PSA test)
Routine pap test
Note: The office visit is covered if pap test is received
on the same day; see Diagnostic and Treatment, above.

Routine mammogram covered for women age 35 Nothing Nothing
and older, as follows:

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

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

Routine Immunizations, limited to: Nothing Nothing
Tetanus-diphtheria (Td) booster once every
10 years, ages 19 and over (except as provided
for under Childhood immunizations)

Influenza/ Pneumococcal vaccines, annually,
age 65 and over

Not covered: All charges All charges
Physical examinations that are not medically
necessary for medical reasons, such as those
required for obtaining or continuing employment
or insurance, attending school or camp, or travel.

2002 PacifiCare of Colorado Section 5a 14
14 Page 15 16
14
Preventive care, children You pay — Standard Option You pay — High Option
Childhood immunizations recommended by the $15 per office visit $10 per office visit
American Academy of Pediatrics

Well-child care charges for routine examinations, $15 per office visit $10 per office visit
immunizations and care (up to age 22 years)

Examinations, such as:
Eye exams to determine the need for
vision correction

Ear exams to determine the need for
hearing correction

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

Not covered: All charges All charges
Physical examinations that are not medically
necessary for medical reasons, such as those
required for obtaining or continuing employment
or insurance, attending school or camp, or travel.

Maternity care

Complete maternity (obstetrical) care, such as: $15 copay per office visit $10 copay per office visit
Prenatal care
Delivery
Postnatal care

Note: Here are some things to keep in mind:
You do not need to precertify your normal
delivery; see page 25 for other circumstances,
such as extended stays for you or your baby.

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

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

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

Not covered: All charges All charges
Any procedure intended solely for sex
determination

Birthing classes
Normal delivery outside of our service area

2002 PacifiCare of Colorado Section 5a 15
15 Page 16 17
15
Family planning You pay — Standard Option You pay — High Option
A broad range of voluntary family planning services, $15 per office visit $10 per office visit
such as:
Voluntary sterilization
Family planning counseling
Information on birth control
Injectable contraceptive drugs
Intrauterine devices (IUDs) and implantable
contraceptive devices, including their insertion
and removal

Diaphragms and cervical caps, including their
fitting

Not covered: All charges All charges
Reversal of voluntary, surgical sterilization
Genetic counseling
Pregnancy test kits and ovulation kits

Infertility services
Diagnosis and treatment of infertility 50% 50%
Artificial insemination
intravaginal insemination (IVI)
intracervical insemination (ICI)
intrauterine insemination (IUI)
This coverage is limited to members who have
been diagnosed as biologically infertile in
accordance with accepted medical practice.

Not covered: All charges All charges
Fertility drugs
Assisted reproductive technology (ART)
procedures

in vitro fertilization
embryo transfer, GIFT and ZIFT
Services and supplies related to excluded ART
procedures

Cost related to donor sperm and donor ova
Infertility services for members who have
undergone a voluntary sterilization procedure

Allergy care
Comprehensive diagnostic allergy evaluation $15 per office visit $10 per office visit
including testing

Allergy injection $5 per visit when not in $5 per visit when not in
conjunction with a conjunction with a
physician s office visit physician s office visit

Allergy serum Nothing Nothing

2002 PacifiCare of Colorado Section 5a 16
16 Page 17 18
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Treatment therapies You pay — Standard Option You pay — High Option
Chemotherapy and radiation therapy Nothing Nothing
Note: High dose chemotherapy in association with
autologous bone marrow transplants are limited to
those transplants listed under Organ/ Tissue
Transplants on page 23.

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

Growth hormone therapy (GHT)
Note: — We will only cover GHT when we
preauthorize the treatment. Your plan physician
will handle this preauthorization process.

Physical and occupational therapy

Physical therapy and occupational therapy: $15 per office visit $10 per office visit
Up to 20 visits or two months per condition, Nothing for inpatient Nothing for inpatient
whichever is greater, if significant improvement
can be expected within two months

Physical/ occupational therapy is limited to services
that assist the member to achieve and maintain self-care
and improved functioning in other activities of
daily living.

Note: We provide physical and occupational up to 20
sessions for each type of therapy per year, for the care
and treatment of congenital defects and birth
abnormalities for children up to age five (5). This is
without regard to whether the condition is acute or
chronic or whether the purpose of the therapy is to
maintain or to improve functional capacity.

Cardiac rehabilitation following a heart transplant, Nothing Nothing
bypass surgery or a myocardial infarction, is provided
at an approved facility for up to 90 sessions for
short-term follow-up care.

Not covered: All charges All charges
Long-term rehabilitative therapy
Special evaluation and/ or therapy for conditions
such as behavior disorders and pulmonary
rehabilitation

Speech therapy
Up to 20 visits or two months per condition, $15 per office visit $10 per office visit.
whichever is greater. Nothing for inpatient Nothing for inpatient

Speech therapy is provided when medically necessary
without regard to whether the purpose of the therapy
is to maintain or to improve functional capacity.

2002 PacifiCare of Colorado Section 5a 17
17 Page 18 19
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Hearing services (testing, treatment, You pay — Standard Option You pay — High Option
and supplies)

Examinations to determine the need, if any, for $15 per office visit $10 per office visit.
hearing correction.

Not covered: All charges All charges
All other hearing testing
Hearing aids, and evaluation for them

Vision services (testing, treatment,
and supplies)

Diagnosis and treatment of diseases of the eye $15 per office visit $10 per office visit
Routine eye exams including refraction, once
every 12 months, to determine the prescription
for corrective lenses, eyeglasses or contact
lenses. You may go directly to a participating
Vision Service Plan (VSP) provider without
a referral or authorization from VSP. For a
list of participating providers call VSP at
888/ 426-4877.

Routine visual acuity exams as part of covered
periodic health exams

We cover eyeglasses when prescribed following All cost over $125 All cost over $125
cataract surgery with an intra ocular lens implant.
Eyeglasses must be obtained through participating
providers, and are covered up to $125 per pair, with a
limit of one pair per surgery and two pairs per lifetime.

Not covered: All charges All charges
Fitting contact lenses
Vision therapy
Radial keratotomy, keratomileusis and excimer
laser surgery

Eyeglasses or contact lenses, other than
following cataract surgery as described above

Foot care

Routine foot care when you are under active $15 per office visit $10 per office visit
treatment for a metabolic or peripheral vascular
disease, such as diabetes.

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

Not covered: All charges All charges
Cutting or trimming of the free edge of toenails,
and similar routine treatment of conditions of
the foot, except as stated above

Foot orthotics, except as covered under Durable
Medical Equipment

2002 PacifiCare of Colorado Section 5a 18
18 Page 19 20
18
Orthopedic and prosthetic devices You pay — Standard Option You pay — High Option
Orthopedic braces and podiatric shoe inserts $15 per office visit $10 per office visit
meeting criteria are covered up to a combined
maximum of $500 per member per calendar year.

Externally worn breast prostheses and surgical
bras, including necessary replacements will be
covered following a mastectomy up to $500 per
member per calendar year.

Internal prosthetic devices, such as artificial
joints, pacemakers, cochlear implants, lenses
following cataract removal, and surgically
implanted breast implants following
mastectomy. Note: We pay internal prosthetic
devices as hospital benefits; see Section 5( c) for
payment information. See 5( b) for coverage of
the surgery to insert the device.

External extremity prosthetics — please refer to
the Durable Medical Equipment benefit for
coverage information.

Not covered: All charges All charges
Foot orthotics, except as covered under Durable
Medical Equipment

Orthotic devices for podiatric use
Arch support
Prostheses for cosmetic purposes
Experimental/ investigational or cosmetic
implants

Durable medical equipment (DME)

The following durable medical equipment is covered Nothing up to the annual $1,500 Nothing up to the annual $1,500
based on criteria established by us, up to $1,500 per benefit limit; all charges benefit limit; all charges
member per calendar year. The criteria may include thereafter thereafter
that the equipment must eliminate the need for
treatment in an acute care or rehabilitative facility.
Please contact us for other criteria.

Coverage is limited to:
Apnea monitors
Bilirubin lights or blankets
Bone stimulators
Continuous passive motion machines (CPM)
External extremity prosthetics (covered only if
the prosthesis will restore function of the
extremity)

Feeding pumps
Hospital beds

2002 PacifiCare of Colorado Section 5a
Durable medical equipment (DME) — Continued on next page 19
19 Page 20 21
Durable medical equipment (DME) You pay — Standard Option You pay — High Option
(continued)

Insulin pump supplies (including cartridges,
extension tubing, batteries, infusion sets, and
customary dressings provided by the pump
supplier to secure infusion sets)

Lymphedema pumps
Nebulizers
Oxygen
Positive airway pressure devices (C-PAP)
(Bi-PAP)

Prosthetic eyes
Suction machines
Traction equipment
Ventilators
Wheelchairs

One peak flow meter per member per lifetime and Nothing Nothing
one glucometer per member per lifetime.

Insulin pumps meeting criteria. Nothing Nothing
Not covered: medical supplies such as: All charges All charges
Crutches
Colostomy supplies
Catheters

Home health services
Home health services of nurses and therapists, Nothing Nothing
including intravenous fluids and medications,
when prescribed by your Plan doctor, who will
periodically review the program for continuing
appropriateness and need.

Mothers with newborns released from the hospital
in accordance with PacifiCare of Colorado
guidelines are entitled to one visit at home by a
nurse, as well as the services of a homemaker for
four hours on two days within 30 days
following delivery .

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

Home care primarily for personal assistance
that does not include a medical component and
is not diagnostic, therapeutic or rehabilitative

19 2002 PacifiCare of Colorado Section 5a 20
20 Page 21 22
20
Chiropractic You pay — Standard Option You pay — High Option
Chiropractic services — up to 20 outpatient visits $15 per office visit $10 per office visit
with a participating chiropractor.

Note: You may self refer to a participating
chiropractor for the 1st visit per
neuromusculoskeletal condition or injury; however
the Plan must approve any additional treatment.

Not covered: All charges All charges
Chiropractic services for maintenance care
Biofeedback

Alternative treatments

Not covered: All charges All charges
Naturopathic services
Hypnotherapy
biofeedback

Educational classes and programs

Smoking Cessation — The StopSmoking SM program is $20 enrollment fee for $20 enrollment fee in the
a one-year self-directed, self-paced smoking cessation StopSmoking SM program StopSmoking SM program
program for our members. After enrollment in the
program, a letter is sent to your PCP to inform him
or her of your participation.

The program includes:
Regularly scheduled motivational phone calls
with a trained smoking cessation specialist.

A StopSmoking kit complete with video and
audio tapes and brochures to guide smokers
to quit.

One of two smoking cessation aid products; a $20 copay per 30-day supply $20 copay per 30-day supply
transdermal patch for nicotine replacement
therapy, or Zyban, a prescription drug. Coverage
of these aids is available for up to 90 days per
year, limited to 3 years per lifetime.

To enroll in the StopSmoking program, or for more
information, please call 800/ 877-777, or 303/ 714-5800
when calling from 303 or 720 area codes.

Not covered: special service clinics, centers, or All charges All charges
programs on an inpatient or outpatient basis, such as:

Education clinics, such as premenstrual (PMS),
lactation, headache, eating disorder, senior
services and stress management

2002 PacifiCare of Colorado Section 5a 21
21 Page 22 23
Surgical procedures You pay — Standard Option You pay — High Option
A comprehensive range of services, such as:
Surgical services including normal pre-and
post-operative care by the surgeon

Services of a surgical assistant and
anesthesiologist when medically necessary

Correction of amblyopia and strabismis
Treatment of fractures, including casting
Removal of tumors and cysts
Endoscopy procedure
Biopsy procedure
Correction of congenital anomalies (see
Reconstructive surgery)

Surgical treatment of morbid obesity based on
criteria established by us

Insertion of internal prosthetic devices. Note: See
Section 5 (a) for device coverage information.

Voluntary sterilization
Treatment of burns

Not covered: All charges All charges
Reversal of voluntary, surgically-induced sterility
Surgery primarily for cosmetic purposes

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

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

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

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

YOUR PHYSICIAN MUST GET SOME SURGICAL PROCEDURES
PREAUTHORIZED. Please refer to the preauthorization information shown in Section 3
to be sure which services and surgeries require preauthorization.

2002 PacifiCare of Colorado Section 5b

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

Benefit Description You pay 22
22 Page 23 24
22
Reconstructive surgery You pay — Standard Option You pay — High Option
Surgery to correct a functional defect
Surgery to correct a condition caused by injury
or surgery if:

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

the condition can reasonably be expected
to be corrected by such surgery

Surgery to correct a condition that existed at or
from birth and is a significant deviation from the
common form or norm. Some examples of
congenital anomalies are cleft lip and cleft palate.

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

surgery to produce a symmetrical
appearance on the other breast;

treatment of any physical complications,
such as lymphedemas;

breast prostheses and surgical bras and
replacements (see Prosthetic devices)

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

Not covered: All charges All charges
Cosmetic surgery — any surgical procedure (or
any portion of a procedure) performed primarily
to improve physical appearance through change
in bodily form, except repair of accidental injury.)

Surgeries related to sex transformation

Oral and maxillofacial surgery

Oral surgical procedures, limited to:
Treatment of congenital conditions of the jaw
that may be demonstrated to cause actual
significant deterioration in the member's
physical condition because of inadequate
nutrition or respiration;

Reduction of fractures of the jaws or facial bones;
Surgical correction of cleft lip, cleft palate or
severe functional malocclusion;

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

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

TMJ surgery and related non-dental treatment.

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

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

2002 PacifiCare of Colorado Section 5b
Oral and maxillofacial surgery — Continued on next page 23
23 Page 24 25
23
Oral and maxillofacial surgery (continued) You pay -Standard Option You pay — High Option
Not covered: All charges All charges
Orthodontic treatment, or other dental related
services for treatment of TMJ.

Oral implants and transplants
Procedures that involve the teeth or their
supporting structures (such as the periodontal
membrane, gingiva, and alveolar bone)

Organ/ tissue transplants

Limited to:
Cornea
Heart
Heart/ lung
Kidney
Liver
Allogeneic (donor) bone marrow and stem cell
transplants

Autologous bone marrow and stem cell
transplants (autologous stem cell and peripheral
stem cell support) for the following conditions:
acute lymphocytic or non-lymphocytic
leukemia; advanced Hodgkin s lymphoma;
advanced non-Hodgkin s lymphoma; advanced
neuroblastoma; breast cancer; multiple
myeloma; epithelial ovarian cancer; and
testicular, mediastinal, retroperitoneal and
ovarian germ cell tumors

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

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

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

We also cover donor screening charges for
immediate family members to include spouses,
parents, children, siblings, and, if appropriate,
grandparents.

Not covered: All charges All charges
Transplants not listed as covered
Implants of artificial organs

$10 per visit in a physician s
office; nothing for outpatient
or inpatient surgery

$15 per visit in a physician s
office; nothing for outpatient
or inpatient surgery

2002 PacifiCare of Colorado Section 5b 24
24 Page 25 26
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Anesthesia You pay -Standard Option You pay — High Option
Professional services provided in: Nothing Nothing
Hospital (inpatient)
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center
Office

2002 PacifiCare of Colorado Section 5b 25
25 Page 26 27
Inpatient hospital You pay -Standard Option You pay -High Option
Room and board, such as:
Semiprivate, or specialized care units, such as
intensive care or cardiac care units;

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

Nothing $300 deductible per person
per year; $500 maximum per
family per year.

(Calendar year deductible
applies.)

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

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

Unlike Sections (a) and (b), in this section the calendar year deductible applies to only a
few benefits. In that case, we added "( calendar year deductible applies)". There is no
deductible on the High Option. The Standard Option calendar year deductible for
hospital admission is $300 per person ($ 500 per family).

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

The amounts listed below are for the charges billed by the facility (i. e., hospital or
surgical center) or ambulance service for your surgery or care. Any costs associated with
the professional charge (i. e., physicians, etc.) are covered in Section 5( a) or (b).

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

2002 PacifiCare of Colorado Section 5c

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

Benefit Description You pay
NOTE: The Standard Option calendar year deductible applies only when we say below: calendar year deductible applies .

Inpatient hospital — Continued on next page 26
26 Page 27 28
26
Inpatient hospital (continued) You pay -Standard Option You pay -High Option
Other hospital services and supplies, such as: Nothing Nothing
Operating, recovery, maternity, and other
treatment rooms

Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays
Blood, blood plasma, and blood products if not
donated or replaced, including processing and
administration

Dressings, splints, casts, and sterile tray services
Medical supplies and equipment, including
oxygen

Anesthetics and anesthesia service when
medically necessary

Not covered: All charges All charges
Custodial care
Non-covered facilities, such as nursing homes,
schools

Special blood handling fees, wound healing
products and storage of cord blood

Personal comfort items, such as telephone,
television, articles for personal hygiene, guest
meals and beds

Private duty nursing care
Take-home drugs and supplies
Hospitalization for any dental procedures,
except for children under certain circumstances

Outpatient hospital or ambulatory
surgical center

Operating, recovery, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and
pathology services

Blood, blood plasma, and blood products if not
donated or replaced, including processing and
administration

Pre-surgical testing
Dressings, casts, and sterile tray services
Medical supplies, including oxygen
Anesthetics and anesthesia service when
medically necessary

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

Nothing $100 copay for outpatient
surgery or 23-hour observation

2002 PacifiCare of Colorado Section 5c
Outpatient hospital or ambulatory surgical center — Continued on next page 27
27 Page 28 29
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Outpatient hospital or ambulatory You pay — Standard Option You pay — High Option
surgical center (continued)

Not covered: All charges All charges
Special blood handling fees, wound healing
products and storage of cord blood

Hospitalization for any dental procedures,
except for children under certain circumstances

Extended care benefits/ skilled
nursing care facility benefits

Subacute care facility services following Nothing Nothing
hospitalization is covered up to 60 days per
calendar year at an approved subacute care facility.
This coverage includes:

Accommodations
Meals
General nursing care
Medical supplies and equipment ordinarily
furnished by the facility

Prescribed drugs and biologicals

Skilled nursing facility (SNF): We cover up to 120 Nothing Nothing
days per calendar year when full-time skilled nursing
care is necessary and confinement in a skilled nursing
facility is medically appropriate as determined by a
Plan doctor and approved by us.
This coverage includes:

Accommodations
Meals
General nursing care
Medical supplies and equipment ordinarily
furnished by the facility

Prescribed drugs and biologicals

Not covered: All charges All charges
Custodial care
Care for chronic conditions
Private room, except when medically necessary
Personal comfort items, such as telephone,
television, articles for personal hygiene, guest
meals and beds

Private duty nursing care

2002 PacifiCare of Colorado Section 5c 28
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Hospice care You pay -Standard Option You pay -High Option
Supportive and palliative care for a terminally ill Nothing Nothing
member is covered in the home or hospice facility
when approved by our Medical Director.
Services include:

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

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

Ambulance
Medically necessary air or ground ambulance $25 per trip $25 per trip
service ordered or authorized by a Plan doctor

2002 PacifiCare of Colorado Section 5c 29
29 Page 30 31
What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your
life or could result in serious injury or disability, and requires immediate medical or surgical care. Some problems are
emergencies because, if not treated promptly, they might become more serious; examples include deep cuts and
broken bones. Others are emergencies because they are potentially life-threatening, such as heart attacks, strokes,
poisonings, gunshot wounds, or sudden inability to breathe. There are many other acute conditions that we may
determine are medical emergencies — what they all have in common is the need for quick action.

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

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

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

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

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

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Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and
exclusions in this brochure.

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

2002 PacifiCare of Colorado Section 5d

Section 5 (d). Emergency services/ accidents
Emergency services/ accidents benefits begin on the next page. 30
30 Page 31 32
30 2002 PacifiCare of Colorado Section 5d
Emergency within our service area You pay -Standard Option You pay -High Option
Emergency care at a doctor's office
During normal business hours $15 per visit $10 per visit
After normal business hours $25 per visit $25 per visit
Emergency care at an urgent care center $25 per visit $25 per visit
Emergency room setting $100 per visit $100 per visit

Not covered: All charges All charges
Follow-up care in the emergency facility
Emergency visits made in non-life or limb
threatening situations without your PCP's
authorization

Emergency room services obtained during
normal physician office hours, except in the
event of a life or limb threatening emergency or
when preauthorized by your PCP

Emergency outside our service area
Emergency care at a doctor's office $25 per visit $25 per visit
Emergency care at an urgent care center $25 per visit $25 per visit
Emergency room setting $100 per visit $100 per visit

We cover up to $400 per person per calendar year for
follow-up care to emergency services received outside
the service area. These services are covered when
needed in order to prevent serious deterioration of
your health that would result from an unforeseen
illness or injury if you are temporarily absent from
our service area and receipt of your health care cannot
be delayed until your return to the service area.

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

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

Ambulance

Ground or air ambulance service approved by us $25 per trip $25 per trip

You pay the appropriate
emergency benefit copay listed
in the box directly above

You pay the appropriate
emergency benefit copay listed
in the box directly above

Benefit Description You pay 31
31 Page 32 33
Mental health and substance abuse benefits You pay -Standard Option You pay -High Option
Diagnostic and treatment services recommended by a
Plan provider and contained in a treatment plan that we
approve. The treatment plan may include services, drugs,
and supplies described elsewhere in this brochure.

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

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

Medication management

Diagnostic tests Nothing Nothing
Services provided by a hospital or other facility $300 per person per year; Nothing
$500 maximum per family
per year

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

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

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

Here are some important things to keep in mind about these benefits:
All benefits are subject to the definitions, limitations, and exclusions in this brochure.
The calendar year deductible or, for facility care, the inpatient deductible apply to almost
all benefits in this Section. We added "( No deductible)" to show when a deductible does
not apply.

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

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

2002 PacifiCare of Colorado Section 5e

Section 5 (e). Mental health and substance abuse benefits
Benefit Description You pay After the calendar year deductible

Mental health and substance abuse benefits — Continued on next page 32
32 Page 33 34
32
Mental health and substance abuse You pay — Standard Option You pay — High Option
benefits (continued)

Not covered: All charges All charges
Psychiatric evaluation or therapy, or substance
abuse treatment, on court order or as a condition
of parole or probation, unless determined by us
to be necessary and appropriate

Services we have not approved
Note: The same exclusions contained in this
brochure that apply to other benefits apply to these
mental health and substance abuse benefits, unless
the services are included in a treatment plan that we
approve. OPM's review of disputes about network
treatment plans will be based on the treatment plan's
clinical appropriateness. OPM will generally not
order one clinically appropriate treatment plan in
favor of another.

Preauthorization To be eligible to receive these benefits you must obtain a treatment plan and follow all of the following authorization processes:

Most PacifiCare members receive mental health or substance abuse services
through PacifiCare Behavioral Health. Simply call toll-free at 888/ 777-2735 and
PacifiCare Behavioral Health will put you in touch with the right mental health
professional and authorize needed services.

If your PCP is affiliated with the Primary Physician Partners (PPP)*, your mental
health and substance abuse services are provided by Pro Behavioral Health. Pro
Behavioral Health's toll-free number is 800/ 944-6527.

If your child's primary care physician is affiliated with Colorado Pediatic
Partners*, you may access mental health services for your child by calling
1-877-700-5300.

* To determine your PCP's affiliation, please check your ID card, call your
PCP or call PacifiCare Customer Service at 800/ 877-9777, or 303/ 714-5800
when calling from 303 or 720 area codes.

To seek our mental health or substance abuse services, you do not need a referral
from your primary care physician. However, please identify yourself as a
PacifiCare member when contacting PacifiCare Behavioral Health, Pro Behavioral
Health or Colorado Pediatric Partners. Also, be sure to present your PacifiCare ID
card each time you visit your mental health professional.

2002 PacifiCare of Colorado Section 5e 33
33 Page 34 35
There are important features you should be aware of. These include:
Who can write your prescription. A Plan physician, an approved non-Plan physician, or a licensed dentist must write
your prescription.

Where you can obtain them. You must fill the prescription at a plan pharmacy or through our mail-order program.
We use a formulary. The PacifiCare Formulary is a list of over 1,600 prescription drugs that physicians use as a guide
when prescribing medications for patients. The Formulary plays an important role in providing safe, effective and
affordable prescription drugs to PacifiCare members. It also allows us to work together with physicians and pharmacies to
ensure that our members are getting the drug therapy they need. A Pharmacy and Therapeutics Committee consisting of
physicians and pharmacists evaluates prescription drugs based on safety, effectiveness, quality treatment and overall value.
The committee considers first and foremost the safety and effectiveness of a medication before reviewing the cost. The
Formulary is updated on a regular basis.

You may obtain a copy of the Formulary by calling Customer Service, or by logging onto the PacifiCare website at
www. pacificare. com/ colorado. PacifiCare uses a generic based Formulary. Prescriptions will be filled with generics
whenever possible. If you or your physician prefer a brand name product when a formulary generic equivalent is available
you will pay the non-formulary copayment.

These are the dispensing limitations. Drugs are dispensed in accordance with the Plan's drug formulary. Prescription
drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed for up to a 30-day supply.
For medications that come in trade size packages, you will be responsible for one applicable copay per prepackaged unit.
Non-formulary drugs will be covered when prescribed by a Plan doctor. Prior-authorization is not needed because there are
different copayments for formulary and non-formulary medications. Clinical edits (limitations) can be used for safety
reasons, quantity limitations and benefit plan exclusions.

A 90-day supply of maintenance medications can be filled through our mail-order prescription drug program. You pay 2
applicable copays per 90-day supply of tablets and capsules, or up to 4 prepackaged units, for a covered medication.
Contact PacifiCare of Colorado's Customer Service Department at 800/ 877-9777, or 303/ 714-5800 when calling from 303
or 720 area codes, for more information — and to receive a mail-order form.

Why use generic drugs? Generic drugs contain the same active ingredients and are equivalent in strength and dosage to
the original brand name product. Generic drugs cost you less money than a brand name drug.

When you have to file a claim. Please refer to Section 7 for information on how to file a pharmacy claim, or contact our
Customer Service Department at 800/ 877-9777, or 303/ 714-5800 when calling from 303 or 720 area codes.

Please Note: We do not coordinate benefits for outpatient prescription drugs.
Prescription drug benefits begin on the next page.

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

All benefits are subject to the definitions, limitations and exclusions in this brochure and
are payable only when we determine they are medically necessary.

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

2002 PacifiCare of Colorado Section 5f

Section 5 (f). Prescription drug benefits 34
34 Page 35 36
34 2002 PacifiCare of Colorado Section 5f
Covered medications and supplies You pay -Standard Option You pay -High Option
We cover the following medications and supplies
prescribed by a Plan physician and obtained from a
Plan pharmacy or through our mail-order program:

Drugs for which a prescription is required by law
Disposable needles and syringes for the
administration of covered prescribed medications

Commercially prepared progesterone and
estrogen products

Intravenous fluids and medication for home use
are covered under "Home health services".
See page 19.

Oral contraceptive drugs; contraceptive
diaphragms; and cervical caps

Coverage for implantable and injectable
contraceptives is listed under the "Family
planning section" located in 5( a)

The following benefit is covered, but limited:
Diabetic glucose and ketone test strips and
lancets dispensed in the manufacturer's
prepackaged unit, up to 100 test strips, or 200
lancets, per 30-day supply. For members who
meet certain criteria, we provide coverage for up
to 200 test strips per 30-day supply.

Insulin

Injectable drugs (except insulin) when preauthorized $10 copay per prescription unit $10 copay per prescription unit
or refill or refill

The following benefit is covered, but limited:
Drugs to treat sexual dysfunction are covered
when plan criteria is met. Contact us for dose
limits.

50% of the cost of the medication
per prescription unit or refill up
to the dosage limit; all charges
above that

50% of the cost of the medication
per prescription unit or refill up
to the dosage limit; all charges
above that

A copay is applied to every two
vials of the same kind of insulin.

You can receive up to six vials
of the same kind of insulin
through the mail-order program
for two applicable copays.

A copay is applied to every two
vials of the same kind of insulin.

You can receive up to six vials
of the same kind of insulin
through the mail-order program
for two applicable copays.

Per 30-day supply or
prepackaged unit:

Formulary Generic -$5
Formulary Brand -$10
Non-Formulary -$20

Per 30-day supply or
prepackaged unit:

Formulary Generic -$10
Formulary Brand -$20
Non-Formulary -$30

Benefit Description You pay After the calendar year deductible

Covered medications and supplies — Continued on next page 35
35 Page 36 37
35
Covered medications and supplies You pay — Standard Option You pay — High Option
(continued)

Not covered: All charges All charges
Drugs available without a prescription or for
which there is a nonprescription equivalent
available

Drugs obtained at a non-Plan pharmacy, except
for out-of-area emergencies

Vitamins and nutritional substances that can be
purchased without a prescription

Medical supplies such as dressings and
antiseptics

Smoking cessation drugs and medication,
including nicotine patches, except through the
StopSmoking program

Drugs for weight reduction
Lifestyle enhancement drugs, including but not
limited to drugs to enhance hair growth, anti-aging
and mental performance

Fertility drugs
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Convenience packaged medications, including
but not limited to Insulin penfill

2002 PacifiCare of Colorado Section 5f 36
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36 2002 PacifiCare of Colorado Section 5g
TDD phone line — 800/ 659-2656
A nurse health manager is available to pregnant women who have specific needs
during their pregnancy. Moms can self-refer to this nurse, or the physician can
refer expecting mothers.

If you are interested in this program, contact Customer Service at 800/ 877-9777,
or 303/ 714-5800 when calling from 303 or 720 area codes.

All PacifiCare members with diabetes are eligible for this program, which helps to
improve their health status and ability to manage their diabetes. The following
components are included:

Outreach program — available to all new enrollees to assure they understand
and can access their full range of PacifiCare benefits.

Taking Charge of Diabetes — An extensive self-education module for
members with diabetes.

Individual case management — This feature is for specific diabetes concerns
that require the involvement of a medical case manager from PacifiCare.

Reminder program — This is a pro-active support program reminding members
about aspects of the clinical management of their diabetes. For example, a
member may receive a phone call to remind them that they need to get a
retinal eye exam.

A telephone follow-up program for PacifiCare members with congestive heart
failure which improves their health status and their ability to cope with their
condition. This program has shown a decrease in the re-admission rate to the
hospital, for those members who have received this intervention. Aspects of this
program include:

Taking Charge of Your Heart Health — An extensive self-education module
for members with congestive heart failure.

Hospital follow-up program — A telemonitoring case management program for
patients following hospitalization for congestive heart failure.

Section 5 (g). Special features
Feature Description
Services for deaf and hearing impaired

Healthy Pregnancy SM Program

Diabetes Management Program

Congestive Heart Failure Program 37
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Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions
in this brochure and are payable only when we determine they are medically necessary.

Plan dentists must provide or arrange your care on the Standard Option, on the High
Option you may go to any dentist you choose.

On the Standard Option there is no deductible, on the High Option the calendar year
deductible is $50 per person/$ 150 per family. The deductible is waived for preventive
services.

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

For more information call PacifiCare Dental Administrators at 1-800-591-5915

2002 PacifiCare of Colorado Section 5h

Section 5 (h). Dental benefits
Dental Benefits -High Option
Service We pay You pay
Preventive and diagnostic services, such as:
Periodic oral evaluation
Intraoral X-rays — complete series (including
bitewings)
Panoramic X-ray
Prophylaxis — (adult, every six months)
Prophylaxis — (child, every six months)
Child — fluoride with prophylaxis
Adult — fluoride with prophylaxis

Basic services, such as:
Amalgam — one surface, permanent
Amalgam — two surfaces, permanent
Root canal — anterior (excluding final restoration)
Root canal — bicuspid (excluding final restoration)
Periodontal scaling and root planing, per quad
Removal of impacted tooth — soft tissue

Major services, such as:
Complete denture — maxillary
Maxillary partial denture — resin base
Pontic
Crown — porcelain fused to high noble metal

Please contact us for our full fee allowance and other details for High Option dental benefits.
Accidental injury benefit
We cover restorative services and supplies necessary to promptly repair (but not replace) sound natural teeth. The need for
these services must result from an accidental injury.

Orthodontics
Please see the end of Section 5( h) for your orthodontic benefits.

100% of the Plan's fee
allowance.

80% of the Plan's fee
allowance, or the dentist's
charge.

50% of the Plan's fee allowance
or the dentist's charge.

All charges over the Plan's fee
allowance up to the dentist's
charge.
The deductible is waived for
preventive care.

$50 deductible and all charges
over the Plan payment up to the
dentist's charge.

$50 deductible and all charges
over the Plan payment up to the
dentist's charge. 38
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38 2002 PacifiCare of Colorado Section 5h
With our plan you receive the following comprehensive program of dental coverage through participating Plan dentists. This
listing represents a description of the benefits and exclusions. For more detailed information regarding covered services and
claims related concerns, call PacifiCare Dental Customer Services at 800/ 228-3384.

Choosing your dentist
Please select a primary care dentist, from the list of Dental Providers available in your area, for each member of your family.
Your dental benefits and services are available only through the participating dentist you selected, except for out-of-area
emergencies. If you wish to change your primary care dentist, call PacifiCare Dental Customer Services.

Receiving care
Member fees are due at the time of service.
NOTE: Your dentist may prescribe certain procedures not covered under your Plan benefit. Non-member fees will be charged
for such services. Where UCR is shown, the procedure is not a covered benefit, and you pay the dentist's usual, customary
and reasonable fee for that service.

Specialty care
If you receive care from a specialist, you pay a 60% member payment (Standard Option) of the PacifiCare contracted
specialists fee schedule.

PacifiCare Dental maintains a panel of qualified Dental Specialists to provide you with the treatment that is beyond the scope
of the General Dentist. Once we have reviewed and approved the recommended specialty referral, we will coordinate the
referral to the closest specialist in your area.

Visits
Office Visit, per visit charge in addition to procedure (may be referred to as a $5
sterilization charge in some offices)
After hours visit, in addition to service provided $30
Missed appointment — without 24 hours notice $20
(copay per each 30 minutes of appointment time)

Preventive
Emergency treatment, palliative $10
Routine teeth cleaning, once every 6 months $10
Topical application to age 14 $7
Oral Hygiene Instructions $0

Diagnostic (film allowance includes exam and diagnosis)
Single, film $4
Additional, up to 12 films $3
Full mouth series (including bite-wings, if necessary) $17
Intra-oral, occlusal view $4
Bite-wing films, 2 films $5
Bite-wing films, 4 films $9
Panographic-type film $20

Service You pay -Standard Option

Dental Benefits -Standard Option 39
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39 2002 PacifiCare of Colorado Section 5h
Crown and bridge — Continued on next page

Restorative Dentistry (fillings)
Amalgam Restorations
Primary teeth, 1 surface $16
Primary teeth, 2 surfaces $20
Primary teeth, 3 surfaces $25
Primary teeth, 4 or more surfaces $28
Permanent teeth, 1 surface $18
Permanent teeth, 2 surfaces $22
Permanent teeth, 3 surfaces $26
Permanent teeth, 4 or more surfaces $30
Composite Resins (tooth colored fillings, fee includes acid etching and/ or bonding)
1 Surface anterior $20
2 Surfaces anterior $28
3 Surface anterior $36
4 Surfaces anterior $42
Pin retention, per tooth ( not including restoration) UCR
Sealants per tooth $10
Sedative base $10

Oral Surgery
Extractions (fees include local anesthesia and routine post-operative visits)
Uncomplicated, single extraction $18
Each additional uncomplicated extraction $18
Surgical removal of an erupted tooth $28
Removal of impacted tooth (soft tissue) $60
Removal of impacted tooth (partially bony) $85
Removal of impacted tooth (completely bony) $110

Other Procedures
Post-operative visit, complications (i. e. osteitis) $0
Biopsy and microscopic examination UCR
Alveoloplasty (edentulous), per quadrant $85
Avleoloectomy per quadrant $65
Intra-oral incision and drainage of abscess (soft tissue) UCR
Frenectomy $45
Removal of exostosis (tori) UCR

Anesthesia
Additional charges for general anesthetics, nitrous oxide, anesthetists or
anesthesiologists are the responsibility of the patient
Local anesthesia $0

Periodontics
Periodontal maintenance procedures (following active surgical and adjunctive $50
periodontal therapies)
Scaling and root planing per quadrant $50
Full mouth debridement $50
Correction of occlusion per quadrant, minor spot grinding (equilibration not a $26
covered benefit)
Gingivectomy per quadrant, includes post-surgical visits $175
Osseous or muco-gingival surgery per quadrant (includes post-surgical visits) $300
Gingivectomy treatment per tooth $35
Gingival flap procedures (includes RP) Quad UCR

Service You pay -Standard Option 40
40 Page 41 42
40 2002 PacifiCare of Colorado Section 5h
Service You pay -Standard Option
Endodontics
Direct pulp capping $12
Therapeutic pulpotomy (in addition to restoration) per treatment $20
Indirect pulp capping (recalcification), including temporary restoration $15

Root Canal Therapy
Anterior RCT $110
Bicuspid RCT, 1-2 canals $160
Molar RCT, 1 canal $110
Molar RCT, 2 canals $160
Molar RCT, 3 canals $220
Molar RCT, 4 canals $250
Apicoectomy and/ or retrograde therapy-per tooth $180
Apicoectomy, separate procedure, per tooth $120
Hemisection, root amputation UCR

Crown and Bridge
Crowns*
Plastic, permanent, processed $120
Porcelain jacket $260
Porcelain with metal $260
Full cast metal $240
3/ 4 metal $240
Crown build up, extensive amalgam/ composite, including pins UCR
Stainless steel, primary $50
Stainless steel, permanent $50
Preformed post and build up UCR
Cast post with core or coping UCR
Crown recementation (or inlay) $15
Bridge recementation $20
Pontics* (artificial tooth on a fixed bridge)
Cast, metal $240
Porcelain with metal $260

*Where precious metal is used, additional copayment will be required.

Prosthetics* (removable)
Dentures*
Dentures, partial dentures and reline allowances include adjustments for a 90-day period
following installation. Fees for specialized techniques involving precision dentures,
personalization or characterization are in addition to those listed.

Complete upper or lower denture $300
Immediate upper or lower denture $320
Partial acrylic upper or lower base (teeth/ clasps extra) $100
Partial, upper or lower with chrome cobalt alloy $350
palatal or lingual bar and acrylic saddles (teeth/ clasps extra)
Unilateral partial base $100
Anterior stayplate base/ temporary $75
Teeth and clasps extra per unit (for partial, stayplates, etc.) $15
Denture/ partial adjustment $15
Office reline, cold cure acrylic $85
Denture reline, laboratory $110
Tissue conditioning, per denture UCR
Denture duplication (jump case), per denture $110
Simple stress breakers $30

*Additional fees will be required for laboratory services for removable prosthetics,
not to exceed $80. 41
41 Page 42 43
41 2002 PacifiCare of Colorado Section 5h
Service You pay -Standard Option
Repairs*
Denture/ partial resin base (no teeth involved) $40
Replace missing or broken teeth, each $25
Replace missing or broken clasp, each $35

*Where precious metal is used, additional copayment will be required.

Space Maintainers
Removable, plastic $50
Fixed, unilateral band type $50
Fixed, stainless steel crown type $50
Fixed, lingual, palatal bar type or bilateral $50

What is not covered: All charges
Care by non-Plan dentists except for authorized referrals or emergencies
Cosmetic dental care
Hospital and medical charges of any kind, including dental services rendered in
a hospital
General anesthesia, including intravenous or inhalation sedation, except when
medically necessary for extractions only
Loss or theft of dentures, appliances or bridgework
Dental treatment started prior to the member's eligibility to receive benefits
under this Plan or started after the member's termination
Other dental services not shown as covered

In-Area emergency
In emergency situations, PacifiCare Dental primary care dentists shall furnish such care as needed immediately or, if
appropriate, not more than 24 hours after the request. Dental emergencies are defined as conditions where
hemorrhage, acute pain or infection of dental origin exists.

During Normal Business Hours: Contact your primary care dental office. If you are unable to contact your
primary care dental office, please call PacifiCare Dental at 800/ 228-3384 and a Dental Customer Services
Representative will assist you.

After Normal Business Hours: Contact your primary care dental office. If you are unable to contact your primary
care dental office, you may seek emergency care only at any licensed dental office. PacifiCare Dental will
reimburse you up to $50.

For emergency care requiring an after-hours appointment, you may be assessed a $30/ visit charge in addition to any
copayment.

Out-of-Area emergency
Coverage for emergency benefits outside the service area is limited to palliative treatment of infection and pain.
Definitive treatment is not covered. The out-of-area coverage reimburses the usual and customary fee up to a
maximum of $50 per occurrence. We must be notified within 30 days.

Out-of-area emergencies are covered as follows:
if the member develops a condition or sustains an injury while temporarily outside of the Plan's service area;
the need for such care was not reasonably foreseeable, and;
it is not feasible for the member to call PacifiCare and present him/ herself to a PacifiCare dentist. 42
42 Page 43 44
42 2002 PacifiCare of Colorado Section 5h
Reimbursement for emergencies
Claims for emergency benefits should be filed with PacifiCare Dental Services, P. O. Box 483, Tustin, CA 92781
within 30 days after the emergency care, and must provide sufficient information to verify entitlement to payment.
Include:

covered member's name and ID number
dentist's name
nature of problem
date of treatment
treatment given
itemized charges
copy of receipt

Orthodontics
The orthodontic benefits described here are for both High Option and Standard Option plans.

Through a PacifiCare panel Orthodontist, plan members are eligible to receive up to a 2-year orthodontic treatment
provided by a PacifiCare contracted provider. You pay orthodontic charges of $2,150 for members under 19 years of
age, and $2,500 for members 19 years or older, plus $300 start-up fees, $250 retention fees and X-ray costs.

What is covered
Comprehensive orthodontic care at a panel orthodontic office for a usual and customary 24 month treatment plan.
The start-up services shall include initial examination, study models, diagnosis, consultation and placement of
orthodontic appliances (braces).
The retention services may include impressions for post-treatment retainers, placement of retainers, retainer
adjustments, and post-treatment supervision as needed. The normal retention fee is $250 and shall not exceed this
amount. This amount is limited to the customary 24 month retention phase.
The orthodontist has agreed that any course of orthodontic treatment initiated under this plan shall be completed, at
the election of the member, under the terms, conditions, and fees provided herein, should the member become
ineligible as a Plan member prior to completion of orthodontic treatment.
A qualified member with cleft lip/ palate is not subject to the limits of this Plan and the benefit for the services of a
specialist shall apply as stated at the beginning of the dental benefit description.
Administrative Fee: If you do not keep an appointment and fail to notify the provider office of cancellation 24
hours in advance, you may be assessed a service charge.

Limitations
Orthodontic treatment must be provided by a member of the PacifiCare orthodontic panel.
Cases that are other than basic and usual may require additional charges.
If a member does not require treatment or elects not to have treatment, after the doctor has completed a diagnosis
and consultation, the patient may be charged a consultation fee of $85.

What is not covered
X-ray fees (orthodontic).
Start-up and retention as described under Orthodontic Benefits.
Lost, stolen or broken appliances.
Procedures not listed or procedures required in addition to basic, usual and customary orthodontic services
including palatal expansion devices, functional appliances and myofunctional therapy.
Work in progress (i. e., cases banded prior to inception of eligibility).
Orthodontic emergencies or changes in treatment necessitated by accidents of any kind, adverse growth patterns or
poor patient cooperation.
Orthodontic treatment and/ or surgical procedures for skeletal abnormalities such as micrognathia, facial
asymmetrical and facial deformities.
Treatment related to temporomandibular joint disorders.
Any procedures considered within the field of general dentistry and those not usually performed in the orthodontic office.
Severe or mutilated malocclusions that are not amiable to ideal orthodontic therapy.
Orthodontic treatment of impacted teeth requiring surgical exposure.
Cosmetic braces (plastic, ceramic, sapphire, lingual, etc.). 43
43 Page 44 45
43
The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed claim about
them. Fees you pay for these services do not count toward FEHB deductibles or out-of-pocket maximums.

PacifiCare Perks SM Program
The PacifiCare Perks Program offers you discounts to alternative care, such as massage therapy and acupuncture, healthy mom
and baby programs, and weight management programs. Call 800/ 531-3341 for a complete list of special discount services.

Supplemental Dental HMO
For a monthly premium, you can enroll in a buy-up HMO dental plan. Benefits will not be coordinated between this plan and
the dental plans included with your medical plan. Call 800/ 591-5915 for more information.

2002 PacifiCare of Colorado Section 5i

Section 5 (i). Non-FEHB benefits available to Plan members 44
44 Page 45 46
44
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not cover it
unless your Plan doctor determines it is medically necessary to prevent, diagnose, or treat your illness, disease, injury or
condition and we agree, as discussed under services requiring our prior approval on page 9.

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

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

2002 PacifiCare of Colorado Section 6

Section 6. General exclusions things we don't cover 45
45 Page 46 47
45
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at Plan
pharmacies, you will not have to file claims. Just present your identification card and pay your copayment, coinsurance, or
deductible.

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

Medical, hospital and In most cases, providers and facilities file claims for you. Physicians must file on pharmacy benefits the form HCFA-1500, Health Insurance Claim Form. Facilities will file on the

UB-92 form. For claims questions and assistance, call us at 800/ 877-9777, or
303/ 714-5800 when calling from 303 or 720 area codes.

When you must file a claim such as for out-of-area care submit it on the
HCFA-1500 or be sure to provide documentation that includes all of the
information shown below. Bills and receipts should be itemized and show:

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

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

Receipts, if you paid for your services.
Submit your claims to: PacifiCare
Attn: Customer Service, CO84-416
P. O. Box 6770
Englewood, CO 80155

Prescription Drugs Please mail your prescription receipts with your name and ID number to:
PacifiCare Solutions Claims Department
P. O. Box 6037
Cypress, CA 90630

Dental services Please provide the same information detailed in the bullets above.
Submit your claims to: PacifiCare Dental Services
P. O. Box 483
Tustin, CA 92781

Deadline for filing your claim Send us all of the documents for your claim as soon as possible. You must submit the claim by December 31 of the year after the year you received the service,

unless timely filing was prevented by administrative operations of Government or
legal incapacity, provided the claim was submitted as soon as reasonably possible.

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

2002 PacifiCare of Colorado Section 7

Section 7. Filing a claim for covered services 46
46 Page 47 48
46
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your
claim or request for services, drugs, or supplies — including a request for preauthorization:

Step Description
1 Ask us in writing to reconsider our initial decision. You must:
(a) Write to us within 6 months from the date of our decision; and
(b) Send your request to us at: PacifiCare
Attn: Member Appeals
P. O. Box 4306
Englewood, CO 80155-4306

Or you can fax us your request at 303/ 714-2643; and
(c) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in
this brochure; and

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

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

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

We will write to you with our decision.

4 If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
90 days after the date of our letter upholding our initial decision; or
120 days after you first wrote to us if we did not answer that request in some way within 30 days;
or
120 days after we asked for additional information.
Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Contracts Division 3,
1900 E Street NW, Washington, D. C. 20415-3630.

2002 PacifiCare of Colorado Section 8

Section 8. The disputed claims process 47
47 Page 48 49
47
Send OPM the following information:
A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;
Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records,
and explanation of benefits (EOB) forms;

Copies of all letters you sent to us about the claim;
Copies of all letters we sent to you about the claim; and
Your daytime phone number and the best time to call.
Note: If you want OPM to review different claims, you must clearly identify which documents apply to which claim.
Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representative,
such as medical providers, must include a copy of your specific written consent with the review request.

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

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

6 If you do not agree with OPM's decision, your only recourse is to sue. If you decide to sue, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed
services, drugs or supplies or from the year in which you were denied precertification or prior approval. This is the
only deadline that may not be extended.

OPM may disclose the information it collects during the review process to support their disputed claim decision. This
information will become part of the court record.

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

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

(a) We haven't responded yet to your initial request for care or preauthorization/ prior approval, then call us at
800/ 877-9777, or 303/ 714-5800 when calling from 303 or 720 area codes, and we will expedite our review; or

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

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

2002 PacifiCare of Colorado Section 8 48
48 Page 49 50
48
When you have other health coverage You must tell us if you are covered or a family member is covered under another group health plan or have automobile insurance that pays health care expenses
without regard to fault. This is called double coverage.
When you have double coverage, one plan normally pays its benefits in full as the
primary payer and the other plan pays a reduced benefit as the secondary payer.
We, like other insurers, determine which coverage is primary according to the
National Association of Insurance Commissioners guidelines.

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

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

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

Medicare has two parts:
Part A (Hospital Insurance). Most people do not have to pay for Part A. If you
or your spouse worked for at least 10 years in Medicare-covered employment,
you should be able to qualify for premium-free Part A insurance. (Someone who
was a Federal employee on January 1, 1983 or since automatically qualifies.)
Otherwise, if you are age 65 or older, you may be able to buy it. Contact 1-800-
MEDICARE for more information.

Part B (Medical Insurance). Most people pay monthly for Part B. Generally, Part
B premiums are withheld from your monthly Social Security check or your
retirement check.

If you are eligible for Medicare, you may have choices in how you get your
healthcare. Medicare + Choice is the term used to describe the various health plan
choices available to Medicare beneficiaries. The information in the next few pages
shows how we coordinate benefits with Medicare, depending on the type of
Medicare managed care plan you have.

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

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

(Primary payer chart begins on next page.)

2002 PacifiCare of Colorado Section 9

Section 9. Coordinating benefits with other coverage 49
49 Page 50 51
49 2002 PacifiCare of Colorado Section 9
Please note, if your Plan physician does not participate in Medicare, you will have to file claims directly with Medicare.

The following chart illustrates whether Original Medicare Plan or this Plan should be the primary payer for you according to
your employment status and other factors determined by Medicare. It is critical that you tell us if you or a covered family
member has Medicare coverage so we can administer these requirements correctly.

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

2) Are an annuitant,
3) Are a reemployed annuitant with the Federal government when
a) The position is excluded from FEHB or,
b) The position is not excluded from FEHB
(Ask your employing office which of these applies to you.)

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

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

6) Are a former Federal employee receiving Workers' Compensation and the
Office of Workers' Compensation Programs has determined that you are (except for claims
unable to return to duty. related to Workers'
Compensation.)

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

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

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

1) Are eligible for Medicare based on disability, and
a) Are an annuitant, or
b) Are an active employee, or
c) Are a former spouse of an annuitant, or
d) Are a former spouse of an active employee

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

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

Then the primary payer is...
Original Medicare This Plan

C. When you or a covered family member have FEHB and 50
50 Page 51 52
50
Claims process when you When we are the primary payer, we process the claim first.
have the Original Medicare When Original Medicare is the primary payer, Medicare processes your claim first.
When you receive your Medicare payment information, please call us at 800/ 877-
9777, or 303/ 714-5800 when calling from 303 or 720 area codes, to find out if you
need to do something about filing the claim with us.

Plan We waive some costs when you have the Original Medicare Plan
When Original Medicare is the primary payer, we will waive some out-of-pocket
costs, as follows:
Physician office visit copayments are waived if you are enrolled in Medicare Part B.
Standard option hospital copayments are waived if you are enrolled in Medicare
Part A.

Medicare managed care plan If you are eligible for Medicare, you may choose to enroll in and get your
Medicare benefits from another type of Medicare+ Choice plan--Medicare
managed care plan. These are health care choices (like HMOs) in some areas of
the country. In most Medicare managed care plans, you can only go to doctors,
specialists, or hospitals that are part of the plan. Medicare managed care plans
provide all the benefits that Original Medicare covers. Some cover extras, like
prescription drugs. To learn more about enrolling in a Medicare managed care
plan, contact Medicare at 1-800-MEDICARE (1-800-633-4227) or at
www. medicare. gov.

If you enroll in a Medicare managed care plan, the following options are available
to you:

This Plan and our Medicare managed care plan: You may enroll in our
Medicare managed care plan and also remain enrolled in our FEHB plan. In this
case, we do not waive any of our copayments, coinsurance, or deductibles for your
FEHB coverage.

This Plan and another plan's Medicare managed care plan: You may enroll in
another plan's Medicare managed care plan and also remain enrolled in our FEHB
plan. We will still provide benefits when your Medicare managed care plan is
primary, even out of the managed care plan's network and/ or service area (if you
use our Plan providers), but we will not waive any of our copayments,
coinsurance, or deductibles. If you enroll in a Medicare managed care plan, tell
us. We will need to know whether you are in the Original Medicare Plan or in a
Medicare managed care plan so we can correctly coordinate benefits with
Medicare.

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

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

2002 PacifiCare of Colorado Section 9 51
51 Page 52 53
51
TRICARE TRICARE is the health care program for eligible dependents of military persons and retirees of the military. TRICARE includes the CHAMPUS program. If both
TRICARE and this Plan cover you, we pay first. See your TRICARE Health
Benefits Advisor if you have questions about TRICARE coverage.

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

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

Once OWCP or similar agency pays its maximum benefits for your treatment, we
will cover your care. You must use our providers.

Medicaid When you have this Plan and Medicaid, we pay first.
When other Government agencies We do not cover services and supplies when a local, State, are responsible for your care or Federal Government agency directly or indirectly pays for them.

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

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

2002 PacifiCare of Colorado Section 9 52
52 Page 53 54
52
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on December 31 of
the same year.
Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. See page 10.

Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 10.
Covered services Care we provide benefits for, as described in this brochure.
Custodial care Any skilled or non-skilled health services, or personal comfort or convenience related services, which provide general maintenance, supportive, preventive and/ or

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

See page 10.
Experimental or
investigational services Our National and Regional Medical Committees determine whether or not treatments, procedures and drugs are no longer considered experimental or

investigational. Our determinations are based on the safety and efficacy of new
medical procedures, technologies, devices and drugs.

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

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

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

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

Plan allowance Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. Plans determine their allowances in different

ways. We determine our allowance by our contracted rate with the participating
provider.

Usual Customary and Providers usual charge for furnishing treatment, service or supply; or the charge Reasonable (UCR) the company determines to be the general rate charged by others who render or

furnish such treatment, services or supplies to persons who reside in the same
geographical area.

Us/ We Us and we refer to PacifiCare of Colorado.
You You refers to the enrollee and each covered family member.

2002 PacifiCare of Colorado Section 10

Section 10. Definitions of terms we use in this brochure 53
53 Page 54 55
53
No pre-existing condition We will not refuse to cover the treatment of a condition that you had before you limitation enrolled in this Plan solely because you had the condition before you enrolled.
Where you can get information See www. opm. gov/ insure. Also, your employing or retirement office can answer about enrolling in the your questions, and give you a Guide to Federal Employees Health Benefits Plans,
FEHB Program brochures for other plans, and other materials you need to make an informed decision about:

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

When your enrollment ends; and
When the next open season for enrollment begins.

We don't determine who is eligible for coverage and, in most cases, cannot change
your enrollment status without information from your employing or retirement
office.

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

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

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

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

When benefits and The benefits in this brochure are effective on January 1. If you joined this Plan premiums start during Open Season, your coverage begins on the first day of your first pay period
that starts on or after January 1. Annuitants' coverage and premiums begin on
January 1. If you joined at any other time during the year, your employing office
will tell you the effective date of coverage.

2002 PacifiCare of Colorado Section 11

Section 11. FEHB facts 54
54 Page 55 56
54
Your medical and claims We will keep your medical and claims information confidential. Only the records are confidential following will have access to it:
OPM, this Plan, and subcontractors when they administer this contract;
This Plan, and appropriate third parties, such as other insurance plans and the
Office of Workers' Compensation Programs (OWCP), when coordinating
benefit payments and subrogating claims;

Law enforcement officials when investigating and/ or prosecuting alleged civil
or criminal actions;

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

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

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

When you lose benefits
When FEHB coverage ends You will receive an additional 31 days of coverage, for no additional
premium, when:

Your enrollment ends, unless you cancel your enrollment, or
You are a family member no longer eligible for coverage.
You may be eligible for spouse equity coverage or Temporary Continuation
of Coverage.

Spouse equity coverage If you are divorced from a Federal employee or annuitant, you may not continue to
get benefits under your former spouse's enrollment. But, you may be eligible for
your own FEHB coverage under the spouse equity law. If you are recently
divorced or are anticipating a divorce, contact your ex-spouse's employing or
retirement office to get RI 70-5, the Guide to Federal Employees Health Benefits
Plans for Temporary Continuation of Coverage and Former Spouse Enrollees, or
other information about your coverage choices.

Temporary Continuation of If you leave Federal service, or if you lose coverage because you no longer qualify
Coverage (TCC) as a family member, you may be eligible for Temporary Continuation of Coverage
(TCC). For example, you can receive TCC if you are not able to continue your
FEHB enrollment after you retire, if you lose your job, if you are a covered
dependent child and you turn 22 or marry, etc.

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

Enrolling in TCC. Get the RI 79-27, which describes TCC, and the RI 70-5, the
Guide to Federal Employees Health Benefits Plans for Temporary Continuation of
Coverage and Former Spouse Enrollees, from your employing or retirement office
or from www. opm. gov/ insure. It explains what you have to do to enroll.

2002 PacifiCare of Colorado Section 11 55
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55
Converting to You may convert to a non-FEHB individual policy if:
individual coverage Your coverage under TCC or the spouse equity law ends. If you canceled your

coverage or did not pay your premium, you cannot convert;
You decided not to receive coverage under TCC or the spouse equity law ends
(if you canceled your coverage or did not pay your premium, you cannot
convert); or

You are not eligible for coverage under TCC or the spouse equity law.

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

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

Getting a Certificate of The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is Group Health Plan Coverage Federal law that offers limited Federal protections for health coverage availability
and continuity to people who lose employer group coverage. If you leave the
FEHB Program, we will give you a Certificate of Group Health Plan Coverage that
indicates how long you have been enrolled with us. You can use this certificate
when getting health insurance or other health care coverage. Your new plan must
reduce or eliminate waiting periods, limitations, or exclusions for health related
conditions based on the information in the certificate, as long as you enroll within
63 days of losing coverage under this Plan. If you have been enrolled with us for
less than 12 months, but were previously enrolled in other FEHB plans, you may
also request a certificate from those plans.

For more information get OPM pamphlet RI 79-27, Temporary Continuation of
Coverage (TCC) under the FEHB Program. See also the FEHB web site
(www. opm. gov/ insure/ health), refer to the "TCC and HIPAA" frequently asked
questions. These highlight HIPAA rules, such as the requirement that Federal
employees must exhaust any TCC eligibility as one condition for guaranteed
access to individual health coverage under HIPAA, and have information about
Federal and State agencies you can contact for more information.

2002 PacifiCare of Colorado Section 11 56
56 Page 57 58
56
The Office of Personnel Management (OPM) will sponsor a high-quality long term care insurance program effective in October
2002. As part of its educational effort, OPM asks you to consider these questions:

What is long term care (LTC) insurance? It's insurance to help pay for long term care services you may need if you can't take care of yourself because of an
extended illness or injury, or an age-related disease such as Alzheimer's.
LTC insurance can provide broad, flexible benefits for care in a nursing home, in an assisted living facility, in your home,
adult day care, hospice care, and more. LTC insurance can supplement care provided by family members, reducing the
burden you place on them.

I'm healthy. I won't need long term care. Or, will I? 76% of Americans believe they will never need long term care, but the facts are that about half of them will. And it's not
just the old folks. About 40% of people needing long term care are under age 65. They may need chronic care due to a
serious accident, a stroke, or developing multiple sclerosis, etc.
We hope you will never need long term care, but you should have a plan just in case. LTC insurance may be vital to your
financial and retirement planning.

Is long term care expensive? Yes. A year in a nursing home can exceed $50,000 and only three 8-hour shifts a week can exceed $20,000 a year, that's
before inflation!
LTC can easily exhaust your savings but LTC insurance can protect it.

But won't my FEHB plan, Medicare or Medicaid cover my long term care? Not FEHB. Look under "Not covered" in sections 5( a) and 5( c) of your FEHB brochure. Custodial care, assisted living, or
continuing home health care for activities of daily living are not covered. Limited stays in skilled nursing facilities can be
covered in some circumstances.
Medicare only covers skilled nursing home care after a hospitalization with a 100 day limit.
Medicaid covers LTC for those who meet their state's guidelines, but restricts covered services and where they can be
received. LTC insurance can provide choices of care and preserve your independence.

When will I get more information? Employees will get more information from their agencies during late summer/ early fall of 2002.
Retirees will receive information at home.

How can I find out more about the program NOW? A toll-free telephone number will begin in mid-2002. You can learn more about the program now at www. opm. gov/ insure/ ltc.

2002 PacifiCare of Colorado Long Term Care Insurance Is Coming Later in 2002!

Long Term Care Insurance Is Coming Later in 2002!
Many FEHB enrollees think that their health plan and/ or Medicare will cover their long term care needs.
Unfortunately, they are WRONG!

How are YOU planning to pay for the future custodial or chronic care you may need? Consider buying long term
care insurance. 57
57 Page 58 59
57 2002 PacifiCare of Colorado Index
Index
Do not rely on this page; it is for your convenience and does not explain your benefit coverage.

Allergy tests 15
Alternative treatment 20, 43
Ambulance 28, 30
Anesthesia 24, 26
Blood and blood plasma 26
Cardiac Rehabilitation 16
Changes for 2002 6
Chemotherapy 16
Chiropractic 20
Claims 45
Coinsurance 10, 52
Colorectal cancer screening 13
Congenital anomalies 21, 22
Contraceptive devices and drugs 15, 34
Coordination of benefits 48
Copayment 10
Covered providers 7
Deductible 10
Definitions 52
Dental care 37
Diagnostic services 12, 13
Diagnostic tests 12, 13
Dialysis 16
Disputed claims review 46
Donor expenses (transplants) 23
Durable medical equipment (DME) 18
Educational classes and programs 20, 36
Effective date of enrollment 53
Emergency/ Urgent Care 29
Experimental or investigational 52
Family planning 15

Foot care 17
General Exclusions 44
Hearing services 17
Home health services 19
Hospice care 28
Identification cards 7
Immunizations, adult 13
Immunizations, children 14
Infertility 15
Inpatient hospital 9, 25
Insulin 34
Laboratory and pathological services 13
Mail order prescription drugs 33
Mammograms 13
Maternity 14
Medicaid 51
Medically necessary 52
Medicare 48
Mental health 31
Newborn care 14
Obstetrical care 14
Occupational therapy 16
Oral and maxillofacial surgery 22
Orthodontics 37, 42
Orthopedic devices 18
Out-of-pocket expenses 10
Outpatient facility care 26
Oxygen 19
Pap test 13
Physical therapy 10
Plan allowance 52

Preauthorization 9, 32
Preventive care, adult 13
Preventive care, children 14
Prescription drugs 33
Primary care physician 7
Prostate cancer screening 13
Prosthetic devices 18
Radiation therapy 16
Reconstructive surgery 22
Room and board 25
Second surgical opinion 12
Service area 5
Skilled nursing facility care 27
Smoking cessation 20
Speech therapy 16
Sterilization procedures 21
Subrogation 51
Substance abuse 31
Syringes 34
TDD phone line 36
Temporary continuation of
coverage 54
Transplants 23
Treatment therapies 16
Vision services 17
Wheelchairs 19
Workers compensation 51
X-rays 13, 26 58
58 Page 59 60
Do not rely on this chart alone. All benefits are provided in full unless indicated and are subject to the definitions, limita-tions,
and exclusions in this brochure. On this page we summarize specific expenses we cover; for more detail, look inside.

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

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

Benefits You Pay — Standard Option You Pay — High Option Page
Medical services provided by
physicians:

Diagnostic and treatment Office visit copay: $15 Office visit copay: $10 12
services provided in the office

Services provided by a hospital:
Inpatient $300 deductible per person per year; Nothing 25
$500 maximum per family per year

Outpatient $100 copay for outpatient surgery or Nothing 25
23-hour observation

Emergency benefits:
In-area $100 per visit $100 per visit 29
Out-of-area $100 per visit $100 per visit 29

Mental health and substance abuse treatment Same as any other illness or condition Same as any other illness or condition 31

Prescription drugs For a 30-day supply or trade-size For a 30-day supply or trade-size 33
package -$10 copay for generic package -$5 copay for generic
formulary prescriptions; $20 copay formulary prescriptions; $10 copay
for brand formulary prescriptions; for brand formulary prescriptions;
$30 copay for non-formulary $20 copay for non-formulary
prescriptions prescriptions

Dental Care You pay copays for most services You pay the applicable percentage of 37
including preventive, restorative, your dentist's charges, or the scheduled
orthodontic and other services. allowance, whichever is less.

Chiropractic Care $15 copay per visit; based on medical $10 copay per visit; based on medical 20
necessity; maximum of 20 visits necessity; maximum of 20 visits
per year per year

Vision Care $15 copay per refraction; one $10 copay per refraction; one 17
refraction every 12 months. refraction every 12 months.

Special features: Health improvement 36
programs

Protection against catastrophic costs Nothing after $3,600/ person or Nothing after $3,600/ person or 10
(your out-of-pocket maximum) $10,000/ family per year $10,000/ family per year
Some costs do not count toward this Some costs do not count toward this
protection and you must continue to protection and you must continue to
pay for some services. pay for some services.

________________________________________
Premium page back cover _______________________________________

58 2002 PacifiCare of Colorado 2002 Summary of Benefits

Summary of benefits for PacifiCare of Colorado -2002 59
59 Page 60
2002 PacifiCare of Colorado 2002 Rate Information
Non-Postal rates apply to most non-Postal enrollees. If you are in a special enrollment category,
refer to the FEHB Guide for that category or contact the agency that maintains your health benefits
enrollment.

Postal rates apply to career Postal Service employees. Most employees should refer to the FEHB
Guide for United States Postal Service Employees, RI 70-2. Different postal rates apply and
special FEHB guides are published for Postal Service Nurses , RI70-2B; and for Postal Service
Inspectors and Office of Inspector General (OIG) employees (see RI 70-2IN).

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

2002 Rate Information for
PacifiCare of Colorado, Inc.

Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly
Type of
Enrollment Code
Gov t
Share
Your
Share
Gov t
Share
Your
Share
USPS
Share
Your
Share

High Option
Self Only

High Option
Self and Family

D61
D62
$97.55
$223.41
$32.51
$116.78
$211.35
$484.06
$70.45
$253.02
$115.43
$263.75
$14.63
$76.44
Standard Option
Self Only

Standard Option
Self and Family

D64
D65
$57.98
$150.14
$19.32
$50.05
$125.61
$325.31
$41.87
$108.44
$68.60
$177.67
$8.70
$22.52 60

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