Pages 1--59 Fallon Community Health Plan

Enrollment codes for this Plan:
JV1 Self Only JV2 Self and Family

This Plan has Excellent accreditation from the
NCQA. See the 2002 Guide for more
information on NCQA.

RI 73-090

For changes
in benefits
see page 8.

A Health Maintenance Organization
http:// www. fchp. org 1
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2002 Fallon Community Health Plan 2 Table of Contents
Table of Contents
Introduction…………………………………………………………………............................................................................................. 4
Plain Language.............................................................................................................................................................................................. 4
Inspector General Advisory........................................................................................................................................................................ 4
Section 1. Facts about this HMO plan ...................................................................................................................................................... 5
How we pay providers ............................................................................................................................................................. 5
Who provides my health care? .............................................................................................................................................. 5
Your rights................................................................................................................................................................................... 6
Service area.................................................................................................................................................................................. 6
Section 2. How we change for 2002 ......................................................................................................................................................... 8
Program-wide changes ............................................................................................................................................................. 8
Changes to this plan .................................................................................................................................................................. 8
Section 3. How you get care ...................................................................................................................................................................... 9
Identification cards .................................................................................................................................................................... 9
Where you get covered care..................................................................................................................................................... 9
Plan providers...................................................................................................................................................................... 9
Plan facilities ........................................................................................................................................................................ 9
What you must do to get covered care .................................................................................................................................. 9
Primary care ......................................................................................................................................................................... 9
Specialty care........................................................................................................................................................................ 9
Hospital care....................................................................................................................................................................... 11
Circumstances beyond our control....................................................................................................................................... 11
Services requiring our prior approval ................................................................................................................................. 11
Coverages of non-plan providers ......................................................................................................................................... 12
Utilization review .................................................................................................................................................................... 13
Section 4. Your costs for covered services ............................................................................................................................................. 14
Copayments........................................................................................................................................................................ 14
Deductible........................................................................................................................................................................... 14
Coinsurance........................................................................................................................................................................ 14
Your out-of-pocket maximum............................................................................................................................................... 14
Section 5. Benefits....................................................................................................................................................................................... 15
Overview ................................................................................................................................................................................... 15
(a) Medical services and supplies provided by physicians and other health care professionals........................ 16
(b) Surgical and anesthesia services provided by physicians and other health care professionals .................... 25
(c) Services provided by a hospital or other facility, and ambulance services ....................................................... 28
(d) Emergency services/ accidents................................................................................................................................... 30
(e) Mental health and substance abuse benefits ........................................................................................................... 32
(f) Prescription drug benefits........................................................................................................................................... 34
(g) Special features ............................................................................................................................................................. 37
Services for deaf and hearing impaired ............................................................................................................... 37 2
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2002 Fallon Community Health Plan 3 Table of Contents
Peace of Mind program........................................................................................................................................... 37
Out-of-area emergency and urgent care.............................................................................................................. 37
Out-of-area student coverage ................................................................................................................................ 38
Interpreter services .................................................................................................................................................. 38
(h) Dental benefits............................................................................................................................................................... 39
(i) Non-FEHB benefits available to plan members ..................................................................................................... 41
Section 6. General exclusions --things we don't cover ....................................................................................................................... 42
Section 7. Filing a claim for covered services........................................................................................................................................ 43
Section 8. The disputed claims process.................................................................................................................................................. 44
Section 9. Coordinating benefits with other coverage ....................................................................................................................... 46
When you have…
Other health coverage ...................................................................................................................................................... 46
Original Medicare ............................................................................................................................................................. 46
Medicare managed care plan ......................................................................................................................................... 48
TRICARE/ Workers' Compensation/ Medicaid ................................................................................................................ 49
Other Government agencies .................................................................................................................................................. 49
When others are responsible for injuries............................................................................................................................. 49
Section 10. Definitions of terms we use in this brochure ................................................................................................................. 50
Section 11. FEHB facts ........................................................................................................................................................................... 51
Coverage information ........................................................................................................................................................... 51
No pre-existing condition limitation ......................................................................................................................... 51
Where you get information about enrolling in the FEHB Program..................................................................... 51
Types of coverage available for you and your family ............................................................................................ 51
When benefits and premiums start............................................................................................................................ 51
Your medical and claims records are confidential.................................................................................................. 52
When you retire ............................................................................................................................................................ 52
When you lose benefits ......................................................................................................................................................... 52
When FEHB coverage ends ......................................................................................................................................... 52
Spouse equity coverage............................................................................................................................................... 52
Temporary Continuation of Coverage (TCC) ......................................................................................................... 53
Converting to individual coverage ........................................................................................................................... 53
Getting a Certificate of Group Health Plan Coverage........................................................................................... 53
Long term care insurance is coming later in 2002 ................................................................................................................................ 54

Index…………………................................................................................................................................................................................. 56
Summary of benefits .................................................................................................................................................................................. 57
Rates ............................................................................................................................................................................................... Back cover 4
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5
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2002 Fallon Community Health Plan 4 Section 1
Introduction
Fallon Community Health Plan 10 Chestnut St.
Worcester, MA 01608
This brochure describes the benefits of Fallon Community Health Plan under our contract number (CS 1917) 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 8. Rates are shown at the end of this brochure.

Plain Language
Teams of Government and health plans' staff worked on all FEHB brochures to make them responsive, accessible, and understandable to the public. For instance,

Except for necessary technical terms, we use common words. For instance, "you" means the enrollee or family
member; "we" means Fallon Community Health Plan.

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

Our brochure and other FEHB plans' brochures have the same format and similar descriptions to help you compare
plans.

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

Inspector General Advisory
Stop health care fraud! Fraud increases the cost of health care for everyone. If you suspect that a physician, pharmacy, or hospital has charged you for services you did not

receive, billed you twice for the same service, or misrepresented any information, do the following:

Call the provider and ask for an explanation. There may be an error. If the provider does not resolve the matter, call us at 1-800-868-5200
(TDD/ TTY: 1-877-608-7677) and explain the situation.
If we do not resolve the issue, call or write The Health Care Fraud Hotline

202/ 418-3300 The United States Office of Personnel Management
Office of the Inspector General Fraud Hotline 1900 E Street, NW, Room 6400
Washington, DC 20415 6
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2002 Fallon Community Health Plan 5 Section 1
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.

Section 1. Facts about this HMO plan
This plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals and other providers that contract with us. These plan providers coordinate your health care services.

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.

Fallon Community Health Plan pays its providers using various payment methods, including capitation, per diem, incentive, and discounted fee-for-service arrangements. Capitation means paying a fixed dollar amount per month for
each member assigned to the provider. Per diem means paying a fixed dollar amount per day for all services rendered. Incentive means a payment that is based on appropriate medical management by the provider. Discounted fee-for-service
means paying the provider's usual, customary and regular fee discounted by a negotiated percentage.
You are entitled to ask if we have special financial arrangements with our physicians that can affect the use of referrals and other services that you might need. To get this information, call our Customer Service Department at 1-800-868-5200
(TDD/ TTY: 1-877-608-7677) and request information about our physician payment arrangements.
Who provides my health care?
This plan is a mixed model prepayment plan that provides two provider options from which to choose, Fallon Plus and Fallon Affiliates. You are asked to select a provider option for each member of your family at the time of enrollment.
However, you may switch from the Fallon Plus to the Fallon Affiliates option and vice versa at any time during the year. The change will become effective on the first day of the month following the plan's receipt of notification.

Each member of the family may choose a different primary care physician from separate provider options. A member's primary care physician provides routine and emergency care and arranges for specialty care as needed.
The plan provides coverage for urgent and emergency care around the world. Within the plan's service area, you must call your doctor for directions before seeking care. Of course, if the emergency is life threatening, go to the nearest
emergency room. Outside of the service area, you are covered for emergency services obtained at any medical facility, but you should call for authorization before seeking any follow-up care. 7
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2002 Fallon Community Health Plan 6 Section 1
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.
We are licensed by the Commonwealth of Massachusetts as an HMO. Fallon Community Health Plan is also a federally qualified HMO.

We have been operating since 1977.
We are a not-for-profit organization.
If you want more information about us, call 1-800-868-5200 (TDD/ TTY: 1-877-608-7677), or write to Fallon Community Health Plan, 10 Chestnut St., Worcester, MA 01608. You may also contact us by fax at 508-831-0912 or visit our website at

www. fchp. org.
Service Area
To enroll in this plan, you must live in or work in our Service Area. This is where our providers practice. Our service area is the following Massachusetts counties: all of Middlesex, Norfolk, Suffolk, and Worcester Counties, as well as parts of
Bristol, Essex, Franklin, Hampden, Hampshire, and Plymouth Counties. This includes the Massachusetts communities listed below.

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. Some additional benefits are also available for out-of-area students (see page
38). Otherwise, we will not pay for any other health care services out of our service area unless the services have prior plan approval.

If you or a covered family member move outside of our service area, you can enroll in another plan. If your dependents live out of the area, 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.

Abington Acton
Andover Arlington
Ashburnham Ashby
Ashland Assonet
Athol Attleboro
Auburn Avon
Ayer Barre
Bedford Bellingham
Belmont Berkley
Berlin Beverly
Billerica Blackstone
Bolton Boston
Boxborough Boxford
Boylston Braintree

Bridgewater Brimfield
Brockton Brookfield
Brookline Burlington
Cambridge Canton
Carlisle Charlton
Chelmsford Chelsea
Clinton Cohasset
Concord Danvers
Dedham Dighton
Douglas Dover
Dracut Dudley
Dunstable Duxbury
East Bridgewater East Brookfield
East Walpole Easton

Essex Everett
Fall River Fitchburg
Foxborough Framingham
Franklin Freetown
Gardner Georgetown
Gloucester Grafton
Groton Halifax
Hamilton Hanover
Hanscom AFB Hanson
Hardwick Harvard
Hathorne Haverhill
Hingham Holbrook
Holden Holland
Holliston Hopedale

Hopkinton Hubbardston
Hudson Hull
Ipswich Kingston
Lakeville Lancaster
Lawrence Leicester
Leominster Lexington
Lincoln Littleton
Lowell Lunenburg
Lynn Lynnfield
Malden Manchester
Mansfield Marblehead
Marlborough Marshfield
Mattapan Maynard
Medfield Medford 8
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2002 Fallon Community Health Plan 7 Section 1
Medway Melrose
Mendon Methuen
Middleborough Middleton
Milford Millbury
Millis Millville
Milton Monson
Nahant Natick
Needham New Braintree
Newton Norfolk
North Andover North Attleboro
North Billerica North Brookfield
North Chelmsford North Reading
Northborough Northbridge
Norton Norwell
Norwood Oakham
Orange Oxford
Palmer Paxton
Peabody Pembroke
Pepperell Petersham
Phillipston Pinehurst
Plainville Plympton
Princeton Quincy
Randolph Raynham
Reading Rehoboth
Revere Rockland
Rockport Rowley
Royalston Rutland
Salem Saugus
Scituate Seekonk
Sharon Sherborn

Shirley Shrewsbury
Somerset Somerville
South Hamilton South Walpole
Southborough Southbridge
Spencer Sterling
Stoneham Stoughton
Stow Sturbridge
Sudbury Sutton
Swampscott Swansea
Taunton Templeton
Tewksbury Topsfield
Townsend Tyngsborough
Upton Uxbridge
Village of Nagog Woods Wales
Walpole Waltham
Ware Warren
Watertown Waverly
Wayland Webster
Wellesley Wenham
West Boylston West Bridgewater
West Brookfield Westborough
Westford Westminster
Weston Westwood
Weymouth Whitman
Wilmington Winchendon
Winchester Winthrop
Woburn Worcester
Wrentham 9
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2002 Fallon Community Health Plan 8 Section 2
Section 2. How we change for 2002
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5 Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here is a
clarification that does not change benefits.
Program-wide changes

We changed the address for sending disputed claims to OPM. (Section 8)

Changes to this Plan
Your share of the non-postal premium will increase by 55.2% for Self Only or 6.0% for Self and Family.

We no longer limit total blood cholesterol tests to certain age groups. (Section 5( a))
We now cover certain intestinal transplants. (Section 5( b))
We changed speech therapy benefits by removing the requirement that services must be required to restore functional speech. (Section 5( a)) 10
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2002 Fallon Community Health Plan 9 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive
services from a plan provider, or fill a prescription at a plan pharmacy. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809,
your health benefits enrollment confirmation (for annuitants), or your Employee Express confirmation letter.

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 1-800-868-5200
(TDD/ TTY: 1-877-608-7677).

Where you get covered care You get care from plan providers and plan facilities. You will only pay copayments, and you will not have to file claims.

Plan providers Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our members.
We list plan providers in the Provider Directory, which we update periodically. If you don't have a Provider Directory, call Customer Service for a copy free of
charge. The list is also on our website at www. fchp. org.
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.
How to get covered care It depends on the type of care you need. First, you and each family member must choose a primary care physician. This decision is important since your primary
care physician provides or arranges for most of your health care.

Primary care Your primary care physician can be a family practitioner, internist or pediatrician (or, in some cases, a physician assistant or nurse practitioner who works under
the supervision of a physician). Your primary care physician will provide most of your health care, or give you a referral to see a specialist.

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

If our contract with your primary care physician is ending, we will notify you in writing at least 30 days prior to the date of the end of his or her contract, except
where the contract has been ended for reasons involving fraud, patient safety or quality of care. If our contract with your primary care physician ends, you will be
required to select a new primary care physician. We will also notify you if you are receiving regular care from a specialist, and that specialist will no longer be
under contract with us.
Specialty care Your primary care physician will refer you to a specialist for needed care. When you receive a referral from your primary care physician, you must return to the
primary care physician after the consultation, unless your primary care physician authorized a certain number of visits without additional referrals. The primary
care physician must provide or authorize all follow-up care. Do not go to the specialist for return visits unless your primary care physician gives you a
referral.

What you must do to get covered care 11
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2002 Fallon Community Health Plan 10 Section 3
However, you may obtain the following Plan services without a referral:
Obstetrical and gynecology services, except for infertility treatment. This includes an annual examination, Pap smear, routine mammogram, and
maternity care. If you are admitted to a hospital as an inpatient (for childbirth, for example), you must notify the plan of your admission.
Routine dental care (See Section 5( h) for a description of covered dental services)
Visits to an oral surgeon for extraction of impacted teeth. (Note: visits to an oral surgeon for any other procedure require a referral and authorization)
Routine eye examinations with an ophthalmologist or optometrist. Outpatient mental health and substance abuse services. Call 1-888-421-8861
(TDD/ TTY: 1-781-994-7660) to locate a plan provider.
Authorization may be required for follow-up visits with these providers if they are beyond the scope of what is described above. Authorization may also be
required if a provider to whom you have self-referred wishes to refer you elsewhere.

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, ask if you can see your current specialist. If your current specialist does not participate with us, you
must receive treatment from a specialist who does. Generally, we will not pay for you to see a specialist who does not participate with our Plan. However,
see "Coverage of Non-Plan Providers" on page 12 for an outline of certain situations in which, in accordance with Massachusetts State law, we will
temporarily cover services from a non-plan provider.
If you are seeing a specialist and your specialist leaves the plan, call your primary care physician, who will arrange for you to see another specialist.
You may receive services from your current specialist until we can make arrangements for you to see someone else.

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

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

contact your new plan.
If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can continue to see
your specialist until the end of your postpartum care, even if it is beyond the 90 days. 12
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2002 Fallon Community Health Plan 11 Section 3
If you are terminally ill and our contract ends with a provider from whom you are receiving treatment related to that illness, you may continue to
receive treatment from that provider.
We will make pediatric specialty care available, including mental health care, provided by persons with recognized expertise in specialty pediatrics.

Hospital care Your plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled
nursing or other type of facility.
If you are in the hospital when your enrollment in our plan begins, call our customer service department immediately at 1-800-868-5200. If you are new to
the FEHB Program, we will arrange for you to receive care.
If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:

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

These provisions apply only to the benefits of the hospitalized person.
Circumstances beyond our control Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In that case,
we will make all reasonable efforts to provide you with the necessary care.

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 authorization.

In most cases, if your primary care physician refers you to a plan provider within your provider option (Fallon Plus or Fallon Affiliates), no authorization is
required. Once your primary care physician tells you that you have been referred, you can make an appointment with the specialist for the services. You
do not need to do anything further and you will not get a letter from the plan.

If the specialist you need is not available from a plan provider in your health care option, your primary care physician needs to request approval from the plan for
coverage of these services. Certain specified covered services also require plan authorization, even if your primary care physician refers you within your plan
option. In these cases, your primary care physician will send a Request for Authorization to the plan. We will make an authorization decision within 2
working days of receipt of medical information. Your primary care physician will be notified of our decision within 24 hours of the time the decision is made.

If we approve the referral, we will send both you and your primary care physician a written notice within two working days of the appeal notification.
When you have received your authorization letter (showing the authorization number), you can call the specialist to make your appointment. If you do not
receive the authorization letter, you will be financially responsible for services that are provided. 13
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2002 Fallon Community Health Plan 12 Section 3
The authorization letter will describe the services for which the plan has approved coverage. If the specialist believes you need additional services or
procedures beyond those authorized, the specialist will request authorization for those services directly from the plan. If we approve the request for additional
services, we will send both you and your primary care physician a written notice.
If we do not approve a primary care physician's or specialist's request for authorization, we will send you a letter explaining our decision and describing
your right to dispute our decision. (See Section 8 for more information.)
Examples of services that do not require plan authorization: Most specialty medical or surgical consultations with plan providers. In
some cases, the specialist may need to obtain an additional referral from your primary care physician and/ or authorization from the plan to continue
covered treatment. Initial evaluations for chiropractic services, physical therapy, speech therapy,
or occupational therapy. Plan authorization is required for additional visits. Allergy injections, for up to 12 months
Chemotherapy, for up to 12 months Outpatient radiation therapy, for up to 12 months
Many outpatient diagnostic tests

Examples of services that do require plan authorization: Many outpatient surgical procedures
Inpatient hospital admissions (including inpatient surgical admissions) Referral to provider a outside your plan option, or to a non-plan provider
Podiatry consultations Transplant evaluation
Cardiac or pulmonary rehabilitation Neuropsychological testing
Pain clinic Certain outpatient diagnostic tests, including CT Scan, EMG/ NCV, genetic
testing, MRI/ MRA scans, Nuclear Medicine Testing, PET/ SPECT and Sleep Study
Durable medical equipment

These are just some examples, not a complete list. To verify whether a service can be authorized by your primary care provider or if it requires plan authorization,
check with your primary care physician or call Customer Service.

Coverage of non-plan providers Once you become a plan member, we will generally only pay for services that you receive from plan providers. However, there are some circumstances in
which we will temporarily pay for services that you receive from a non-plan provider, if you had been receiving care from that provider prior to becoming a
member: If your prior primary care physician is not a participating provider in any
health insurance plan that FEHB offers to you, we will pay for services from that provider for 30 days from your effective date.
If you are receiving an ongoing course of treatment from a provider who is not a participating provider in any health insurance plan that FEHB offers to
you, we will pay for services from that provider for 30 days from your effective date.
If you are terminally ill, and you are receiving ongoing treatment from a provider who is not a participating provider in any health insurance plan
that FEHB offers to you, we will pay for your services from that provider until your death. 14
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2002 Fallon Community Health Plan 13 Section 3
In all cases, the provider must agree to accept reimbursement for services at our rates, and to adhere to our quality assurance standards, and other policies and
procedures such as obtaining appropriate referrals and prior authorizations. You will be eligible for benefits as if the provider was under contract with us.

Utilization Review Our case management program reviews and evaluates the health care our members receive to make sure that our members' care is coordinated, and that
appropriate levels of service are available to all members.

The program is staffed by licensed registered nurse case managers, physician reviewers and specialists who are in routine contact with our health care
providers. They use national, evidence-based criteria that are reviewed annually by a committee of health plan and community-based physicians to determine the
medical appropriateness of selected services requested by your physician. These criteria are approved as being consistent with generally accepted standards of
medical practice, including prudent layperson standards for emergency room care.

We also develop in-house criteria, making use of local specialist input and current medical literature, as well as guidelines from Medicare and the
Commonwealth of Massachusetts.

To obtain information about the status or outcome of a utilization review decision, call 1-800-868-5200, extension 69915 (TDD/ TTY: 1-877-608-7677). 15
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2002 Fallon Community Health Plan 14 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay to a provider, facility, pharmacy, etc., when you receive services.

Example: When you see your primary care physician you pay a copayment of $10 per office visit.
Deductible We do not have a deductible.
Coinsurance We do not have coinsurance.
Your catastrophic protection out-of-pocket maximum We do not have an out-of-pocket maximum. 16
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2002 Fallon Community Health Plan 15 Section 5
Section 5. Benefits --Overview
(See page 8 for how our benefits changed this year and page 57 for a benefits summary

NOTE: This benefits section is divided into subsections. Please read the important things you should keep in mind at the beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the following
subsections. To obtain claims forms, claims filing advice, or more information about our benefits, contact us at 1-800-868-5200 or at our website at www. fchp. org.
(a) Medical services and supplies provided by physicians and other health care professionals ............................................ 16-24
Diagnostic and treatment services Lab, X-ray, and other diagnostic tests
Preventive care, adult Preventive care, children
Maternity care Family planning
Infertility services Allergy care
Treatment therapies Physical and occupational therapies

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

(b) Surgical and anesthesia services provided by physicians and other health care professionals...................................... 25-27
Surgical procedures Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services......................................................................... 28-29
Inpatient hospital Outpatient hospital or ambulatory surgical
center
Extended care benefits/ skilled nursing care facility benefits
Hospice care Ambulance

(d) Emergency services/ accidents .................................................................................................................................................... 30-31 Medical emergency Ambulance
(e) Mental health and substance abuse benefits............................................................................................................................. 32-33
(f) Prescription drug benefits ............................................................................................................................................................ 34-36
(g) Special features .............................................................................................................................................................................. 37-38 Flexible benefits option

Services for deaf and hearing impaired
Interpreter Services
Peace of Mind Program
Out-of-area and emergency care
Out-of-area student coverage
(h) Dental benefits ............................................................................................................................................................................... 39-40
(i) Non-FEHB benefits available to plan members ........................................................................................................................... 41
Summary of benefits .................................................................................................................................................................................. 57 17
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2002 Fallon Community Health Plan 16 Section 5a
Section 5 (a). Medical services and supplies p and other health care professi
I M
P O
R T
A N
T

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

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

Benefit Description
Diagnostic and treatment services
Professional services of physicians
In physician's office
In an urgent care center
Office medical consultations
Second surgical opinion
Outpatient self-management diabetic training and education, including medical nutrition therapy

At home

Professional services of physicians
During a hospital stay
In a skilled nursing facility

Lab, X-ray and other diagnostic tests

Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
CAT Scans/ MRI
Ultrasound
Electrocardiogram and EEG 18
18 Page 19 20
2002 Fallon Community Health Plan 17 Section 5a
Preventive care, adult
Routine screenings, such as:
Total Blood Cholesterol – once every three years
Colorectal Cancer Screening, including

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

Prostate Specific Antigen (PSA test) – one annually for men age 40 and older
Routine Pap test
Note: The office visit is covered if Pap test is received on the same day; see Diagnosis and Treatment, above.

Routine mammogram– covered for women age 35 and older, as follows:
From age 35 through 39, one during this five-year period
From age 40 and up, one every calendar year

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

Routine immunizations, limited to:
Tetanus-diphtheria (Td) booster – once every 10 years, ages 19 and over (except as provided for under Childhood immun
Influenza/ Pneumococcal vaccines, annually, age 65 and over

Childhood immunizations recommended by the American Academy of Pediatrics

Well-child care charges for routine examinations, immunizations and care (up to age 22)
Physcial examination, history, measurements, sensory screening, neuro-psyciatric evaluation, and development screen children under six years of age

Screening for lead poisoning, for children under six years of age Hereditary and metabolic screening at birth, newborn hearing screening test performed before the new born infant is
hospital or birthing center, tuberculin tests, hematocrit, hemoglobin, and other appropriate blood test and urinalysis
Maternity care

Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Note: Here are some things to keep in mind: You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. This inclu

circumcision, routine
Maternity care (Continued)

examination, hearing screening, and medically necessary treatments of congenital defects, birth abnormalities or prema other care for an infant who requires non-routine treatment only if we cover the infant under a "Self and Family" enroll
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 infant who requires non-routine treatment only if we cover the infant under a Self and Family enrollment. 19
19 Page 20 21
2002 Fallon Community Health Plan 18 Section 5a
We pay hospitalization and surgeon services (delivery) the same as for illness and injury. See Hospital benefits (Section (Section 5b).
We cover the following services when provided during an inpatient maternity admission: childbirth, nursery charges, circu examination, hearing screening and medically necessary treatments of cogenital defects, birth abnormalities or premature b
Not covered: Routine sonograms to determine fetal age, size or sex
Family planning
Voluntary family planning services, limited to:
Voluntary sterilization
Injectable contraceptive drugs (such as Depo Provera)
Diaphragms
NOTE: We cover oral contraceptives under the prescription drug benefit.

Intrauterine devices (IUDs)

Norplant (a surgically implanted contraceptive)

Not covered: reversal of voluntary surgical sterilization, genetic counseling, 20
20 Page 21 22
2002 Fallon Community Health Plan 19 Section 5a
Infertility services
Fallon covers the diagnosis and treatment of infertility, as defined under Massachusetts law.
To be eligible, you must be an individual who: (1) Is unable to conceive or produce conception during a period of one year;

(2) should expect fertility as a natural state; and (3) is a pre-menopausal female or a female who is experiencing menopause at a premature age.

Approval for Assisted Reproductive Technology (ART) is contingent upon review of your medical history by a Plan Medic coverage guidelines for all ART services are available by contacting the Customer Service Department at 1-800-868-5200 (T
Coverage is provided for the services below when determined to be medically necessary by a Plan Medical Director. Origi cycles; if you wish to continue beyond 4 cycles, further medical review by the Medical Director is required.
Office visits with a Plan physician or specialty care physician for the evaluation and diagnosis of fertility, and diagnos services

Artificial insemination:
— intravaginal insemination (IVI)
— intracervical insemination (ICI)
— intrauterine insemination (IUI)
Other assisted reproductive technologies (ART) including:
— gamete intrafallopian transfer
— intracytoplasmic sperm injection
— zygote intrafallopian transfer
In vitro fertilization
Sperm, egg, and/ or inseminated egg procurement, processing, and banking
Fertility drugs
(Note: We cover injectable fertility drugs under medical benefits and oral fertility drugs under the prescription drug benef

Infertility services (Continued)
Not covered:
Treatments, services and supplies which have not been determined to be medically necessary
Donor egg transfer for women who are menopausal, except as stated above
Chromosome studies of a donor (sperm or egg)
Charges for the storage of donor sperm, eggs, or embryo that remain in storage after the completion of an approved treatment cycle
Compensation to a donor (this does not include charges related to the procurement and processing of sperm, egg, and inseminated eg donor's insurance does not cover these costs)

Supplies that may be purchased without a physician's written order, such as ovulation test kits
Services which are necessary due to a voluntary sterilization, of for which there is no diagnosis of infertility
Surrogacy or gestational carrier services
Transportation costs to or from the medical facility
Allergy care 21
21 Page 22 23
2002 Fallon Community Health Plan 20 Section 5a
Testing and treatment
Allergy injection

Allergy serum
Not covered: provocative food testing and sublingual allergy desensitization
Treatment therapies
Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants list Transplants on page 27.

Respiratory and inhalation therapy
Dialysis – Hemodialysis and peritoneal dialysis
Intravenous (IV)/ Infusion Therapy – Home IV and antibiotic therapy
Growth hormone therapy (GHT)
Note: Growth hormone is covered under the prescription drug benefit.
Note: We will only cover GHT when we preauthorize the treatment. See your plan physician for preauthorization; he or s that establishes that the GHT is medically necessary. Ask us to authorize GHT before you begin treatment; otherwise, we w

from the date you submit the information. If you do not ask or if we determine GHT is not medically necessary, we will no services and supplies. See Services requiring our prior approval in Section 3.

Physical and occupational therapies
Up to 60 consecutive days or 20 nonconsecutive visits (whichever is greater) per condition per calendar year for the service — qualified physical therapists and
— occupational therapists.
Note: We only cover therapy to restore bodily function when there has been a total or partial loss of bodily function due to
Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction
Early intervention services for children through age three for services such as physical, occupational and speech therapy, n psychological counseling. Benefits are limited to a maximum of $3,200 per calendar year per child and $9,600 over the term

Not covered:
long-term rehabilitative therapy
exercise programs
massage therapy

Speech therapy 22
22 Page 23 24
2002 Fallon Community Health Plan 21 Section 5a
Up to 60 consecutive days or 20 nonconsecutive visits (whichever is greater) per condition per calendar year.
Medically necessary services for the diagnosis and treatment of speech, language and hearing disorders provided by a speech-language pathologist or audiologist.

Hearing services (testing, treatment, and supplies)
Hearing testing for children through age 17

Not covered: all other hearing testing
hearing aids, testing and examinations for them
Vision services (testing, treatment, and supplies)
Diagnosis and treatment of diseases of the eye

Eye exam to determine the need for vision correction Annual eye refractions, including written lens prescriptions for eyeglasses

Not covered:
Eyeglasses or contact lenses
Eye exercises and orthoptics
Radial keratotomy and other refractive surgery
Eye examination for contact lenses

Foot care
Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes (pre
See orthopedic and prosthetic devices for information on podiatric shoe inserts.

Not covered:
Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot,
Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the t surgery)

Orthopedic and prosthetic devices
Prosthetic devices, such as artificial limbs and eyes

Scalp hair prosthesis (wigs) for members who have suffered hair loss as a result of any treatment for cancer or leukemia 23
23 Page 24 25
2002 Fallon Community Health Plan 22 Section 5a
Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy
Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast imp Note: We pay internal prosthetic devices as hospital benefits; see Section 5( c) for payment information. See 5( b) for cov

the device.
Occlusal splint for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome. 24
24 Page 25 26
2002 Fallon Community Health Plan 23 Section 5a
Orthopedic and prosthetic devices (Continued)
Not covered:
orthopedic and corrective shoes
arch supports
foot orthotics
heel pads and heel cups
lumbosacral supports
corsets, trusses, elastic stockings, support hose, and other supportive devices
Durable medical equipment (DME)

Rental or purchase, at our option, including repair and adjustment, of durable medical equipment prescribed by your plan dialysis equipment. Under this benefit, we also cover:

hospital beds
wheelchairs
crutches
walkers
blood glucose monitors for home use; therapeutic/ molded shoes and shoe inserts for the treatment of severe diabetic fo magnifying aids and voice synthesizers for blood glucose monitors, for use by the legally blind.

Not covered:
Items that are not covered include, but are not limited to: air conditioners, air purifiers, arch supports, ear plugs (i. e., to prevent fluid fr during water activities), foot orthotics, orthopedic shoes (except when part of a brace) or other supportive devices for the feet, articles of

stockings, bedpans, raised toilet seats, dehumidifiers, dentures, elevators, safety grab bars, car seats, seizure helmets, hearing aids, heati exercise equipment or similar devices.

Home health services
Home health care ordered by a plan physician and provided by a registered nurse (R. N.), licensed practical nurse (L. P. N nurse (L. V. N.), or home health aide. Services include:

— skilled nursing care
— physical therapy, occupational therapy, oxygen therapy, intravenous therapy, and medications
— medical social services, nutritional services and home health aide services
— medical and surgical supplies and durable medical equipment
— medication visits to monitor, evaluate or adjust the prescription medication dosage that is being prescribed for a med condition

Not covered: 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 rehabil

Chiropractic
Chiropractic services for acute musculoskeletal conditions. The condition must be new or an exacerbation of a previou be provided by a plan chiropractor and requires a referral from a primary care doctor. Coverage is provided for up to 25
25 Page 26 27
2002 Fallon Community Health Plan 24 Section 5a
Alternative treatments
Not covered: naturopathic services
hypnotherapy acupuncture
biofeedback

Educational classes and programs
Coverage is limited to:

Smoking Cessation – Up to $100 for one smoking cessation program per member per lifetime, including all related expen
Diabetes self-management (may require preauthorization)
Health education and nutritional services, such as health education, library services, nutrition classes and programs, beha women's wellness.

The Fallon Foundation offers many health education programs and classes at the Lifetime Center for Family Health, 630A those who want to take a more active role in their health care. (Similar classes and programs also may be available in other
affiliated hospitals.) In addition, the Lifetime Center offers a variety of free brochures and booklets that provide informatio prevention and coping with various illnesses. 26
26 Page 27 28
2002 Fallon Community Health Plan 25 Section 5b
Section 5 (b). Surgical and an and other h
Benefit Description
Surgical procedures
A comprehensive range of services, such as: Operative procedures

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

Voluntary sterilization Treatment of burns
Note: Generally, we pay for internal prostheses (devices) according to where the procedure is done. For example, we pay H pacemaker and Surgery benefits for insertion of the pacemaker.

Not covered: Reversal of voluntary sterilization
Routine treatment of conditions of the foot; see Foot care. 27
27 Page 28 29
2002 Fallon Community Health Plan 26 Section 5b
Reconstructive surgery
Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if:
the condition produced a major effect on the member's appearance and the condition can reasonably be expected to be corrected by such surgery

Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm
anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks; webbed fingers; and webbed toes.

All stages of breast reconstruction surgery following a mastectomy, such as:
surgery to produce a symmetrical appearance on the other breast treatment of any physical complications, such as lymphedemas

breast prostheses and surgical bras and replacements (see Prosthetic devices) Note: If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the
after the procedure.
Not covered: Cosmetic surgery – any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance throu
except repair of accidental injury Surgeries related to sex transformation

Oral and maxillofacial surgery
Oral surgical procedures, limited to: Reduction of fractures of the jaws or facial bones;

Surgical correction of cleft lip, cleft palate or severe functional malocclusion; Removal of stones from salivary ducts;
Excision of leukoplakia or malignancies; Excision of cysts and incision of abscesses when done as independent procedures; and

Other surgical procedures that do not involve the teeth or their supporting structures. Not covered:
Oral implants and transplants Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone) 28
28 Page 29 30
2002 Fallon Community Health Plan 27 Section 5b
Organ/ tissue transplants
Limited to:
Cornea
Heart
Heart/ lung, for patients under 60 with end-stage primary or secondary pulmonary hypertension
Kidney
Liver
Lung, for patients under age 60 with end-stage obstructive or restrictive pulmonary disease Allogeneic (donor) bone marrow transplants for leukemia, aplastic anemia, severe combined immunodeficiency disease

syndrome for patients with high risk lymphoblastic lymphoma in remission, or for patients under age 60 with myelody Autologous bone marrow transplants (autologous stem cell and peripheral stem cell support) for the following conditio
remission; advanced Hodgkin's disease; resistant non-Hodgkin's disease; recurrent or refractive neuroblastoma; or brea Intestinal transplants (small intestine) and the small intestine with the liver or small intestine with multiple organs such
pancreas Human leukoctye (HLA) or histocompatability locus antigen testing for A, B, or DR antigens, or any combination thereo
marrow transplant donor suitability
Services must be provided at a plan-affiliated transplant facility, subject to your acceptance into the facility's program. The the final determination on eligibility for transplant coverage. The plan may require that members receive their transplant a

If a covered bone marrow transplant is not available from a plan provider, benefits will be paid at the same benefit level fo non-plan provider.
Note: We cover related medical and hospital expenses of the donor when we cover the recipient.
Not covered: Donor screening tests and donor search expenses, except as listed above, and those performed for the actual donor

Transplants not listed as covered, including but not limited to bone marrow transplants for treatment of solid tumors Services for the organ donor that are covered by another insurance plan
Services for the organ donor if the recipient is not a member of this plan Transportation, housing or home cleaning services incurred by either the donor or recipient

Anesthesia
Professional services provided in –
Hospital (inpatient)

Professional services provided in –
Hospital outpatient department Skilled nursing facility

Ambulatory surgical center Office 29
29 Page 30 31
2002 Fallon Community Health Plan 28 Section 5c
Section 5 (c). Services pr and am
Benefit Description
Inpatient hospital
Room and board, such as ward, semiprivate, or intensive care accommodations;

general nursing care; and meals and special diets.

NOTE: If you want a private room when it is not medically necessary, you pay the additional charge above the semiprivat
Other hospital services and supplies, such as: Operating, recovery, maternity, and other treatment rooms

Prescribed drugs and medicines Diagnostic laboratory tests and X-rays
Administration of blood and blood products Blood or blood plasma, if not donated or replaced
Dressings, splints, casts, and sterile tray services Medical supplies and equipment, including oxygen
Anesthetics, including nurse anesthetist services Take-home items
Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home
Not covered: Custodial care
Non-covered facilities, such as nursing homes or schools Personal comfort items, such as telephone, television, barber services, guest meals and beds
Private nursing care 30
30 Page 31 32
2002 Fallon Community Health Plan 29 Section 5c
Outpatient hospital or ambulatory surgical center
Operating, recovery, and other treatment rooms Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology services Administration of blood, blood plasma, and other biologicals
Blood and blood plasma, if not donated or replaced Presurgical testing
Dressings, casts, and sterile tray services Medical supplies, including oxygen
Anesthetics and anesthesia service
NOTE: – We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical cover the dental procedures.

Extended care benefits/ skilled nursing care facility benefits
The plan provides a comprehensive range of benefits for 100 days per calendar year when full-time skilled nursing care is n in a skilled nursing facility is medically appropriate as determined by a plan doctor and approved by the plan. All necessar
including: Bed, board, and general nursing care
Drugs, biologicals, equipment and supplies ordinarily provided or arranged by the skilled nursing facility, when prescrib

Not covered: custodial care or long-term inpatient care
Hospice care
Supportive and palliative care for a terminally ill member is covered in the home or hospice facility. Services include outpa counseling, and short-term inpatient care for up to 5 days of continuous inpatient care. These services are provided under
doctor who certified that the patient is in the terminal stages of illness, with a life expectancy of approximately 6 months or

Not covered: Independent nursing, homemaker services
Ambulance
Local professional ambulance service when medically appropriate 31
31 Page 32 33
2002 Fallon Community Health Plan 30 Section 5d
Section 5 (d). Em
What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or an injury (mental or physical) that you believe more detailed definition, as required by Massachusetts state law). Some problems are emergencies because, if not treated p

potentially life-threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or sudden inability to breathe. The quick action.

What to do in case of emergency:
Emergencies within our service area:
If you are in an emergency situation, please call your primary care physician. In extreme emergencies, if you are unable to hospital emergency room. Be sure to tell the emergency room personnel that you are a plan member so you can notify the p
plan has been notified in a timely manner.
If you need to be hospitalized, the plan must be notified as soon as reasonably possible. If you are hospitalized in a non-pla any ambulance charges covered in full.

Benefits are available for care from non-plan providers only if a delay in reaching a plan provider would result in death, di plan or provided by plan providers.

Emergencies outside our service area:
Benefits are available for any medically necessary health service that is immediately required because of injury or unforese
If you need to be hospitalized, the plan must be notified as soon as reasonably possible. If a plan doctor believes care can b
Any follow-up care recommended by plan providers must be approved by the plan or provided by plan providers. 32
32 Page 33 34
2002 Fallon Community Health Plan 31 Section 5d
Benefit Description
Emergency within our service area

Emergency care at a doctor's office Emergency care at an urgent care center

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

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

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

Not covered:
Elective care or non-emergency care
Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area
Medical and hospital costs resulting from a normal full-term delivery of a baby outside the service area

Ambulance
Professional ambulance service when medically appropriate. See 5( c) for non-emergency service.

Not covered:
air ambulance, when not appropriate to medical and geographical conditions transfers between hospitals when the patient's medical condition does not warrant that he/ she be

transported to another facility 33
33 Page 34 35
2002 Fallon Community Health Plan 32 Section 5e
Section 5 (e). Mental health and substance abuse benefits
I M
P O
R T
A N
T

When you get our approval for services and follow a treatment plan we approve, cost-sharing and limitations for plan mental health and substance abuse benefits will be no greater than for similar
benefits for other illnesses and conditions.
Here are some important things to keep in mind about these benefits:
All benefits are subject to the definitions, limitations, and exclusions in this brochure.

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.
Mental health and Substance Abuse treatment may be provided by a psychiatrist, psychologist, psychotherapist, licensed clinical specialist in psychiatric and mental health nursing, licensed
independent clinical social worker, mental health counselor, pediatric specialist, or other provider as authorized by the plan.

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

I M
P O
R T
A N
T

Benefit Description You pay
Mental health and substance abuse benefits You Pay
All diagnostic and treatment services recommended by a plan provider and authorized by the plan (when necessary). 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 any necessary authorization.

Your cost sharing responsibilities are no other illness or conditions.

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

Medication management

$10 per outpatient visit

Diagnostic tests Nothing
Services provided by a hospital or other facility
Services in approved alternative care settings such as partial
hospitalization, residential treatment, full-day hospitalization, facility based intensive outpatient treatment

Nothing 34
34 Page 35 36
2002 Fallon Community Health Plan 33 Section 5e
Mental health and substance abuse benefits (Continued) You Pay
Not covered: Services we have not approved.
Note: OPM will base its review of disputes about treatment plans on the treatment plan's clinical appropriateness. OPM will generally not order us to

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

All charges.

Preauthorization To be eligible to receive these benefits you must obtain plan authorization when nece
Inpatient services require preauthorization. To access services, call 1-888-421-8861 (T 7660).

You may self-refer, without prior plan authorization, for outpatient services with a p assistance in finding a contracted provider, call 1-888-421-8861 (TDD/ TTY: 781-994- 35
35 Page 36 37
2002 Fallon Community Health Plan 34 Section 5f
Section 5 (f). P 36
36 Page 37 38
2002 Fallon Community Health Plan 35 Section 5f
Benefit Description
Covered medications and supplies
We cover the following medications and supplies prescribed by a plan physician and obtained from a plan pharmacy or th program:
Drugs and medicines that by Federal law of the United States require a physician's prescription for their purchase, exc covered. This includes drugs used as off-label basis for treatment of cancer and HIV/ AIDS.
Diabetic supplies and medications, including insulin, insulin syringes, blood glucose monitoring strips, urine glucose s insulin pumps, insulin pump supplies, and insulin pens.
Disposable needles and syringes for the administration of covered medications Drugs for sexual dysfunction (contact us for preauthorization and dose limits)
Oral contraceptives and contraceptive devices Fertility drugs
Allergy serum Injectable agents
Emergency prescriptions (up to a 14-day supply) provided out of the service area as part of an approved emergency tr

Injectable contraceptive drugs, such as Depo Provera

Special medical formulas to treat certain metabolic disorders as required by Massachusetts law. Metabolic disorders co phenylketonuria, tyrosinemia, homocystinuria, maple syrup urine disease, propionic acidemia, methylmalonic acidem
medically necessary to protect unborn fetuses of pregnant women with phenylketonuria

Food products which have been modified to be low in protein for individuals with inherited diseases of amino acids an 37
37 Page 38 39
2002 Fallon Community Health Plan 36 Section 5f
Covered medications and supplies (Continued)
Enteral formulas for home use in the treatment of malabsorption caused by Crohn's disease, ulcerative colitis, gastroes gastrointestinal motility, chronic internal pseudo-obstruction, and inherited diseases of amino acids and organic acids.

Not covered:
Drugs and supplies for cosmetic purposes
Drugs to enhance athletic performance
Drugs obtained at a non-plan pharmacy; except for out-of-area emergencies
Vitamins, nutrients and food supplements even if a physician prescribes or administers them
Nonprescription medicines
Medical supplies such as dressings and antiseptics
Nicotine patches, and gum or other smoking cessation products unless supplied to you as part of an approved smoking cessation pro 38
38 Page 39 40
2002 Fallon Community Health Plan 37 Section 5g
Section 5 (g). Special features
Feature Description

Services for deaf and hearing impaired You may access our TTD/ TTY equipment at 1-877-608-7677.

Peace of Mind™ Program If you are a Fallon Plus or Fallon Affiliates member and you want to see a Boston-base usual physician), you may do so under the Peace of Mind Program if you meet the foll
Care is only for covered services as described in this brochure. The same copayments You must have already seen a plan specialist for this condition within the past three m
A referral to a specific Peace of Mind physician is made by your plan physician and a The physician is on staff at Massachusetts General Hospital, Brigham and Women's H
(Boston), New England Medical Center or Dana-Farber Cancer Institute. Services for Boston IVF instead of one of these four hospitals.

Once the plan has authorized the Peace of Mind referral to a specific physician, you m see this specialist for a consultation. You may continue on with this specialist for treat
plan physician at any time for care. If you wish to see any other Peace of Mind provid separate referral from your plan physician and receive authorization from the plan, m
above.
You should advise your Peace of Mind Program provider that all laboratory, X-ray se authorized in advance by the plan. To ensure coverage, the Peace of Mind Program p
plan's Referral Management staff to make arrangements for these services. Whenever be made for these services to be performed by plan providers.

You may use the Peace of Mind program for all specialty care except mental health, su chiropractic services. You may not use the Peace of Mind program for any primary ca
internal medicine, family practice, pediatrics or routine obstetrics. If you have not me above or you or your physician have not obtained plan authorization for a Peace of M
will not be covered by the plan and the Peace of Mind Program provider may hold yo

Out-of-area emergency and
urgent care

Send all claims for urgent or emergency care to us within six months of the date of serv claims yourself, or the provider may submit them directly. With your authorization, w
to the provider. Otherwise, we will send any payment to you. All bills should include services, the dates of service and the charge for each service. We will pay for the reason
full, minus the appropriate copayment.
Claims for services in a foreign country may be submitted if the services are not provid country. The bills must be itemized and in English (or translated into English). Paymen

you must pay the provider. 39
39 Page 40 41
2002 Fallon Community Health Plan 38 Section 5g
Out-of-area student coverage We cover students attending school outside the plan service area, for additional benefi out-of-area, if authorized by the plan in advance. Coverage continues to age 22 or unti occurs first.
Outpatient services to treat the abuse of, or addiction to, alcohol and drugs. You p Non-elective inpatient services if the plan is notified as soon as reasonably possible
Non-routine office visits. You pay a $10 copay per visit. Diagnostic lab and X-ray services connected with non-routine office visits. You pa
Outpatient services to diagnose and/ or treat mental conditions. You pay a $10 cop Short-term rehabilitation services, including physical, occupational, and speech the
outpatient visits per calendar year. Not covered out-of-area:
Routine physicals, gynecological exams, vision screening, hearing screening, or other routi Maternity care or delivery
Outpatient surgical procedures that could have been delayed until return to the Plan servic Durable medical equipment (e. g. wheelchairs), including maintenance and replacement
Preventive dental care Second opinion
Home health care Non-emergency prescription drugs

Interpreter services We will, upon request, provide members with interpreters and translation services rela Health Plan administrative procedures. 40
40 Page 41 42
2002 Fallon Community Health Plan 39 Section 5h
Section 5 (h). Dental benefits
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

Plan dentists must provide or arrange your care.
We have no calendar year deductible.
We cover hospitalization for dental procedures only when a non-dental physical impairment exists which makes hospitalization necessary to safeguard the health of the patient; we do not cover the

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

Accidental injury benefit You pay
We cover emergency medical care such as to relieve pain and stop bleeding as a result of an accidental injury to sound natural
teeth or tissues, when provided as soon as medically possible after the injury. This does not include restorative or other
services.

$10 per visit

While out of the plan service area, you are also covered for some limited urgent dental care services. This includes treatments for
minor ailments such as a toothache, or loose filling. Coverage is provided for up to $50 per incident.
$10 per visit

Dental benefits
Preventive dental care services are covered; services are available twice per calendar year; you pay a $10 copay for the office visit, and additional copayments for minor restorative care services as follows;

ADA Description You pay Code
110 Initial oral examination $10 120 Periodic oral examination 10
130 Emergency oral examination 10 140 Ltd. oral evaluation (problem focused) 10
150 Comprehensive oral evaluation 10 220 Intraoral (periapical, first film) 10
230 Intraoral (periapical, each additional film) 10 240 Intraoral (occlusal film) 10
270 Bitewing (single film) 10 272 Bitewings (two films) 10
273 Bitewings (three films) 10 274 Bitewings (four films) 10
460 Pulp vitality tests 10 470 Diagnostic casts 10

Preventive (Cleanings) 1110 Prophylaxis (adult, every six months) 10
1120 Prophylaxis (child, every six months) 10 1201 Top application flouride (includes prophylaxis— child < age 16) 10
1203 Top application flouride (excludes prophylaxis— child < age 16) 10 1205 Top application flouride (includes prophylaxis— adult age 16 and over) 10
1330 Oral hygiene instruction 10
Minor Restorative (Fillings) 2110 Amalgam (one surface, primary) 13
2120 Amalgam (two surfaces, primary) 18 41
41 Page 42 43
2002 Fallon Community Health Plan 40 Section 5h
2130 Amalgam (three surfaces, primary) 22 2140 Amalgam (four or more surfaces, primary) 28
2150 Amalgam (two surfaces, permanent) 15 2160 Amalgam (three surfaces, permanent) 22
2161 Amalgam (four or more surfaces, permanent) 28 2330 Resin (one surface, anterior) 19
2331 Resin (two surfaces, anterior) 22 2332 Resin (three surfaces, anterior) 28
2335 Resin (three surfaces, or involving incisal angle— anterior) 33 2385 Resin (one surface, posterior permanent) 19
2386 Resin (two surfaces, posterior permanent) 25 2387 Resin (three or more surfaces, posterior permanent) 35

Procedures not shown are not covered by the Plan. 42
42 Page 43 44
2002 Fallon Community Health Plan 41 Section 5i
Section 5 (i). Non-FEHB benefits available to plan members
The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed claim about them. Fees you pay for these services do not count toward FEHB deductibles or out-of-pocket

maximums.

Dental services discounts— The plan has arranged for discounts for non-covered dental services at participating providers. If you would like a list of the services and the fee schedule, contact the Fallon Customer Service
Department at 1-800-868-5200 (TDD/ TTY: 1-877-608-7677).
Eyewear discounts— Fallon has arranged for discounts on eyeglass frames, prescription lenses and complete contact lens at participating Fallon optical providers. For more information, contact the Fallon Customer Service
Department at 1-800-868-5200 (TDD/ TTY: 1-877-608-7677).
Hearing aid discounts— The plan has arranged for discounts off the regular price of hearing aids and assistive listening devices. Contact the Fallon Customer Service Department at 1-800-868-5200 (TDD/ TTY: 1-877-608-7677)
for a complete list of providers.
Fitness center discounts— Members of the plan are entitled to discounted memberships at several area health clubs. Discounts vary from club to club. For information on participating health clubs and the associated
discounts, call the Fallon Customer Service Department at 1-800-868-5200 (TTD/ TTY: 1-877-608-7677).
Medicare prepaid plan enrollment— This plan offers Medicare recipients the opportunity to enroll in the plan through Medicare. As indicated on page 46, annuitants and former spouses with FEHB coverage and Medicare
Part B may elect to drop their FEHB coverage and enroll in a Medicare prepaid plan when one is available in their area. They may then later re-enroll in the FEHB Program. Most federal annuitants have Medicare Part A. Those
without Medicare Part A may join this Medicare prepaid program but will probably have to pay for hospital coverage in addition to the Part B premium. Before you join the plan, ask whether the plan covers hospital
benefits and, if so, what you have to pay. Contact your retirement system for information on dropping your FEHB enrollment and changing to a Medicare prepaid plan. Contact Fallon Customer Service at 1-800-868-5200
(TDD/ TTY: 1-877-608-7677) for information on the benefits available under the Medicare HMO.
Weight Watchers program— Plan members are entitled to one twelve-week membership in each calendar year, at no cost. Additional memberships and food products are not covered under this feature.

Benefits on this page are not part of the FEHB contract. 43
43 Page 44 45
2002 Fallon Community Health Plan 42 Section 6
Section 6. General exclusions--things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not cover it unless your plan doctor determines it is medically necessary to prevent, diagnose, or
treat your illness, disease, injury, or condition and we agree, as discussed under Services Requiring Our Prior Approval on page 11.

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, including services received for reasons of preference or convenience

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. 44
44 Page 45 46
2002 Fallon Community Health Plan 43 Section 7
Section 7. Filing a claim for covered services
When you see plan physicians, receive services at plan hospitals and facilities, or obtain your prescription drugs at plan pharmacies, you will not have to file claims. Just present your identification card and pay your
copayment
You will only need to file a claim when you receive emergency services from non-plan providers. Sometimes these providers bill us directly. Check with the provider. If you need to file the claim, here is the process:

Medical and hospital benefits In most cases, providers and facilities file claims for you. Physicians must file on the form HCFA-1500, Health Insurance Claim Form.
Facilities will file on the UB-92 form. For claims questions and assistance, call us at 1-800-868-5200 (TDD/ TTY: 1-877-608-7677).

When you must file a claim— such as for out-of-area care— submit it on the HCFA-1500 or a claim form that includes the information shown
below. Bills and receipts should be itemized and show:
Covered member's name and ID number;
Name and address of the physician or facility that provided the service or supply;

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

Receipts, if you paid for your services.
Submit your claims to:
Fallon Community Health Plan Claims Department
10 Chestnut St. Worcester, MA 01608

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. 45
45 Page 46 47
2002 Fallon Community Health Plan 44 Section 8
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your claim or request for services, drugs, or supplies – including a request for preauthorization:

Step Description
1 Ask us in writing to reconsider our initial decision. You must: (a) Write to us within 6 months from the date of our decision; and
(b) Send your request to us at: Fallon Community Health Plan, Consumer Affairs Department, 10 Chestnut St., Worcester, MA 01608; or fax it to us at 508-755-7393; or make your request by telephone at 1-800-868-5200
(TDD/ TTY: 1-800-607-7677 ) Monday through Friday, 8: 30 a. m. to 5: 00 p. m.; or make your request in person at our Consumer Affairs Department; 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. Also include your name, FCHP identification
number, and the name of any FCHP representative with whom you have spoken.
If you send us a written or electronic grievance, we will acknowledge your request in writing within 15 business days from the date that we receive the request. If you call us or come in to our offices, we will put your grievance

in writing and send a written statement to you or your authorized representative within 48 hours of the time that we talked to you.

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
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. Your grievance will be reviewed by FCHP administrators and/ or physicians who are knowledgeable about the matters at issue in the grievance. As part of certain types of review, we may ask you
to participate in a conference.
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. Our response will describe the specific information considered as well as an explanation for the decision.
You may ask for a reconsideration of a final adverse determination if any relevant information was received too late to review within the time limits described above, or is expected to become available within a reasonable time
period after you receive our written response. If we agree to reconsider, we will indicate a new time period for review in writing. This would not be longer than 30 days from the date we agree to the reconsideration.

If we do not complete a review in the time limits specified above, the decision will automatically be in favor of the member. Time limits include any extensions made by mutual written agreement between you or your
authorized representative and the plan
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. 46
46 Page 47 48
2002 Fallon Community Health Plan 45 Section 8
Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Contracts Division 3, 1900 E Street, NW, Washington, DC 20415-3630.
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

6

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.
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 1-800-868-5200 and we will expedite our review. If you have a terminal illness, and if our review of your
expedited review results in denial of coverage, you may request a conference. We will schedule the conference within 10 business days from the date on which we receive your request; or within five business
days if your physician determines, after consultation with a plan medical director, that based on standard medical practice, the effectiveness of the proposed treatment, services or supplies or any alternative
treatment, services or supplies would be materially reduced if not provided at the earliest possible date. You may attend the conference, but your attendance is not required; 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 3 at 202-606-0737 from 8 a. m. to 5 p. m. Eastern time. 47
47 Page 48 49
2002 Fallon Community Health Plan 46 Section 9
Section 9. Coordinating benefits with other coverage
When you have other health You must tell us if you are covered or a family member is covered under Coverage another group health plan or have automobile insurance that pays health
care expenses without regard to fault. This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in full as the primary payer and the other plan pays a reduced benefit as
the secondary payer. We, like other insurers, determine which coverage is primary according to the National Association of Insurance
Commissioners' guidelines.
When we are the primary payer, we will pay the benefits described in this brochure.

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

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

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

employment, you should be able to qualify for premium-free Part A insurance. (Someone who was a Federal employee on
January 1, 1983 or since automatically qualifies.) Otherwise, if you are age 65 or older, you may be able to buy it. Contact 1-800-
MEDICARE for more information.
Part B (Medical Insurance). Most people pay monthly for Part B. Generally, Part B premiums are withheld from your monthly Social

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

The Original Medicare Plan (Original Medicare) is available everywhere in the United States. It is the way everyone used to get Medicare benefits
and is the way most people get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist, or hospital that accepts
Medicare. The Original Medicare Plan pays its share and you pay your share. Some things are not covered under Original Medicare, like
prescription drugs.
When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care.

The Original Medicare Plan
(Part A or Part B) 48
48 Page 49 50
2002 Fallon Community Health Plan 47 Section 9
The following chart illustrates whether the Original Medicare Plan or this plan should be the primary payer for you according to your employment status and other factors determined by Medicare. It is critical that you tell us
if you or a covered family member has Medicare coverage so we can administer these requirements correctly.
Primary Payer Chart
Then the primary payer is… A. When either you --or your covered spouse --are age 65 or over and …

Original Medicare This Plan
1) 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 unable to return to duty

(except for claims related to Workers'

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

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

b) Are an active employee, or
c) Are a former spouse of an annuitant, or
d) Are a former spouse of an active employee 49
49 Page 50 51
2002 Fallon Community Health Plan 48 Section 9
Claims process when you have the Original Medicare Plan— You probably will never have to file a claim form when you have both our
plan and the Original Medicare Plan.
When we are the primary payer, we process the claim first.
When Original Medicare is the primary payer, Medicare processes
your claim first. In most cases, your claims will be coordinated automatically and we will pay the balance of covered charges. You

will not need to do anything. To find out if you need to do something about filing your claims, call us at 1-800-868-5200
(TDD/ TTY: 1-877-608-7677).
We do not waive any costs when you have Medicare.

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

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

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

If you do not enroll in If you do not have one or both Parts of Medicare, you can still be covered Medicare Part A or Part B under the FEHB Program. We will not require
you to enroll in Medicare Part B and, if you can't get premium-free Part A, we will not ask you to enroll in it. 50
50 Page 51 52
2002 Fallon Community Health Plan 49 Section 9
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 illness or injury that the Office of Workers' Compensation Programs (OWCP) or a similar

federal or state agency determines they must provide
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 injuries for injuries or illness caused by another person, you must reimburse us
for any expenses we paid. However, we will cover the cost of treatment that exceeds the amount you received in the settlement .

If you do not seek damages you must agree to let us try. This is called subrogation. If you need more information, contact us for our
subrogation procedures. 51
51 Page 52 53
2002 Fallon Community Health Plan 50 Section 10
Section 10. Definitions of terms we use in this brochure
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends
on December 31 of the same year.

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

Covered services Care we provide benefits for, as described in this brochure.
Custodial care Care furnished to meet nonmedically necessary needs such as assistance in mobility, dressing, bathing, eating, preparation of special diets, and
taking medication. Custodial Care is not covered by the plan.

Experimental or investigational services The plan's Benefits & Technology Assessment Committee determines
what procedures, devices, and services are experimental or investigational using FDA guidelines and long-term clinical studies.
Clinical studies are used to ensure that the procedure, device, or service has proven to be more effective over currently accepted procedures,
devices, or service.

Group health coverage Health care coverage through a partnership, association, or corporation that has an agreement to pay the plan, or its agent, the plan premium for
a group of subscribers. FEHB is an example of a group.

Medical necessity A medical or hospital service which is rendered for treatment or diagnosis of an injury or illness, not furnished primarily for the
convenience of the member, physician or provider, and is in accordance with professionally recognized medical standards and plan medical
criteria.

Provider A person, agency or facility that may furnish health care to you under the terms of this contract. This includes doctors of medicine, osteopathy
and podiatry; registered nurse anesthetists; and nurse practitioners.

Us/ We Us and we refer to Fallon Community Health Plan
You You refers to the enrollee and each covered family member. 52
52 Page 53 54
2002 Fallon Community Health Plan 51 Section 11
Section 11. FEHB facts
No pre-existing condition We will not refuse to cover the treatment of a condition that you had limitation before you enrolled in this plan solely because you had the condition
before you enrolled.
Where you can get information See www. opm. gov/ insure. Also, your employing or retirement office about enrolling in the can answer your questions, and give you a Guide to Federal Employees

FEHB Program Health Benefits Plans, brochures for other plans, and other materials you need to make an informed decision about:

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

When your enrollment ends
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, for you and your family your spouse, and your unmarried dependent children under age 22,
including any foster children or stepchildren for which your employing or retirement office authorizes coverage. 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 (adopted children are eligible from the time of placement in the home).
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 premiums start plan during Open Season, your coverage begins 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. 53
53 Page 54 55
2002 Fallon Community Health Plan 52 Section 11
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

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 If you are divorced from a Federal employee or annuitant, you may be coverage 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.

In the event of divorce, the subscriber's former spouse may remain covered under the FEHB family coverage. Coverage may continue, with
no additional premium due, unless: (1) the divorce decree does not require (or no longer requires) the subscriber to maintain health
insurance coverage for the former spouse, or (2) either the subscriber or the former spouse remarry.

If the subscriber remarries and wishes to add his or her new spouse to the family coverage, the former spouse remains eligible for coverage
under FEHB. However, the former spouse must move from family coverage to individual coverage and additional premium will be
required; the former spouse only remains eligible under the group if the divorce decree provides for such coverage. If the former spouse
remarries, the former spouse's eligibility ends. 54
54 Page 55 56
2002 Fallon Community Health Plan 53 Section 11
Notice of cancellation of coverage of a former spouse will be mailed to the former spouse at his or her last known address, along with notice of
any applicable right to reinstate coverage retroactively to the date of cancellation. The former spouse may also be eligible for continuation of
coverage or conversion to an individual guarantee-issue policy.
Temporary Continuation of coverage (TCC) If you leave Federal service, or if you lose coverage because you no
longer qualify as a family member, you may be eligible for Temporary Continuation of Coverage (TCC). For example, you can receive TCC if
you are not able to continue your FEHB enrollment after you retire, if you lose your job, if you are a covered dependent child and you turn 22
or marry, etc.
You may not elect TCC if you are fired from your Federal job due to gross misconduct.

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

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

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 Group Health Plan Coverage (HIPPA) is 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 55
55 Page 56 57
2002 Fallon Community Health Plan 54 Section 11
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.

Long Term Care Insurance is coming later in 2002!

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:

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 nursing home care, care in an assisted living facility, care in your home, adult day care, hospice

care, and more. It can supplement care provided by family members,
reducing the burden you place on them.

Welcome to the club! 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 everyone should have a plan just in case. Many people now consider long term care insurance to be

vital to their financial and retirement planning.
Yes, it can be very expensive. A year in a nursing home can exceed $50,000. Home care for only three 8-hour shifts a week can exceed
$20,000 a year. And that's before inflation!
Long term care can easily exhaust your savings. Long term care insurance can protect your savings.

Not FEHB. Look at the "Not covered" blocks in sections 5( a) and 5( c) of your FEHB brochure. Health plans don't cover custodial care or a stay in an
assisted living facility or a continuing need for a home health aide to help
you get in and out of bed and with other activities of daily living. Limited
stays in skilled nursing facilities can be covered in some circumstances.
Medicare only covers skilled nursing home care (the highest level of nursing care) after a hospitalization for those who are blind, age 65 or older

or fully disabled. It also has a 100 day limit.

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? You should consider buying long-term care insurance.

What is long term care
(LTC) insurance?

I'm healthy. I won't need
long term care. Or, will I?

Is long term care expensive?
But won't my FEHB plan,
Medicare or Medicaid cover
my long term care? 56
56 Page 57 58
2002 Fallon Community Health Plan 55 Section 11
Medicaid covers long term care for those who meet their state's poverty guidelines, but has restrictions on covered services and where they can be
received. Long term care insurance can provide choices of care and
preserve your independence.

Employees will get more information from their agencies during the LTC open enrollment period in the late summer/ early fall of 2002.
Retirees will receive information at home.
Our toll-free teleservice center will begin in mid-2002. In the meantime, you can learn more about the program on our web site at
www. opm. gov/ insure/ ltc.

When will I get more information
on how to apply for this new
insurance coverage?

How can I find out more about the
program NOW? 57
57 Page 58 59
2002 Fallon Community Health Plan 56 Index
Index
Do not rely on this page; it is for your convenience and may not show all pages where the terms appear.

Accidental injury 39 Allergy tests 20
Alternative treatment 24, 45 Ambulance 28, 29, 30, 31
Anesthesia 25, 26, 27 Autologous bone marrow transplant 20, 27
Biopsies 25 Birthing centers 17
Blood and blood plasma 28, 29 Casts 28, 29
Catastrophic protection 14, 57 Chemotherapy 12, 20
Childbirth 10, 18 Cholesterol tests 8, 17
Circumcision 17, 18 Claims 35, 37, 43, 44, 45, 47, 48
Coinsurance 5, 14, 48, 52 Colorectal cancer screening 17
Congenital anomalies 18, 25, 26 Contraceptive devices and drugs 18
Covered charges 48 Crutches 23
Deductible 5, 14, 39, 41, 48 Definitions 50
Dental care 10, 29, 39, 40 Diagnostic services 12, 16, 32, 38
Disputed claims review 44, 45 Donor expenses (transplants) 27
Dressings 28, 29 Durable medical equipment (DME) 12, 23
Educational classes and programs 24 Effective date of enrollment 9, 12, 50, 51
Emergency 5, 30, 31, 35, 37, 39, 43 Experimental or investigational 42, 50
Eyeglasses 21 Family planning 18
Fecal occult blood test 17 General Exclusions 42
Hearing services 21, 41 Home health services 23, 38
Hospice care 29

Hospital 5, 9, 10, 11, 12, 16, 17, 22, 25, 27, 28
Immunizations 5, 17 Infertility 10, 19, 37
Inpatient Hospital Benefits 28 Insulin 35
Laboratory and pathological services 19, 28, 29, 37
Magnetic Resonance Imagings (MRIs) 12, 16
Mail Order Prescription Drugs 57 Mammograms 10, 16, 17
Maternity Benefits 10, 17, 18, 28 Medicaid 49, 54, 55
Medicare 54 Members 11, 12, 13, 26, 27, 38,
41, 43 Mental Conditions/ Substance
Abuse Benefits 10, 11, 32, 33 Newborn care 17
Non-FEHB Benefits 41 Nurse
Licensed Practical Nurse 23 Nurse Anesthetist 28
Nurse Practitioner 9, 50 Registered Nurse 13, 23
Nursery charges 17, 18 Occupational therapy 12,
21, 23 Office visits 5, 14, 17, 19, 38,
57 Oral and maxillofacial surgery 26
Orthopedic devices 22, 23 Out-of-pocket expenses 14,
41 Outpatient facility care x29
Oxygen 23, 28 Pap test 10, 16
Physical examination 5 Physical therapy 12, 23

Physician 5, 9, 10, 11, 12, 14, 16, 19, 20, 23, 25, 34, 35, 37,
44, 45, 50, 57 Preauthorization 20, 22, 24, 25,
28, 32, 33, 34, 35, 44 Preventive care, adult 17
Preventive care, children 17 Prescription drugs 9, 18, 19,
21, 23, 34, 35, 36, 41, 43, 46, 48
Preventive services 57 Prior approval 11
Prostate cancer screening 17 Prosthetic devices 22, 23, 25, 26
Psychologist 32 Radiation therapy 12
Renal dialysis 20, 23, 46 Room and board 28
Second surgical opinion 16 Skilled nursing facility care 11, 16,
23, 27, 29, 54 Smoking cessation 24
Speech therapy 8, 12, 21 Splints 22, 28
Sterilization procedures 18, 25 Subrogation 49
Substance abuse 10, 32, 57 Surgery 18, 21, 22, 25, 26, 28
Anesthesia 25, 27, 29 Oral 26
Outpatient 12, 18, 29, 31 Reconstructive 26
Syringes 35 Temporary continuation of
coverage 52, 53, 54 Transplants 8, 12, 20, 27, 46
Treatment therapies 20 Vision services 21, 57
Well child care 17 Wheelchairs 23
Workers' compensation 47, 49 X-rays 16, 19, 28, 38 58
58 Page 59
2002 Fallon Community Health Plan 57 Summary
Summary of benefits for Fallon Community Health Plan -2002
Do not rely on this chart alone. All benefits are provided in full unless indicated and are subject to the
definitions, limitations, and exclusions in this brochure. On this page we summarize specific expenses we cover; for more detail, look inside.

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

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

Benefits
Medical services provided by physicians:
Diagnostic and treatment services provided in the office..........

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

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

Mental health and substance abuse treatment ...............................
Prescription drugs .................................................................................

Dental Care ..........................................................................................
Vision Care...........................................................................................
Special features....................................................................................

Protection against catastrophic costs (your out-of-pocket maximum) 59

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