Pages 1--48 from Trigon HealthKeepers

Serving: Eastern Virginia, including the Peninsula, Hampton Roads and Tidewater areas;
Central Virginia, including Fredericksburg, Richmond, Charlottesville and Southside areas; Western Virginia, including Roanoke, Lexington, and Bedford areas; and
Southwestern Virginia, including the Wytheville and New River Valley areas.

Enrollment in this Plan is limited. You must live or work in our geographic service area to enroll. See page 5 for requirements.

Enrollment codes for this Plan:
X81 Self Only X82 Self and Family

RI 73-235

For changes
in benefits, see page 7

This Plan has excellent accreditation from
the NCQA. See the 2002 Guide for more
information on accreditation. 1
1 Page 2 3
2002 Trigon HealthKeepers Table of Contents 2
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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Service Area. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Section 2. How we change for 2002 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Program-wide changes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Changes to this Plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Section 3. How you get care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Identification cards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Where you get covered care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Plan providers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Plan facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
What you must do to get covered care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Primary care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Specialty care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Hospital care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Circumstances beyond our control. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Services requiring our prior approval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Section 4. Your costs for covered services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Copayments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Deductible. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Coinsurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Your out-of-pocket maximum. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Section 5. Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
( a) Medical services and supplies provided by physicians and other health care professionals . . . . . . . . . . . . . . 13
( b) Surgical and anesthesia services provided by physicians and other health care professionals . . . . . . . . . . 19
( c) Services provided by a hospital or other facility, and ambulance services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
( d) Emergency services/ accidents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
( e) Mental health and substance abuse benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
( f) Prescription drug benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
( g) Special features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Flexible benefits option. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 2
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2002 Trigon HealthKeepers Table of Contents 3
24 hour nurse line. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Early Intervention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Travel Benefit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Clinical Trials for Cancer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
( h) Dental benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
( i) Non-FEHB benefits available to Plan members. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Section 6. General exclusions --things we don' t cover. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Section 7. Filing a claim for covered services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Section 8. The disputed claims process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Section 9. Coordinating benefits with other coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
When you have
Other health coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Original Medicare. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Medicare managed care plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
TRICARE/ Workers' Compensation/ Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Other Government agencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Section 10. Definitions of terms we use in this brochure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Section 11. FEHB facts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Coverage information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
No pre-existing condition limitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Where you get information about enrolling in the FEHB Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Types of coverage available for you and your family . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
When benefits and premiums start . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Your medical and claims records are confidential. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
When you retire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
When you lose benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
When FEHB coverage ends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Spouse equity coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Temporary Continuation of Coverage ( TCC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Converting to individual coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Getting a Certificate of Group Health Plan Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Long term care insurance is coming later in 2002 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Summary of benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Rates . . Back cover 3
3 Page 4 5
2002 Trigon HealthKeepers 4 Section 1
Introduction
HealthKeepers, Inc.
P. O. Box 26623
Richmond, VA 23285-0031
1 ( 800) 421-1880

This brochure describes the benefits of Trigon HealthKeepers, offered by HealthKeepers, Inc. , under our contract ( CS 2091) 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 7. 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 Trigon HealthKeepers, offered by HealthKeepers, Inc .

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) 421-1880 and explain the situation.

If we do not resolve the issue, call or write:
THE HEALTH CARE FRAUD HOTLINE
202/ 418-3300
The United States Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street, NW, Room 6400
Washington, DC 20415.

Penalties for Fraud Anyone who falsifies a claim to obtain FEHB Program benefits can be prosecuted for fraud. Also, the Inspector General may investigate anyone who uses an ID card if the
person tries to obtain services for someone who is not an eligible family member, or is no 4
4 Page 5 6
2002 Trigon HealthKeepers 5 Section 1
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 or coinsurance.

Who provides my health care?
HealthKeepers, Inc. is a mixed model HMO offering both the individual practice and group practice modes of delivery. Members have
access to all Plan specialists when authorized by their primary care doctor.

Your Rights
OPM requires that all FEHB Plans to 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 receive financial credits from drug manufacturers based on the total volume of claims processed for their products used by members. These credits are used to help stabilize premiums. Reimbursements to pharmacies are not affected by these credits.

If you want more information about us, call 1 ( 800) 421-1880, or write to HealthKeepers at P. O. Box 26623, Richmond, VA 23285-
0031. You may also visit our website at www. trigon. com/ federal.

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
comprised of the following Virginia cities and counties:

Central Virginia: Albemarle, Amelia, Brunswick, Buckingham, Caroline, Charles City, Charlotte, Charlottesville, Chesterfield,
Colonial Heights, Cumberland, Dinwiddie, Emporia, Fluvanna, Fredericksburg, Goochland, Greene, Greensville, Hanover, Henrico,
Hopewell, King George, Louisa, Lunenburg, Madison, Mecklenburg, Nelson, New Kent, Nottoway, Orange, Petersburg, Powhatan,
Prince Edward, Prince George, Richmond, Spotsylvania, Stafford, Sussex.

Eastern Virginia: Chesapeake, Essex, Gloucester, Hampton, Isle of Wight, James City, King and Queen, King William, Mathews,
Middlesex, Newport News, Norfolk, Poquoson, Portsmouth, Richmond County, Suffolk, Surry, Virginia Beach, Westmoreland,
Williamsburg, York.

Western Virginia: Bedford, Bedford City, Botetourt, Buena Vista, Craig, Franklin County, Floyd, Giles, Lexington, Montgomery,
Pulaski, Radford, Roanoke, Roanoke City, Rockbridge, Salem, Tazewell, Wythe. 5
5 Page 6 7
2002 Trigon HealthKeepers 6 Section 1
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, except as described below. We will not pay for any other health care services, except as described below.

If you or a covered family member move outside of our service area, you can enroll in another plan. If your dependent lives out of the
area ( for example, your child goes to college in another state) , you should consider enrolling in a fee-for-service plan or an HMO that
has agreements with affiliates in other areas, such as HealthKeepers, Inc. 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.

The Trigon HealthKeepers service area is the area in which HealthKeepers, Inc. is licensed to sell Trigon HealthKeepers coverage.
However, we participate in Blues CONNECT, the Blue Cross and Blue Shield Association s HMO national network, expanding your
coverage to 41 states and the District of Columbia.

If you are traveling outside of the service area and have an unexpected illness or injury requiring urgent care, contact the Trigon
HealthKeepers 24-hour Nurse Advisor Line for authorization within 48 hours of receiving urgent care. Providers may request full
payment in advance and as a result, you will need an itemized bill to file a claim with us for reimbursement.

Members traveling outside the service area who require followup care for a condition currently under treatment will need to
prearrange any needed services with their Primary Care Physician in advance.

Trigon HealthKeepers gives you and your covered dependents the flexibility to become Guest Members of an affiliated Blue Cross
and Blue Shield HMO when staying outside the Trigon HealthKeepers service area for at least 90 days. Blues CONNECT provides
care for members on extended out of town trips, away at school, or when families live apart. To join, contact our Member Services
Department for a Guest Membership application. An Away From Home coordinator will make all the necessary arrangements for you
or your dependent to access your Trigon HealthKeepers benefits while away from home. A special Guest Membership ID card will be
sent to you for your dependent to use when medical care is needed. 6
6 Page 7 8
2002 Trigon HealthKeepers 7 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
Speech therapy is covered for non-rehabilitative purposes when medically necessary, up to 60 days per condition. Previously, rehabilitative speech therapy was covered up to 90 days per condition. The copayment of $ 20 per office visit remains the same.

Changes to this Plan
Your share of the non-Postal premium will increase by 8.3% for Self Only or 3.5% for Self and Family.
The copayment for outpatient surgery received in a freestanding or hospital based center is now $ 100 per visit. Previously, it was $ 50 per visit.

The copayment for hospital emergency room visits is now $ 100 per visit. Previously, it was $ 50 per visit. The copayment is waived if admitted to the hospital.
The copayment for routine outpatient maternity care is now $ 50 per pregnancy. Previously, there was no copayment. We changed the address for sending disputed claims to OPM. 7
7 Page 8 9
2002 Trigon HealthKeepers 8 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) 421-1880.

Where you get covered care You get care from Plan providers and Plan facilities. You will only pay copayments; ; there are no deductibles or coinsurance, and you will not have to file claims in most
circumstances.

Plan providers maintain the physician-patient relationship with you and are solely
responsible for all medical services. The relationship between us and Plan providers is an
independent contractor relationship. Plan providers are not our employees or agents and
our employees are not employees or agents of any Plan provider.

Plan providers Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our members. We credential Plan
providers according to national standards.
We list Plan providers in the provider directory, which we update periodically. The list is
also on our website.

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

What you must do It depends on the type of care you need. First, you and each family member must choose
to get covered care a primary care physician. This decision is important since your primary care physician provides or arranges for most of your health care. Send us your completed Primary Care

Physician Selection Form, found in your Trigon HealthKeepers Network Listing for
Federal Employees, immediately upon enrollment. If you do not select a primary care
physician upon enrollment, we will select one for you.

Primary care Your primary care physician can be a general practitioner, family practitioner, internist or pediatrician. Your primary care physician will provide most of your health care, or give
you a referral to see a specialist.
If you want to change primary care physicians or if your primary care physician leaves
the Plan, call us. We will help you select a new one.

Specialty care Your primary care physician will refer you to a specialist for needed care. 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. However,
without a referral you may see a Plan participating obstetrician-gynecologist for all
services ( except inpatient hospital services and outpatient surgery) in the care of or
related to the female reproductive system and breasts.

Here are other things you should know about specialty care:
If you need to see a specialist frequently because of a life-threatening, degenerative or disabling condition that requires specialized medical care over a prolonged period of
time, your primary care physician will work with us to develop a treatment plan to see 8
8 Page 9 10
2002 Trigon HealthKeepers 9 Section 3
your specialist for a standing treatment period 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 have been diagnosed with cancer, you may get a standing referral from your primary care physician to another plan provider who is a board-certified physician in
pain management or an oncologist. These providers shall consult with the primary care
physician concerning the pain management plan, but not direct you to other health care
services.

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

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

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

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

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

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

Hospital care Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled nursing or other type of
facility.
If you are in the hospital when your enrollment in our Plan begins, call our customer
service department immediately at 1 ( 800) 421-1880. 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 hospital benefit of the hospitalized person. 9
9 Page 10 11
2002 Trigon HealthKeepers 10 Section 3
Circumstances beyond our control Under certain extraordinary circumstances, such as natural disasters, war, riot, civil insurrection, epidemic, or any other emergency or similar event not within our control
resulting in our facilities, personnel or financial resources being unavailable to provide or
arrange for the provision of covered services, 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 We and your primary care physician will formally arrange for all necessary consultations and referrals to other plan providers or, if no plan provider is available, non-plan

providers. Unauthorized visits to any provider other than your primary care physician are
not covered services, unless otherwise specified herein. 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 Referral Authorization. Your physician must
obtain referrals for services such as: inpatient hospital, medical services provided by
specialists, x-ray and laboratory, services in skilled nursing facilities, rehabilitation, home
health care, durable medical equipment health education, and ambulance services. 10
10 Page 11 12
2002 Trigon HealthKeepers 11 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 the 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 and when you go in the hospital, you pay $ 100 per admission.

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

Coinsurance Coinsurance is the percentage of our negotiated fee that you must pay for your care. We do not have coinsurance.

Your catastrophic protection
out-of-pocket maximum
for deductibles, coinsurance
and copayments After your copayments total $ 1,500 per person or $ 3,000 per family enrollment in any calendar year, you do not have to pay any more for covered services. However,

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

Prescription drugs Dental services
Vision care Chiropractic services

Be sure to keep accurate records of your copayments since you are responsible for
informing us when you reach the maximum. 11
11 Page 12 13
2002 Trigon HealthKeepers 12 Section 5
Section 5. Benefits OVERVIEW ( See page 7 for how our benefits changed this year and page 47 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) 421-1880 or at our website at
www. trigon. com/ federal .

( a) Medical services and supplies provided by physicians and other health care professionals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-18
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. . . . . . . . . . . . . . . . . . . . . . . . . . . 19-21
Surgical procedures Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue transplants
Anesthesia
( c) Services provided by a hospital or other facility, and ambulance services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22-23
Inpatient hospital Outpatient hospital or ambulatory surgical
center
Extended care benefits/ skilled nursing care facility Hospice care
Ambulance
( d) Emergency services/ accidents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24-25
Medical emergency Ambulance
( e) Mental health and substance abuse benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26-27
( f) Prescription drug benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
( g) Special features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Flexible Benefits Option 24 hour Nurse Line Travel Benefit Clinical Trials for Cancer

( h) Dental benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
( i) Non-FEHB benefits available to Plan members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Summary of benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 12
12 Page 13 14
2002 Trigon HealthKeepers 13 Section 5( b)
Section 5 ( a) Medical services and supplies provided by physicians and
other health care professionals

I M
P O
R T
A N
T

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

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

coverage, including with Medicare.

I M
P O
R T
A N
T

Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
In physician s office
$ 10 per office visit to your primary care
physician

$ 20 per office visit to a specialist when
authorized by your primary care
physician

Professional services of physicians
In an urgent care center
$ 20 per visit to an urgent care
center

During a hospital stay No copayment for physician services during a hospital stay

In a skilled nursing facility No copayment for physician services in a skilled nursing facility
Office medical consultations Second surgical opinion $ 10 per office visit to your primary care physician
$ 20 per office visit to a specialist when
authorized by your primary care
physician

At home $ 20 per doctor s house call
Lab, X-ray and other diagnostic tests
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG

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

$ 10 per office visit to your primary
care physician,

$ 20 per office visit to a specialist
when authorized by your primary
care physician 13
13 Page 14 15
2002 Trigon HealthKeepers 14 Section 5( b)
Preventive care, adult You pay
Periodic health assessments ( in accordance with recommendations of
the American College of Physicians so long as they are consistent with
accepted medical practices as we determine) , such as:
Screening x-rays Laboratory test services

Prostate Specific Antigen ( PSA test) Digital rectal examination
Total Blood Cholesterol Colorectal Cancer Screening ( in accordance with recommendations of
the American College of Gastroenterology, in consultation with the
American Cancer Society) , including

--Fecal occult blood test
--Flexible sigmoidoscopy
--Colonoscopy
--Barium enema

$ 10 per office visit to your primary
care physician

Annual gynecological examination ( which consists of a breast exam,
pelvic exam and annual testing performed by any FDA-approved
gynecologic cytology screening technologies, including Pap smears) ,
when performed by your primary care physician or a Plan obstetrician-
gynecologist. No primary care physician referral is necessary.

$ 10 per office visit

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 through 64, one every calendar year

At age 65 and older, one every two consecutive calendar years

$ 20 per office visit

Routine immunizations, in accordance with recommendations of the
American College of Physicians and consistent with accepted medical
practices.

$ 10 per office visit to your primary
care physician

Not covered: Physical exams required by court order, for obtaining or
continuing employment or insurance, attending schools or camp,
participating in sports, or travel.

All charges

Preventive care, children
Childhood immunizations recommended by the American Academy of Pediatrics $ 10 per office visit to your primary care physician

Well-child care including routine examinations, screening x-rays, and laboratory services ( from birth to under age 22)
Periodic health assessments, such as:
--Eye exams through age 18 to determine the need for vision
correction.
--Ear exams through age 18 to determine the need for hearing
correction

$ 10 per office visit to your primary
care physician

Maternity care
Complete maternity ( obstetrical) care, such as:
Prenatal care Delivery

Postnatal care

$ 50 per pregnancy for routine
outpatient care

$ 20 per office visit for non-routine
diagnostic testing

$ 100 per inpatient hospital
admission 14
14 Page 15 16
2002 Trigon HealthKeepers 15 Section 5( b)
Maternity care ( Continued) You pay
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. We will extend your

inpatient stay if medically necessary.
We cover routine nursery care of the newborn child during the mother s covered maternity stay. We will cover other care of an

infant who requires non-routine treatment only if we cover the
infant under a Self and Family enrollment.

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

benefits ( Section 5b) .
Family planning
A broad range of voluntary family planning services, such as:
Voluntary sterilization, such as tubal ligations and vasectomies Surgically implanted contraceptives ( such as Norplant)

Injectable contraceptive drugs ( such as Depo provera)
Intrauterine devices ( IUDs)
Diaphragms
Note: we cover oral contraceptives under the prescription drug benefit.

$ 10 per office visit to your primary care
physician

$ 20 per office visit to a specialist when
authorized by your primary care
physician

$ 100 per visit for outpatient
surgery received in a freestanding
or hospital based center

Not covered:
reversal of voluntary surgical sterilization, Genetic counseling, genetic testing other than fetal screenings.

Services for potential illnesses that may result from genetic pre-
disposition are not covered in the absence of signs or symptoms.

All charges.

Infertility services
Diagnosis and treatment of infertility, in accordance with standards of
accepted medical practice as we determine and when authorized in
advance, such as:

Artificial insemination: --intravaginal insemination ( IVI)

--intracervical insemination ( ICI)
--intrauterine insemination ( IUI)

$ 20 per office visit

Not covered:
Assisted reproductive technology ( ART) procedures, such as: --in vitro fertilization

--embryo transfer, gamete GIFT and zygote GIFT
--zygote transfer
Services and supplies related to excluded ART procedures Cost of donor sperm

Cost of donor egg Fertility drugs

All charges.

Allergy care
Testing and treatment
Allergy injection
$ 10 per office visit to your primary care
physician

$ 20 per office visit to a specialist when
authorized by your primary care
physician 15
15 Page 16 17
2002 Trigon HealthKeepers 16 Section 5( b)
Allergy care ( Continued) You pay
Allergy serum Nothing

Not covered: provocative food testing and sublingual allergy
desensitization
All charges.

Treatment therapies
Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone
marrow transplants are limited to those transplants listed under
Organ/ Tissue Transplants on page 23.

Respiratory and inhalation therapy Dialysis Hemodialysis and peritoneal dialysis

Intravenous ( IV) / Infusion Therapy Home IV and antibiotic therapy
Growth hormone therapy ( GHT)
Note: Growth hormone is covered under prescription drug benefit
Note: We will only cover GHT when we preauthorize the treatment.
Your physician handles the prior authorization process by sending a
written request and applicable medical records to our Drug Prior
Authorization Unit.

$ 10 per office visit to your primary care
physician

$ 20 per office visit to a specialist when
authorized by your primary care
physician

Physical and occupational therapies
Up to 90 days per condition for the services of each of the following:

--qualified physical therapists and
--occupational therapists.

Note: We cover therapy only if we judge that significant
improvement can be expected within 90 days.

Cardiac rehabilitation, as we authorize as medically necessary and
when performed by an HMO provider

$ 20 per office visit
Nothing per visit during covered
inpatient admission

Not covered:
long-term rehabilitative therapy exercise programs All charges.

Speech Therapy
Up to 60 days per condition, when medically necessary. $ 20 per office visit
Nothing per visit during covered
inpatient admission

Hearing services ( testing, treatment, and supplies)

Hearing testing for children through age 18 ( see Preventive care, children ) $ 10 per office visit

Not covered:
all other hearing testing hearing aids, testing and examinations for them All charges. 16
16 Page 17 18
2002 Trigon HealthKeepers 17 Section 5( b)
Vision services ( testing, treatment, and supplies) You pay
Annual eye examination from the providers we designate to provide this service.

Annual contact lens examination from the providers we designate to provide this service.
$ 10 per office visit
$ 25 per office visit, in addition to
the $ 10 copayment for eye exam

Vision screening to determine the need for vision correction for children through age 18 ( see Preventive care, children ) $ 10 per office visit

Not covered:
Eyeglasses or contact lenses
Radial keratotomy and other refractive surgery

All charges.

Foot care
Podiatric services, limited to services for diabetic foot debridement $ 10 per office visit to your primary care physician

$ 20 per office visit to a specialist when
authorized by your primary care
physician

Not covered:
Routine foot care, such as the removal of corns or calluses and the trimming of toenails All charges.

Orthopedic and prosthetic devices
Rental or purchase, at our option, including repair and adjustment, of orthopedic and prosthetic devices prescribed by your Plan
physician and authorized by us.
Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy

Note: You must obtain orthopedic and prosthetic devices from the
provider we designate. Limited to $ 1,000 per member per calendar year
for any combination of orthopedic items, prosthetic devices, or Durable
Medical Equipment . We calculate the $ 1,000 limit by accumulating the Allowable Charge for each item until you reach a total of $ 1,000 for

any combination of items.

Nothing,
until you reach the maximum
benefit of $ 1,000 per member per
calendar year, then all charges.

Not covered:
Items for your convenience dental appliances

hearing aids penile implants
corrective appliances, artificial aids, devices, or equipment not specified as covered herein

All charges. 17
17 Page 18 19
2002 Trigon HealthKeepers 18 Section 5( b)
Durable medical equipment ( DME) You pay
Rental or purchase, at our option, including repair and adjustment, of durable medical equipment prescribed by your Plan physician and
authorized by us, such as oxygen and dialysis equipment.
Note: You must obtain Durable Medical Equipment from the provider
we designate. Limited to $ 1,000 per member per calendar year for any
combination of orthopedic items, prosthetic devices , or Durable
Medical Equipment. We calculate the $ 1,000 limit by accumulating the
Allowable Charge for each item until you reach a total of $ 1,000 for
any combination of items. Oxygen and related supplies are not subject
to or counted toward this calendar year maximum. We do not consider
any equipment or supplies used for the treatment of diabetes to be
durable medical equipment and they are not be subject to or counted
toward this calendar year maximum.

Nothing,
until you reach the maximum
benefit of $ 1,000 per member per
calendar year, then all charges.

Not covered:
Items for your convenience
All charges.

Home health services
Home health care on a part-time or intermittent basis ordered by a Plan physician and authorized by us and provided by a registered
nurse ( R. N. ) , licensed practical nurse ( L. P. N) , licensed vocational
nurse ( L. V. N. ) , or home health aide.
Services include nursing care, short-term rehabilitative services, home infusion therapy, medical supplies and other medically

necessary services, oxygen therapy, intravenous therapy and
medications.

Nothing,

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
rehabilitative
Non-medical services

All charges.

Chiropractic
Chiropractic services, from the providers we designate and when
authorized by our contractor.
$ 10 per office visit,

limited to 20 visits per member
per calendar year

Alternative treatments
No benefit All charges

Educational classes and programs
We cover health education services when authorized or furnished by us.
This includes outpatient self-management training and education
therapy, including smoking cessation, and medical nutrition therapy,
furnished in person to members with diabetes by a certified, registered
or licensed health care professional.

$ 10 per office visit to your primary care
physician

$ 20 per office visit to a specialist
when authorized by your primary
care physician

Not covered:
Nutrition counseling and related services, except when provided as part of diabetes education
All charges 18
18 Page 19 20
2002 Trigon HealthKeepers 19 Section 5( b)
Section 5 ( b) . Surgical and anesthesia services provided by physicians and other
health care professionals

I M
P O
R T
A N
T

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

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

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

the facility ( i. e. hospital, surgical center, etc. ) .

I M
P O
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A N
T

Benefit Description You pay
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 Insertion of internal prosthetic devices. See 5( a) Orthopedic and
prosthetic devices for device coverage information.
Voluntary sterilization Treatment of burns

Nothing,
included in your per-visit or per-
admission copayment

Not covered:
Reversal of voluntary sterilization and complications incidental to such procedures

Routine treatment of conditions of the foot; see Foot care.

All charges.

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. Examples of

congenital anomalies are: protruding ear deformities; cleft lip; cleft
palate; birth marks; webbed fingers; and webbed toes.

Nothing,
included in your per-visit or per-
admission copayment

continued on next page 19
19 Page 20 21
2002 Trigon HealthKeepers 20 Section 5( b)
Reconstructive Surgery ( Continued) You pay
All stages of breast reconstruction surgery following a mastectomy, such as:
--surgery to produce a symmetrical appearance on the other breast;
--treatment of any physical complications, such as lymphedemas;
--breast prostheses and surgical bras and replacements ( see
Prosthetic devices)

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

Nothing,
included in your per-visit or per-
admission copayment

Not covered:
Cosmetic surgery-surgery and procedures performed mainly to improve or alter a person s appearance, including body piercing and

tattooing. However, cosmetic surgery and procedures do not include a
surgery or procedure to correct deformity resulting from disease,
trauma, or congenital abnormalities that cause functional
impairment, or from a previous therapeutic process.
Services related to cosmetic surgery. Surgeries, procedures, services and supplies related to sex

transformation

All charges

Oral and maxillofacial surgery
Oral surgical procedures, limited to:
Surgical correction of congenital defects such as cleft lip and cleft palate;

Dental services needed as a result of an accidental injury that occurred while enrolled with us, and if we approve your plan of
treatment submitted within 60 days of the injury;
Preventive dental care to prepare the mouth for radiation therapy to treat head and neck cancer

Medical or surgical procedures that do not involve the teeth or their supporting structures occurring within or adjacent to the oral cavity
or sinuses, or related to temporomandibular joint ( TMJ) pain
dysfunction syndrome

Nothing,
included in your per-visit or per-
admission copayment

Not covered: All other procedures involving the teeth or areas
surrounding the teeth, such as
Shortening or lengthening of the mandible or maxillae Surgical correction of malocclusion or mandibular retrognathia

unless such condition prevents normal function
Dental appliances required to treat TMJ pain dysfunction syndrome or to correct malocclusion or mandibular retrognathia

Treatment of natural teeth due to diseases or accidental injury occurring before our effective date of coverage, or for which a
treatment plan was not submitted within 60 days
Biting and chewing related injuries Restorative services and supplies necessary to repair, remove or

replace sound natural teeth
Extraction of wisdom teeth

All charges. 20
20 Page 21 22
2002 Trigon HealthKeepers 21 Section 5( b)
Organ/ tissue transplants You pay
Limited to:
Cornea Heart

Heart/ lung Kidney
Kidney/ Pancreas Liver
Lung: Single Double Pancreas
Small bowel
Small bowel-liver transplants Allogeneic ( donor) bone marrow transplants

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

High dose chemotherapy, high dose radiation, and any supporting autologous bone marrow transplants or other forms of autologous

stem cell rescue when used to treat certain conditions.
Note: We cover charges related to the removal of a living organ from a
donor and transportation costs. When both the donor and recipient are
members of this plan, each is entitled to receive covered services. When
only the recipient is a member, both the recipient and the donor are
entitled to receive covered services. The donor s benefits are limited to
only those not available to the donor from any other source.

Nothing,
included in your per-visit or per-
admission copayment

Not covered:
Donor screening tests and donor search expenses for potential donors who are not immediate blood-related family members

( parent, child, or sibling) .
Implants of artificial organs Artificial heart transplants

Transplants not listed as covered

All charges

Anesthesia
Professional services provided in
Hospital ( inpatient) Hospital outpatient department

Skilled nursing facility Ambulatory surgical center
Office

Nothing,
Included in your per-visit or per-
admission copayment 21
21 Page 22 23
2002 Trigon HealthKeepers 22 Section 5( c)
Section 5 ( c) . Services provided by a hospital or other facility, and
ambulance services

I M
P O
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A N
T

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

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

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

associated with the professional charge ( i. e. , physicians, etc. ) are covered in
Section 5( a) or ( b) .

I M
P O
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A N
T

Benefit Description You pay
Inpatient hospital
Room and board, such as
ward, semiprivate, or intensive care accommodations ( or private room when medically necessary and ordered by a Plan physician) ;

general nursing care; and meals and special diets.

$ 100 per admission

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 whole blood, blood, blood plasma, blood
derivatives, blood volume expanders, professional donor fees
Dressings, splints, casts, and sterile tray services Medical supplies and equipment, including oxygen

Anesthetics Physical therapy, radiation therapy, inhalation therapy,
chemotherapy, occupational and speech therapy
Any other medically necessary services as part of inpatient care

Nothing

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

Personal comfort items, such as telephone, television, barber services, guest meals and beds
Private nursing care

All charges. 22
22 Page 23 24
2002 Trigon HealthKeepers 23 Section 5( c)
Outpatient hospital or ambulatory surgical center You pay
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 Pre-surgical testing
Dressings, casts, and sterile tray services Medical supplies, including oxygen
Anesthetics and anesthesia service

$ 100 copayment per visit

Extended care benefits/ skilled nursing care facility benefits
Extended care benefit: The following items and services will be
provided to you as an inpatient in a skilled nursing bed or a Plan skilled
nursing facility or in a skilled nursing bed in a Plan hospital when we
authorize:
Plan Physician visits Room and board in semi-private accommodations,

Rehabilitative services, Drugs
Biologicals Supplies furnished for use in the skilled nursing facility and other
medically necessary services and supplies
Limited to 100 days per member per illness or condition

Nothing

Not covered: custodial or residential care in a skilled nursing facility or
any other facility
All charges

Hospice care
We cover hospice care we authorize for members diagnosed with a
terminal illness with a life expectancy of six months or less. Covered
services include the following:
Skilled nursing care Home infusion therapy drugs for palliative care, pain management

Services of a medical social worker Services of a home health aide or homemaker
Physical speech or occupational therapy Durable medical equipment
Routine medical supplies Routine lab services
Counseling, including nutrition, for member s care and death Bereavement counseling for immediate family members both
before and after the member s death
Short-term inpatient care, including respite care and procedures necessary for pain control and acute chronic symptom management.

Respite care means non-acute inpatient care for the member to
provide the member s primary caregiver a temporary break. Respite
care may be provided only on an intermittent, non-routine and
occasional basis and not more than 5 days every 90 days.

Nothing

Not covered: Independent nursing, homemaker services All charges
Ambulance
Local professional ambulance service when medically appropriate and
authorized by us. In an emergency, authorization not required.
Nothing 23
23 Page 24 25
2002 Trigon HealthKeepers 24 Section 5( d)
Section 5 ( d) . Emergency services/ accidents
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.

We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with

other coverage, including with Medicare.

I M
P O
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A N
T

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

What to do in case of emergency:
Emergencies within our service area: Medical care is available through your primary care physician 7 days a week, 24 hours a day. For instructions on how to receive care, call your primary care
physician, or a nurse advisor at 1 ( 800) 382-9625. If the emergency is such that immediate action is
demanded, you should be taken to the nearest appropriate medical facility.

Emergencies outside our service area: If an Emergency occurs when you are temporarily outside the service area, you should obtain care at the nearest medical facility. Benefits for continuing or follow-up
treatment must be pre-arranged by your primary care physician and provided in the service area.

Notification: In the event of an emergency requiring hospitalization, you or your representative must
notify us within 48 hours after care is commenced or on the next business day. Failure to do so may result
in denial of benefits. This applies to services received within or outside the service area.

Non-Plan Providers: We cover services rendered by providers other than Plan providers when the
condition treated is an emergency as defined above.

Benefit Description You pay
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
$ 10 per visit to your primary
care physician

$ 20 per visit to a specialist
$ 20 per visit to an urgent care
center

$ 100 per visit to a
hospital emergency room

( waived if admitted)

Not covered: Elective care or non-emergency care All charges. 24
24 Page 25 26
2002 Trigon HealthKeepers 25 Section 5( d)
Emergency outside our service area You pay
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
$ 10 per visit to a primary
care physician

$ 20 per visit to a specialist
$ 20 per visit to an urgent care
center

$ 100 per visit to a
hospital emergency room

( waived if admitted)

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

All charges.

Ambulance
Professional ambulance service when medically appropriate.
See 5( c) for non-emergency service.
Nothing 25
25 Page 26 27
2002 Trigon HealthKeepers 26 Section 5( e)
Section 5 ( e) . Mental health and substance abuse benefits
I M
P O
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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.
We have no deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other

coverage, including with Medicare.
YOU MUST GET PREAUTHORIZATION 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
All diagnostic and treatment services recommended by a Plan provider
and contained in a treatment plan that we approve. The treatment plan
may include services, drugs, and supplies described elsewhere in this
brochure.

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

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

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

Medication management

$ 10 per visit to your primary
care physician

$ 20 per visit to a specialist

Diagnostic tests Nothing if you receive these
services during your office
visit; otherwise

$ 10 per visit to your primary
care physician

$ 20 per visit to a specialist

Services provided by a hospital or other facility
Services in approved alternative care settings such as partial
hospitalization, half-way house, residential treatment, full-day
hospitalization, facility based intensive outpatient treatment

$ 100 per admission 26
26 Page 27 28
2002 Trigon HealthKeepers 27 Section 5( e)
Mental health and substance abuse benefits ( Continued) You pay
Not covered:
Services we have not approved. Methadone maintenance at any level of care

Services for biofeedback therapy, smoking or nicotine addition Marital, family, educational or training services

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 a treatment plan and follow all the following authorization processes:
A primary care physician referral is not necessary to access mental
health/ substance abuse services. You, a family member, or your
physician may access care directly by calling the mental health toll-
free number on your identification card, 1 ( 800) 991-6045. Network
providers are listed in our directory, but because HealthKeepers, Inc.
networks are subject to change, please call the toll free number to
verify that a provider is in the network, to request care, or to obtain
referral information.

Limitation We may limit your benefits if you do not obtain a treatment plan. 27
27 Page 28 29
2002 Trigon HealthKeepers 28 Section 5( f)
Section 5 ( f) . Prescription drug benefits
I
M
P
O
R
T
A
N
T

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

All benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.
We have no deductible
Some drugs and drug therapies require prior authorization. Prior authorization is required for medications approved for restricted uses and quantities that exceed

program limitations. Your physician handles the prior authorization process by
sending a written request and applicable medical records to our Drug Prior
Authorization Unit.

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.

I
M
P
O
R
T
A
N
T

There are important features you should be aware of. These include:
Who can write your prescription. A licensed physician must write the prescription
Where you can obtain them. You must fill the prescription at a plan pharmacy
We have an open formulary. Our prescription drug coverage gives you access to all brand name and generic drugs within the confines of your benefit design. Unlike closed formularies that restrict

individual drugs, your three-tier plan excludes only non-covered classes of drugs. All covered brand
name and generic drugs are categorized into three specific tiers and each tier is assigned a
copayment level:
First-tier drug means a low cost prescription drug, typically a generic drug Second-tier drug means a moderate cost prescription drug, typically a multi-source brand name

drug. A multi-source brand name drug is a brand name drug with a generic equivalent.
Third-tier drug means a high cost prescription drug, typically a single-source brand name drug. A single-source brand name drug is a brand name drug without a generic equivalent.

We make the determination of whether a particular drug is a first-, second-, or third-tier drug. In exercising our discretion, we will consider a number of factors when classifying drugs into tiers,
such as the absolute cost of the drug, the relative cost of the drug within its therapeutic class, the
availability of over the counter alternatives, and certain clinical effectiveness and economic
factors.
These are the dispensing limitations:

For each prescription, we will cover up to a 31-day or 100-unit supply, whichever is less.
Certain drugs are subject to additional dosage limitations. Because the list is subject to change, you or your physician may contact us for updated dosage limitations.

We do not cover quantities of any drug or medication above the recommended maximum daily dose or duration established by the FDA or any of the standard reference compendia, However,
we will not deny coverage of prescription drugs used in the treatment of cancer pain on the basis
that the dosage exceeds the recommended level, if prescribed in compliance with established
statutes pertaining to patients with intractable cancer pain. We do not cover drugs and
medications not approved by the FDA for the purpose prescribed. However, benefits will not be
denied for any drug or medication approved by the FDA for use in the treatment of cancer on the
basis that the drug has not been approved by the FDA for the specific type of cancer, provided
the drug has been recognized as safe and effective for treatment of that specific type of cancer in
any of the standard reference compendia.

Generic drugs will be dispensed. You may request a brand name drug and pay the difference between the brand name drug and the generic drug, in addition to your applicable copayment.

When you have to file a claim. The many pharmacies that participate in our network are listed in your provider directory and will file claims for you. Any member-submitted claims must be
submitted on a Plan Pharmacy claim form, with receipts and a written explanation attached, within
120 days of the date the prescription was filled.

Prescription drug benefits begin on the next page. 28
28 Page 29 30
2002 Trigon HealthKeepers 29 Section 5( f)
Benefit Description You pay
Covered medications and supplies
We cover medically necessary prescribed legend drugs ( drugs not
available over the counter) when prescribed by a Plan physician and
obtained from a Plan pharmacy, such as:

Compound medications of which at least 1 ingredient is a legend drug Growth hormones

Injectable insulin and syringes, and needles for the administration of injectable insulin
Home blood glucose monitors, lancets and blood glucose test strips for members with diabetes
Diaphragms, birth control pills, and other FDA-approved prescription contraceptive drugs and devices
Drugs and medicines that by Federal law of the United States require a physician s prescription for their purchase, except those listed as Not
covered .
Drugs for sexual dysfunction, subject to dosage limitation and prior authorization.

Intravenous fluids and medications for home use and some injectable drugs are covered under Medical and Surgical Benefits

$ 5 copayment ( first tier)
$ 10 copayment ( second tier)
$ 25 copayment ( third tier)

Not covered:
Drugs and supplies for cosmetic purposes Drugs for weight control

Fertility drugs Smoking cessation devices or medications
Vitamins and nutritional substances that can be purchased without a prescription
Nonprescription medicines Drugs to enhance athletic performance
Drugs obtained at a non-Plan pharmacy, except for out-of-area emergencies

All Charges 29
29 Page 30 31
2002 Trigon HealthKeepers 30 Section 5( g)
Section 5 ( g) . Special features
Feature Description

Flexible Benefits
Option

Under the flexible benefits option, we determine the most effective
way to provide services.

We may identify medically appropriate alternatives to traditional care and coordinate other benefits as a less costly alternative

benefit.
Alternative benefits are subject to our ongoing review.
By approving an alternative benefit, we cannot guarantee you will get it in the future.

The decision to offer an alternative benefit is solely ours, and we may withdraw it at any time and resume regular contract benefits.
Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process.

24 hour nurse line For any of your health concern, 24 hours a day, 7 days a week, you may call the HealthKeepers Nurse Advisor Line at 1-800-382-9625
and talk with a registered nurse who will discuss treatment options and
answer your health questions.

Travel Benefit Please see page 6 for a description of Blues CONNECT , the Blue Cross and Blue Shield Health Maintenance Organization national
network that expands your coverage to 41 states and the District of
Columbia. 30
30 Page 31 32
2002 Trigon HealthKeepers 31 Section 5( g)
Section 5 ( g) . Special features
Clinical Trials for
Cancer

The following definitions apply:
Cooperative group means a formal network of facilities that
collaborate on research projects and have an established NIH
( National Institutes of Health) -approved peer review program
operating within the group. " Cooperative group" includes ( i) the
National Cancer Institute Clinical Cooperative Group and ( ii) the
National Cancer Institute Community Clinical Oncology Program.

" Multiple project assurance contract" means a contract between an
institution and the Federal Department of Health and Human
Services that defines the relationship of the institution to the
Federal Department of Health and Human Services and sets out the
responsibilities of the institution and the procedures that will be
used by the institution to protect human subjects.

We cover clinical trials for cancer, including ovarian cancer trials,
when the following requirements are met:

Coverage will be provided if the treatment is being conducted in a Phase II, Phase III or Phase IV clinical trial. Coverage may be

provided on a case-by-case basis if the treatment is being provided
in a Phase I clinical trial.

Clinical trials must be approved by one of the following:
NCI ( National Cancer Institute) ; An NCI cooperative group or NCI center;

The FDA ( Federal Food and Drug Administration) in the form of an investigational new drug application;
The Federal Department of Veterans Affairs; or An institutional review board of an institution in the
Commonwealth of Virginia that has a multiple project assurance
contract approved by the Office of Protection from Research
Risks of the NCI.

The facility and personnel providing the treatment shall be capable of doing so by virtue of their experience, training and expertise.

Coverage shall be provided only if:
There is no clearly superior, non-investigational treatment alternative;

The available clinical or preclinical data provide a reasonable expectation that the treatment will be at least as effective as
the non-investigational alternative; and
The member and the physician or health care provider who provides services to the member under this paragraph

conclude that the member s participation in the clinical trial
would be appropriate.

Coverage does not include the cost of non-health care services, such as travel or lodging, costs associated with managing the

research associated with the clinical trial or the cost of the
investigational drug or device. 31
31 Page 32 33
2002 Trigon HealthKeepers 32 Section 5( h)
Section 5 ( h) . Dental benefits
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 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 nondental 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.

I M
P O
R T
A N
T

Accidental injury benefit You pay
Dental services needed as a result of an accidental injury that occurred
while enrolled with us, and if we approve your plan of treatment
submitted within 60 days of the injury;

$ 20 copayment per specialist
doctor visit.

Not covered:
All other dental services not shown as covered.
Biting and chewing related injuries

Dental benefits
We have no other dental benefits. 32
32 Page 33 34
2002 Trigon HealthKeepers 33 Section 5( i)
Section 5 ( i) . Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed claim about
them . Fees you pay for these services do not count toward FEHB deductibles or out-of-pocket maximums.

HealthKeepers Dental
Discount Program

( available in some areas)

HealthKeepers introduces your brand-new Dental Discount Program. Need a
check-up, a crown or filling, or braces? Simply show your Trigon
HealthKeepers identification card to a participating dentist to receive a 20%
discount off normal fees. Best of all, there are no claim forms to file, and no
referral or pre-authorization required. We are pleased to offer this program to
you at no additional cost .

Trigon Healthy
Complements Program
Discounts on Alternative
Therapy, Wellness and
Herbals

Interested in alternative therapies? Your Healthy Complements program links
you to healthy discounts of 25% on acupuncture, massage therapy and
additional chiropractic services. You even have guaranteed discounts on
vitamins, nutritional supplements and other health-related products, with no
shipping charges. Want savings on health clubs and fitness centers? No sweat,
they re yours! And if you can t tell Gingko from Ginseng, help is a click
away. Just log on to www. trigon. com for Health Complements online, your
complete alternative health care resource. From aromatherapy to yoga, you ll
find it here, all at no additional cost to you.

Expanded Vision Care,
including LASIK and PRK
Vision Surgery Discounts

As a Trigon HealthKeepers member, your vision care vendor offers you great
discounts on vision services and supplies, including eyewear, contacts and
vision correction surgery. You can purchase anything from eyeglasses and
sunglasses to contact lenses and lens cleaner. Simply present your Trigon
HealthKeepers identification card to receive your discount. This program is
available at no additional cost to you.

Support for Managing
Ongoing Conditions Means
Better Health

Baby Benefits Program
C. Everett Koop
National Health Award for
Healthier Babies

If you or a family member has an ongoing condition asthma, diabetes,
coronary artery disease or congestive heart failure you know the impact it
has on your life. The Trigon Disease Management program brings together
the tools needed to successfully manage these conditions. From access to
registered nurses 24 hours a day, to self-monitoring tools, to newsletters
containing information on the latest updates about your condition, the disease
management program can help you stay at your peak. The Trigon
HealthKeepers Disease Management Program is available at no additional
cost to you.

Expecting? Here s the best baby gift of all good health special delivery
from your Baby Benefits program. With Baby Benefits, you ll have access to
a team of registered nurses who will work closely with you, monitoring your
progress and answering your questions to give you the information you need
throughout your pregnancy. They are available whenever you need them 24
hours a day, every day. Your nurse counselors will help identify the potential
for premature delivery from the earliest signs and get you the help you need
to reduce that risk. Throughout your pregnancy, answers, support and
resources are available to help make sure your baby is healthy as can be, right
from the start. This program is available to the enrollee at no additional cost . 33
33 Page 34 35
2002 Trigon HealthKeepers 34 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.

We do not cover the following:
Care by non-Plan providers except for authorized referrals or emergencies ( See Emergency Benefits) ;
Services, drugs, or supplies which are not medically necessary.
Services, drugs, or supplies you receive while you are not enrolled in this Plan;
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. 34
34 Page 35 36
2002 Trigon HealthKeepers 35 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. We have no coinsurance or deductible.

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

Medical 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) 421-1880.
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:
HealthKeepers, Inc.
P. O. Box 26623
Richmond, VA 23285-0031

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.

Prescription drugs Any member-submitted claims must be submitted on a Plan Pharmacy claim form, with receipts and a written explanation attached, within 120 days of the date the prescription
was filled.
Submit your claims to:
HealthKeepers, Inc.
P. O. Box 26623
Richmond, VA 23285-0031

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. 35
35 Page 36 37
2002 Trigon HealthKeepers 36 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: HealthKeepers, Inc. , PO Box 26623, Richmond VA 23285; and
( c) Include a statement about why you believe our initial decision was wrong, based on specific
benefit provisions in this brochure; and
( d) Include copies of documents that support your claim, such as physicians' letters, operative reports,
bills, medical records, and explanation of benefits ( EOB) forms.

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

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

4 If you do not agree with our decision, you may ask OPM to review it. You must write to OPM within:

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

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. 36
36 Page 37 38
2002 Trigon HealthKeepers 37 Section 8
The disputed claims process ( Continued)
Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your
representative, such as medical providers, must include a copy of your specific written consent with the
review request.

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

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

6 If you do not agree with OPM s decision, your only recourse is to sue. If you decide to sue, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services, drugs, or supplies or from the year in which you were denied precertification or prior
approval. This is the only deadline that may not be extended.
OPM may disclose the information it collects during the review process to support their disputed claim
decision. This information will become part of the court record.

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

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

( a) We haven' t responded yet to your initial request for care or preauthorization/ prior approval, then call us at 1 ( 800) 421-1880
and we will expedite our review; or

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

You can call OPM' s Health Benefits Contracts Division 3 at 202/ 606-0755 between 8 a. m. and 5 p. m. eastern time. 37
37 Page 38 39
2002 Trigon HealthKeepers 38 Section 9
Section 9. Coordinating benefits with other coverage
When you have other health coverage You must tell us if you are covered or a family member is covered under another group health plan or 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. Your care must continue to be
authorized by your Primary Care Physician as required.

The Original Medicare Plan ( Part A or Part B) 38
38 Page 39 40
2002 Trigon HealthKeepers 39 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 anactive employee with theFederalgovernment( including whenyou or
afamily member areeligiblefor Medicaresolely because of adisability) ,

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
39
39 Page 40 41
2002 Trigon HealthKeepers 40 Section 9
Claims process when you have the Original Medicare Plan Your provider must file
a Medicare 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.

We waive some costs when you have the Original Medicare Plan When Original
Medicare is the primary payer, we will waive our copayment on inpatient hospital
admissions. We do not waive any other costs.

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 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 Medicare Part A or Part B covered 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.

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

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

Medicaid When you have this Plan and Medicaid, we pay first.
When other Government agencies We do not cover services and supplies when a local, State,
are responsible for your care or Federal Government agency directly or indirectly pays for them. 40
40 Page 41 42
2002 Trigon HealthKeepers 41 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. See page 11.

Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. We do not have coinsurance
Covered services Care we provide benefits for, as described in this brochure.
Deductible A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for those services. We do not have
deductibles.

Experimental/ Investigational Any service or supply may be determined to be experimental or investigational in the Plan s sole discretion, based on the following four criteria:
1. Any supply or drug must have received final approval to market by the United States
Food and Drug Administration;
2. There must be sufficient information in the peer-reviewed medical and scientific
literature to enable the Plan to make conclusions about safety and efficacy;
3. The available scientific evidence must demonstrate a beneficial effect on health
outcomes outside a research setting; and
4. The service or supply must be as safe and effective outside a research setting as
existing diagnostic or therapeutic alternatives.

Medical necessity Medically necessary services mean those covered services that are consistent with the diagnosis and treatment of your condition, are efficacious, are in accordance with
standards of good medical practice, are not simply for your or your provider s
convenience, and are performed in the most cost-effective setting available to you. We
will determine the medical necessity of a given service or procedure.

Us/ We Us and we refer to Trigon HealthKeepers, offered by HealthKeepers, Inc.
You You refers to the enrollee and each covered family member. 41
41 Page 42 43
2002 Trigon HealthKeepers 42 Section 11
Section 11. FEHB facts
No pre-existing condition We will not refuse to cover the treatment of a condition that you had
limitation before you enrolled in this Plan solely because you had the condition before you enrolled.

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

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

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

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

Types of coverage available Self Only coverage is for you alone. Self and Family coverage is for
for you and your family you, your spouse, and your unmarried dependent children under age 22, including any foster children or stepchildren your employing or retirement office

authorizes coverage for. Under certain circumstances, you may also continue
coverage for a disabled child 22 years of age or older who is incapable of self-
support.

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

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

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

When benefits and The benefits in this brochure are effective on January 1. If you joined this Plan
premiums start during Open Season, your coverage begins on the first day of your first pay period that starts on or after January 1. Annuitants coverage and premiums begin on January 1. If you

joined at any other time during the year, your employing office will tell you the effective
date of coverage.

Your medical and claims We will keep your medical and claims information confidential. Only 42
42 Page 43 44
2002 Trigon HealthKeepers 43 Section 11
records are confidential the following will have access to it: OPM, this Plan, and subcontractors when they administer this contract;
This Plan and appropriate third parties, such as other insurance plans and the Office of Workers' Compensation Programs ( OWCP) , when coordinating
benefit payments and subrogating claims;
Law enforcement officials when investigating and/ or prosecuting alleged civil or criminal actions;

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

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

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

Temporary continuation
of 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 ( f you canceled your
coverage or did not pay your premium, you cannot convert0
You decided not to receive coverage under TCC or the spouse equity law; or
You are not eligible for coverage under TCC or the spouse equity law. 43
43 Page 44 45
2002 Trigon HealthKeepers 44 Section 11
If you leave Federal service, your employing office will notify you of your right
to convert. You must apply in writing to us within 31 days after you receive this
notice. However, if you are a family member who is losing coverage, the
employing or retirement office will not notify you. You must apply in writing to
us within 31 days after you are no longer eligible for coverage.

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

Getting a Certificate of The Health Insurance Portability and Accountability Act of 1996 ( HIPAA)
Group Health Plan Coverage is a Federal law that offers limited Federal protections for health coverage availability and continuity to people who lose employer group coverage. If you

leave the FEHB Program, we will give you a Certificate of Group Health Plan
Coverage that indicates how long you have been enrolled with us. You can use
this certificate when getting health insurance or other health care coverage. Your
new plan must reduce or eliminate waiting periods, limitations, or exclusions for
health related conditions based on the information in the certificate, as long as
you enroll within 63 days of losing coverage under this Plan. If you have been
enrolled with us for less than 12 months, but were previously enrolled in other
FEHB plans, you may also request a certificate from those plans.

For more information, get OPM pamphlet RI 79-27, Temporary Continuation of
Coverage ( TCC) under the FEHB Program. See also the FEHB web site
( www. opm. gov/ insure/ health) ; refer to the " TCC and HIPAA" frequently asked
question. 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. 44
44 Page 45 46
2002 Trigon HealthKeepers 45
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. LTC 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 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.
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.
OPM s toll-free teleservice center will begin in mid-2002. In the meantime, you can learn more about the program on OPM s web site at
www. opm. gov/ insure/ ltc.

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?

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? 45
45 Page 46 47
2002 Trigon HealthKeepers 46 Index
Index
Do not rely on this page; it is for your convenience and may not show all pages where the terms appear.

A llergy tests 15 Alternative treatment 18, 33
Ambulance 23 Anesthesia 21
Autologous bone marrow transplant 21
B lood and blood plasma 22 Breast cancer screening 14

C asts 19, 22, 23 Catastrophic protection 11
Changes for 2002 7 Chemotherapy 16
Childbirth 14, 33 Cholesterol tests 14
Claims 35 Colorectal cancer screening 14
Congenital anomalies 19 Contraceptive devices and drugs 15, 29
Coordination of benefits 38
Crutches 18 D efinitions 41

Dental care 32, 33 Diagnostic services 13
Disputed claims review 36 Donor expenses ( transplants) 21
Dressings 22 Durable medical equipment ( DME) 18
E ducational classes and programs 18 Effective date of enrollment 42
Emergency 24 Experimental or investigational 34, 41
Eyeglasses 17, 33 F amily planning 15, 28
Fecal occult blood test 14
G eneral Exclusions 34 H earing services 16

Home health services 18

Hospice care 23 Home nursing care 18
Hospital 22
I mmunizations 14 Infertility 15

Inhospital physician care 19 Inpatient Hospital Benefits 22
Insulin 29
L aboratory and pathological services 13

M achine diagnostic tests 13 Magnetic Resonance Imagings
( MRIs) 13 Mammograms 14
Maternity Benefits 14, 33 Medicaid 40
Medically necessary 34, 41 Medicare 38
Members 41 Mental Conditions/ Substance
Abuse Benefits 26
N ewborn care 15 Non-FEHB Benefits 33

Nursery charges 15 O bstetrical care 14, 33
Occupational therapy 16 Office visits 13
Oral and maxillofacial surgery 20 Orthopedic devices 17
Out-of-pocket expenses 11 Outpatient facility care 23
Oxygen 18
P ap test 14 Physical examination 14

Physical therapy 16 Pre-admission testing 13

Preventive care, adult 14 Preventive care, children 14
Prescription drugs 28 Preventive services 14
Prior approval 8, 31 Prostate cancer screening 14
Prosthetic devices 17 Psychologist 26
Psychotherapy 26
R adiation therapy 16 Renal dialysis 16

Room and board 22 S econd surgical opinion 13
Skilled nursing facility care 23 Smoking cessation 18, 29
Speech therapy 16 Splints 22, 23
Sterilization procedures 15, 19 Substance abuse 26
Surgery 19, 22, 23
Anesthesia 21 Oral 20

Outpatient 19, 23 Reconstructive 19
Syringes 28
T emporary continuation of coverage 43

Transplants 21 Treatment therapies 16
V ision services 17, 33 W ell child care 14
Wheelchairs 18 Workers compensation 40
X -rays 13 46
46 Page 47 48
2002 Trigon HealthKeepers 47 Summary
Summary of benefits for Trigon HealthKeepers, offered by HealthKeepers, Inc. 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 You Pay Page
Medical services provided by physicians:
Diagnostic and treatment services provided in the office. . . . . . . . . . . . . . . . . . . . Office visit copay: $ 10 primary care; $ 20 specialist 13

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

$ 100 per admission copay
$ 100 per visit copay
22
23
Emergency benefits:
In-area. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Out-of-area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$ 100 per emergency room visit
$ 100 per emergency room visit
24
25
Mental health and substance abuse treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Regular cost sharing 26
Prescription drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . First tier: $ 5 copay
Second tier: $ 10 copay
Third tier: $ 25 copay

28

Dental Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 20 copay for accidental injury
only 32

Vision Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 10 copay for annual eye exam,
$ 25 copay for contact lens exam 17

Special features:
Flexible Benefits Option 24 Hour Nurse Line

Travel Benefit Clinical Trials for Cancer

30

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

Nothing after $ 1,500/ Self Only or
$ 3,000/ Family enrollment per year

Some costs do not count toward
this protection

11 47
47 Page 48
2002 Trigon HealthKeepers 48 Rates
2002 Rate Information for
Trigon HealthKeepers

Non-Postal rates apply to most non-Postal enrollees. If you are in a special enrollment category, refer to the
FEHB Guide for that category or contact the agency that maintains your health benefits enrollment.

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

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

Serving: Eastern Virginia, including the Peninsula, Hampton Roads and Tidewater areas;
Central Virginia, including Fredericksburg, Richmond, Charlottesville and Southside areas; Western Virginia, including Roanoke, Lexington, and Bedford areas; and

Southwestern Virginia, including the Wytheville and New River Valley areas

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

Self Only X81 $ 84.84 $ 28.28 $ 183.82 $ 61.27 $ 100.39 $ 12.73

Self and Family X82 $ 215.45 $ 71.81 $ 466.80 $ 155.60 $ 254.94 $ 32.32 48

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