Pages 1--52 from UHP HealthCare

Enrollment codes:
C41 Self Only
C42 Self and Family

RI 73-269

UHP HEALTHCARE http:// www. uhphealthcare. com
This Plan has accreditation from
the JCAHO. See the 2002 Guide
for information on JCAHO

For changes
in benefits,
see page

8

Authorized for distribution by the: 1
1 Page 2 3
2002 UHP HEALTHCARE Table of Contents 2
Table of Contents
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Plain Language . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Inspector General Advisory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Section 1. Facts about this HMO plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
How we pay providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Your Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Service Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Section 2. How we change for 2002 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Program-wide changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Changes to this Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Section 3. How you get care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Identification cards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Where you get covered care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Plan providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Plan facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
What you must do to get covered care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Primary care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Specialty care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Hospital care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Circumstances beyond our control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Services requiring our prior approval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Section 4. Your costs for covered services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Copayments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Deductible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Coinsurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Your out-of-pocket maximum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Section 5. Benefits Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
(a) Medical services and supplies provided by physicians and other health care professionals . . . . . . . 14
(b) Surgical and anesthesia services provided by physicians and other health care professionals. . . . . . 22
(c) Services provided by a hospital or other facility, and ambulance services . . . . . . . . . . . . . . . . . . . . 25
(d) Emergency services/ accidents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
(e) Mental health and substance abuse benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
(f) Prescription drug benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
(g) Special features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Flexible Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 2
2 Page 3 4
2002 UHP HEALTHCARE Table of Contents 3
Table of Contents (Continued)
(h) Dental benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
(i) Non-FEHB benefits available to Plan members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Section 6. General exclusions things we don't cover . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Section 7. Filing a claim for covered services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Section 8. The disputed claims process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Section 9. Coordinating benefits with other coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
When you have...
Other health coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Original Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Medicare managed care plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
TRICARE/ Workers' Compensation/ Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Other Government agencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
When others are responsible for injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Section 10. Definitions of terms we use in this brochure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Section 11. FEHB facts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Coverage information
No pre-existing condition limitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Where you get information about enrolling in the FEHB Program . . . . . . . . . . . . . . . . . . . . . . . . . 46
Types of coverage available for you and your family . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Your medical and claims records are confidential . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
When you retire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
When you lose benefits
When FEHB coverage ends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Spouse equity coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Temporary Continuation of Coverage (TCC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Converting to individual coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Getting a certificate of Group Health Plan coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Long term care insurance is coming later in 2002 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Summary of Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Back cover 3
3 Page 4 5
2002 UHP HEALTHCARE Introduction/ Plain Language
Introduction
UHP HEALTHCARE
3405 W. Imperial Highway
Inglewood, CA 90303

This brochure describes the benefits of UHP HEALTHCARE under contract CS 2032 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 are
summarized on page 53. 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 UHP HEALTHCARE.

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 us 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.

4 4
4 Page 5 6
2002 UHP HEALTHCARE Inspector General Advisory
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 800/ 544-0088 and
explain the situation.
If we do not resolve the issue, call or write to:

THE HEALTH CARE FRAUD HOTLINE
202/ 418-3300
The United States Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street, NW, Room 6400, Washington, DC 20415.

Penalties for Fraud Anyone who falsifies a claim to obtain FEHB Program benefits can be
prosecuted for fraud. Also, the Inspector General may investigate anyone who
uses an ID card if the person tries to obtain services for someone who is not an
eligible family member, or is no longer enrolled in the Plan and tries to obtain
benefits. Your agency may also take administrative action against you.

5 5
5 Page 6 7
2002 UHP HEALTHCARE Section 1
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
co-payments, 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 co-payments or
coinsurance.

UHP HEALTHCARE is a non-profit, federally qualified and state licensed health maintenance organization. It has a
combination group practice and IPA health-care delivery system, serving members in parts of Los Angeles, Orange,
Riverside and San Bernardino counties. Each member must live or work within UHP's Service Area to enroll and may
choose his or her own primary care doctor from the staff of the medical group or IPA office selected.

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

UHP HEALTHCARE has an overall Satisfaction Rating of 91%, from the 2001 Member Satisfaction Survey
We were founded in 1973
UHP HEALTHCARE is a not-for-profit, Federally Qualified HMO.

If you want more information about us, call 800/ 544-0088, or write to Member Services. You may also contact us by
fax at 310/ 412-1288 or visit our website at www. uhphealthcare. com.

6 6
6 Page 7 8
2002 UHP HEALTHCARE Section 1
Service Area
To enroll in this Plan, you must live in our Service Area.

Los Angeles County
90001-08 90240-42 90601-08 90846 91340 91612
90010-29 90245 90631 91001 91343-45 91702
90031-42 90247-50 90637-40 91006 91356 91706
90056-59 90254-55 90650 91010 91364 91722-24
90061-69 90260-62 90660 91016 91367 91731-33
90071 90266 90670 91024 91401-03 91740
90074 90270 90701 91030 91405-06 91744-48
90077 90274 90706 91010-08 91411 91754
90079 90277-78 90710 91125 91423 91765
90089 90280-81 90712-17 91302-07 91436 91770
90201 90291-93 90732 91311 91501-02 91775-77
90203 90301-05 90744-48 91316 91504-06 91789-92
90210-13 90308-10 90801-15 91324-26 91509 91801
90220-22 90401-05 90822 91330-31 91601-02 91803
90230-31 90501-06 90840 91335 91604-08 93063

Orange County
90620-23 90742-43 92626-28 92670 92799 92825
90630 92601 92631-33 92683-84 92087 92895
90680 92605 92635 92686-87 92812
90720 92615 92640-49 92701-08 92814
90740 92621-22 92655 92728 92716

Riverside County
92324
San Bernardino County
91739 92318 92336 92354 92376 92427
92316 92324 92345-46 92369 92401-18

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

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

7 7
7 Page 8 9
2002 UHP HEALTHCARE Section 2
Section 2. How we change for 2002
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5
Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here is a
clarification that does not change benefits.

Program-wide changes

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

We changed speech therapy benefits by removing the requirement tht services must be required to restore
functional speech. (Section 5( a))

We no longer limit total blood cholesterol tests to certain age groups. (Section 5( a))
We now cover certain intestinal transplants Section 5( b).
Your share of the non-Postal premium will increase by 6.0% for Self Only or 6.0% for Self and Family.

8 8
8 Page 9 10
2002 UHP HEALTHCARE Section 3
Section 3. What you must do to get covered care
We will send you an identification (ID) card when you enroll. You should carry
your ID card with you at all times. You must show it whenever you receive
services from a Plan provider, or fill a prescription at a Plan pharmacy. Until
you receive your ID card, use your copy of the Health Benefits Election Form,
SF-2809, your health benefits enrollment confirmation (for annuitants), or your
Employee Express confirmation letter.

If you do not receive your ID card within 30 days after the effective date of
your enrollment, or if you need replacement cards, call us at 800/ 544-0088.

You get care from "Plan providers" and "Plan facilities." You will only pay co-payments,
deductibles, and/ or coinsurance as described in this brochure, and
you will not have to file claims

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 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.

It depends on the type of care you need. First, you and each family member
must choose a primary care physician. This decision is important since your
primary care physician provides or arranges for most of your health care. To
select a primary care physician, consult the "Primary Care Physician" section
of the UHP HEALTHCARE Provider Directory. Choose either a clinic or an
individual physician. Your family members can choose their own primary care
physicians from this section too.

Your primary care physician can be "Family Practice," "General Practice,"
"Pediatrics," (for children only), "Internal Medicine" or an "OB/ GYN" (for
women only). Note that not all OB/ GYNs choose to be primary care
physicians; some prefer a specialty practice only. 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.

Your primary care physician will refer you to a specialist for needed care.
When you receive a referral from your primary care physician, you must return
to the primary care physician after the consultation, unless your primary care
physician authorized a certain number of visits without additional referrals.
The primary care physician must provide or authorize all follow-up care. Do
not go to the specialist for return visits unless your primary care physician
gives you a referral. However, you may see an OB/ GYN within your Primary
Care Physician's medical group without a referral.

9

Identification cards
Where you get covered care
Plan providers

Plan facilities
What you must do

Primary care

Specialty care 9
9 Page 10 11
2002 UHP HEALTHCARE Section 3
Here are other things you should know about specialty care:
If you need to see a specialist frequently because of a chronic, complex, or
serious medical condition, your primary care physician will develop a
treatment plan that allows you to see your specialist for a certain number
of visits without additional referrals. Your primary care physician will use
our criteria when creating your treatment plan. The physician may have to
get an authorization, or approval, beforehand.

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

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:

-teminate 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.

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

If you are in the hospital when your enrollment in our Plan begins, call our
customer service department immediately at 800/ 544-0088. 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

10

Hospital care 10
10 Page 11 12
2002 UHP HEALTHCARE Section 3
The 92nd day after you become a member of this Plan, whichever happens
first.

These provisions apply only to the benefits of the hospitalized person.

Under certain extraordinary circumstances, such as natural disasters, we may
have to delay your services or we may be unable to provide them. In that case,
we will make all reasonable efforts to provide you with the necessary care.

Your primary care physician has authority to refer you for most services. For
certain services, however, your physician must obtain approval from us. Before
giving approval, we consider if the service is covered, medically necessary, and
follows generally accepted medical practice.

We call this review and approval process "prior authorization." Your physician
must obtain prior authorization for the services such as inpatient
hospitalizations and most visits to a specialist. Before giving approval, we
consider if the service is medically necessary, and if it follows generally
accepted medical practice. UHP will provide benefits for covered services only
when the services are medically necessary to prevent, diagnose or treat your
illness or condition.

11

Circumstances beyond our control
Services requiring our prior approval 11
11 Page 12 13
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 co-payment of
$10 per office visit.

Deductible UHP HEALTHCARE does not have a deductible.
Coinsurance UHP HEALTHCARE does not have coinsurance.

We have no out-of-pocket maximum

12 2002 UHP HEALTHCARE Section 4 12
12 Page 13 14
2002 UHP HEALTHCARE Section 5
Section 5. Benefits OVERVIEW (See page 8 for how our benefits changed this year and page 55 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 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
800/ 544-0088 or our website at www. uhphealthcare. com.

(a) Medical services and supplies provided by physicians and other health care professionals ............................... 14-21
Diagnostic and treatment services Hearing services (testing, treatment, and supplies)
Lab, X-ray, and other diagnostic tests Vision services (testing, treatment, and supplies)
Preventive care, adult Foot care
Preventive care, children Orthopedic and prosthetic devices
Maternity care Durable medical equipment (DME)
Family planning Home health services
Infertility services Chiropractic
Allergy care Alternative treatments
Treatment therapies Educational classes and programs
Physical and occupational therapies
Speech therapy

(b) Surgical and anesthesia services provided by physicians and other health care professionals ...................... 22-24
Surgical procedures Oral and maxillofacial surgery
Reconstructive surgery Organ/ tissue transplants
Anesthesia

(c) Services provided by a hospital or other facility, and ambulance services..................................................... 25-27
Inpatient hospital Extended care benefits/ skilled nursing care
Outpatient hospital or ambulatory surgical center facility benefits
Hospice care
Ambulance

(d) Emergency services/ accidents ......................................................................................................................... 28-29
Medical emergency
Ambulance

(e) Mental health and substance abuse benefits .................................................................................................... 30-31

(f) Prescription drug benefits ................................................................................................................................ 32-33
(g) Special features ..................................................................................................................................................... 34
Flexible Benefits Option................................................................................................................................. 34
(h) Dental benefits ...................................................................................................................................................... 35
(i) Non-FEHB benefits available to Plan members ................................................................................................... 36
Summary of benefits ........................................................................................................................................................ 51

13 13
13 Page 14 15
Section 5 (a) Medical services and supplies provided by physicians and other
health care professionals

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.

Benefit Description You pay
NOTE: The calendar year deductible applies to almost all benefits in this Section.
We say "( No deductible)" when it does not apply.

Diagnostic and treatment services
Professional services of physicians
In physician's office $10 per visit

Professional services of physicians $10 per visit
In an urgent care center
During a hospital stay
In a skilled nursing facility
Office medical consultations
Second opinion: Medical or Surgical

At home -Doctor's house call $10 per visit
At home -Visits by nurses and health aids Nothing

14 2002 UHP HEALTHCARE Section 5a

I
M
P
O
R
T
A
N
T

I
M
P
O
R
T
A
N
T 14
14 Page 15 16
15 2002 UHP HEALTHCARE Section 5a
Lab, X-ray and other diagnostic tests
Tests, such as: Nothing if you receive these
Blood tests services during your office visit;
Urinalysis otherwise, $10 per visit
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG

Preventive care, adult
Routine screenings, such as: $10 per visit
Total Blood Cholesterol -once every three years
Colorectal Cancer Screening, including
-Fecal occult blood test

-Sigmoidoscopy, screening -every five years starting at age 50 $10 per visit
Prostate Specific Antigen (PSA test) -one annually for men age $10 per visit
40 and older

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

Routine mammogram -covered for women age 35 and older, $10 per visit
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

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

Routine immunizations, limited to: $10 per visit
Tetanus-diphtheria (Td) booster -once every 10 years, ages19
and over (except as provided for under Childhood immunizations)
Influenza/ Pneumococcal vaccines, annually, age 65 and over 15
15 Page 16 17
Preventive care, children You Pay
Childhood immunizations recommended by the American Academy $10 per visit
of Pediatrics

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

Examinations, such as:
-Eye exams through age 17 to determine the need for vision
correction.
-Ear exams through age 17 to determine the need for hearing
correction
-Examinations done on the day of immunizations up to age 22)

Maternity care
Complete maternity (obstetrical) care, such as: $10 per visit
Prenatal care
Delivery
Postnatal care
Note: Here are some things to keep in mind:
You do not need to pre-certify your normal delivery; see page 11
for other circumstances, such as extended stays for you or your baby.
You may remain in the hospital up to 48 hours after a regular
delivery and 96 hours after a cesarean delivery. UHP HEALTHCARE's
physicians will extend your inpatient stay if medically necessary.
We cover routine nursery care of the newborn child during the
covered portion of the mother's maternity stay. We will cover
other care of an infant who requires non-routine treatment only if
we cover the infant under a Self and Family enrollment.
We pay hospitalization and surgeon services (delivery) the same as
for illness and injury. See Hospital benefits (Section 5c) and
Surgery benefits (Section 5b).

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

16 2002 UHP HEALTHCARE Section 5( a) 16
16 Page 17 18
Family planning You Pay
A broad range of voluntary family planning services, limited to: $10 per visit
Voluntary sterilization
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.

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

Infertility services

Diagnosis and treatment of infertility, such as: $10 per visit
Artificial insemination:
-intravaginal insemination (IVI)
-intracervical insemination (ICI)
-intrauterine insemination (IUI)
Fertility drugs
Note: We cover injectable fertility drugs under medical benefits and oral
fertility drugs under the prescription drug benefit.

Not covered:
Assisted reproductive technology (ART) procedures, such as: All charges.
-in vitro fertilization
-embryo transfer, gamete GIFT and zygote ZIFT
-zygote transfer
Services and supplies related to excluded ART procedures
Cost of donor sperm
Cost of donor egg

Allergy care

Testing and treatment $10 per visit
Allergy injection

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

2002 UHP HEALTHCARE Section 5( a) 17 17
17 Page 18 19
Treatment therapies You Pay
Chemotherapy and radiation therapy $10 per visit
Note: High dose chemotherapy in association with autologous bone
marrow transplants are limited to those transplants listed under
Organ/ Tissue Transplants on page 24.
Respiratory and inhalation therapy
Dialysis -Hemodialysis and peritoneal dialysis
Intravenous (IV)/ Infusion Therapy -Home IV and antibiotic
therapy
Growth hormone therapy (GHT)

Note: Growth hormone is covered under the prescription drug benefit
Note: -We will only cover GHT when we preauthorize the treatment.
Your primary care physician will contact the Plan to establish that the
GHT is medically necessary. We will only cover GHT services from
the date your physician submits the information. GHT requires that it is
medically necessary and receives the prior authorization of the Plan. We
will not cover the GHT or related services and supplies if the medical
criteria are not met. UHP Healthcare defines GHT as a medical benefit.

Physical and occupational therapies
60 visits per condition for the services of each of the following: $10 per office visit
qualified physical therapists and
occupational therapists. $10 per outpatient visit

Note: We only cover therapy to restore bodily function when there Nothing per visit during covered
has been a total or partial loss of bodily function due to illness or inpatient admission
injury.

Cardiac rehabilitation following a heart transplant, bypass surgery or
a myocardial infarction, is provided for up to 60 sessions.

Speech therapy
Provided on an inpatient or outpatient basis for up to two consecutive $10 per office visit
months per condition as medically necessary when provided by $10 per outpatient visit
qualified speech therapists.
60 visits per condition Nothing per visit during cover
impatient admission

Not covered:
long-term rehabilitative therapy
exercise programs

18 2002 UHP HEALTHCARE Section 5( a) 18
18 Page 19 20
Hearing services (testing, treatment, and supplies) You pay
First hearing aid and testing only when necessitated by accidental $10 per visit
injury
Hearing testing for children through age 17 (see Preventive care,
children)

Not covered: All charges.
all other hearing testing
hearing aids, testing and examinations

Vision services (testing, treatment, and supplies)

One pair of eyeglasses or contact lenses to correct an impairment $10 per visit
directly caused by accidental ocular injury or intraocular surgery
(such as for cataracts)

Eye exam to determine the need for vision correction for children $10 per visit
through age 17 (see Preventive Care for Children)

Not covered:
Eyeglasses or contact lenses and, after age 17, examinations for All charges.
them
Eye exercises and orthoptics
Radial keratotomy and other refractive surgery

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

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

Treatment of weak, strained or flat feet or bunions or spurs; and of
any instability, imbalance or subluxation of the foot (unless the
treatment is by open cutting surgery)

19 2002 UHP HEALTHCARE Section 5( a) 19
19 Page 20 21
20 2002 UHP HEALTHCARE Section 5( a)
Orthopedic and prosthetic devices You pay
Artificial limbs and eyes; stump hose $10 per visit
Externally worn breast prostheses and surgical bras, including
necessary replacements, following a mastectomy
Internal prosthetic devices, such as artificial joints, pacemakers,
cochlear implants, and surgically implanted breast implant
following mastectomy. Note: We pay internal prosthetic devices as
hospital benefits; see Section 5( c) for payment information. See
5( b) for coverage of the surgery to insert the device.
Corrective orthopedic appliances for non-dental treatment of
temporomandibular joint (TMJ) pain dysfunction syndrome.

Not covered: All charges.
Orthopedic and corrective shoes
Arch supports
Foot orthotics
Heel pads and heel cups
Lumbosacral supports
Corsets, trusses, elastic stockings, support hose, and other
supportive devices
Prosthetic replacements provided less than 12 months after the last
one we covered.

Durable medical equipment (DME)
Rental or purchase, at our option, including repair and adjustment, of $10 per item
durable medical equipment prescribed by your Plan physician, such as
oxygen and dialysis equipment. Under this benefit, we also cover:
hospital beds;
wheelchairs;
crutches;
walkers;
blood glucose monitors; and
insulin pumps.
Note: Call us at 1-800-544-0088 as soon as your Plan physician
prescribes this equipment. If you require equipment not covered, UHP
HEALTHCARE will arrange with a health care provider to rent or sell
you durable medical equipment at discounted rates. Call for more
information.

Not covered: All charges.
Motorized wheel chairs;
Bedside commodes 20
20 Page 21 22
2002 UHP HEALTHCARE Section 5( a)
Home health services You pay
Home health care ordered by a Plan physician and provided by a $10 per visit
registered nurse (R. N.), licensed practical nurse (L. P. N.), licensed
vocational nurse (L. V. N.), or home health aide.
Services include oxygen therapy, intravenous therapy and
medications.
Physical, Speech or Occupational therapy, when ordered by your
UHP Healthcare primary care physician.

Not covered:
nursing care requested by, or for the convenience of, the patient or the patient's family;
home care primarily for hygiene, feeding, exercising, moving the patient, homemaking,
companionship or giving oral medication.

Chiropractic
Manipulation of the spine and extremities $10 per visit
Adjunctive procedures such as ultrasound, electrical muscle
stimulation, vibratory therapy, and cold pack application .

Alternative treatments
Acupuncture -by a doctor of medicine or osteopathy for: $10 per visit
anesthesia, pain relief

Not covered: All charges
naturopathic services
hypnotherapy
biofeedback

Educational classes and programs
Coverage is limited to: Nothing
Smoking Cessation -up to $100 for one smoking cessation program
per member per lifetime, including such related expenses such as
drugs.
Diabetes self-management
Prenatal classes

21 21
21 Page 22 23
You pay After the calendar year deductible... Benefit Description
I
M
P
O
R
T
A
N
T

I
M
P
O
R
T
A
N
T

2002 UHP HEALTHCARE Section 5( b)

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

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.
UHP Healthcare has 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. Any costs associated with the facility charge (i. e.
hospital, surgical center, etc.) are covered in Section 5 (c).

Surgical procedures
A comprehensive range of services, such as: $10 per visit
Operative procedures
Treatment of fractures, including casting
Normal pre-and post-operative care by the surgeon
Correction of amblyopia and strabismus
Endoscopy procedures
Biopsy procedures
Removal of tumors and cysts
Correction of congenital anomalies (see reconstructive surgery)
Surgical treatment of morbid obesity a condition in which an
individual weighs 100 pounds or 100% over his or her normal
weight according to current underwriting standards; eligible
members must be age 18 or over
Insertion of internal prosthetic devices. See 5( a) -Orthopedic and
prosthetic devices for device coverage information.
Voluntary sterilization
Treatment of burns

Note: Generally, we pay for internal prostheses (devices) according to $10 per visit
where the procedure is done. For example, we pay Hospital benefits
for a pacemaker and Surgery benefits for insertion of the pacemaker.

Not covered:
Reversal of voluntary sterilization
Routine treatment of conditions of the foot; see Foot Care.

22 22
22 Page 23 24
2002 UHP HEALTHCARE Section 5( b) 23
Reconstructive surgery You pay
Surgery to correct a functional defect $10 per visit
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.
All stages of breast reconstruction surgery following a mastectomy,
such as:
-surgery to produce a symmetrical appearance on the other breast;
-treatment of any physical complications, such as lymphedemas;
-breast prostheses and surgical bras and replacements (see
Prosthetic devices)
Note: If you need a mastectomy, you may choose to have the procedure
performed on an inpatient basis and remain in the hospital up to 48
hours after the procedure.

Not covered: All Charges
Cosmetic surgery -any surgical procedure (or any portion of a
procedure) performed primarily to improve physical appearance
through change in bodily form, except repair of accidental injury
Surgeries related to sex transformation

Oral and maxillofacial surgery
Oral surgical procedures, limited to: $10 per visit
Reduction of fractures of the jaws or facial bones;
Surgical correction of cleft lip, cleft palate or severe functional
malocclusion;
Removal of stones from salivary ducts;
Excision of leukoplakia or malignancies;
Excision of cysts and incision of abscesses when done as
independent procedures; and
Other surgical procedures that do not involve the teeth or their
supporting structures.

Not covered: All charges.
Oral implants and transplants
Procedures that involve the teeth or their supporting structures
(such as the periodontal membrane, gingiva, and alveolar bone) 23
23 Page 24 25
2002 UHP HEALTHCARE Section 5( b)
Organ/ tissue transplants You pay
Limited to: Nothing
Cornea
Heart
Heart/ lung
Kidney
Liver
Lung: Single -Double
Pancreas
Allogenic (donor) bone marrow transplants;
Autologous bone marrow transplants (autologous stem cell and
peripheral stem cell support) for the following conditions with the
prior approval by a UHP Healthcare Medical Director: acute
lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's
lymphoma; advanced non-Hodgkin's lymphoma; advanced
neuroblastoma; breast cancer; multiple myeloma; epithelial ovarian
cancer; and testicular, mediastinal, retroperitoneal and ovarian germ
cell tumors
Intestinal transplants (small intestine) and the small intestine with
the liver or small intestine with multiple organs such as the liver,
stomach, and pancreas.
National Transplant Program

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

Note: We cover related medical and hospital expenses of the donor
when the recipient is a member of UHP Healthcare.

Not covered: All charges
Donor screening tests and donor search expenses, except those
performed for the actual donor
Implants of artificial organs
Transplants not listed as covered

Anesthesia
Professional services provided in -Nothing
Hospital (inpatient)
Professional services provided in -
Hospital outpatient department
Skilled nursing facility $10 per office visit
Ambulatory surgical center
Office

24 24
24 Page 25 26
You pay Benefit Description
I
M
P
O
R
T
A
N
T

I
M
P
O
R
T
A
N
T

25 2002 UHP HEALTHCARE Section 5( c)

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

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).

Inpatient hospital
Room and board, such as Nothing
Ward, semiprivate, or intensive care accommodations;
General nursing care; and
Meals and special diets.

NOTE: If you want a private room when it is not medically necessary,
you pay the additional charge above the semiprivate room rate.

Inpatient hospital continued on next page. 25
25 Page 26 27
2002 UHP HEALTHCARE Section 5( c) 26
Inpatient hospital (Continued) You pay
Other hospital services and supplies, such as: Nothing
Operating, recovery, maternity, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays
Administration of blood and blood products
Blood or blood plasma, if not donated or replaced
Dressings, splints, casts, and sterile tray services
Medical supplies and equipment, including oxygen
Anesthetics, including nurse anesthetist services
Take-home items
Medical supplies, appliances, medical equipment and any covered
items billed by a hospital for use at home

Not covered: All charges.
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

Outpatient hospital or ambulatory surgical center
Operating, recovery, and other treatment rooms Nothing
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

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

Not covered: blood and blood derivatives not replaced by the member All charges 26
26 Page 27 28
Extended care benefits/ skilled nursing care facility benefits You pay
UHP Healthcare provides a comprehensive range of benefits for up to Nothing
30 days per calendar year when full-time skilled nursing care is
necessary and confinement in a skilled nursing facility is medically
appropriate as determined by a UHP Healthcare doctor and approved by
UHP Healthcare. All necessary services are covered, including:

Bed, board and general nursing care
Drugs, biologicals, supplies, and equipment ordinarily provided or
arranged by the skilled nursing facility when prescribed by a UHP
doctor.

Not covered: custodial care All Charges
Hospice care

Supportive and palliative care for a terminally ill member is covered in Nothing
the home or hospice facility. Services include inpatient and outpatient
care, and family counseling; these services are provided under the
direction of a UHP doctor who certifies that the patient is in the
terminal stages of illness, with a life expectancy of approximately
six months or less.

Not covered: Independent nursing, homemaker services All charges
Ambulance
Local professional ambulance service when medically appropriate Nothing

27 2002 UHP HEALTHCARE Section 5( c) 27
27 Page 28 29
You pay Benefit Description
Section 5 (d). Emergency services/ accidents
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.

UHP HEALTHCARE has 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.

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.

Emergency within our service area
Emergency care at a doctor's office $50 or 50% of charges,
whichever is less.
Emergency care at an urgent care center Co-pays are waived if
Emergency care as an outpatient or inpatient at a hospital, you are admitted to
including doctors' services the hospital

Not covered: Elective care or non-emergency care All charges.
Emergency outside our service area

Emergency care at a doctor's office $50 or 50% of charges,
whichever is less.
Emergency care at an urgent care center Co-pays are waived if
Emergency care as an outpatient or inpatient at a hospital, you are admitted to
including doctors' services the hospital

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

28 2002 UHP HEALTHCARE Section 5( d)

I
M
P
O
R
T
A
N
T

I
M
P
O
R
T
A
N
T 28
28 Page 29 30
Ambulance
Professional ambulance service when medically appropriate. No charge
See 5( c) for non-emergency service.

Not covered:
air ambulance All Charges

29 2002 UHP HEALTHCARE Section 5( d) 29
29 Page 30 31
You pay Benefit Description
I
M
P
O
R
T
A
N
T

I
M
P
O
R
T
A
N
T

Section 5 (e). Mental health and substance abuse benefits
Parity
When you get our approval for services and follow a treatment plan we approve, cost-sharing
and limitations for Plan mental health and substance abuse benefits will be no greater than for
similar benefits for other illnesses and conditions.

Here are some important things to keep in mind about these benefits:

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

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

Mental health and substance abuse benefits
All diagnostic and treatment services recommended by a Plan provider Your cost sharing
and contained in a treatment plan that we approve. The treatment plan responsibilities are no
may include services, drugs, and supplies described elsewhere in this greater than for other illness
brochure. or conditions.

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

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

Medication management

Mental health and substance abuse benefits -Continued on next page

30 2002 UHP HEALTHCARE Section 5( e) 30
30 Page 31 32
Mental health and substance abuse benefits (Continued) You pay
Diagnostic tests $10 per visit
Services provided by a hospital or other facility Nothing
Services in approved alternative care settings such as partial
hospitalization, half-way house, residential treatment, full-day
hospitalization, facility based intensive outpatient treatment

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

Pre-authorization To be eligible to receive these benefits you must obtain a treatment plan and follow
all of the following authorization processes: Your primary care physician has
authority to refer you for most services. For certain services, however, your
physician must obtain approval from us. Before giving approval, we consider if the
service is covered, medically necessary, and follows generally accepted medical
practice.

We call this review and approval process "prior authorization." Your physician must
obtain prior authorization for the services such as inpatient hospitalizations and
most visits to a specialist. Before giving approval, we consider if the service is
medically necessary, and if it follows generally accepted medical practice. UHP will
provide benefits for covered services only when the services are medically
necessary to prevent, diagnose or treat your illness or condition. Services must be
received at Plan facilities, 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.

You and each family member must choose a primary care physician when you
enroll in this Plan. This decision is important since your primary care physician
provides or arranges for most of your health care. To select a primary care
physician, consult the "Primary Care Physician" section of the UHP Healthcare
Provider Directory. Choose either a clinic or an individual physician. Your family
members can choose their own primary care physicians from this section too. You
may obtain a provider directory by calling UHP Healthcare Member Services at 1-
800-544-0088. The list is also on our website: www. uhphealthcare. com.

Limitation We may limit your benefits if you do not obtain a treatment plan.

31 2002 UHP HEALTHCARE Section 5( e) 31
31 Page 32 33
I
M
P
O
R
T
A
N
T

I
M
P
O
R
T
A
N
T

Section 5 (f). Prescription drug benefits
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.

UHP Healthcare has 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.

There are important features you should be aware of. These include:
Who can write your prescription. A plan physician must write the prescription.
Where you can obtain them. You must fill the prescription at a plan pharmacy.
We use a formulary. UHP Healthcare's Formulary Pharmacy & Therapeutics Advisory Committee, which is
part of UHP Healthcare's Utilization Management Program, determines which drugs are to be included in
UHP's drug formulary. The Committee is an advisory group consisting of medical, pharmacy and other
professionals. This committee serves as the governing body for the Formulary system and currently includes
the UHP Medical Director, contracted Medical Group Prescribers, the UHP Pharmacy Director, contracted
Pharmacy Provider Pharmacists, and the UHP Utilization Management Director. The primary purposes of the
UHP Formulary Pharmacy & Therapeutics Advisory Committee are to develop UHP's medication formulary
and to provide members cost-effective and quality drug therapy.

These are the dispensing limitations. Drugs are prescribed by a UHP or referral doctor and obtained at a
UHP pharmacy will be dispensed for up to a 30-day supply or 100 unit supply, whichever is less; or one
commercially prepared unit (i. e., one inhaler, one vial ophthalmic medication or insulin). You pay a $5 copay
per prescription unit or refill for generic drugs or for name brand drugs when generic substitution is not
permissible. When generic substitution is permissible (i. e., a generic drug is available and the prescribing
doctor does not require the use of a name brand drug), but you request the name brand drug, you pay the price
difference between the generic and the name brand drug as well as the $5 copay per prescription unit or refill.

Drugs are prescribed by UHP doctors and dispensed in accordance with UHP Healthcare's drug formulary.
Nonformulary drugs will be covered when prescribed by a UHP doctor. UHP Healthcare must arrange for the
nonformulary drug to be dispensed when requested to do so by the prescribing doctor.

Why use generic drugs?
1. Generic drugs offer a safe and economic way to meet your prescription drug needs.
2. Generic drugs contain the same active ingredients and are equivalent in strength and dosage to the
original brand name product.

3. The U. S. Food and Drug Administration sets quality standards for generic drugs to ensure that these
drugs meet the same standards of quality and strength as brand name drugs.

4. A generic prescription costs you -and us -less than a name brand prescription.

32 2002 UHP HEALTHCARE Section 5( f) 32
32 Page 33 34
You pay Benefit Description
33
Covered medications and supplies
Drugs are prescribed by UHP doctors and dispensed in accordance with $5 per prescription unit (30 day
UHP Healthcare's drug formulary. Nonformulary drugs will be covered supply or 100 units, whichever is
when prescribed by a UHP doctor. UHP Healthcare must arrange for less)
the nonformulary drug to be dispensed when requested to do so by the
prescribing doctor.

We cover the following medications and supplies prescribed by a Plan
physician and obtained from a Plan pharmacy.

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.

Oral and injectable contraceptive drugs; contraceptive diaphragms
Implanted contraceptive devices; you pay nothing for device;
implantation and removal is provided by UHP Healthcare

Insulin (a copay charge applies to each vial)
Intrauterine devices
Diabetic supplies, including insulin syringes, needles, glucose test
tablets and test tape, Benedict's solution or equivalent and acetone
test tablets

Disposable needles and syringes needed to inject covered prescribed
medication

Drugs to treat sexual dysfunction
Oral fertility drugs
Injectable fertility drugs, and other injectables are covered under
Medical Benefits

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

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

Vitamins and nutritional substances that can be purchased without a
prescription

Medical supplies such as dressings and antiseptics
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Non-prescription contraceptive drugs and devices
Implanted time-release medications, except Norplant

2002 UHP HEALTHCARE Section 5( f) 33
33 Page 34 35
Feature Description
34

Section 5 (g). Special features
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.

2002 UHP HEALTHCARE Section 5( g) 34
34 Page 35 36
35
Section 5 (h). Dental benefits
Accidental injury benefit
We cover restorative services and supplies necessary to promptly repair (but not replace) sound natural teeth.
The need for these services must result from an accidental injury. You pay nothing.

Dental benefits
We offer no other dental benefits.

2002 UHP HEALTHCARE Section 5( h) 35
35 Page 36 37
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.

Medicare prepaid plan enrollment -UHP HEALTHCARE offers Medicare recipients the opportunity to enroll in UHP
HEALTHCARE through Medicare. As indicated on page 7, annuitants and former spouses with FEHB coverage and
Medicare Parts A and B may elect to drop their FEHB coverage and enroll in a Medicare prepaid plan when one is
available in their area. They may then later re-enroll in the FEHB program. Contact your retirement system for
information on dropping your FEHB enrollment and changing to a Medicare prepaid plan. Contact us at 1-800/ 847-
1222 for information on UHP's Medicare prepaid plan and the cost of that enrollment.

36 2002 UHP HEALTHCARE Section 5( i) 36
36 Page 37 38
37
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 you receive while you are not enrolled in this Plan;
Services, drugs, or supplies that are not medically necessary;
Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric
practice;

Experimental or investigational procedures, treatments, drugs or devices;
Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered
if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest;

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

2002 UHP HEALTHCARE Section 6 37
37 Page 38 39
38 2002 UHP HEALTHCARE 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 co-payment..
You will only need to file a claim when you receive emergency services from non-plan providers. Sometimes these
providers bill us directly. Check with the provider. If you need to file the claim, here is the process:

Medical, hospital drug 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 800/ 544-0088.

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: UHP HEALTHCARE, 3405 W. Imperial Highway,
Inglewood, CA 90303

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

When we need more information
Please reply promptly when we ask for additional information. We may delay processing or deny your claim if you do
not respond. 38
38 Page 39 40
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 pre-authorization:

Step Description

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: UHP HEALTHCARE, 3405 W. Imperial Highway, Inglewood, CA 90303; 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.

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 medical provider for more information. If we ask your provider, we will send you a copy
of our request-go to step 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.

If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
a. 90 days after the date of our letter upholding our initial decision; or
b. 120 days after you first wrote to us if we did not answer that request in some way within 30 days; or
c. 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 DC 20415-3630.

39 2002 UHP HEALTHCARE Section 9

1
2
3
4 39
39 Page 40 41
The disputed claims process (Continued)
Send OPM the following information:
A statement about why you believe our decision was wrong, based on specific benefit provisions in this
brochure;
Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical
records, and explanation of benefits (EOB) forms;
Copies of all letters you sent to us about the claim;
Copies of all letters we sent to you about the claim; and
Your daytime phone number and the best time to call.
Note: If you want OPM to review different claims, you must clearly identify which documents apply to which
claim.
Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your
representative, such as medical providers, must include a copy of your specific written consent with the review
request.
Note: The above deadlines may be extended if you show that you were unable to meet the deadline because of
reasons beyond your control.

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

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

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

NOTE: If you have a serious or life threatening condition (one that may cause permanent loss of bodily
functions or death if not treated as soon as possible), and
(a) We haven't responded yet to your initial request for care or preauthorization/ prior approval, then call us at
800/ 544-0088 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.

40 2002 UHP HEALTHCARE Section 8

5
6 40
40 Page 41 42
41
Section 9. Coordinating benefits with other 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.

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.

2002 UHP HEALTHCARE Section 9

When you have...
Other health
coverage

What is Medicare?

The Original
Medicare Plan
(Part A or Part B) 41
41 Page 42 43
42
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
A. When either you -or your covered spouse -are age 65 or over and ... Then the primary payer is...

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

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

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

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

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

2002 UHP HEALTHCARE Section 9 42 42
42 Page 43 44
Claims process when you have the Original Medicare Plan You
probably will never have to file a claim form when you have both
our Plan and the Original Medicare Plan.

When we are the primary payer, we process the claim first.
When Original Medicare is the primary payer, Medicare processes your
claim first. In most cases, your claims will be coordinated automatically
and we will pay the balance of covered charges. You will not need to do
anything. To find out if you need to do something about filing your
claims, call us at 1-800-544-0088.

We do not waive any costs when you have Medicare.
If you are eligible for Medicare, you may choose to enroll in and get your
Medicare benefits from another type of Medicare + Choice plan a Medicare
managed care plan. These are health care choices (like HMOs) in some areas
of the country. In most Medicare managed care plans, you can only go to
doctors, specialists, or hospitals that are part of the plan. Medicare managed
care plans provide all the benefits that Original Medicare covers. Some cover
extras, like prescription drugs. To learn more about enrolling in a Medicare
managed care plan, contact Medicare at 1-800-MEDICARE (1-800-633-4227)
or at www. medicare. gov.

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

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

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

Suspended FEHB 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 have one or both Parts of Medicare, you can still be 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.

.

43 2002 UHP HEALTHCARE Section 9

Medicare managed care
plan

If you do not enroll in
Medicare
(Part A or Part B) 43
43 Page 44 45
TRICARE is the health care program for members, eligible dependents of
military persons and retirees of the military. TRICARE includes the
CHAMPUS program. If both TRICARE and this Plan cover you, we pay first.
See your TRICARE Health Benefits Advisor if you have questions about
TRICARE coverage.

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.

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

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

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

If you have a malpractice claim because of services you did or did not receive
from a plan provider, it must go to binding arbitration. Contact us about how
to begin our binding arbitration process.

44 44 2002 UHP HEALTHCARE Section 9

TRICARE
Workers'
Compensation

Medicaid
When other
Government
agencies are
responsible for your
care

When others are
responsible for
injuries

If you have a
malpractice claim 44
44 Page 45 46
45 2002 UHP HEALTHCARE Section 10
Section 10. Definitions of terms we use in this brochure
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.

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

Care we provide benefits for, as described in this brochure.

Services which are not intended to cure a patient's condition or which do not
require the continued attention of medical personnel; examples include
assistance in the activities of daily living.

The determination that a service is experimental or investigational is based on
(1) reference to relevant federal regulations, such as those contained in Title 42,
Code of Federal Regulations, Chapter IV (Health Finance Administration) and
Title 21, Code of Federal Regulations, Chapter I (Food and Drug
Administration); (2) consultation and provider organizations, academic and
professional specialists pertinent to the specific service; and (3) reference to
current medical literature.

Us and we refer to UHP HEALTHCARE.
You refers to the enrollee and each covered family member.

45

Calendar year
Copayment
Covered services
Custodial care

Experimental or investigational Service

Us/ We
You 45
45 Page 46 47
46 2002 UHP HEALTHCARE Section 11
Section 11. FEHB facts
We will not refuse to cover the treatment of a condition that you had
before you enrolled in this Plan solely because you had the condition before
you enrolled.

See www. opm. gov/ insure. Also, your employing or retirement office
can answer your questions, and give you a Guide to Federal Employees
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.

Self Only coverage is for you alone. Self and Family coverage is for
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.

The benefits in this brochure are effective on January 1. If you joined this Plan
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.

Coverage Information
No pre-existing condition
limitation

Where you can get
information about enrolling
in the FEHB Program

Types of coverage available
for you and your family

When benefits and premium start 46
46 Page 47 48
We will keep your medical and claims information confidential. Only 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, 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).

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.

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

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.

Get the RI 79-27, which describes TCC, and the RI 70-5, the Guide 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.
47 2002 UHP HEALTHCARE Section 11

Your medical and claims
records are confidential

When you retire
When you lose benefits
When FEHB coverage
ends

Spouse equity coverage
Temporary
Continuation of
Coverage

Enrolling in TCC 47
47 Page 48 49
You may convert to a non-FEHB individual policy if: individual coverage
Your coverage under TCC or the spouse equity law ends (if you canceled
your coverage or did not pay your premium, you cannot convert)
You decided not to receive coverage under TCC or the spouse equity law;
or
You are not eligible for coverage under TCC or the spouse equity law.

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

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

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) 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.

48 2002 UHP HEALTHCARE Section 11

Converting to individual
coverage

Getting a Certificate of
Group Health Plan
Coverage 48
48 Page 49 50
Long Term Care Insurance Is Coming Later in 2002!
Many FEHB enrollees think that their health plan and/ or Medical will cover their long-term care needs.
Unfornately, 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 insurance.

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

Welcome to the club!
76% of Americans believe they will never need long term care, but the
facts are that about half of them will. And it's not just the old folks.
About 40% of people needing long term care are under age 65. They may
need chronic care due to a serious accident, a stroke, or developing
multiple sclerosis, etc.
We hope you will never need long term care, but everyone should have a
plan just in case. Many people now consider long term care insurance to be
vital to their financial and retirement planning.

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

Not FEHB. Look at the "Not covered" blocks in sections 5( a) and 5( c) of
your FEHB brochure. Health plans don't cover custodial care or a stay in
an assisted living facility or a continuing need for a home health aide to
help you get in and out of bed and with other activities of daily living.
Limited stays in skilled nursing facilities can be covered in some
circumstances.
Medicare only covers skilled nursing home care (the highest level of
nursing care) after a hospitalization for those who are blind, age 65 or
older or fully disabled. It also has a 100 day limit.
Medicaid covers long term care for those who meet their state's poverty
guidelines, but has restrictions on covered services and where they can be
received. Long term care insurance can provide choices of care and
preserve your independence.

Employees will get more information from their agencies during the LTC
open enrollment period in the late summer/ early fall of 2002.
Retirees will receive information at home.

Our toll-free teleservice center will begin in mid-2002. In the meantime,
you can learn more about the program on our web site at
www. opm. gov/ insure/ ltc.

49 2002 UHP HEALTHCARE Section 11

What is long term care
(LTC) insurance?

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

Is long term care expensve?
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? 49
49 Page 50 51
50 2002 UHP HEALTHCARE Index
Accidental injury 35
Allergy tests 17
Alternative treatment 21
Allogenetic (donor) bone marrow
transplant 22

Ambulance 27, 29
Anesthesia 22, 24
Autologous bone marrow
transplant 22

Biopsies 22
Birthing centers 16
Blood and blood plasma 26
Breast cancer screening 15
Casts 22, 26
Catastrophic protection 35
Changes for 2002 Chemotherapy
18

Childbirth 16
Chiropractic 21
Cholesterol tests 15
Circumcision 16
Claims 42, 43
Coinsurance 38
Colorectal cancer screening 14
Congenital anomalies 22
Contraceptive devices and drugs
14, 32

Coordination of benefits 41
Covered charges 40
Covered providers 9
Crutches 20
Deductible 12
Definitions 45
Dental care 35
Diagnostic services 14,15, 26
Disputed claims review 39
Donor expenses (transplants) 24
Dressings 26
Durable medical equipment
(DME) 30

Educational classes and programs
21

Effective date of enrollment 42
Emergency 28
Experimental or investigational 45
Eyeglasses 19
Family planning 17
Fecal occult blood test 15
General Exclusions 37

Hearing services 19
Home health services 21
Hospice care 27
Home nursing care 21
Hospital 10, 25, 31
Immunizations 15
Infertility 17
Inhospital physician care 14
Inpatient Hospital Benefits 14, 25
Insulin 20, 33
Laboratory and pathological services 15
Machine diagnostic tests 15, 26
Magnetic Resonance Imagings (MRIs) 15
Mail Order Prescription Drugs 32
Mammograms 15
Maternity Benefits 16
Medicaid 44
Medically necessary 9, 12
Medicare 41, 43
Members 40
Mental Conditions/ Substance Abuse
Benefits 30

Neurological testing 30
Newborn care 16
Non-FEHB Benefits 36
Nurse
Licensed Practical Nurse 21
Nurse Anesthetist 26
Nurse Midwife 21
Nurse Practitioner 27
Psychiatric Nurse 30
Registered Nurse 21
Nursery charges 16
Obstetrical care 16
Occupational therapy 18, 21
Ocular injury 19
Office visits 4, 14
Oral and maxillofacial surgery 23
Orthopedic devices 20
Ostomy and catheter supplies 33
Out-of-pocket expenses 12
Outpatient facility care 26
Oxygen 26
Pap test 15
Physical examination 16
Physical therapy 18, 21
Physician 14
Pre-admission testing 31

Precertification 16
Preventive care, adult 16
Preventive care, children 16
Prescription drugs 32
Preventive services 15
Prior approval 31
Prostate cancer screening 15
Prosthetic devices 20
Psychologist 30
Psychotherapy 30
Radiation therapy 18
Renal dialysis 42
Room and board 25
Second surgical opinion 14
Skilled nursing facility care 27
Smoking cessation 30
Speech therapy 18, 21
Splints 20
Sterilization procedures 22
Subrogation 44
Substance abuse 30
Surgery 22
Anesthesia 22
Oral 22
Outpatient 26
Reconstructive 22
Syringes 22
Temporary continuation of
coverage 47

Transplants 24
Treatment Therapies 18
Vision services 16, 19
Well child care 16
Wheelchairs 20
Workers' compensation 44
X-rays 15

Index
Do not rely on this page; it is for your convenience and may not show all pages where the terms appear. 50
50 Page 51 52
Summary of benefits for UHP HEALTHCARE -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.
Below, an asterisk () means the item is subject to the $xx calendar year deductible. {use this bullet only if it
applies}

Benefits You Pay Page
Medical services provided by physicians:
Diagnostic and treatment services provided in the office.............. $10 per office visit 14

Services provided by a hospital:
Inpatient.......................................................................................... Nothing 25
Outpatient ....................................................................................... Nothing 26

Emergency benefits:
In-area.............................................................................................. $50 or 50% of charges, 28
whichever is less

Out-of-area ...................................................................................... $50 or 50% of charges, 28
Mental health and substance abuse treatment ................................... Regular cost sharing 30
Prescription drugs .............................................................................. $5 per prescription unit or refill 32
Dental Care ........................................................................................ Nothing for restorative services 39
and supplies to repair sound
natural teeth resulting from an
accidental injury

Vision Care ........................................................................................ $10 for a Routine Exam 19
Special features: Flexible options 34
Protection against catastrophic costs ................................................ We do not have an out-of-pocket 41
(your out-of-pocket maximum) maximum

51 2002 UHP HEALTHCARE Summary 51
51 Page 52
2002 Rate Information for
UHP HEALTHCARE

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 .

Non-postal Premium Postal Premium
Biweekly Monthly Biweekly
Type of Code Govt Your Govt Your USPS Your
Enrollment Share Share Share Share Share Share

Self Only C41 $ 59.81 $ 19.93 $129.58 $ 43.19 $ 70.77 $ 8.97
Self and Family C42 $127.43 $ 42.47 $276.09 $ 92.03 $150.79 $ 19.11

52 2002 UHP HEALTHCARE Rate Information 52

Page Navigation Panel