Pages 1--60 from Keystone Health Plan East

Serving: The Philadelphia area
Enrollment in this Plan is limited. You must live or work in our geographic service area to enroll. See page 7 for requirements.

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

RI 73-483
Enrollment codes for this Plan:
ED1 Self Only ED2 Self and Family

For changes in benefits
see page 8. 1
1 Page 2 3
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
Who provides my health care? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
— Specialty care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
— Hospital care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Circumstances beyond our control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Services requiring our prior approval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Section 4. Your costs for covered services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
— Copayments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
— Deductible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
— Coinsurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Your catastrophic protection out-of-pocket maximum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Section 5. Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
(a) Medical services and supplies provided by physicians and other health care professionals . . . . . . 15
(b) Surgical and anesthesia services provided by physicians and other health care professionals . . . . 24
(c) Services provided by a hospital or other facility, and ambulance services. . . . . . . . . . . . . . . . . . . 28
(d) Emergency services/ accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
(e) Mental health and substance abuse benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
(f) Prescription drug benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

2002 Keystone Health Plan East 2 Table of Contents 2
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(g) Special features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
— Services for deaf and hearing impaired . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
— Urgent care/ travel benefit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
(h) Dental benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
(i) Non-FEHB benefits available to Plan members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Section 6. General exclusions — things we don't cover . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Section 7. Filing a claim for covered services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Section 8. The disputed claims process. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Section 9. Coordinating benefits with other coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
When you have . . .
— Other health coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
— Original Medicare. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
— Medicare managed care plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
TRICARE/ Workers' Compensation/ Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
When other Government agencies are responsible for your care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
When others are responsible for injuries. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Section 10. Definitions of terms we use in this brochure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Section 11. FEHB facts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Coverage information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
— No pre-existing condition limitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
— Where you can get information about enrolling in the FEHB Program . . . . . . . . . . . . . . . . . . . . . 51
— Types of coverage available for you and your family . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
— When benefits and premiums start . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
— Your medical and claims records are confidential . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
— When you retire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
When you lose benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
— When FEHB coverage ends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
— Spouse equity coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
— Temporary Continuation of Coverage (TCC). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
— Converting to individual coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
— Getting a Certificate of Group Health Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Long Term Care Insurance is coming later in 2002 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Summary of benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Back cover

2002 Keystone Health Plan East 3 Table of Contents 3
3 Page 4 5
Introduction
Keystone Health Plan East, Inc. 1901 Market Street
Philadelphia, PA 19103
This brochure describes the benefits of Keystone Health Plan East under our contract (CS 2339) with the Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. This brochure is the
official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations, and exclusions of this brochure.

If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled for Self and Family coverage, each eligible family member is also entitled to these benefits. You do not have a right to
benefits that were available before January 1, 2002, unless those benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2002, and changes are summarized on page 8. Rates are shown at the end of this brochure.

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

— Except for necessary technical terms, we use common words. For instance, "you" means the enrollee or family member; "we" means Keystone Health Plan East.
— We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the Office of Personnel Management. If we use others, we tell you what they mean first.
— Our brochure and other FEHB plans' brochures have the same format and similar descriptions to help you compare plans.
If you have comments or suggestions about how to improve the structure of this brochure, let OPM know. Visit OPM's "Rate Us" feedback area at www. opm. gov/ insure or e-mail OPM at fehbwebcomments@ opm. gov. You may
also write to OPM at the Office of Personnel Management, Office of Insurance Planning and Evaluation Division, 1900 E Street, NW, Washington, DC 20415.

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

— Call the provider and ask for an explanation. There may be an error.
— If the provider does not resolve the matter, call us at 1-800/ 227-3114 and explain the situation.

— If we do not resolve the issue, call or write:
THE HEALTH CARE FRAUD HOTLINE 202/ 418-3300

The United States Office of Personnel Management Office of the Inspector General Fraud Hotline
1900 E Street, NW, Room 6400 Washington, DC 20415.

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

2002 Keystone Health Plan East 5 Introduction/ Plain Language/ Advisory 5
5 Page 6 7
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and other providers that contract with us. These Plan providers coordinate your health care services.

HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in addition to treatment for illness and injury. Our providers follow generally accepted medical practice when
prescribing any course of treatment.
When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You only pay the copayments described in this brochure. When you receive emergency services from non-Plan providers, you may
have to submit claim forms.
You should join an HMO because you prefer the plan's benefits, not because a particular provider is available. You cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician,
hospital, or other provider will be available and/ or remain under contract with us.
How we pay providers
We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure. These Plan providers accept a negotiated payment from us, and you will only be responsible for your copayments.

Who provides my health care?
Keystone Health Plan East, a wholly owned subsidiary of Independence Blue Cross, is an individual practice prepayment (IPP) plan that provides access to care throughout the greater Philadelphia area. Members and their
family members may select their own primary care doctor from among the 2,611 who practice within the Plan's service area. There are approximately 9,700 specialty care doctors who participate with the Plan. Your primary care
doctor will arrange for the necessary specialty and hospital care you need at one of the Plan's participating specialist offices or at a participating Plan hospital throughout the Plan's service area.

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.
If you want more information about us, call 1-800/ 227-3114, or write to Keystone Health Plan East, 1901 Market Street, Philadelphia, Pennsylvania 19103. You may also visit our website at www. ibx. com/ fep.

2002 Keystone Health Plan East 6 Section 1 6
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Service Area
To enroll in this Plan, you must live in or work in our Service Area. This is where our providers practice. Our Service Area is: The Pennsylvania counties of Bucks, Chester, Montgomery, Delaware and Philadelphia.

Ordinarily, you must get your care from providers who contract with us, except for emergency care required while you are outside our Service Area. However, as a Keystone Health Plan East member, you have access to urgent care
through a nationwide network of Blue Cross and Blue Shield traditional providers (BlueCard Providers). If you become ill while visiting outside our Service Area, call 1-800/ 810-BLUE to find names and addresses of nearby
participating Blue Cross and Blue Shield traditional providers (BlueCard Providers). This number is also found on the back of your ID card. Before you obtain urgent care, call Patient Care Management at 1-800-227-3116 the phone
number on your ID Card to have the care preauthorized. An office visit copayment will be collected when the service is rendered. You will not need to file a claim. No coverage will be provided for urgent care that has not been
preauthorized.
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. Through our Guest Membership benefit, members who are away from home for at least 90 days may temporarily enroll in another Blue
Cross and Blue Shield network HMO. Members are also eligible for Guest Membership for up to six months if, for example, they are assigned out-of-area temporarily. Guest Membership enables members to receive the full range of
HMO benefits and services offered by the hosting HMOs. To enroll, members simply contact their Member Services at the number located on the back of your ID card at least 30 days in advance. The Coordinator will make all the
necessary arrangements for Guest Membership and take care of all the billing details. Also, your prescription drug card works in more than 52,000 pharmacies in the United States. If you or a family member move, you do not have to
wait until Open Season to change plans. Contact your employing or retirement office.

2002 Keystone Health Plan East 7 Section 1 7
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Section 2. How we change for 2002
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5 Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here is a
clarification that does not change benefits.
Program-wide changes
— We changed the address for sending disputed claims to OPM. (Section 8)

Changes to this Plan
— Your share of the non-Postal premium will increase by 20.2% for Self Only or 34.0% for Self and Family.
— We now cover certain intestinal transplants. (Section 5( b))
— We changed speech therapy benefits by removing the requirement that services must be required to restore functional speech. (Section 5( a))

— We no longer limit total blood cholesterol tests to certain age groups. (Section 5( a))
— We now provide hand therapy for 60 consecutive days per condition, subject to no member copay. (Section 5( a))
— Urgent care provided by a Blue Cross and Blue Shield traditional network provider (BlueCard Providers), outside our Service Area, must be preauthorized and is now subject to an office visit copayment that will be

collected when the service is rendered. No coverage will be provided for urgent care that has not been preauthorized. (Sections 1 and 5( g))

2002 Keystone Health Plan East 8 Section 2 8
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Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you
receive services from a Plan provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the Health
Benefits Election Form, SF-2809, your health benefits enrollment confirmation (for annuitants), or your Employee Express confirmation
letter.
If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at

1-800/ 227-3114.
Where you get covered care You get care from "Plan providers" and "Plan facilities." You will only pay copayments, and you will not have to file claims.

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

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

What you must do It depends on the type of care you need. First, you and each family to get covered care 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.

It is the responsibility of your primary care doctor to obtain any necessary authorizations from the Plan before referring you to a specialist or making
arrangements for hospitalization. Services of other providers are covered only when there has been a referral by the member's primary care doctor
except for: dental care, vision care, and visits to the OB/ GYN for preventive care, routine maternity care or problems related to
gynecological conditions when medically necessary. Non-routine care provided by Reproductive Endocrinologist/ Infertility Specialists and
Gynecologic Oncologists continue to require a referral from the primary care physician.

Treatment for mental conditions and substance abuse may be obtained directly from Magellan Behavioral Health. Magellan Behavioral Health,
or any other mental health administrator for Keystone Health Plan East, manage all care related to mental health and substance abuse services and
will determine what specialty care is appropriate and which specialists will be utilized. Questions about related benefits and precertification
should be directed to Magellan Behavioral Health at 1-800/ 688-1911.
If you enroll, you will be asked to complete a primary care doctor selection form and send it directly to the Plan, indicating the name of the

2002 Keystone Health Plan East 9 Section 3 9
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primary care doctor selected for you and each member of your family. You are required to select a personal doctor from among participating
plan primary care doctors located within the Plan's service area. Please note that if you reside in New Jersey and work in Pennsylvania within our
service area, you must select a primary care doctor whose practice is in Pennsylvania within our service area. Your dependents may select a
personal doctor from among participating plan primary care doctors in Pennsylvania or New Jersey. You and your dependents may have only
one dentist who must be selected from a list of participating plan dentists located within the Plan's service area.

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

— Specialty care Your primary care physician will refer you to a specialist for needed care. 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 physician gives you a referral. However, you may get dental care, vision care, and see an obstetrician/ gynecologist for preventive care,
and for routine maternity care or problems related to gynecological conditions when medically necessary, without a referral.

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.

2002 Keystone Health Plan East 10 Section 3 10
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— If you have a chronic or disabling condition and lose access to your specialist because we:
— terminate our contract with your specialist for other than cause; or
— drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB Plan; or

— reduce our service area and you enroll in another FEHB Plan,
you may be able to continue seeing your specialist for up to 90 days after you receive notice of the change. Contact us or, if we drop out
of the Program, contact your new plan.
If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can
continue to see your specialist until the end of your postpartum care, even if it is beyond the 90 days.

— Hospital care Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission
to a skilled nursing or other type of facility.
If you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at 1-800/ 227-3114. If you
are new to the FEHB Program, we will arrange for you to receive care.
If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:

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

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

2002 Keystone Health Plan East 11 Section 3 11
11 Page 12 13
Services requiring our Your primary care physician has authority to refer you for most services. prior approval For certain services, however, your physician must obtain approval from
us. Before giving approval, we consider if the service is covered, medically necessary, and follows generally accepted medical practice.

We call this review and approval process preauthorization. Your physician must obtain preauthorization for the following services such as:
— All non-emergency hospital admissions — All obstetrical admissions
— All same day surgery/ short procedure unit admissions — Outpatient therapies: speech, cardiac, pulmonary, respiratory,
home infusion — Other facility services: skilled nursing, home health, hospice,
birthing center — Rental/ purchase of durable medical equipment and prosthesis
(purchases over $100.00 and all rentals) — Non-emergency ambulance services
— Spinal manipulation services — Some medications that have specific uses and are administered in
outpatient settings or physician offices
Members are not responsible for payment of services if the provider does not obtain preauthorization of services.

2002 Keystone Health Plan East 12 Section 3 12
12 Page 13 14
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
— Copayments A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc. when you receive services.

Example: When you see your primary care physician you pay a copayment of $10 per office visit or a copayment of $15 per office visit
when you see a specialist.
— Deductible We do not have a deductible.
Note: If you change plans during open season, you do not have to start a new deductible under your old plan between January 1 and the effective
date of your new plan. If you change plans at another time during the year, you must begin a new deductible under your new plan.

— Coinsurance We do not have coinsurance.
Your catastrophic protection After your copayments total $1,000 per person or $2,000 per family out-of-pocket maximum enrollment in any calendar year, you do not have to pay any more for

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

— Prescription drugs
— Dental services

Be sure to keep accurate records of your copayments since you are responsible for informing us when you reach the maximum.

2002 Keystone Health Plan East 13 Section 4 13
13 Page 14 15
Section 5. Benefits — OVERVIEW
(See page 8 for how our benefits changed this year and page 57 for a benefits summary.)

NOTE: This benefits section is divided into subsections. Please read the important things you should keep in mind at the beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the
following subsections. To obtain claims forms, claims filing advice, or more information about our benefits, contact us at 1-800/ 227-3114.

(a) Medical services and supplies provided by physicians and other health care professionals . . . . . . . . . . . . . . 15-23
— Diagnostic and treatment services — Speech therapy — Lab, X-ray, and other diagnostic tests — Hearing services (testing, treatment, and

— Preventive care, adult supplies) — Preventive care, children — Vision services (testing, treatment, and
— Maternity care supplies) — Family planning — Foot care
— Infertility services — Orthopedic and prosthetic devices — Allergy care — Durable medical equipment (DME)
— Treatment therapies — Home health services — Physical, occupational, and hand therapies — Chiropractic
— Alternative treatments — Educational classes and programs

(b) Surgical and anesthesia services provided by physicians and other health care professionals . . . . . . . . . . . . 24-27
— Surgical procedures — Oral and maxillofacial surgery — Reconstructive surgery — Organ/ tissue transplants

— Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services . . . . . . . . . . . . . . . . . . . . . . . . . . . 28-30
— Inpatient hospital — Extended care benefits/ skilled nursing care — Outpatient hospital or ambulatory surgical facility benefits

center — Hospice care — Ambulance

(d) Emergency services/ accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31-32
— Medical emergency — Ambulance

(e) Mental health and substance abuse benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33-34
(f) Prescription drug benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35-37
(g) Special features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
— Services for deaf and hearing impaired — Urgent care/ travel benefit

(h) Dental benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39-40
(i) Non-FEHB benefits available to Plan members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Summary of benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

2002 Keystone Health Plan East 14 Section 5 14
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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.
— Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other

coverage, including with Medicare.

2002 Keystone Health Plan East 15 Section 5( a)
Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
— In physician's office
— Office medical consultations $15 per office visit to a specialist
— Second surgical opinion

Professional services of physicians Nothing
— In an urgent care center
— During a hospital stay
— In a skilled nursing facility

At home. $15 per visit
Not covered: All charges.
— Charges for completion of insurance forms
— Charges for missed appointments

$10 per office visit to your primary care physician 15
15 Page 16 17
Lab, X-ray and other diagnostic tests You pay
Laboratory tests, such as: Nothing
— Blood tests
— Urinalysis
— Non-routine pap tests
— Pathology
— X-rays
— Non-routine Mammograms
— CAT Scans/ MRI
— Ultrasound
— Electrocardiogram and EEG

Preventive care, adult
Routine screenings, based on medical necessity and risk 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
Prostate Specific Antigen (PSA test) – one annually for men age 40 and older

Routine pap test $10 per office visit to your primary care physician; $15 per office visit to a
specialist; nothing for the test

2002 Keystone Health Plan East 16 Section 5( a) 16
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2002 Keystone Health Plan East 17 Section 5( a)
Preventive care, adult (Continued) You pay
Routine mammogram – covered for women age 35 and older, as follows: Nothing
— From age 35 through 39, one during this five year period
— From age 40 and older, one every calendar year

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 office visit
— Tetanus-diphtheria (Td) booster – once every 10 years, ages 19 and over (except as provided for under Childhood immunizations)

— Influenza/ Pneumococcal vaccines, annually, age 65 and over
— Other adult immunizations as recommended by the Centers for Disease Control and Prevention and approved by Keystone

Preventive care, children
— Childhood immunizations recommended by the American Academy $10 per office visit of Pediatrics

— Well-child care charges for routine examinations, immunizations and care (up to age 22)
— Examinations, such as: $10 per office visit
— 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) 17
17 Page 18 19
Maternity care You pay
Complete maternity (obstetrical) care, such as: $15 only applies to first visit
— Prenatal care
— Delivery
— Postnatal care
Note: Here are some things to keep in mind:
— You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will extend your inpatient

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

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

— We pay hospitalization and surgeon services (delivery) the same as for illness and injury. See Hospital benefits (Section 5c) and Surgery
benefits (Section 5b).
Not covered: Routine sonograms to determine fetal age, size or sex All charges.

Family planning
A broad range of voluntary family planning services, limited to: $15 per specialist office visit
— Voluntary sterilization
— Surgically implanted contraceptives (such as Norplant) $5 prescription drug copay for the implant, plus $15 per specialist

office visit; nothing when the device is implanted during a
covered hospitalization.
— Injectable contraceptive drugs (such as Depo Provera) $5 prescription drug copay for up to a three-cycle supply, plus $15 per

specialist office visit.
— Intrauterine devices (IUDs) – Device covered under the Prescription $5 prescription drug copay for drug benefit; insertion and removal of device covered under Family the device, plus $15 per specialist

planning benefit. office visit.
— Diaphragms $5 prescription drug copay for the device, plus $15 per specialist

office visit.
Note: We cover oral contraceptives under the Prescription drug benefit.

2002 Keystone Health Plan East 18 Section 5( a) 18
18 Page 19 20
2002 Keystone Health Plan East 19 Section 5( a)
Family planning (Continued) You pay
Not covered: All charges.
— Reversal of voluntary surgical sterilization
— Genetic counseling
— Removal of surgically implanted time-release medication before the end of the expected life, unless medically necessary and approved by

the Plan.

Infertility services
Diagnosis and treatment of infertility, such as: $15 per specialist office visit
— Artificial insemination:
— intravaginal insemination (IVI)
— intracervical insemination (ICI)
— intrauterine insemination (IUI)
— Fertility drugs
Note: We cover non-injectable and oral fertility drugs under the Prescription drug benefit.

Not covered: All charges.
— Assisted reproductive technology (ART) procedures, such as:
— 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 $15 per specialist office visit
Allergy injection

Allergy serum Nothing
Not covered: provocative food testing and sublingual allergy All charges. desensitization 19
19 Page 20 21
Treatment therapies You pay
— Chemotherapy and radiation therapy Nothing
Note: High dose chemotherapy in association with autologous bone marrow transplants are limited to those transplants listed under

Organ/ Tissue Transplants on page 27.
— Respiratory and inhalation therapy
— Dialysis – Hemodialysis and peritoneal dialysis
— Intravenous (IV)/ Infusion Therapy – Home IV and antibiotic therapy
— Growth hormone therapy (GHT)
Note: We will only cover GHT when we preauthorize the treatment. If we determine GHT is not medically necessary, we will not cover the GHT or

related services and supplies. See Services requiring our prior approval in Section 3.

Physical, occupational, and hand therapies
— 60 consecutive days per condition for the services of each of the Nothing following if significant improvement can be expected within 2 months

— qualified physical therapists;
— occupational therapists, and
— hand therapists
Note: We only cover therapy to restore bodily function when there has been a total or partial loss of bodily function due to illness or injury.

Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction, is provided for up to 12 weeks.

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

Speech therapy
60 consecutive days per condition for the services of qualified Nothing speech therapists

2002 Keystone Health Plan East 20 Section 5( a) 20
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2002 Keystone Health Plan East 21 Section 5( a)
Hearing services (testing, treatment, and supplies) You pay
Hearing testing for children through age 17 $10 per office visit (see Preventive care, children)

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

Vision services (testing, treatment, and supplies)
One eye refraction every two calendar years. $15 per specialist office visit

Frames and corrective lenses every two calendar years. All charges after Plan's $35 allowance every two calendar years.

One pair of eyeglasses or contact lenses to correct an impairment Nothing 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 office visit through age 17 (see preventive care)

Not covered: All charges.
Contact lens fittings
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 office visit or peripheral vascular disease, such as diabetes.

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

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) 21
21 Page 22 23
Orthopedic and prosthetic devices You pay
Artificial limbs limited to initial device only; stump hose Nothing
Artificial lenses following cataract surgery
Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy

Internal prosthetic devices, such as artificial joints, pacemakers, and surgically implanted breast implant following mastectomy.
Note: 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.

Braces; limited to initial purchase and fitting
Not covered: All charges.
cost of a cochlear implanted device
orthopedic and corrective shoes
arch supports
foot orthotics, unless for treatment of diabetes
heel pads and heel cups
lumbosacral supports
corsets, trusses, elastic stockings, support hose, and other supportive devices

prosthetic or orthopedic replacements, except for children when required due to natural growth
dental prostheses
cranial prostheses including wigs and other devices intended to replace hair

Durable medical equipment (DME)
Rental, or at our option, the initial purchase per medical episode, Nothing including repair and adjustment, of standard durable medical equipment

prescribed by your Plan physician, such as oxygen and dialysis equipment. Under this benefit, we also cover:

standard hospital beds
standard wheelchairs
crutches
walkers
blood glucose monitors; and
insulin pumps

Not covered: All charges.
Motorized wheelchairs
Customized durable medical equipment
Replacements of DME

2002 Keystone Health Plan East 22 Section 5( a) 22
22 Page 23 24
2002 Keystone Health Plan East 23 Section 5( a)
Home health services You pay
Home health care ordered by a Plan physician and provided by a Nothing 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.

Not covered: All charges.
nursing care requested by, or for the convenience of, the patient or the patient's family;

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

Chiropractic
Spinal manipulation will be provided for up to 60 consecutive days Nothing per condition if significant improvement can be expected in the two

month period.

Alternative treatments
Not covered: All charges.
naturopathic services
hypnotherapy
biofeedback
acupuncture

Educational classes and programs
Coverage is limited to: Nothing
— Diabetes self-management training and education through community-based programs certified by the American Diabetes

Association or Pennsylvania Department of Health. Covered services may also be provided by these contracted providers; a licensed health
care professional; or at a hospital on an outpatient basis. 23
23 Page 24 25
2002 Keystone Health Plan East 24 Section 5( b)
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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.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other

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

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

Benefit Description You pay
Surgical procedures
A comprehensive range of services, such as: Nothing
Operative procedures
Treatment of fractures, including casting
Normal pre-and post-operative care by the surgeon
Correction of amblyopia and strabismus
Endoscopy procedures
Biopsy procedures
Removal of tumors and cysts
Correction of congenital anomalies (see reconstructive surgery)
Surgical treatment of morbid obesity
Insertion of internal prosthetic devices. See 5( a) – Orthopedic and prosthetic devices for device coverage information.

Surgical procedures continued on next page. 24
24 Page 25 26
2002 Keystone Health Plan East 25 Section 5( b)
Surgical procedures (Continued) You pay
Voluntary sterilization Nothing
Treatment of burns
Note: Generally, we pay for internal prostheses (devices) according to where the procedure is done. For example, we pay Hospital benefits for a

pacemaker and Surgery benefits for insertion of the pacemaker.
Not covered: All charges.
Reversal of voluntary sterilization
Routine treatment of conditions of the foot; see Foot care.

Reconstructive surgery
Your physician must obtain approval from us before providing service. Nothing
Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if:
— the condition produced a major effect on the member's appearance and

— the condition can reasonably be expected to be corrected by such surgery
Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of
congenital anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks; webbed fingers; and webbed toes. 25
25 Page 26 27
Reconstructive surgery (Continued) You pay
All stages of breast reconstruction surgery following a mastectomy, Nothing 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 require preapproval by the Plan, and are limited to: Nothing
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)

2002 Keystone Health Plan East 26 Section 5( b) 26
26 Page 27 28
2002 Keystone Health Plan East 27 Section 5( b)
Organ/ tissue transplants You pay
Limited to: Nothing
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single – Double
Pancreas
Allogeneic (donor) bone marrow transplants
Autologous bone marrow transplants (autologous stem cell and peripheral stem cell support) for the following conditions: acute lymphocytic or

non-lymphocytic leukemia; advanced Hodgkin's lymphoma; advanced non-Hodgkin's lymphoma; advanced neuroblastoma; breast cancer;
multiple myeloma; epithelial ovarian cancer; and testicular, mediastinal, retroperitoneal and ovarian germ cell tumors

— Intestinal transplants (small intestine) and the small intestine with the liver or small intestine with multiple organs such as the liver, stomach
and pancreas.
Note: We cover related medical and hospital expenses of the member donor when we cover the recipient.

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)
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center
Office 27
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2002 Keystone Health Plan East 28 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 Sections 5( a) or (b).

Benefit Description You pay
Inpatient hospital
Room and board, such as Nothing
ward, semiprivate, or intensive care or cardiac 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. 28
28 Page 29 30
2002 Keystone Health Plan East 29 Section 5( c)
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
— 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 and schools
— Personal comfort items, such as telephone, television, barber services, guest meals and beds

— Private nursing care
— Blood and blood derivatives not replaced by the member

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. 29
29 Page 30 31
Extended care benefits/ skilled nursing care facility benefits You pay
Extended care benefit:
We provide a comprehensive range of benefits for up to 180 days per Nothing calendar year when full-time skilled nursing care is necessary and

confinement in a skilled nursing facility is medically appropriate as determined by a Plan doctor and approved by the Plan.

Not covered: custodial care, rest cures, domiciliary or convalescent All charges. care, personal comfort items, such as telephones and television

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 Plan doctor who certifies that the patient is in the terminal stages of
illness, with a life expectancy of approximately six months or less.
Not covered: Independent nursing, homemaker services All charges.

Ambulance
Local professional ambulance service when medically appropriate Nothing and authorized by a Plan doctor.

2002 Keystone Health Plan East 30 Section 5( c) 30
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2002 Keystone Health Plan East 31 Section 5( d)

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.

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.

What to do in case of emergency:
Emergencies within our service area:

If you are in an emergency situation, please call your primary care doctor. In extreme emergencies, if you are unable to contact your doctor, contact the local emergency system (e. g., the 911 telephone system) or go to the
nearest hospital emergency room.
If you are hospitalized in non-Plan facilities and Plan doctors believe care can be better provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges covered in full.

Benefits are available for care from non-Plan providers in a medical emergency only if delay in reaching a Plan provider would result in death, disability or significant jeopardy to your condition.
To be covered by this plan, any follow-up care recommended by non-plan providers must be approved by the Plan or provided by Plan providers.
Emergencies outside our service area:
Benefits are available for any medically necessary health service that is immediately required because of injury or unforeseen illness.

If you need to be hospitalized, the Plan must be notified within 48 hours or on the first working day following your admission, unless it was not reasonably possible to notify the Plan within that time. If a Plan doctor believes care
can be better provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges covered in full.

To be covered by this Plan, any follow up care recommended by non-Plan providers must be approved by the Plan or provided by Plan providers. 31
31 Page 32 33
Benefit Description You pay
2002 Keystone Health Plan East 32 Section 5( d)
Emergency within our service area
Emergency care at a doctor's office $10 per office visit

Emergency care at an urgent care center $35 per visit; waived if admitted to a hospital or if you
Emergency care as an outpatient or inpatient at a hospital, are referred to the ER by your including doctors' services PCP and services could have
been provided by your doctor.
Not covered: Elective care or non-emergency care All charges.

Emergency outside our service area
Emergency care at a doctor's office $10 per office visit

Emergency care at an urgent care center $35 per visit; waived if admitted to a hospital.
Emergency care as an outpatient or inpatient at a hospital, including doctors' services

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

Ambulance
Professional ambulance or air ambulance service when medically Nothing appropriate.

See 5( c) for non-emergency service. 32
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2002 Keystone Health Plan East 33 Section 5( e)
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Section 5 (e). Mental health and substance abuse benefits
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.

Benefit Description You pay
Mental health and substance abuse benefits
All diagnostic and treatment services recommended by a Plan provider and contained in a treatment plan that we approve. The treatment plan

may include services, drugs, and supplies described elsewhere in this brochure.

Note: Plan benefits are payable only when we determine the care is clinically appropriate to treat your condition and only when you receive
the care as part of a treatment plan that we approve.
Professional services, including individual or group therapy by $15 per specialist office visit providers such as psychiatrists, psychologists, or clinical social workers

Medication management

Mental health and substance abuse benefits – Continued on next page.

Your cost sharing responsibilities are no greater than for other
illnesses or conditions. 33
33 Page 34 35
Mental health and substance abuse benefits You pay
Diagnostic tests Nothing
Services provided by a hospital or other facility
Services in approved alternative care settings such as partial hospitalization, 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.

Preauthorization To be eligible to receive these benefits you must obtain a treatment plan and follow all the following authorization processes:
Treatment for mental conditions, including various mental illnesses and substance abuse, is coordinated directly by Magellan Behavioral Health, or any other
behavioral health administrator we designate. Magellan Behavioral Health, acting as our mental health administrator, manages all care related to mental health and
substance abuse services, including referrals to mental health and substance abuse specialists. Questions about related benefits and precertification should be
directed to Magellan Behavioral Health at 1-800/ 688-1911.

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

2002 Keystone Health Plan East 34 Section 5( e) 34
34 Page 35 36
2002 Keystone Health Plan East 35 Section 5( f)
There are important features you should be aware of. These include:
Who can write your prescription. A licensed Plan physician or licensed Plan dentist must write the prescription.

Where you can obtain them. You must fill the prescription at a Plan pharmacy, or by mail at a Plan mail order pharmacy for maintenance medications, except for prescriptions required because of an
out-of-area emergency.

These are the dispensing limitations. Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed for up to a 34-day supply, or 120 unit supply, or
maximum allowed dosage as prescribed by law, whichever is less. Maintenance drugs may be obtained through the Plan Mail Order pharmacy for up to a 90-day supply. Prescription refills will
not be provided beyond six (6) months from the most recent dispensing date. Prescription refills will be dispensed only if 75% of the previously dispensed quantity has been consumed based on the
dosage prescribed.

Why use generic drugs? Generic drugs are lower-priced drugs that are the therapeutic equivalent to more expensive name brand drugs. They must contain the same active ingredients and must be
equivalent in strength and dosage to the original name brand product. Generics cost less than the equivalent name brand product. 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 name brand drugs. You can save money by using generic drugs. However, you and your physician have
the option to request a name-brand, even if a generic option is available. Using the most cost-effective medication saves money.

When you have to file a claim. Prescription drugs obtained from a non-Plan pharmacy, for an out-of-area emergency will be reimbursed. You must submit acceptable proof-of-payment with a direct
reimbursement form. All claims for payment must be received within ninety (90) days of the date of proof-of-purchase. Direct reimbursement forms may be obtained by calling 1-800/ 227-3114.

Prescription drug benefits begin on the next page.

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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.
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. 35
35 Page 36 37
2002 Keystone Health Plan East 36 Section 5( f)
Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan physician, or licensed Plan dentist, and obtained from a Plan pharmacy or

through our mail order program:
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 – up to a three-cycle supply for a single copay.

Contraceptive diaphragms and IUDs
Implanted time-release medications, such as Norplant
Insulin, with a copay charge applied to each vial
Diabetic supplies, including disposable insulin needles and syringes, glucose test tablets and test tape, Benedict's solution or equivalent,

acetone test tablets, diabetic blood testing strips, lancets and glucometers. Copay applies to each diabetic supply, except lancets
and glucometers obtained through a Plan Participating Pharmacy.
Disposable needles and syringes for the administration of covered medications

Prenatal and pediatric vitamins
Oral and non-injectable fertility drugs
Drugs to treat sexual dysfunction may be subject to dosage limitations. Contact the Plan for dose limits.

At a Retail Pharmacy for up to a 34-day supply or 120 units,
whichever is less.
A $5 copay per prescription unit or refill for generic or name brand drugs.

At a Retail Pharmacy for up to a 90-day supply for maintenance
medications:
A $15 copay per prescription unit or refill for generic or name brand drugs.

At a Mail Order Pharmacy for up to a 90-day supply for maintenance
medications:
A $5 copay per prescription unit or refill for generic or name brand drugs. 36
36 Page 37 38
2002 Keystone Health Plan East 37 Section 5( f)
Covered medications and supplies (continued) You pay
Not covered: All Charges.
Drugs and supplies used for cosmetic purposes
Vitamins and nutritional substances that can be purchased without a prescription, except for prenatal and pediatric vitamins

Drugs available without a prescription or for which there is a nonprescription equivalent available
The cost of a prescription drug when the usual and customary charge is less than the member's prescription drug copay
Drugs obtained at a non-Plan pharmacy, except for out-of-area emergencies
Medical supplies such as dressings and antiseptics
Drugs to enhance athletic performance
Refills resulting from loss or theft, or any unauthorized refills
Nicotine patches or gum or any other pharmacological therapy for smoking cessation

Injectable fertility drugs
Pharmacological therapy for weight reduction or diet agents, except for treatment of Morbid Obesity 37
37 Page 38 39
Section 5 (g). Special features
Feature Description

Services for deaf and TDD #215/ 241-2018 hearing impaired

Urgent care/ travel benefit Ordinarily, you must get your care from providers who contract with us. As a Keystone Health Plan East member, you have access to urgent care
through a nationwide network of Blue Cross and Blue Shield providers. Urgent care includes covered services provided in order to treat an
unexpected illness or injury that is not life-threatening. The services must be required in order to prevent a serious deterioration in your or a covered
family member's health if treatment were delayed.
If you become ill or injured while visiting outside the service area, call 1-800-810-BLUE to find names and addresses of nearby participating
Blue Cross and Blue Shield providers. Before you obtain any urgent care, call Patient Care Management at 1-800-227-3116, the phone number on
your ID Card to have care preauthorized. An office visit copayment will be collected when the service is rendered. You will not need to file a
claim.
No coverage will be provided for urgent care that has not been preauthorized.

2002 Keystone Health Plan East 38 Section 5( g) 38
38 Page 39 40
2002 Keystone Health Plan East 39 Section 5( h)
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Section 5 (h). Dental benefits
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

Plan dentists must provide or arrange your care.
We cover hospitalization for dental procedures only when a nondental physical impairment exists which makes hospitalization necessary to safeguard the health of the

patient; we do not cover the dental procedure unless it is described below.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other

coverage, including with Medicare.

Benefit Description You pay
Accidental injury benefit
We cover restorative services and supplies necessary to promptly repair $15 copay per visit (but not replace) sound natural teeth. The services are covered if they

are initiated within 6 months after the accident, or as other medical conditions permit, and are provided by participating Plan dentists. The
need for these services must result from an accidental injury.

Dental benefits are continued on next page. 39
39 Page 40 41
2002 Keystone Health Plan East 40 Section 5( h)
Dental benefits
Service You Pay
The following dental services are covered when provided by participating $5 copay per office visit Plan general dentists:

Preventive services:
Oral examination and diagnosis (limited to once in 6 months)
Prophylaxis/ teeth cleaning to include scaling and polishing (limited to once in 6 months)

Topical fluoride (includes child and adult)
Oral hygiene instruction

Diagnostic services:
Complete series X-rays
Intraoral occlusal film
Bitewings (limited to once in 6 months)
Emergency examination
Panoramic film
Cephalometric film

Restorative services:
Amalgam (silver) restoration to primary and permanent teeth
Anterior and posterior composite restoration to primary and permanent teeth

Pin restoration
Sedative restoration (per tooth)
Emergency treatment (palliative)

Other services:
Endodontic
Orthodontic
Oral surgery
Single unconnected crowns
Prosthodontics

Out-of-area dental services:
We will provide coverage for dental services in connection with dental emergencies for palliative treatment (to relieve pain). To receive

payment for these services, you must submit a receipt to Member Services. The receipt must be itemized and show the dental services
performed and the charge for each service.
Not covered: Other dental services not shown as covered All charges.

All charges after the Plan maximum allowance of $25 per occurrence.

A discounted amount; what you pay may change periodically, so call us
for the amounts you pay for these dental services. 40
40 Page 41 42
2002 Keystone Health Plan East 41 Section 5( i)
Section 5 (i). Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed claim about them. Fees you pay for these services do not count toward FEHB deductibles or
out-of-pocket maximums.
Keystone Health Plan East also offers members these Distinct Health Enhancement Opportunities:
Weight Management Program — Keystone and Weight Watchers have special offer for those who want to lose weight and keep it off! Keystone Members receive 100% reimbursement up to $200 on Weight
Watchers 1 or a network hospital program of their choice.
New Fitness Reimbursement Program — To give members added incentive to maintain an active lifestyle, we will reimburse members up to $150 of their annual fitness club fees. Members can now enjoy
the flexibility of joining any approved fitness club and working out at multiple fitness clubs. Visits can be recorded by swipe-card, computer printout, telephone or logbook. Members must complete 120 visits per
365-day enrollment period to receive reimbursement.
Smoking Cessation Program — If you smoke, quitting is one of the best things you can do for your health. Better yet, when you kick the habit, we'll help foot the bill! You can get up to $200 back when
you complete your choice of a variety of proven smoking cessation programs. And to give you more incentive, we now will reimburse you the costs of nicotine replacement products and smoking cessation
aids. If you choose a smoking cessation program that costs less than $200, you can use the difference toward the purchase of nicotine replacement products, such as "the patch" or chewing gum.

Red Cross CPR and First Aid Course Reimbursement — Keystone Health Plan East members will receive up to $25 reimbursement for any course offered by the American Red Cross.
Child Safety Program — Offers tips on how to reduce children's risk for household accidents such as burns, injuries from firearms, choking, and accidental poisonings. Our newly enhanced Family Health
Portfolio includes "Mr. Yuk" stickers to place on poisonous substances, a coupon for a free bottle of Syrup of Ipecac, reimbursement up to $25 for a bike helmet, tips for safe bicycling and more.

Baby Blueprints — Our maternity program helps identify possible risk factors during pregnancy. It also offers educational materials and up to $50 back for the cost of any childbirth class.
For more information — Call the Health Resource Center 1-800/ 275-2583 or 215/ 241-3367 in the Philadelphia area. 41
41 Page 42 43
Section 6. General exclusions — things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not cover it unless your Plan doctor determines it is medically necessary to prevent, diagnose, or treat
your illness, disease, injury, or condition and we agree, as discussed under What Services Require Our Prior Approval on page 12.

We do not cover the following:
Care by non-Plan providers except for authorized referrals or emergencies (see Emergency Benefits);
Services, drugs, or supplies you receive while you are not enrolled in this Plan;
Services, drugs, or supplies that are not medically necessary;
Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice;

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

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

2002 Keystone Health Plan East 42 Section 6 42
42 Page 43 44
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or fill your prescription drugs at Plan pharmacies, you will not have to file claims. Just present your identification card and pay your copayment.

You will only need to file a claim when you receive emergency services from non-Plan providers. Sometimes these providers bill us directly. Check with the provider. If you need to file the claim, here is the process:
Medical, Hospital and 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 1-800/ 227-3114.

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: Keystone Health Plan East 1901 Market Street
Philadelphia, PA 19103
Deadline for filing your claim Send us all of the documents for your claim as soon as possible. You must submit the claim by December 31 of the year after the year you
received the service, unless timely filing was prevented by administrative operations of Government or legal incapacity,
provided the claim was submitted as soon as reasonably possible.
When we need more information Please reply promptly when we ask for additional information. We may delay processing or deny your claim if you do not respond.

2002 Keystone Health Plan East 43 Section 7 43
43 Page 44 45
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your claim or request for services, drugs, or supplies – including a request for preauthorization:

Step Description
1 Ask us in writing to reconsider our initial decision. You must: (a) Write to us within 6 months from the date of our decision; and
(b) Send your request to us at: 1901 Market Street, Philadelphia, PA 19103; and
(c) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure; and

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

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

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

We will write to you with our decision.

4 If you do not agree with our decision, you may ask OPM to review it. You must write to OPM within:
90 days after the date of our letter upholding our initial decision; or
120 days after you first wrote to us – if we did not answer that request in some way within 30 days; or
120 days after we asked for additional information.

Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Contracts Division 3, 1900 E Street, NW, Washington, D. C. 20415-3630.

Send OPM the following information
A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;

Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms;
Copies of all letters you sent to us about the claim;
Copies of all letters we sent to you about the claim; and
Your daytime phone number and the best time to call.

Note: If you want OPM to review different claims, you must clearly identify which documents apply to which claim.

2002 Keystone Health Plan East 44 Section 8 44
44 Page 45 46
Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representative, such as medical providers, must include a copy of your specific written consent with the
review request.
Note: The above deadlines may be extended if you show that you were unable to meet the deadline because of reasons beyond your control.

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

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

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

NOTE: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and
(a) We haven't responded yet to your initial request for care or preauthorized/ prior approval, then call us at 1-800/ 227-3114 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.

2002 Keystone Health Plan East 45 Section 8 45
45 Page 46 47
Section 9. Coordinating benefits with other coverage
When you have other health coverage You must tell us if you are covered or a family member is covered under another group health plan or have automobile insurance that pays health
care expenses without regard to fault. This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in full as the primary payer and the other plan pays a reduced benefit as the

secondary payer. We, like other insurers, determine which coverage is primary according to the National Association of Insurance
Commissioners' guidelines.
When we are the primary payer, we will pay the benefits described in this brochure.

When we are the secondary payer, we will determine our allowance. After the primary plan pays, we will pay what is left of our allowance,
up to our regular benefit. We will not pay more than our allowance.
What is Medicare? Medicare is a Health Insurance Program for:
People 65 years of age and older.
Some people with disabilities, under 65 years of age.
People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant).

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

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

Security check or your retirement check.
If you are eligible for Medicare, you may have choices in how you get your health care. Medicare + Choice is the term used to describe the

various health plan choices available to Medicare beneficiaries. The information in the next few pages shows how we coordinate benefits
with Medicare, depending on the type of Medicare managed care plan you have.

The Original Medicare Plan The Original Medicare Plan (Orginial Medicare) is a Medicare+ Choice (Part A or Part B) plan that is available everywhere in the United States. It is the way
everyone used to get Medicare benefits and is the 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 Orginial Medicare Plan pays its share and you pay your share. Some things are not covered under
Original Medicare, like prescription drugs.
When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care.

Your care must continue to be authorized by your Plan PCP. We will not waive any of our copayments.
(Primary payer chart begins on next page.)

2002 Keystone Health Plan East 46 Section 9 46
46 Page 47 48
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 (except for claims

that 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, or
d) Are a former spouse of an active employee
Please note, if your Plan physician does not participate in Medicare, you will have to file a claim with Medicare.

2002 Keystone Health Plan East 47 Section 9 47
47 Page 48 49
Claims process when you have the Orginial 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/ 227-3114.
We do not waive any costs when you have Medicare.
Medicare managed care plan If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from another type of Medicare+ Choice plan – a
Medicare managed care plan. These are health care choices (like HMOs) in some areas of the country. In most Medicare managed care plans, you
can only go to doctors, specialists, or hospitals that are part of the plan. Medicare managed care plans provide all the benefits that Original
Medicare covers. Some cover extras, like prescription drugs. To learn more about enrolling in a Medicare managed care plan, contact Medicare
at 1-800-MEDICARE (1-800-633-4227) or at www. medicare. gov.
If you enroll in a Medicare managed care plan, the following options are available to you:

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

This Plan and another plan's Medicare managed care plan: You may enroll in another plan's Medicare managed care plan and also remain
enrolled in our FEHB plan. We will still provide benefits when your Medicare managed care plan is primary, even out of the managed care
plan's network and/ or service area (if you use our Plan providers), but we will not waive any of our copayments. If you enroll in a Medicare
managed care plan, tell us. We will need to know whether you are in the Original Medicare Plan or a Medicare managed care plan so we can
correctly coordinate benefits with Medicare.
Suspended FEHB coverage to enroll in a Medicare managed care plan: If you are an annuitant or former spouse, you can suspend your
FEHB coverage to enroll in a Medicare managed care plan, eliminating your FEHB premium. (OPM does not contribute to your Medicare
managed care plan premium.) For information on suspending your FEHB enrollment, contact your retirement office. If you later want to
re-enroll in the FEHB Program, generally you may do so only at the next open season unless you involuntarily lose coverage or move out of
the Medicare managed care plan's service area.
If you do not enroll in If you do not have one or both Parts of Medicare, you can still be Medicare Part A or Part B covered under the FEHB Program. We will not require you to enroll in
Medicare Part B and, if you can't get premium-free Part A, we will not ask you to enroll in it.

2002 Keystone Health Plan East 48 Section 9 48
48 Page 49 50
TRICARE TRICARE is the health care program for eligible dependents of military persons and retirees of the military. TRICARE includes the CHAMPUS
program. If both TRICARE and this Plan cover you, we pay first. See your TRICARE Health Benefits Advisor if you have questions about
TRICARE coverage.
Workers' Compensation We do not cover services that:
you need because of a workplace-related illness or injury that the Office of Workers' Compensation Programs (OWCP) or a similar
Federal or State agency determines they must provide; or
OWCP or similar agency pays for through a third party injury settlement or other similar proceeding that is based on a claim you
filed under OWCP or similar laws.
Once OWCP or similar agency pays its maximum benefits for your treatment, we will cover your care. You must use our providers.

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

When others are responsible When you receive money to compensate you for medical or hospital for injuries 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.

2002 Keystone Health Plan East 49 Section 9 49
49 Page 50 51
Section 10. Definitions of terms we use in this brochure
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and
ends on December 31 of the same year.
Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 13.

Covered services Care we provide benefits for, as described in this brochure.
Custodial Care Care provided primarily for maintenance of the patient or care which (Domiciliary Care) is designed essentially to assist the patient in meeting his/ her activities
of daily living and which is not primarily provided for its therapeutic value in the treatment of an illness, disease, bodily injury, or condition.
Custodial care includes, but is not limited to, help in walking, bathing, dressing, feeding, preparation of special diets and supervision of self-administration
of medications which do not require the technical skills or professional training of medical or nursing personnel in order to be
performed safely and effectively.
Experimental or To establish if a biological, medical device, drug or procedure is or is not investigational services experimental/ investigational, a technology assessment is performed.
The results of the assessment provide the basis for the determination of the service's status (e. g., medically effective, experimental, etc.).
Technology assessment is the review and evaluation of available data from multiple sources using industry standard criteria to assess the
medical effectiveness of the service. Sources of data used in technology assessment include, but are not limited to, clinical trials, position papers,
articles published by local and/ or nationally accepted medical organizations or peer-reviewed journals, information supplied by
government agencies, as well as regional and national experts and/ or panels and, if applicable, literature supplied by the manufacturer.

Us/ We Us and we refer to Keystone Health Plan East.
You You refers to the enrollee and each covered family member.

2002 Keystone Health Plan East 50 Section 10 50
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Section 11. FEHB facts
No pre-existing condition We will not refuse to cover the treatment of a condition that you had limitation before you enrolled in this Plan solely because you had the condition
before you enrolled.
Where you can get information See www. opm. gov/ insure. Also, your employing or retirement office about enrolling in the can answer your questions, and give you a Guide to Federal Employees

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

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

When your enrollment ends; and
When the next open season for enrollment begins.
We don't determine who is eligible for coverage and, in most cases, cannot change your enrollment status without information from your
employing or retirement office.
Types of coverage available Self Only coverage is for you alone. Self and Family coverage is for for you and your family you, your spouse, and your unmarried dependent children under age 22,
including any foster children or stepchildren your employing or retirement office authorizes coverage for. Under certain circumstances,
you may also continue coverage for a disabled child 22 years of age or older who is incapable of self-support.

If you have a Self Only enrollment, you may change to a Self and Family enrollment if you marry, give birth, or add a child to your
family. You may change your enrollment 31 days before to 60 days after that event. The Self and Family enrollment begins on the first day
of the pay period in which the child is born or becomes an eligible family member. When you change to Self and Family because you
marry, the change is effective on the first day of the pay period that begins after your employing office receives your enrollment form;
benefits will not be available to your spouse until you marry.
Your employing or retirement office will not notify you when a family member is no longer eligible to receive health benefits, nor will we.
Please tell us immediately when you add or remove family members from your coverage for any reason, including divorce, or when your
child under age 22 marries or turns 22.
If you or one of your family members is enrolled in one FEHB plan, that person may not be enrolled in or covered as a family member by
another FEHB plan.

2002 Keystone Health Plan East 51 Section 11 51
51 Page 52 53
When benefits and The benefits in this brochure are effective on January 1. If you joined premiums start 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.
Your medical and claims 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 When you retire, you can usually stay in the FEHB Program. Generally, you must have been enrolled in the FEHB Program for the last five years
of your Federal service. If you do not meet this requirement, you may be eligible for other forms of coverage, such as temporary continuation
of coverage (TCC).
When you lose benefits
When FEHB coverage ends You will receive an additional 31 days of coverage, for no additional premium, when:

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

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

Temporary Continuation of If you leave Federal service, or if you lose coverage because you no Coverage (TCC) 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.

2002 Keystone Health Plan East 52 Section 11 52
52 Page 53 54
Enrolling in TCC. Get the RI 79-27, which describes TCC, and the RI 70-5, the Guide to Federal Employees Health Benefits Plans for
Temporary Continuation of Coverage and Former Spouse Enrollees, from your employing or retirement office or from www. opm. gov/ insure.
It explains what you have to do to enroll.
Converting to You may convert to a non-FEHB individual policy if: individual coverage
Your coverage under TCC or the spouse equity law ends (If you canceled your coverage or did not pay your premium, you cannot

convert);
You decided not to receive coverage under TCC or the spouse equity law; or

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

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

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

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

2002 Keystone Health Plan East 53 Section 11 53
53 Page 54 55
Long Term Care Insurance Is Coming Later in 2002!
The Office of Personnel Management (OPM) will sponsor a high-quality long term care insurance program effective in October 2002. As part of its educational effort, OPM asks you to consider these questions:
What is long term care It's insurance to help pay for long term care services you may need if you can't (LTC) insurance? 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.
I'm healthy. I won't need Welcome to the club! long term care. Or, will I? 76% of Americans believe they will never need long term care, but the facts are
that about half of them will. And it's not just the old folks. About 40% of people needing long term care are under age 65. They may need chronic care
due to a serious accident, a stroke, or developing multiple sclerosis, etc. We hope you will never need long term care, but 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.

Is long term care expensive? 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.
But won't my FEHB plan, Not FEHB. Look at the "Not covered" blocks in sections 5( a) and 5( c) of your Medicare or Medicaid cover FEHB brochure. Health plans don't cover custodial care or a stay in an assisted
my long term care? 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.

When will I get more information Employees will get more information from their agencies during the LTC open on how to apply for this new enrollment period in the late summer/ early fall of 2002.
insurance coverage? Retirees will receive information at home.
How can I find out more about Our toll-free teleservice center will begin in mid-2002. In the meantime, you the program NOW? can learn more about the program on our web site at www. opm. gov/ insure/ ltc.

Many FEHB enrollees think that their health plan and/ or Medicare will cover their long-term care needs. Unfortunately, they are WRONG!
How are YOU planning to pay for the future custodial or chronic care you may need?
You should consider buying long-term care insurance.

2002 Keystone Health Plan East 54 Long Term Care Insurance 54
54 Page 55 56
Index
Do not rely on this page; it is for your convenience and may not show all pages where the terms appears.

Accidental injury 39 Allergy tests 19
Allogeneic (donor) bone marrow transplant 27
Alternative treatment 23 Ambulance 32
Anesthesia 27 Autologous bone marrow
transplant 27 Biopsies 24
Birthing centers 29 Blood and blood plasma 29
Breast cancer screening 17 Casts 29
Catastrophic protection 13 Changes for 2002 8
Chemotherapy 20 Childbirth 18
Chiropractic 23 Cholesterol tests 16
Circumcision 18 Claims 43
Coinsurance 13 Colorectal cancer screening 16
Congenital anomalies 24 Contraceptive devices and drugs 36
Coordination of benefits 46 Covered charges 9
Covered providers 9 Crutches 22
Deductible 13 Definitions 50
Dental care 39 Diagnostic services 16
Disputed claims review 44 Donor expenses (transplants) 27
Dressings 29 Durable medical equipment
(DME) 22 Educational classes and programs 23
Effective date of enrollment 4 Emergency 31
Experimental or investigational 50 Eyeglasses 21
Family planning 18

Fecal occult blood test 16 General Exclusions 42
Hand therapy 20 Hearing services 21
Home health services 23 Hospice care 30
Home nursing care 23 Hospital 11
Immunizations 17 Infertility 19
Inhospital physician care 15 Inpatient Hospital Benefits 28
Insulin 36 Laboratory and pathological
services 16 Machine diagnostic tests 16
Magnetic Resonance Imagings (MRIs) 16
Mail Order Prescription Drugs 35 Mammograms 17
Maternity Benefits 18 Medicaid 49
Medically necessary 9 Medicare 46
Members 4 Mental Conditions/ Substance Abuse
Benefits 33 Neurological testing 16
Newborn care 18 Non-FEHB Benefits 41
Nurse Licensed Practical Nurse 28
Nurse Anesthetist 29 Nurse Midwife 18
Nurse Practitioner 28 Psychiatric Nurse 33
Registered Nurse 28 Nursery charges 18
Obstetrical care 18 Occupational therapy 20
Ocular injury 21 Office visits 15
Oral and maxillofacial surgery 26 Orthopedic devices 22
Ostomy and catheter supplies 29

Out-of-pocket expenses 13 Outpatient facility care 29
Oxygen 29 Pap test 16
Physical examination 17 Physical therapy 20
Physician 10 Pre-admission testing 29
Precertification 12 Preventive care, adult 16
Preventive care, children 17 Prescription drugs 35
Preventive services 16 Prior approval 12
Prostate cancer screening 16 Prosthetic devices 22
Psychologist 33 Psychotherapy 33
Radiation therapy 20 Renal dialysis 20
Room and board 28 Second surgical opinion 15
Skilled nursing facility care 30 Smoking cessation 41
Speech therapy 20 Splints 29
Sterilization procedures 18 Subrogation 49
Substance abuse 33 Surgery 24
Anesthesia 27 Oral 26
Outpatient 27 Reconstructive 25
Syringes 36 Temporary continuation of
coverage 52 Transplants 27
Treatment therapies 20 Urgent care/ travel benefit 38
Vision services 21 Well child care 17
Wheelchairs 22 Workers' compensation 49
X-rays 16

2002 Keystone Health Plan East 55 Index 55
55 Page 56 57
NOTES:
2002 Keystone Health Plan East 56 Notes 56
56 Page 57 58
Summary of Benefits for Keystone Health Plan East – 2002
Do not rely on this chart alone. All benefits are provided in full unless indicated and are subject to the definitions, limitations and exclusions in this brochure. On this page we summarize specific expenses we cover;
for more detail, look inside.
If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on your enrollment form.

We only cover services provided or arranged by Plan physicians, except in emergencies.
Benefits Description You pay Page
Medical services provided by physicians

Diagnostic and treatment services provided in the office . . . . . . . . . 15

Services provided by a hospital: Inpatient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nothing 28
Outpatient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nothing 29
Emergency benefits: In-area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $35 per emergency room 31

visit; waived if admitted
Out-of-area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $35 per emergency room 31 visit; waived if admitted

Mental health and substance abuse treatment . . . . . . . . . . . . . . . . . . . . .. Regular cost sharing 33
Prescription drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . At a Retail Pharmacy: $5 35 copay for generic or name

brand drugs for up to a 34-day supply; $15 copay
for up to a 90-day supply for maintenance drugs.
At a Mail Order Pharmacy: $5 copay for generic or
name brand drugs for up to a 90-day supply for
maintenance drugs.
Dental Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Accidental injury benefit; $15 copay per visit

Preventive, Diagnostic, and Restorative dental care $5 copay per visit
Vision Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 One refraction every two years. $15 copay per visit

Special Features: Services for deaf and hearing impaired; and 38 Urgent care/ travel benefit.
Protection against catastrophic costs Nothing after $1,000/ Self 13 (your out-of-pocket maximum) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Only or $2,000/ Family
enrollment per year
Some costs do not count toward this protection.

Office visit copay: $10 primary care; $15
specialist

2002 Keystone Health Plan East 57 Summary 57
57 Page 58 59
58
58 Page 59 60
59
59 Page 60
2002 Rate Information for
Keystone Health Plan East

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 and Tool & Die employees (see 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. Refer to the applicable FEHB Guide.

Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly
Type of Gov't Your Gov't Your USPS Your Enrollment Code Share Share Share Share Share Share

Self Only ED1 $96.45 $32.15 $208.97 $69.66 $114.13 $14.47
Self and Family ED2 $223.41 $115.49 $484.06 $250.22 $263.75 $75.15 60

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