Pages 1--59 from Western Health Advantage

RI 73-780

Western Health Advantage http:// www. westernhealth. com
2002

Serving: Portions of Northern California
Enrollment in this Plan is limited. You must live or work in our Geographic service area to enroll. See page 7 for requirements.

Enrollment codes for this Plan:
5Z1 Self Only 5Z2 Self and Family

For changes in benefits
see page 8. 1
1 Page 2 3
2002 Western Health Advantage 2 Table of Contents
Table of Contents
Introduction………………………………………………………………….............................................................. 4
Plain Language………………………………………………………………............................................................ 4
Inspector General Advisory..................................................................................................................................... 4
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 .................................................................................................................................... 9
Specialty care ................................................................................................................................ 10
Hospital care.................................................................................................................................. 10
Circumstances beyond our control........................................................................................................ 11
Services requiring our prior approval.................................................................................................... 11
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 .................................................................................................... 30
(e) Mental health and substance abuse benefits ................................................................................ 33
(f) Prescription drug benefits .......................................................................................................... 35 2
2 Page 3 4
2002 Western Health Advantage 3 Table of Contents
(g) Special features…………………………………………………………………………….…… 38
Advantage Referral Program
(h) Dental benefits ………………………………………………………………….……………… 39
Section 6. General exclusions --things we don't cover……………………………………………………………… 40
Section 7. Filing a claim for covered services .................................................................................................... …41
Section 8. The disputed claims process .................................................................................................................. 43
Section 9. Coordinating benefits with other coverage ............................................................................................. 45
When you have…
Other health coverage ...................................................................................................................... 45
The Original Medicare Plan ............................................................................................................. 45
Medicare managed care plan............................................................................................................ 48
TRICARE/ Workers' Compensation/ Medicaid ....................................................................................... 48
Other Government agencies .................................................................................................................. 49
When others are responsible for injuries ................................................................................................ 49
If you have a malpractice claim ............................................................................................................ 49
Section 10. Definitions of terms we use in this brochure .......................................................................................... 50
Section 11. FEHB facts ........................................................................................................................................... 52

Coverage information............................................................................................................................ 52
No pre-existing condition limitation ........................................................................................ 52
Where you get information about enrolling in the FEHB Program ............................................ 52
Types of coverage available for you and your family ............................................................... 52
When benefits and premiums start ........................................................................................... 52
Your medical and claims records are confidential.................................................................... 53
When you retire....................................................................................................................... 53
When you lose benefits ......................................................................................................................... 53
When FEHB coverage ends ..................................................................................................... 53
Spouse equity coverage ........................................................................................................... 53
Temporary Continuation of Coverage (TCC) ........................................................................... 53
Enrolling in TCC..................................................................................................................... 54
Converting to individual coverage ........................................................................................... 54
Getting a Certificate of Group Health Plan Coverage ............................................................... 54
Long term care insurance is coming later in 2002 ..................................................................................................... 55
Index…………….. .................................................................................................................................................. 57

Summary of benefits ................................................................................................................................................ 58
Rates………… .. ........................................................................................................................................ Back cover 3
3 Page 4 5
2002 Western Health Advantage 4 Introduction/ Plain Language/ Advisory
Introduction
Western Health Advantage 1331 Garden Highway, Suite 100
Sacramento, CA 95833-9773
This brochure describes the benefits of Western Health Advantage (WHA) under our contract (CS 2840) 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 Western Health Advantage.
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.

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 1-888-563-2250
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 4
4 Page 5 6
2002 Western Health Advantage 5 Introduction/ Plain Language/ Advisory
Penalties for Fraud Anyone who falsifies a claim to obtain FEHB Program benefits can be prosecuted for fraud. Also, the Inspector General may investigate
anyone who uses an ID card if the person tries to obtain services for someone who is not an eligible family member, or is no longer enrolled
in the Plan and tries to obtain benefits. Your agency may also take administrative action against you. 5
5 Page 6 7
2002 Western Health Advantage 6 Section 1
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and other providers that contract with us. These Plan providers coordinate your health care services.

HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in addition to treatment for illness and injury. Our providers follow generally accepted medical practice when
prescribing any course of treatment.
When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You only pay the copayments, or coinsurance described in this brochure. When you receive emergency services from non-Plan
providers, you may have to submit claim forms.
You should join an HMO because you prefer the plan's benefits, not because a particular provider is available. You cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician,
hospital, or other provider will be available and/ or remain under contract with us.
How we pay providers
We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure. These Plan providers accept a negotiated payment from us, and you will only be responsible for your copayments, or
coinsurance.
Who provides my health care
Our plan doctors treat patients in a group practice arrangement at multiple convenient locations near your home or office. WHA features some of the region's premiere medical professionals, giving our members access to
more than 500 primary care doctors and more than 1100 specialty physicians. Each member of your family can choose their own primary care doctor. He/ she is responsible for coordinating your health care with specialists and
other medical providers. To give you more flexibility in choosing specialty care, WHA offers you access to all the specialty physicians in the network, not just those who are affiliated with your primary care doctor's medical
group.
When you enroll, you will be asked to let the Plan know which primary care physician (s) you've selected for you and each member of your family by sending a Primary Care Designation form to the Plan. If you need help
choosing a doctor, call the Plan. Members may change their doctor selection monthly by notifying the Plan 30 days in advance. Each member of the family may choose their own primary care doctor from the complete list of
participating primary care physicians. Your Primary Care doctor will make arrangements for you to seek specialty care when the need arises. Women can self-refer to participating OB/ Gyn doctors whenever they need
these services without a referral, and everyone can self-refer for an annual eye exam to one of the participating eye specialists.

WHA wants you to receive the care you need, when you need it. In most cases your primary care doctor will be available for urgent visits. When that is not possible, we also offer a unique program, which ensures access to
another primary care doctor for acute medical needs within one working day. Please call your primary care doctor's office when you have an urgent situation and need to see a doctor.

Your Rights
OPM requires that all FEHB Plans provide certain information to their FEHB members. You may get information about us, our networks, providers, and facilities. OPM's FEHB website (www. opm. gov/ insure) lists the specific types
of information that we must make available to you. Some of the required information is listed below. Western Health Advantage is a full service, not-for-profit health care plan operating in Sacramento, Yolo, and
portions of Placer, Solano, and El Dorado Counties. Western Health Advantage was created by local health care providers in 1997 who believe health care can be
delivered in a managed care environment without sacrificing service and quality. 6
6 Page 7 8
2002 Western Health Advantage 7 Section 1
Western Health Advantage has been granted "New Health Plan" Accreditation effective December 1, 1999 by NCQA.
If you want more information about us, call 916/ 563-2250 or toll free 1-888/ 563-2250, or write to:
Western Health Advantage 1331 Garden Highway, Suite 100
Sacramento, CA 95833
You may also contact us by fax at 916/ 563-3182 or visit our website at www. westernhealth. com.
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: all of Sacramento and Yolo Counties, and portions of the following counties: Placer, El Dorado
and Solano (zip codes shown below).
Placer County zip codes:
95602, 95603, 95604, 95631( partial), 95648, 95650, 95658, 95661, 95663, 95677, 95678, 95681, 95703, 95713, 95722, 95736, 95746, 95747, 95765

El Dorado County zip codes:
95613, 95614, 95619, 95623, 95633, 95634, 95635, 95636, 95656, 95667, 95672, 95675, 95682, 95684, 95709, 95726, 95762

Solano County zip codes:
94512, 94533, 94535, 94571, 94585, 95620, 95625, 95687, 95688, 95696
Ordinarily, you must get your care from providers who contract with us. If you receive care outside our service area, we will pay only for emergency care benefits. We will not pay for any other health care services out of our
service area unless the services have prior plan approval.
If you or a covered family member move outside of our service area, you can enroll in another plan. If your dependents live out of the area (for example, if your child goes to college in another state), you should consider
enrolling in a fee-for-service plan or an HMO that has agreements with affiliates in other areas. If you or a family member move, you do not have to wait until Open Season to change plans. Contact your employing or retirement
office. 7
7 Page 8 9
2002 Western Health Advantage 8 Section 2
Section 2. How we change for 2002
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5 Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here is a
clarification that does not change benefits.

Program-wide changes
We changed the address for sending disputed claims to OPM. (Section 8)

Changes to this Plan
Your share of the non-Postal premium will increase by 21.3% for Self Only or 21.3% for Self and Family.
We now show coverage for certain intestinal transplants. (Section 5( b))
We changed speech therapy benefits by removing the requirement that services must be required to restore functional speech, and we now provide coverage for speech therapy at 14 visits per condition subject to a $10
copay per visit. (Section 5( a))
We no longer limit total blood cholesterol tests to certain age groups. (Section 5( a))
We have contracted with Magellan Behavior Inc. to administer our Mental Health and Substance Abuse benefit. (Section 5( e))

We have changed our Drug Pharmacy Manager to Merck-Medco Inc. (Section 5( f)) 8
8 Page 9 10
2002 Western Health Advantage 9 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it
whenever you receive services from a Plan provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the
Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation (for annuitants), or your Employee Express confirmation
letter.
If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 916/ 563-2250
or 1-888/ 563-2250

Where you get covered care You get care from "Plan providers" and "Plan facilities." You will only pay copayments and coinsurance, 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 www. westernhealth. com.

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 www. westernhealth. com.

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. You may designate a
different primary care physician for each member if you wish. This decision is important since your primary care physician provides or
arranges for most of your health care.

If you have never been seen by the primary care physician you choose, please call his or her office before designating him or her as your primary
care physician. Not only are some practices temporarily closed because they are full, but this also gives the office the opportunity to explain any
new patient requirements.
The name of your primary care physician will appear on your WHA identification card. If you do not designate a primary care physician at
the time of enrollment, WHA will assign one to you.

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 physician or if your primary care physician leaves the Plan, call us. We will help you select a new one. 9
9 Page 10 11
2002 Western Health Advantage 10 Section 3
Specialty care Your primary care physician will refer you to a specialist for needed care. When you receive a referral from your primary care physician, you must
return to the primary care physician after the consultation, unless your primary care physician authorized a certain number of visits without
additional referrals. The primary care physician must provide or authorize all follow-up care. Do not go to the specialist for return visits unless your
primary care physician gives you a referral. However, women can self-refer to participating OB/ GYN doctors whenever they need these services,
without a referral, and everyone can self-refer for an annual eye exam to one of the participating eye specialists.

Here are other things you should know about specialty care:
If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician
will develop a treatment plan that allows you to see your specialist for a certain number of visits without additional referrals. Your primary
care physician will use our criteria when creating your treatment plan. The treatment plan will permit you to visit your specialist without the
need to obtain further referrals.
If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician. Your primary care physician will decide
what treatment you need. If he or she decides to refer you to a specialist, ask if you can see your current specialist. If your current
specialist does not participate with us, you must receive treatment from a specialist who does. Generally, we will not pay for you to see
a specialist who does not participate with our Plan.
If you are seeing a specialist and your specialist leaves the Plan, call your primary care physician, who will arrange for you to see another
specialist. You may receive services from your current specialist until we can make arrangements for you to see someone else.

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

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

Hospital care Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission
to a skilled nursing or other type of facility.
If you are in the hospital when your enrollment in our Plan begins, call our Member Service Department immediately at 916/ 563-2250 or 10
10 Page 11 12
2002 Western Health Advantage 11 Section 3
1-888/ 563-2250. If you are new to the FEHB Program, we will arrange for you to receive care.
If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:
You are discharged, not merely moved to an alternative care center; or
The day your benefits from your former plan run out; or
The 92 nd day after you become a member of this Plan, whichever happens first.

These provisions apply only to the hospital benefit of the hospitalized person.

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

Services requiring our 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 Prior Authorization. Your physician must obtain prior authorization before sending you to a
hospital, referring you to a specialist, or recommending follow-up care.
Any prior authorization is conditioned upon the member being duly enrolled at the time the covered services are received. If WHA denies
authorization, and the member goes ahead and obtains the service anyway, the member will be responsible for the cost of any services not
authorized by WHA. Additionally, if the member is not duly enrolled or if such authorized services are provided after the date the member's
enrollment ceased, the member will reimburse WHA, if necessary.
Your WHA ID card alerts your provider that you are a WHA member and that certain services will require prior authorization when needed.
Your physician will receive written notice of authorized or denied services and you will be notified of any denials. Please direct your
questions about prior authorization to your primary care physician.
An example of procedures and services that need prior authorization are:
Any provider not listed in WHA's provider directory is a non-participating provider and you must obtain prior authorization from
WHA before obtaining services. All second opinions performed by non-participating providers
require prior authorization from WHA or its delegated medical group.
Some outpatient services, such as diagnostic testing, X-rays, and surgical procedures require prior authorization.
All inpatient hospitalization requires prior authorization, except in an emergency situation.
Hospice services are covered with prior authorization. 11
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2002 Western Health Advantage 12 Section 3
Infertility services are covered including testing, consultations, examinations, diagnostic surgical services related to hospitalizations
or facilities, and drug therapy. Services are covered when obtained with prior authorization.
Chiropractic care (when traditional therapies have been ineffective), when obtained from participating providers upon referral from
primary care physician and with prior authorization. Acupuncture, (when traditional therapies have been ineffective),
when obtained from participating providers upon referral from primary care physician and with prior authorization.
Non-emergency medical transport inside or outside the service area, except with prior authorization.
Medically necessary services as determined by WHA, for the treatment of morbid obesity with a prior authorization. 12
12 Page 13 14
2002 Western Health Advantage 13 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive services.

Example: When you see your primary care physician you pay a copayment of $10 per office visit.
Deductible We do not have a deductible.

Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care.
Example: In our Plan, you pay 50% of our allowance for infertility services, and 20% of our allowance for orthopedic devices, prosthetic
devices, and durable medical equipment.

Your catastrophic protection After your copayments and coinsurance total $750 per person or $1,500 out-of-pocket maximum per family enrollment in any calendar year, you do not have to pay any

for copayments and coinsurance more for covered services. However, copayments and coinsurance for the following services do not count toward your out-of-pocket maximum,
and you must continue to pay copayments and coinsurance for these services: prescription drugs, durable medical equipment, prosthetic
devices and orthotic devices.
Be sure to keep accurate records of your copayments and coinsurance since you are responsible for informing us when you reach the maximum. 13
13 Page 14 15
2002 Western Health Advantage 14 Section 5
Section 5. Benefits --OVERVIEW (See page 8 for how our benefits changed this year and page 58 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 benefits in the following
subsections. To obtain claims forms, claims filing advice, or more information about our benefits, contact us at 1-888/ 563-2250 or at our website at www. westernhealth. com.

(a) Medical services and supplies provided by physicians and other health care professionals………………… 15-23
Diagnostic and treatment services Lab, X-ray, and other diagnostic tests
Preventive care, adult Preventive care, children
Maternity care Family planning
Infertility services Allergy care
Treatment therapies Physical and occupational therapies

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

(b) Surgical and anesthesia services provided by physicians and other health care professionals ...................... 24-27
Surgical procedures Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services................................................... 28-29
Inpatient hospital Outpatient hospital or ambulatory surgical
center
Extended care benefits/ skilled nursing care facility benefits
Hospice care Ambulance

(d) Emergency services/ accidents ................................................................................................................... 30-32 Medical emergency Ambulance
(e) Mental health and substance abuse benefits ............................................................................................... 33-34
(f) Prescription drug benefits.......................................................................................................................... 35-37
(g) Special features.............................................................................................................................................. 38 Advantage Referral Program

(h) Dental benefits............................................................................................................................................... 39
Summary of benefits............................................................................................................................................. 58 14
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2002 Western Health Advantage Section 5( a) 15
Section 5 (a) Medical services and supplies provided by physicians and other health care professionals
I M
P O
R T
A N
T

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

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

coverage, including with Medicare.

I M
P O
R T
A N
T

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

Professional services of physicians
In an urgent care center
During a hospital stay
In a skilled nursing facility

Nothing

Office medical consultations
? Second surgical opinion
$10 per office visit

? At home $10 per office visit 15
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2002 Western Health Advantage Section 5( a) 16
Lab, X-ray and other diagnostic tests You pay
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG

Nothing

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

$10 per office visit, no charge if performed at
laboratory only.

-Sigmoidoscopy, screening – every five years starting at age 50 $10 per office visit
Prostate Specific Antigen (PSA test) – one annually for men age 40 and older $10 per office visit, no charge if performed at
laboratory only.
Routine pap test $10 per office visit, no charge for test.

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

Nothing

Not covered: Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, or travel. All charges.
Routine immunizations, limited to:
Tetanus-diphtheria (Td) booster – once every 10 years, ages19 and over (except as provided for under Childhood immunizations)

Influenza/ Pneumococcal vaccines, annually, age 65 and over

Nothing for immunizations, office visit copay may apply. 16
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2002 Western Health Advantage Section 5( a) 17
Preventive care, children You pay
Childhood immunizations recommended by the American Academy of Pediatrics Nothing

Well-child care charges for routine examinations, immunizations and care (through age 22)
Examinations, such as:
-Eye exams
-Ear exams
-Examinations done on the day of immunizations

$10 per office visit

? Testing and treatment of Phenylketonuria (PKU), which includes the cost of any special foods or formula over and above a "regular diet" $10 per office visit
Maternity care
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Note: Here are some things to keep in mind:
You do not need to preauthorize your normal delivery; see page 29 for other circumstances, such as extended stays for you or your

baby.
You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will extend

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

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

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

Nothing

Not covered: Routine sonograms to determine fetal age, size or sex All charges 17
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2002 Western Health Advantage Section 5( a) 18
Family planning You pay
A broad range of voluntary family planning services, limited to:
Voluntary sterilization
Surgically implanted contraceptives (such as Norplant)

? Injectable contraceptive drugs (such as Depo provera)
? Intrauterine devices (IUDs)
? Diaphragms

NOTE : We cover oral contraceptives under the prescription drug benefit.

$10 per office visit
$200 copayment for Norplant and other

implanted time-release contraceptives.

$10 per office visit.
$10 per office visit.
$10 per office visit.

Not covered: reversal of voluntary surgical sterilization, genetic counseling. All charges
Infertility services
Diagnosis and treatment of infertility, such as:
Artificial insemination:
-intravaginal insemination (IVI)
-intracervical insemination (ICI)
-intrauterine insemination (IUI)
Fertility drugs

Services may include one gamete interfallopian transfer (" GIFT") or one in-vitro fertilization (IVF) but only one of these procedures is covered
per Lifetime.

50% of the charges
50% of charges
50% of charges

Not covered:
Assisted reproductive technology (ART) procedures, such as:
embryo transfer
Services and supplies related to excluded ART procedures
Cost of donor sperm

Cost of donor egg

All charges. 18
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2002 Western Health Advantage Section 5( a) 19
Allergy care You pay
Testing and treatment
Allergy injection
$10 per office visit

$10 per office visit
Allergy serum Nothing
Not covered: provocative food testing and sublingual allergy desensitization All charges.

Treatment therapies
Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone marrow transplants are limited to those transplants listed under

Organ/ Tissue Transplants on page 26.
Respiratory and inhalation therapy
Dialysis – Hemodialysis and peritoneal dialysis
Intravenous (IV)/ Infusion Therapy – Home IV and antibiotic therapy

Growth hormone therapy (GHT)
Note: Growth hormone is covered under the prescription drug benefit.

Nothing

Physical and occupational therapies
For the services of each of the following:
-qualified physical therapists;
-occupational therapists.
Note: We only cover therapy to restore bodily function when there has been a total or partial loss of bodily function due to illness or

injury.
? Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction, is provided for up to 36 sessions

$10 per office visit
$10 per outpatient visit
Nothing per visit during covered inpatient admission

$10 per office visit

Not covered:
long-term rehabilitative therapy
exercise programs

All charges. 19
19 Page 20 21
2002 Western Health Advantage Section 5( a) 20
Speech therapy You pay
14 visits per condition $10 per office visit

Hearing services (testing, treatment, and supplies)
First hearing aid and testing only when necessitated by accidental injury

Hearing testing for all ages.
$10 per office visit
$10 per office visit

Not covered: hearing aids, testing and examinations for them, except when
necessitated by accidental injury
hearing aid batteries.

All charges.

Vision services (testing, treatment, and supplies)
Annual eye exam $10 per office visit

One pair of eyeglasses or contact lenses to correct an impairment directly caused by accidental ocular injury or intraocular surgery

(such as for cataracts)
$10 per office visit

Eye exam to determine the need for vision correction for children through age 17 (see preventive care, children)
Annual eye refractions
$10 per office visit
$10 per office visit

Not covered:
Eyeglasses or contact lenses (except as above) or frames
Eye exercises and orthoptics
Radial keratotomy and other refractive surgery.

All charges.

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

See orthopedic and prosthetic devices for information on podiatric shoe inserts.
$10 per office visit

Foot care –continued on next page 20
20 Page 21 22
2002 Western Health Advantage Section 5( a) 21
Foot care (Continued) You pay
Not covered:
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)

All charges.

Orthopedic and prosthetic devices
Artificial limbs and eyes; stump hose
Leg and knee braces; foot orthotics when medically necessary
Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy

Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implant
following mastectomy. Note: We pay internal prosthetic devices as hospital benefits; see Section 5 (c) for payment information. See
5( b) for coverage of the surgery to insert the device.
Penile Prostheses which are medically necessary secondary to trauma, tumor, or physical disease to the circulatory system or
nerve supply and are not of a psychological cause.
Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.

20% of charges
20% of charges
20% of charges

50% of charges
20% of charges
Not covered:
orthopedic and corrective shoes
arch supports
foot orthotics when not medically necessary
heel pads and heel cups
back braces or other lumbosacral supports
corsets, trusses, elastic stockings, support hose, and other supportive devices

prosthetic replacements provided less than 3 years after the last one we covered

All charges 21
21 Page 22 23
2002 Western Health Advantage Section 5( a) 22
Durable medical equipment (DME) You pay
Rental or purchase, at our option, including repair and adjustment, of durable medical equipment prescribed by your Plan physician, such as

oxygen, oxygen equipment and dialysis equipment. Under this benefit, we also cover:

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

20% of charges

Not covered: Motorized wheelchairs All charges.
Home health services
Home health care ordered by a Plan physician and provided by a registered nurse (R. N.), licensed practical nurse (L. P. N.), licensed
vocational nurse (L. V. N.), or home health aide.
Services include oxygen therapy, intravenous therapy and medications.

Nothing

Not covered: Nursing care requested by, or for the convenience of, the patient or
the patient' s family; Home care primarily for personal assistance that does not include a
medical component and is not diagnostic, therapeutic, or rehabilitative.

All charges.

Chiropractic
Services must be obtained by a referral from your WHA primary care doctor and obtained from a Landmark Healthcare participating plan chiropractor. Up
to 20 visits per calendar year are covered with prior authorization. Services include the following:

Examinations
Manipulation
Conjunctive Physiotherapy
X-rays

$15 per office visit 22
22 Page 23 24
2002 Western Health Advantage Section 5( a) 23
Alternative treatments You pay
Acupuncture -Services must be obtained by a referral from your WHA primary care doctor and obtained from a Landmark Healthcare participating

Acupuncturist. Up to 20 visits per calendar year are covered with prior authorization. Services include the following:

Acupuncture Electroacupuncture
Moxibustion Cupping
Acupressure, when acupuncture is not clinically appropriate

$15 per office visit

Not covered: naturopathic services
hypnotherapy biofeedback
All charges.

Educational classes and programs
Coverage is limited to:

Smoking Cessation-Nicotine transdermal systems, such as Habitrol or Nicoderm are covered as a "Wellness Benefit". You must obtain a
prescription from your primary care physician. One 10-week treatment will be covered per member under any current or future WHA contract.

100% of the cost of the medication, initially. Upon remaining smoke free
for 90 days after treatment, as certified by your physician, WHA will
reimburse you in full. You must be an active participant in WHA at the time
of the reimbursement. Reimbursement should be requested
within 60 days of certification.

Diabetes self-management $10 per office visit 23
23 Page 24 25
2002 Western Health Advantage 24 Section 5( b)
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
I M
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Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

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

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

surgical center, etc.) are covered in Section 5 (c).
YOUR PHYSICIAN MUST GET PRIOR AUTHORIZATION OF SOME SURGICAL PROCEDURES. Please refer to the prior authorization information shown in Section 3 to be sure which

services require prior authorization.

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Benefit Description You pay
Surgical procedures
A comprehensive range of services, such as
Operative procedures Treatment of fractures, including casting

Normal pre-and post-operative care by the surgeon Correction of amblyopia and strabismus
Endoscopy procedures Biopsy procedures
Removal of tumors and cysts Correction of congenital anomalies (see reconstructive surgery)
Surgical treatment of morbid obesity --a condition in which an individual weighs 100 pounds or 100% over his or her normal
weight according to current underwriting standards. Insertion of internal prosthetic devices. See 5( a) – Orthopedic and
prosthetic devices for device coverage information. Voluntary sterilization
Treatment of burns
Note: Generally, we pay for internal prostheses (devices) according to where the procedure is done. For example, we pay Hospital benefits for a
pacemaker and Surgery benefits for insertion of the pacemaker.

$10 per office visit

Surgical procedures -continued on next page 24
24 Page 25 26
2002 Western Health Advantage 25 Section 5( b)
Surgical procedures (Continued) You pay
Not covered: Reversal of voluntary sterilization

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

Reconstructive surgery
Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if:
-the condition produced a major effect on the member's appearance and

-the condition can reasonably be expected to be corrected by such surgery
Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of
congenital anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks; webbed fingers; and webbed toes.

Nothing

All stages of breast reconstruction surgery following a mastectomy, such as:
-surgery to produce a symmetrical appearance on the other breast;
-treatment of any physical complications, such as lymphedemas;
-breast prostheses and surgical bras and replacements (see Prosthetic devices)

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

Nothing
20% of charges

Not covered: 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

All charges 25
25 Page 26 27
2002 Western Health Advantage 26 Section 5( b)
Oral and maxillofacial surgery You pay
Oral surgical procedures, limited to: Reduction of fractures of the jaws or facial bones;

Surgical correction of cleft lip, cleft palate or severe functional malocclusion;
Removal of stones from salivary ducts; Excision of leukoplakia or malignancies;
Excision of cysts and incision of abscesses when done as independent procedures; and
Other surgical procedures that do not involve the teeth or their supporting structures.

$10 per visit if in physician's office.

Not covered: Oral implants and transplants
Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone), including
any dental care involved in the treatment of temporomandibulor joint (TMJ) pain dysfunction sysdrome.

All charges

Organ/ tissue transplants
Limited to:
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
Limited Benefits -Treatment for breast cancer, multiple myeloma, and epithelial ovarian cancer may be provided in an NCI-or NIH-approved

clinical trial at a Plan-designated center of excellence and if approved by the Plan's medical director in accordance with the Plan's protocols.

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

Nothing 26
26 Page 27 28
2002 Western Health Advantage 27 Section 5( b)
Organ/ tissue transplants (Continued) You pay
Not covered: Donor screening tests and donor search expenses, except those

performed for the actual donor Implants of artificial organs

Transplants not listed as covered

All charges

Anesthesia
Professional services provided in – Hospital (inpatient) Nothing

Professional services provided in – Hospital outpatient department
Skilled nursing facility Ambulatory surgical center
Office

Nothing 27
27 Page 28 29
2002 Western Health Advantage 28 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
I M
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A N
T

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

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

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

with the professional charge (i. e., physicians, etc.) are covered in Sections 5( a) or (b).
YOUR PHYSICIAN MUST GET PRIOR AUTHORIZATION OF HOSPITAL STAYS

I M
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Benefit Description You pay
Inpatient hospital Room and board, such as

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

Other hospital services and supplies, such as:
Operating, recovery, maternity, and other treatment rooms Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays Administration of blood and blood products
Blood or blood plasma, if not donated or replaced Dressings, splints, casts, and sterile tray services
Medical supplies and equipment, including oxygen Anesthetics, including nurse anesthetist services
Take-home items Medical supplies, appliances, medical equipment, and any covered
items billed by a hospital for use at home

Nothing 28
28 Page 29 30
2002 Western Health Advantage 29 Section 5( c)
Inpatient hospital (Continued) You pay
Not covered: Custodial care
Non-covered facilities, such as nursing homes, schools Personal comfort items, such as telephone, television, barber services,
guest meals and beds Private nursing care

All charges

Outpatient hospital or ambulatory surgical center
Operating, recovery, and other treatment rooms
Prescribed drugs and medicines Diagnostic laboratory tests, X-rays, and pathology services

Administration of blood, blood plasma, and other biologicals Blood and blood plasma, if not donated or replaced
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.

Nothing

Not covered: blood and blood derivatives not replaced by the member All charges
Extended care benefits/ skilled nursing care facility benefits
The Plan provides a comprehensive range of benefits with no dollar or day limit when full-time skilled nursing care is necessary and confinement in a
skilled nursing facility is medically appropriate as determined by a Plan doctor.
Nothing

Not covered: custodial care All charges
Hospice care

Supportive and palliative care for a terminally ill member is covered in the home or a 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.

Nothing

Not covered: Independent nursing, homemaker services All charges
Ambulance
Local professional ambulance service when medically appropriate. Nothing 29
29 Page 30 31
2002 Western Health Advantage 30 Section 5( d)
Section 5 (d). Emergency services/ accidents
I M
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A N
T

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

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

coverage, including with Medicare.

I M
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What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or could result in serious injury or disability, and requires immediate medical or surgical care. Some problems are

emergencies because, if not treated promptly, they might become more serious; examples include deep cuts and broken bones. Others are emergencies because they are potentially life-threatening, such as heart attacks, strokes, poisonings,
gunshot wounds, or sudden inability to breathe. There are many other acute conditions that we may determine are medical emergencies – what they all have in common is the need for quick action.

Emergency Services and Care also pertain to:
Psychiatric screening, examination, evaluation, and treatment by a physician, or other personnel to the extent permitted by applicable law and within the scope of their licensure and privileges.

Care and treatment necessary to relieve or eliminate the psychiatric emergency medical condition within the capability of a facility.

What to do in case of emergency:
Emergencies within the service area:
When an Emergency situation arises call "911" or go directly to the nearest hospital Emergency Room. If that care is obtained from a non-Participating Provider, we will reimburse the provider for covered medical services received for
Emergency situations, less the applicable co-payment.
If you are hospitalized at a non-participating facility because of an Emergency, WHA must be notified within 24 hours unless it was not reasonably possible to notify the Plan within that time. This telephone call is extremely important. If
you are unable to make the call, have someone else make it for you, such as a Family Member, friend or hospital staff member. WHA will work with the hospital and Physicians coordinating your care and, if possible, arrange for your
transfer back to a participating hospital as well as make appropriate payment provisions.
Follow-up care after an emergency room visit is not considered an Emergency situation. If you receive Emergency treatment from an emergency room physician or non-Participating Physician and you return to the emergency room or
physician for follow-up care (for example, removal of stitches or redressing a wound), you will be responsible for the cost.

Call your Primary Care Physician for all follow-up care. If your health problem requires a specialist, he/ she will refer you to an appropriate Participating provider as needed.

Emergency services/ accidents – continued on next page 30
30 Page 31 32
2002 Western Health Advantage 31 Section 5( d)
Emergency services/ accidents (Continued) __________________________________________________________________________________________________________________________________
Emergencies outside the service area: WHA covers you for Urgent Care and Emergency Care services wherever you are in the world. Please note that
emergency room visits are not covered for non-Emergency situations. When an Emergency situation arises while you are outside of the Service Area call "911" or go directly to the nearest hospital Emergency Room.
Benefits are available for any medically necessary health service that is immediately required because of injury or unforeseen illness.

If you are hospitalized at a non-participating facility because of an Emergency, WHA must be notified within 24 hours unless it was not reasonably possible to notify the Plan within that time. This telephone call is extremely important. If
you are unable to make the call, have someone else make it for you, such as a Family Member, friend or hospital staff member. WHA will work with the hospital and Physicians coordinating your care and, if possible, arrange for your
transfer back to a participating hospital as well as make appropriate payment provisions.
Follow-up care after an emergency room visit is not considered an Emergency situation. If you receive Emergency treatment from an emergency room physician or non-Participating Physician and you return to the emergency room or
physician for follow-up care (for example, removal of stitches or redressing a wound), you will be responsible for the cost.

Call your Primary Care Physician for all follow-up care. If your health problem requires a specialist, he/ she will refer you to an appropriate Participating provider as needed.

Benefit Description You pay
Emergency within our service area

Emergency care at a doctor's office
Emergency care at an urgent care center
Emergency care as an outpatient or inpatient at a hospital, including doctors' services.

$10 per office visit
$15 per visit
$50 per visit (copay is waived if admitted to a hospital)

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

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

$10 per office visit
$15 per visit

$50 per visit (copay is waived if admitted to a hospital)

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

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

All charges. 31
31 Page 32 33
2002 Western Health Advantage 32 Section 5( d)
Ambulance You pay
Professional ambulance service, including air ambulance, when medically appropriate.

See 5( c) for non-emergency service.

Nothing 32
32 Page 33 34
2002 Western Health Advantage 33 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
I M
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T

When you get our approval for services and follow a treatment plan we approve, cost-sharing and limitations for Plan mental health and substance abuse benefits will be no greater than for
similar benefits for other illnesses and conditions.
Here are some important things to keep in mind about these benefits:
All benefits are subject to the definitions, limitations, and exclusions in this brochure.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with

other coverage, including with Medicare.

YOU MUST CALL MAGELLAN BEHAVIORAL HEALTH, INC. TO ACCESS SERVICES. See the instructions after the benefits description below.

I M
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T

Benefit Description You pay
Mental health and substance abuse benefits

All diagnostic and treatment services recommended by a Plan provider and contained in a treatment plan that we approve. The treatment plan may
include services, drugs, and supplies described elsewhere in this brochure.

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

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

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

Mental health and substance abuse benefits -continued on next page 33
33 Page 34 35
2002 Western Health Advantage 34 Section 5( e)
Mental health and substance abuse benefits (Continued) You Pay
Diagnostic Tests Nothing
Services provided by a hospital or other facility

Services in approved alternative care settings such as partial hospitalization, half-way house, residential treatment, full-day hospitalization, facility based
intensive outpatient treatment

Nothing

Not covered: Services we have not approved.
Note: OPM will base its review of disputes about treatment plans on the treatment plan' s clinical appropriateness. OPM will generally not order us to pay

or provide one clinically appropriate treatment plan in favor of another

All charges.

Preauthorization To be eligible to receive these enhanced behavioral health and substance abuse benefits, you must obtain a treatment plan and follow
all of our network authorization processes. These include:
You do not need a referral from your primary care physician.
You must call Magellan Behavioral Health Inc. at 1-800/ 424-1778
to access behavioral health and substance abuse services. Notification is required for services at all levels of care to avoid non-authorization

of benefits.
Inpatient services must be authorized by Magellan prior to
admission or within 48 hours of an emergency admission.

Outpatient services are authorized by calling the Magellan 800
number for a referral and authorization to a Magellan provider.

Limitation We may limit your benefits if you do not obtain a treatment plan. 34
34 Page 35 36
2002 Western Health Advantage Section 5( f) 35
Section 5 (f). Prescription drug benefits
I M
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A N
T

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

All benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.
Some medications may require prior authorization to ensure the appropriate use of the drug.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other
coverage, including with Medicare.

I M
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T

There are important features you should be aware of. These include:
Who can write your prescription. A licensed physician must write the prescription.
Where you can obtain them. You may fill the prescription at a participating pharmacy, or by mail if the prescription is for maintenance medications, which are to be taken beyond 60 days. You may contact

Merck-Medco Customer Services department at 1-800/ 903-8664, to request additional "Prescription by Mail" order forms.

We use a formulary. The "Three Tier Copay Plan" means there is not a closed formulary, but three different copays. All generic medications are covered at the lowest copay; brand name medications on the
formulary, i. e., Preferred Drug List (PDL) have the middle level copay; and brand name medications not on the formulary, i. e., PDL (non-preferred or non-formulary) have the highest copay. However, in all three
categories a number of the drugs may need prior authorization to ensure the appropriate use of the drug. Members may request a copy of the PDL by calling 1-888/ 563-2250 or view the document on the web page:
www. westernhealth. com.
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 30-day supply. You pay a $5 copay per
prescription unit or refill for generic drugs or $10 copay per prescription unit or refill for name brand drugs on the formulary, i. e., Preferred Drug List (PDL); and a $20 copay per prescription unit or refill
for Non-Preferred (non-formulary) name brand medications per each 30-day supply or 120-unit supply, whichever is less. In no event will the copay exceed the cost of the prescription drug. When generic
substitution is permissible (i. e., a generic drug is available and the prescribing doctor does not require the use of a name brand drug), but you request the name brand drug, you pay the price difference
between the generic and name brand drug as well as the $10 copay per prescription unit or refill. Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan's formulary policy. Non-formulary
drugs will be covered when prescribed by a Plan doctor. Covered prescription medications that are to be taken beyond 60 days are considered maintenance
medications. Maintenance medications are used in the treatment of chronic conditions like arthritis, high blood pressure, heart conditions, and diabetes. Oral contraceptives are also available through the
mail order program. Maintenance medications may be obtained through Merck-Medco mail order service, WHA's pharmacy benefit manager. You can request the order form and brochure for this
benefit by contacting Merck-Medco Customer Service Department at 1-800/ 903-8664 The initial prescription for maintenance medications is dispensed through a participating pharmacy (limited to a
30-day supply). Subsequent refills for a 90-day supply may be obtained through the Mail Order Program. You pay a $10 copay for a 90-day supply of generic medication, a $20 copay for a 90-day
supply of brand name medication on the formulary, i. e., Preferred Drug List (PDL); and a $40 copay for a 90-day supply of brand name medication which is Non-Preferred (non-formulary) through the Mail
Order Program. In this way, you receive a 90-day supply of medication for only two copays.

35
35 Page 36 37
2002 Western Health Advantage Section 5( f) 36
Why use generic drugs? Generic drugs offer a safe and economic way to meet your prescription drug needs. The generic name of a drug is its chemical name; the name brand is the name under which the
manufacturer advertises and sells a drug. Under federal law, generic and name brand drugs must meet the same standards for safety, purity, strength, and effectiveness. A generic prescription costs you –
and us— less than a name brand prescription.

When you have to file a claim. If you have to pay for a covered prescription, you may submit your receipt, along with a claim form to PAID Prescriptions, L. L. C., an affiliate of Merck-Medco, and you
will be reimbursed for the cost of the medication, less the applicable copay. To obtain claim forms call Merck-Medco Member Services at 1-800/ 903-8664.

Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan physician and obtained from a Plan pharmacy or through our mail order

program:
Drugs and medicines that by state or Federal law of the United States, require a physician's prescription for their purchase, except those listed

as Not Covered
Insulin with a copay charge applied to each vial Disposable needles and syringes for the administration of covered

medications Glucose test tablets and test tape, Benedict's solution or equivalent,
and acetone test tablets are covered up to a 30-day supply per copay Contraceptive drugs and devices including diaphragms
Inhalers (limited to two per prescription) Prescription prenatal vitamins or vitamins in conjunction with
fluoride

Retail pharmacy:
$5 copay per 30-day supply for generic drugs

$10 copay per 30-day supply for formulary, i. e., preferred name brand
drugs
$20 copay per 30-day supply for name brand drugs not on the

formulary, i. e., Preferred Drug List
Mail order pharmacy:
$10 copay per 90-day supply for generic drugs

$20 copay per 90-day supply for formulary, i. e., preferred name brand
drugs
$40 copay per 90-day supply for name brand drugs not on the

formulary, i. e., Preferred Drug List

Note: If there is no generic equivalent available, you will still have to pay
the name brand copay

Drugs for sexual dysfunction. Episodic medications for the treatment of sexual dysfunction are limited to 6 pills per 30-day supply.
Fertility drugs 50% of charges

? Covered medications dispensed by a non-participating pharmacy outside of WHA's Service Area for Urgent Care or Emergency care
only. Maximum 10 day supply.
Submit your receipt to PAID Prescriptions, L. L. C., an affiliate of
Merck-Medco, and you will be reimbursed the full purchase price
less the applicable copayment
Covered medications and supplies -continued on next page 36
36 Page 37 38
2002 Western Health Advantage Section 5( f) 37
Covered medications and supplies (continued) You pay
Nicotine transdermal systems, such as Habitrol or Nicoderm are covered as a "Wellness Benefit". You must obtain a prescription
from your primary care physician. One 10-week treatment will be covered per member under any current or future Western
Health Advantage contract.

100%
(Upon remaining smoke-free for 90 days as certified by your primary care physician,

Western Health Advantage will reimburse you in full. You must be active with Western
Health Advantage at the time of reimbursement. Reimbursement should be
requested within 60 days of certification)

Not covered:
Drugs and supplies for cosmetic purposes;
Vitamins, nutrients and food supplements that can be purchased without a prescription (except for special food products that are

medically necessary for the treatment of PKU) even if a physician prescribes or administers them;

Nonprescription medicines.
Medical supplies such as dressings and antiseptics
Drugs obtained at a non-Plan pharmacy except for out-of-area emergencies

Drugs to enhance athletic purposes

All Charges 37
37 Page 38 39
2002 Western Health Advantage Section 5( g) 38
Section 5 (g). Special features
Feature Description

Advantage Referral Program In order to expand the choice of specialists, WHA has implemented a unique program, the Advantage Referral Program, which allows you to access all
specialists in our network rather than just those who have a direct relationship with your primary care physician. Your primary care physician will treat most of

your health care needs. If he or she determines that your medical condition requires specialty care, you will be referred to an appropriate provider. You may,
however, request to be referred to any of the WHA network specialists. In most cases, you will be comfortable with the specialist that your primary care
physician selects; however, if you already have a relationship with a network specialist, or prefer another network specialist, you may ask to be referred to him
or her instead. The provider directory lists all of the network specialists approved for referrals by your primary care physician. Self-referred annual well-woman
exams, obstetrical services and annual eye exams are included in the Advantage Referral Program and do not require a primary care physician referral or prior
authorization, as long as the provider is listed in the WHA provider directory. 38
38 Page 39 40
2002 Western Health Advantage 39 Section 5( h)
Section 5 (h). Dental benefits
I M
P O
R T
A N
T

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

We cover hospitalization for dental procedures only when a non-dental physical impairment exists which makes hospitalization necessary to safeguard the health of the patient; we do not
cover the dental procedure unless it is described below
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage,

including with Medicare.

I M
P O
R T
A N
T
Accidental injury benefit You Pay

We cover restorative services and supplies necessary to promptly repair (but not replace) sound natural

teeth. The need for these services must result from an accidental injury.
Nothing

Dental benefits
We have no other dental benefits. 39
39 Page 40 41
2002 Western Health Advantage 40 Section 6
Section 6. General exclusions --things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not cover it unless your Plan doctor determines it is medically necessary to prevent, diagnose, or
treat your illness, disease, injury or condition and we agree, as discussed under What Services Require Our Prior Approval on page 11.

We do not cover the following:
Care by non-Plan providers except for authorized referrals or emergencies (see Emergency Benefits);
Services, drugs, or supplies you receive while you are not enrolled in this Plan;
Services, drugs, or supplies that are not medically necessary;
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. 40
40 Page 41 42
2002 Western Health Advantage Section 7 41
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, or
coinsurance.
You will only need to file a claim when you receive emergency services from non-Plan providers. Sometimes these providers bill us directly. Check with the provider. If you need to file the claim, here is the process:

Medical and hospital benefits In most cases, providers and facilities file claims for you. Physicians must file on the form HCFA-1500, Health Insurance
Claim Form. Facilities will file on the UB-92 form. For claims questions and assistance, call us at 916/ 563-2250 or 1-888/ 563-2250.

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:
Western Health Advantage Attn: Claims Department
1331 Garden Highway, Suite 100 Sacramento, CA 95833-9773 41
41 Page 42 43
2002 Western Health Advantage Section 7 42
Prescription drugs If you have to pay for a covered medication in an urgent/ emergent situation, and use a non-participating pharmacy, you will need to
submit a Merck-Medco claim form with your receipt. To obtain a claim form call Merck-Medco Customer Services Department at
1-800-903-8664. You will be reimbursed in full less the applicable copay. Submit the claim form and your receipt to:

PAID Prescriptions, L. L. C. P. O. Box 2277
Lee's Summit, MO 64063-2277

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. 42
42 Page 43 44
2002 Western Health Advantage 43 Section 8
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your claim or request for services, drugs, or supplies – including a request for preauthorization:

Step Description
1 Ask us in writing to reconsider our initial decision. You must: (a) Write to us within 6 months from the date of our decision; and
(b) Send your request to us at: Western Health Advantage, 1331 Garden Highway, Suite 100, Sacramento, CA 95833-9773; 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, DC 20415-3630 43
43 Page 44 45
2002 Western Health Advantage 44 Section 8
The Disputed Claims Process (Continued)
Send OPM the following information:
A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;

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

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

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

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 prior approval. This is
the only deadline that may not be extended.
OPM may disclose the information it collects during the review process to support their disputed claim decision. This information will become part of the court record.

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

NOTE: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and
(a) We haven't responded yet to your initial request for care or preauthorization/ prior approval, then call us at 916/ 563-2250 or 1-888/ 563-2250 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. 44
44 Page 45 46
2002 Western Health Advantage 45 Section 9
Section 9. Coordinating benefits with other coverage
When you have other health coverage You must tell us if you are covered or a family member is covered under another group health plan or have automobile insurance that pays health care
expenses without regard to fault. This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in full as the primary payer and the other plan pays a reduced benefit as the
secondary payer. We, like other insurers, determine which coverage is primary according to the National Association of Insurance Commissioners'
guidelines.
When we are the primary payer, we will pay the benefits described in this brochure.

When a member has available benefits with another health plan or insurance policy, WHA as a secondary payer, will pay only the remaining allowable
charges whether or not a claim is made to the primary payer. Duplicate coverage does not reduce member's obligation to make all required
copayments.

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

When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care. Your 45
45 Page 46 47
2002 Western Health Advantage 46 Section 9
care must continue to be authorized by your primary care physician. WHA does not duplicate any benefits to which members are entitled under
workers' compensation law, employer liability laws, Medicare Part A and B, or TRICARE (CHAMPUS). WHA retains all sums payable under these
laws for services provided.
By your enrollment, you agree to submit the necessary documents requested by WHA to assist in recovering the maximum value of services you receive
under Medicare, TRICARE (CHAMPUS), the workers' compensation law, or any other health plans or insurance policies.

We will not waive any of our copayments, or coinsurance.
(Primary payer chart begins on next page.) 46
46 Page 47 48
2002 Western Health Advantage 47 Section 9
The following chart illustrates whether the Original Medicare Plan or this Plan should be the primary payer for you according to your employment status and other factors determined by Medicare. It is critical that you tell us if you or a
covered family member has Medicare coverage so we can administer these requirements correctly.
Primary Payer Chart
Then the primary payer is… A. When either you --or your covered spouse --are age 65 or over and …

Original Medicare This Plan
1) Areanactiveemployee withtheFederalgovernment (includingwhenyouor a family member are eligible for Medicare solely because of a disability),

2) Are an annuitant,
3) Are a reemployed annuitant with the Federal government when…
a) The position is excluded from FEHB or………………………………

b) The position is not excluded from FEHB………………………….
(Ask your employing office which of these applies to you.)

4) Are a Federal judge who retired under title 28, U. S. C., or a Tax Court judge who retired under Section 7447 of title 26, U. S. C. (or if
your covered spouse is this type of judge),
5) Are enrolled in Part B only, regardless of your employment status, (for Part B
services)

(for other
services)
6) Are a former Federal employee receiving Workers'Compensation and the Office of Workers'Compensation Programs has determined

that you are unable to return to duty,

(except for claims
related to Workers' Compensation.)

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

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

b) Are an active employee, or

c) Are a former spouse of an annuitant, or
d) Are a former spouse of an active employee

Please note, if your Primary Care Physician does not participate in Medicare, you will have to file a claim with Medicare 47
47 Page 48 49
2002 Western Health Advantage 48 Section 9
Claims process when you have the Original Medicare Plan – You probably will never have to file a claim form when you have both our Plan
and the Original Medicare Plan.

When we are the primary payer, we process the claim first.
When Original Medicare is the primary payer, Medicare processes your claim first. In most cases, your claims will be coordinated automatically
and we will pay the balance of covered charges. You will not need to do anything. To find out if you need to do something about filing your
claims, call us at 916/ 563-2250.
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 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, or coinsurance. If you enroll in a Medicare
managed care plan, tell us. We will need to know whether you are in the Original Medicare Plan or in a Medicare managed care plan so we can
correctly coordinate benefits with Medicare.
Suspended FEHB coverage to enroll in a Medicare managed care plan: If you are an annuitant or former spouse, you can suspend your FEHB
coverage to enroll in a Medicare managed care plan, eliminating your FEHB premium. (OPM does not contribute to your Medicare managed care plan
premium.) For information on suspending your FEHB enrollment, contact your retirement office. If you later want to re-enroll in the FEHB Program,
generally you may do so only at the next open season unless you involuntarily lose coverage or move out of the Medicare managed care
plan's service area.
If you do not enroll in If you do not have one or both Parts of Medicare, you can still be covered Medicare Part A or Part B under the FEHB Program. We will not require you to enroll in Medicare
Part B and, if you can't get premium-free Part A, we will not ask you to enroll in it.

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. 48
48 Page 49 50
2002 Western Health Advantage 49 Section 9
Workers' Compensation We do not cover services that:
you need because of a workplace-related illness or injury that the Office of Workers' Compensation Programs (OWCP) or a similar Federal or
State agency determines they must provide; or
OWCP or a similar agency pays for through a third party injury settlement or other similar proceeding that is based on a claim you filed under
OWCP or similar laws.
Once OWCP or similar agency pays its maximum benefits for your treatment, we will cover your care. You must use our providers.

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

When others are responsible In cases of injuries caused by any act or omission of a third party for injuries (including, without limitation, motor vehicle accidents and Workers'
Compensation cases), WHA will furnish covered services. However, in the event of any recovery from a third party on account of such injuries, the
member will reimburse WHA for the value of the services and benefits, as set forth below. By enrolling in this Plan, each member grants WHA a lien
on any such recovery and agrees to protect the interests of WHA when there is possibility that a third party may be liable for a member's injuries. Each
member specifically agrees as follows: a) Each member will give prompt notification to WHA of the name and
location of the third party, if known, and of the circumstances which caused the injuries; and
b) Each member will execute and deliver to WHA or its nominee any and all lien authorizations, assignments or other documents requested by
WHA which may be necessary or appropriate to protect the legal rights of WHA or its nominee fully and completely.

This reimbursement will not exceed the total amount of recovery you obtain. The member may not take any action that might prejudice WHA's
subrogation rights.

If you receive a judgment or settle a claim for injury and the judgment or settlement does not specifically include payment for medical costs, WHA
will nevertheless have a lien against such recovery for the value of the covered services and benefits at prevailing rates.

If you have a malpractice claim If you have a malpractice claim because of services you did or did not receive from a plan provider, it must go to binding arbitration. Contact us
about how to begin our binding arbitration process. 49
49 Page 50 51
2002 Western Health Advantage 50 Section 10
Section 10. Definitions of terms we use in this brochure
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on
December 31 of the same year.

Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. See page 13.

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 Means care which can be provided by a layperson, which does not require the continuing attention of trained medical or paramedical personnel, and
which has no significant relation to treatment of a medical condition.

Experimental or In order to determine whether or not a procedure, service, or supply is investigational services experimental or investigational, we gather appropriate information for a
decision that will be made by medical professionals. The information we collect may include medical records, current reviews of medical literature
and scientific evidence, results of current studies or clinical trials, and approvals by regulatory bodies. After reviewing all pertinent information,
we make our determination and notify you of the decision.

We will also notify you of the opportunity to request an external review. Your request must be made within 5 business days of the receipt of our
denial. A panel of physicians or other providers who are experts in the treatment of your medical condition and knowledgeable about the
recommended therapy will do the external independent review. All costs associated with the external review are covered in full and the
recommendations of the expert outside reviewers will be followed.

Group health coverage A policy protecting a specified minimum number of persons usually having the same employer.

Medical necessity Means that which WHA determines: is appropriate and necessary for the diagnosis or treatment of the
member's medical condition, in accordance with professionally recognized standards of care;
is not mainly for the convenience of member or member's physician or other provider; and
is the most appropriate supply or level of service for the injury or illness.

For hospital admissions, this means that acute care as an inpatient is necessary due to the kind of services the member is receiving, and that
safe and adequate care cannot be received as an outpatient or in a less intensive medical setting. 50
50 Page 51 52
2002 Western Health Advantage 51 Section 10
Plan allowance Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. Plans determine their allowances in
different ways. We determine our allowance as follows:
your portion of the cost is a percentage of the Plan's discounted contract rate and the contract rate is payment in full.

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

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

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

When your enrollment ends; and
When the next open season for enrollment begins.
We don't determine who is eligible for coverage and, in most cases, cannot change your enrollment status without information from your

employing or retirement office.

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

If you have a Self Only enrollment, you may change to a Self and Family enrollment if you marry, give birth, or add a child to your family. You
may change your enrollment 31 days before to 60 days after that event. The Self and Family enrollment begins on the first day of the pay period
in which the child is born or becomes an eligible family member. When you change to Self and Family because you marry, the change is effective
on the first day of the pay period that begins after your employing office receives your enrollment form; benefits will not be available to your
spouse until you marry.
Your employing or retirement office will not notify you when a family member is no longer eligible to receive health benefits, nor will we.
Please tell us immediately when you add or remove family members from your coverage for any reason, including divorce, or when your child
under age 22 marries or turns 22.
If you or one of your family members is enrolled in one FEHB plan, that person may not be enrolled in or covered as a family member by another
FEHB plan. 52
52 Page 53 54
2002 Western Health Advantage 53 Section 11
When benefits and The benefits in this brochure are effective on January 1. If you joined this premiums start plan during Open Season, your coverage begins on 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. 53
53 Page 54 55
2002 Western Health Advantage 54 Section 11
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 Group Health Plan Coverage (HIPAA) is a Federal law that offers limited Federal protections for
health coverage availability and continuity to people who lose employer group coverage. If you leave the FEHB Program, we will give you a
Certificate of Group Health Plan Coverage that indicates how long you have been enrolled with us. You can use this certificate when getting
health insurance or other health care coverage. Your new plan must reduce or eliminate waiting periods, limitations, or exclusions for health
related conditions based on the information in the certificate, as long as you enroll within 63 days of losing coverage under this Plan. If you have
been enrolled with us for less than 12 months, but were previously enrolled in other FEHB plans, you may also request a certificate from
those plans.
For more information, get OPM pamphlet RI 79-27, Temporary Continuation of Coverage (TCC) under the FEHB Program. See also the
FEHB web site (www. opm. gov/ insure/ health); refer to the "TCC and HIPAA" frequently asked 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. 54
54 Page 55 56
2002 Western Health Advantage 55 Long Term Care Insurance
Long Term Care Insurance Is Coming Later in 2002!
The Office of Personnel Management (OPM) will sponsor a high-quality long term care insurance program effective in
October 2002. As part of its educational effort, OPM asks you to consider these questions:

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

Welcome to the club! 76% of Americans believe they will never need long term care, but
the facts are that about half of them will. And it's not just the old folks. About 40% of people needing long term care are under age
65. They may need chronic care due to a serious accident, a stroke, or developing multiple sclerosis, etc.
We hope you will never need long term care, but everyone should have a plan just in case. Many people now consider long term care
insurance to be vital to their financial and retirement planning.
Yes, it can be very expensive. A year in a nursing home can exceed $50,000. Home care for only three 8-hour shifts a week can exceed
$20,000 a year. And that's before inflation! Long term care can easily exhaust your savings. Long term care
insurance can protect your savings.
Not FEHB. Look at the "Not covered" blocks in sections 5( a) and 5( c) of your FEHB brochure. Health plans don't cover custodial
care or a stay in an assisted living facility or a continuing need for a home health aide to help you get in and out of bed and with other
activities of daily living. Limited stays in skilled nursing facilities can be covered in some circumstances.
Medicare only covers skilled nursing home care (the highest level of nursing care) after a hospitalization for those who are blind, age 65
or older or fully disabled. It also has a 100 day limit. Medicaid covers long term care for those who meet their state's
poverty guidelines, but has restrictions on covered services and where they can be received. Long term care insurance can provide
choices of care and preserve your independence.
Employees will get more information from their agencies during the LTC open enrollment period in the late summer/ early fall of 2002.
Retirees will receive information at home.

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

What is long term care (LTC) insurance?

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

Is long term care expensive?
But won't my FEHB plan, Medicare or Medicaid cover
my long term care?

When will I get more information on how to apply for this new
insurance coverage? 55
55 Page 56 57
2002 Western Health Advantage 56 Long Term Care Insurance
Our toll-free teleservice center will begin in mid-2002. In the meantime, you can learn more about the program on our web site at
www. opm. gov/ insure/ ltc.
How can I find out more about the program NOW? 56
56 Page 57 58
2002 Western Health Advantage 57 Index
Index
Do not rely on this page; it is for your convenience and may not show all pages where the terms appear.
Accidental injury 39 Allergy care 19
Allogeneic (donor) bone marrow transplant 26
Alternative treatment 23 Ambulance 28
Anesthesia 24 Autologous bone marrow transplant 26
Biopsies 24 Blood and blood plasma 28
Breast cancer screening 26 Casts 29
Catastrophic protection 57 Changes for 2002 8
Chemotherapy 19 Childbirth 17
Chiropractic 22 Cholesterol tests 16
Claims 41 Coinsurance 50
Colorectal cancer screening 16 Congenital anomalies 24
Contraceptive devices and drugs 18 Coordination of benefits 45
Covered providers 6 Crutches 22
Definitions 50 Dental care 39
Diagnostic services 15 Dialysis 19
Disputed claims review 41 Donor expenses (transplants) 26
Dressings 28 Durable medical equipment (DME) 22
Educational classes and programs 23 Effective date of enrollment 4
Emergency 30 Experimental or investigational 50
Eyeglasses 20

Family planning 18 Fecal occult blood test 16
General Exclusions 40 Hearing services 20
Home health services 22 Hospice care 29
Home nursing care 22 Hospital 28
Immunizations 17 Infertility 18
Inhospital physician care 28 Inpatient Hospital Benefits 28
Insulin 36 Laboratory and pathological
services 15 Magnetic Resonance Imagings
(MRIs) 16 Mail Order Prescription Drugs 35
Malpractice claim 49 Mammograms 16
Maternity Benefits 17 Medicaid 49
Medically necessary 50 Medicare 45
Members 6 Mental Conditions/ Substance
Abuse Benefits 33 Newborn care 17
Nurse Licensed Practical Nurse 22
Nurse Anesthetist 28 Nurse Practitioner 22
Registered Nurse 22 Nursery charges 17
Obstetrical care 17 Occupational therapy 19
Ocular injury 20 26 Office visits 6
Orthopedic devices 21 Oral and maxillofacial surgery 26

Out-of-pocket expenses 13 Outpatient facility care 29
Oxygen 22 Pap test 16
Physical examination 16 Physical therapy 19
Physician 9 Preventive care, adult 16
Preventive care, children 17 Prescription drugs 35
Preventive services 16 Prior approval 11
Prostate cancer screening 16 Prosthetic devices 21
Psychologist 33 Radiation therapy 19
Room and board 28 Second surgical opinion 15
Skilled nursing facility care 29 Speech therapy 20
Splints 28 Sterilization procedures 18
Subrogation 49 Substance abuse 33
Surgery 24 w Anesthesia 24
w Outpatient 24 w Reconstructive 25
Syringes 36 Temporary continuation of
coverage 53 Transplants 26
Treatment therapies 19 Vision services 20
Well child care 17 Wheelchairs 22
Workers' compensation 49 X-rays 16 57
57 Page 58 59
2002 Western Health Advantage 58 Summary
Summary of benefits for Western Health Advantage – 2002
Do not rely on this chart alone. All benefits are provided in full unless indicated and are subject to the
definitions, limitations, and exclusions in this brochure. On this page we summarize specific expenses we cover; for more detail, look inside.

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

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

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

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

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

28
29
Emergency benefits:
In-area.........................................................................................
Out-of-area.................................................................................. $50 per hospital emergency room $50 per hospital emergency room

30
31
Mental health and substance abuse treatment..................................... Regular cost sharing 33
Prescription drugs.............................................................................
Retail pharmacy for up to a 30 day supply per prescription unit or refill
Mail order for up to a 90 day supply per prescription unit or refill

Retail pharmacy: $5 copay for generic drugs; $10 copay for formulary name brand drugs; and
$20 copay for non-formulary name brand drugs
Mail order pharmacy: $10 copay for generic drugs; $20 copay for formulary name brand
drugs; and $40 copay for non-formulary name brand drugs

35

Dental Care …………………………………………………………… We cover restorative services and supplies necessary to promptly
repair (but not replace) sound natural teeth. The need for these services must result from an accidental injury.
Nothing 39

Vision Care.................................................................................... Annual eye exams; one pair eyeglasses or contact lenses to correct
an impairment directly caused by accidental ocular injury or intraocular surgery (such as for cataracts); eye exam to determine the
need for vision correction for children through age 17; and annual eye refractions.

$10 per office visit 20

Special features: Advantage Referral Program 38
Protection against catastrophic costs ..............................................
(Your out-of-pocket maximum)

Nothing after $750/ Self Only or $1,500/ Self and Family enrollment per year

Some costs do not count toward this protection
13 58
58 Page 59
2002 Western Health Advantage Rates
2002 Rate Information for
WESTERN HEALTH ADVANTAGE

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

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

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

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

Self Only 5Z1 $81.66 $27.22 $176.93 $58.98 $96.63 $12.25
Self and Family 5Z2 $195.98 $65.33 $424.63 $141.54 $231.91 $29.40 59

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