Pages 1--65

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

For changes in benefits see
page 8.

This Plan has commendable accreditation from the NCQA. See the 2003 Guide for
more information on accreditation.

Enrollment codes for this Plan:
171 Self Only 172 Self and Family

RI 73-029 1.
1 Page 2 3
Dear Federal Employees Health Benefits Program Participant:
I am pleased to present this Federal Employees Health Benefits (FEHB) Program plan brochure for 2003. The brochure explains all the benefits this health plan offers to its enrollees. Since
benefits can vary from year to year, you should review your plan's brochure every Open Season. Fundamentally, I believe that FEHB participants are wise enough to determine the care
options best suited for themselves and their families.
In keeping with the President's health care agenda, we remain committed to providing FEHB members with affordable, quality health care choices. Our strategy to maintain quality and cost
this year rested on four initiatives. First, I met with FEHB carriers and challenged them to contain costs, maintain quality, and keep the FEHB Program a model of consumer choice and
on the cutting edge of employer-provided health benefits. I asked the plans for their best ideas to help hold down premiums and promote quality. And, I encouraged them to explore all
reasonable options to constrain premium increases while maintaining a benefits program that is highly valued by our employees and retirees, as well as attractive to prospective Federal
employees. Second, I met with our own FEHB negotiating team here at OPM and I challenged them to conduct tough negotiations on your behalf. Third, OPM initiated a comprehensive
outside audit to review the potential costs of federal and state mandates over the past decade, so that this agency is better prepared to tell you, the Congress and others the true cost of mandated
services. Fourth, we have maintained a respectful and full engagement with the OPM Inspector General (IG) and have supported all of his efforts to investigate fraud and waste within the
FEHB and other programs. Positive relations with the IG are essential and I am proud of our strong relationship.

The FEHB Program is market-driven. The health care marketplace has experienced significant increases in health care cost trends in recent years. Despite its size, the FEHB Program is not
immune to such market forces. We have worked with this plan and all the other plans in the Program to provide health plan choices that maintain competitive benefit packages and yet keep
health care affordable.
Now, it is your turn. We believe if you review this health plan brochure and the FEHB Guide you will have what you need to make an informed decision on health care for you and your
family. We suggest you also visit our web site at www. opm. gov/ insure.

Sincerely,

Kay Coles James Director 2.
2 Page 3 4
Notice of the Office of Personnel Management's Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE
REVIEW IT CAREFULLY.
By law, the Office of Personnel Management (OPM), which administers the Federal Employees Health Benefits (FEHB) Program, is required to protect the privacy of your personal medical information. OPM is also required to
give you this notice to tell you how OPM may use and give out (" disclose") your personal medical information held by OPM.

OPM will use and give out your personal medical information:
. To you or someone who has the legal right to act for you (your personal representative), .
To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is protected,

. To law enforcement officials when investigating and/ or prosecuting alleged or civil or criminal actions, and .
Where required by law.

OPM has the right to use and give out your personal medical information to administer the FEHB Program. For example:

. To communicate with your FEHB health plan when you or someone you have authorized to act on your
behalf asks for our assistance regarding a benefit or customer service issue. . To review, make a decision, or litigate your disputed claim.

. For OPM and the General Accounting Office when conducting audits.
OPM may use or give out your personal medical information for the following purposes under limited circumstances:
. For Government healthcare oversight activities (such as fraud and abuse investigations), .
For research studies that meet all privacy law requirements (such as for medical research or education), and . To avoid a serious and imminent threat to health or safety.

By law, OPM must have your written permission (an "authorization") to use or give out your personal medical information for any purpose that is not set out in this notice. You may take back (" revoke") your written permission
at any time, except if OPM has already acted based on your permission.
By law, you have the right to:
. See and get a copy of your personal medical information held by OPM. .
Amend any of your personal medical information created by OPM if you believe that it is wrong or if information is missing, and OPM agrees. If OPM disagrees, you may have a statement of your disagreement

added to your personal medical information. . Get a listing of those getting your personal medical information from OPM in the past 6 years. The listing
will not cover your personal medical information that was given to you or your personal representative, any 3.
3 Page 4 5

information that you authorized OPM to release, or that was given out for law enforcement purposes or to pay for your health care or a disputed claim.
. Ask OPM to communicate with you in a different manner or at a different place (for example, by sending
materials to a P. O. Box instead of your home address). . Ask OPM to limit how your personal medical information is used or given out. However, OPM may not be

able to agree to your request if the information is used to conduct operations in the manner described above. . Get a separate paper copy of this notice.

For more information on exercising your rights set out in this notice, look at www. opm. gov/ insure on the web. You may also call 202-606-0191 and ask for OPM's FEHB Program privacy official for this purpose.
If you believe OPM has violated your privacy rights set out in this notice, you may file a complaint with OPM at the following address:
Privacy Complaints Office of Personnel Management
P. O. Box 707 Washington, DC 20004-0707

Filing a complaint will not affect your benefits under the FEHB Program. You also may file a complaint with the Secretary of the Department of Health and Human Services.
By law, OPM is required to follow the terms in this privacy notice. OPM has the right to change the way your personal medical information is used and given out. If OPM makes any changes, you will get a new notice by mail
within 60 days of the change. The privacy practices listed in this notice will be effective April 14, 2003. 4.
4 Page 5 6
5.
5 Page 6 7
Table of Contents
Introduction. ............................................................... 4
Plain Language............................................................... 4
Stop Health Care Fraud!................................................. 5
Section 1. Facts about this HMO plan .......................................................................................................................... 6
How we pay providers ................................................................................................................................. 6
Who provides my health care?..................................................................................................................... 6
Your Rights.................................................................................................................................................. 6
Service Area ................................................................................................................................................ 7
Section 2. How we change for 2003.. ............................................................... 8
Program-wide changes................................................................................................................................. 8
Changes to this Plan..................................................................................................................................... 8
Section 3. How you get care ... ..................................................................................................................... 9
Identification cards ...................................................................................................................................... 9
Where you get covered care......................................................................................................................... 9
. Plan providers........................................................................................................................................ 9
. Plan facilities ......................................................................................................................................... 9
What you must do to get covered care......................................................................................................... 9
. Primary care .......................................................................................................................................... 9
. Specialty care ........................................................................................................................................ 9
. Hospital care........................................................................................................................................ 10
Circumstances beyond our control............................................................................................................. 11
Services requiring our prior approval ........................................................................................................ 11
Section 4. Your costs for covered services ................................................................................................................. 12
. Copayments......................................................................................................................................... 12
. Deductible ........................................................................................................................................... 12
. Coinsurance......................................................................................................................................... 12
Your catastrophic protection out-of-pocket maximum.............................................................................. 12
Section 5. Benefits ...................................................................................................................................................... 13
Overview ................................................................................................................................................... 13
(a) Medical services and supplies provided by physicians and other health care professionals ........... 14
(b) Surgical and anesthesia services provided by physicians and other health care professionals ....... 23
(c) Services provided by a hospital or other facility, and ambulance services ..................................... 27
(d) Emergency services/ accidents......................................................................................................... 30
(e) Mental health and substance abuse benefits.................................................................................... 32
(f) Prescription drug benefits ............................................................................................................... 34

2003 UNICARE HMO Table of Contents 2 6.
6 Page 7 8
7.
7 Page 8 9
(g) Special features................................................................................................................................. 38
. Flexible benefits option
. Services for the deaf and hearing impaired
(h) Dental benefits ................................................................................................................................ 39
(i) Non-FEHB benefits available to Plan members.............................................................................. 40
Section 6. General exclusions --things we don't cover ............................................................................................. 41
Section 7. Filing a claim for covered services ............................................................................................................ 42
Section 8. The disputed claims process ...................................................................................................................... 44
Section 9. Coordinating benefits with other coverage ................................................................................................ 46
When you have other health coverage
. What is Medicare.................................................................................................................................. 46
. Medicare managed care plan................................................................................................................ 49
. TRICARE and CHAMPVA................................................................................................................. 50
. Worker's Compensation....................................................................................................................... 50
. Medicaid............................................................................................................................................... 50
. Other Government agencies ................................................................................................................. 50
. When others are responsible for injuries .............................................................................................. 50
Section 10. Definitions of terms we use in this brochure ........................................................................................... 51
Section 11. FEHB facts .............................................................................................................................................. 51
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
. Children's Equity Act ....................................................................................................................... 53
. When benefits and premiums start.................................................................................................... 54
. When you retire ................................................................................................................................ 54
When you lose benefits............................................................................................................................ 54
. When FEHB coverage ends ............................................................................................................ 54
. Spouse equity coverage................................................................................................................... 54
. Temporary Continuation of Coverage (TCC) ................................................................................. 54
. Converting to individual coverage .................................................................................................. 55
. Getting a Certificate of Group Health Plan Coverage..................................................................... 55

Long term care insurance is still available................................................................................................ 56
Index ......................................................................................................................................................... 57
Summary of benefits................................................................................................................................. 64
Rates ........................................................................................................................................... back cover

2003 UNICARE HMO Table of Contents 3 8.
8 Page 9 10

Introduction
This brochure describes the benefits of UNICARE HMO under our contract (CS 2877) with the Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. The address for UNICARE
Health Plans of the Midwest, Inc. d/ b/ a UNICARE HMO is:
UNICARE HMO Sears Tower
233 S. Wacker Drive, 39 th Floor Chicago, Illinois 60606-6309

This brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations, and exclusion of this brochure. It is your responsibility to be informed about your health benefits.
If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in 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, 2003, unless those benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2003, and changes are summarized on page 8. Rates are shown at the end of this brochure.

Plain Language
All FEHB brochures are written in plain language to make them 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 UNICARE HMO.
We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the Office of Personnel Management. If we use others, we tell you what they mean first.
Our brochure and other FEHB plans' brochures have the same format and similar descriptions to help you compare plans.
If you have comments or suggestions about how to improve the structure of this brochure, let OPM know. Visit OPM's "Rate Us" feedback area at www. opm. gov/ insure or e-mail OPM at fehbwebcomments@ opm. gov. You may
also write to OPM at the Office of Personnel Management Office of Insurance Planning and Evaluation Division, 1900 E. Street, NW, Washington, DC 20415-3650.

2003 UNICARE HMO Introduction/ Plain Language/ Advisory 4 9.
9 Page 10 11
Stop Health Care Fraud!
Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits (FEHB) Program premium.
OPM's Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program regardless of the agency that employs you or from which you retired.

Protect Yourself From Fraud -Here are some things you can do to prevent fraud:
. Be wary of giving your plan identification (ID) number over the telephone or to people you do not know, except
to your doctor, other provider, or authorized plan or OPM representative. . Let only the appropriate medical professionals review your medical record or recommend services.

. Avoid using health care providers who say that an item or service is not usually covered, but they know how to
bill us to get it paid. . Carefully review explanations of benefits (EOBs) that you receive from us.

. Do not ask your doctor to make false entries on certificates, bills or records in order to get us to pay for an item
or service. . If you suspect that a provider 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 312/ 234-8855 and explain the situation. .
If we do not resolve the issue:

CALL --THE HEALTH CARE FRAUD HOTLINE 202-418-3300
OR WRITE TO: The United States Office of Personnel Management
Office of the Inspector General Fraud Hotline 1900 E Street, NW, Room 6400
Washington, DC 20415
. Do not maintain as a family member on your policy: .
your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise); or

. your child over age 22 (unless he/ she is disabled and incapable of self support). .
If you have any questions about the eligibility of a dependent, check with your personnel office if you are employed or with OPM if you are retired.

. You can be prosecuted for fraud and your agency may take action against you if you falsify a claim to obtain
FEHB benefits or try to obtain services for someone who is not an eligible family member or who is no longer enrolled in the Plan.

2003 UNICARE HMO Introduction/ Plain Language/ Advisory 5 10.
10 Page 11 12

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. The Plan is solely
responsible for the selection of these providers in your area. Contact the Plan for a copy of their most recent provider directory.

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

How we pay providers
We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure. These Plan providers accept a negotiated payment from us, and you will only be responsible for your copayments or
coinsurance.

Who provides my health care?
UNICARE HMO is an Independent Physician Association (IPA) model HMO Plan with a broad network of physicians who practice at contracted medical groups. Federal employees who enroll in our Plan can select a doctor
from among more than 2,800 primary care physicians associated with more than 90 hospitals throughout the greater Chicago metropolitan area.

Your Rights
OPM requires that all FEHB Plans provide certain information to their FEHB members. You may get information about us, our networks, providers and facilities. OPM's FEHB website (www. opm. gov/ insure) lists the specific
types of information that we must make available to you. Some of the required information is listed below.
. UNICARE Health Plans of the Midwest, Inc. is licensed in both the State of Illinois and the State of Indiana and
we are compliant with the laws of each state as they pertain to HMO plans. . UNICARE HMO has been in existence since 1993.

. We have a commendable accreditation from the National Committee of Quality Assurance (NCQA) that reviews
health plans. If you want more information about us, call 312/ 234-8855 or 888/ 234-8855 (outside of the Ameritech local calling

area).

2003 UNICARE HMO Section 1 6 11.
11 Page 12 13
Service Area
To enroll in this Plan, you must live in or work in our Service Area. Our Service Area is the Chicago Metropolitan area and includes the Illinois counties of Cook, DuPage, Kane, Kankakee, Kendall, Lake, McHenry and Will and the
Indiana counties of Lake and Porter. This is where our providers practice.
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 urgent or emergency benefits. We will not pay for any other health care services.

If you or a covered family member moves 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 moves, you do not have to wait until Open Season to change plans. Contact your employing or retirement
office.
If you need urgent or emergency care when you are away from home, you should call UNICARE HMO at 800/ 782-0180. Service is available 24 hours a day, 7 days a week. If your unexpected illness is not an emergency, you
should call this number before seeking treatment. For life-threatening medical emergencies, you should seek treatment from the nearest medical facility and inform the hospital or physician that you are a member of UNICARE
HMO. You should then contact UNICARE HMO at 800/ 782-0180 within 24 hours after medical care begins.

2003 UNICARE HMO Section 1 7 12.
12 Page 13 14
Section 2. How we change for 2003
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
. A Notice of the Office of Personnel Management's Privacy Practices is included. .
A section on the Children's Equity Act describes when an employee is required to maintain Self and Family coverage.

. Program information on TRICARE and CHAMPVA explains how annuitants or former spouses may suspend
their FEHB Program enrollment. . Program information on Medicare is revised.

. By law, the DoD/ FEHB Demonstration project ends on December 31, 2002.
Changes to this Plan
. Your share of the non-Postal premium will increase by 45. 4% for Self Only or 53. 5% for Self and Family.

2003 UNICARE HMO Section 2 8 13.
13 Page 14 15

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 obtain 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 312/ 234-8855 or
888/ 234-8855 (outside of the Ameritech local calling area).

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

. Plan providers Plan providers are physicians and other health care professionals in our service
area that we contract with to provide covered services to our members. We list Plan providers according to national standards.

We list Plan providers in the provider directory, which we update periodically. The list is also on our website at http:// www. unicare. 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.

What you must do It depends on the type of care you need. First, you and each family to get covered care member must choose a primary care physician. This decision is
important since your primary care physician provides or arranges for most of your health care. To select a Primary Care Physician, call us at
312/ 234-8855 or 888/ 234-8855 (outside of the Ameritech local calling area).

. Primary care Your primary care physician can be a family practitioner, internist or
pediatrician. Your primary care physician will provide most of your health care, or give you a referral to see a specialist.

If you want to change primary care physicians or if your primary care physician leaves the Plan, call us. We will help you select a new one.
. Specialty care Your primary care physician will refer you to a specialist for needed care.
When you receive a referral from your primary care physician, you must return to the primary care physician after the consultation, unless your primary

care physician authorized a certain number of visits without additional referrals. The primary care physician must provide or authorize all follow-up
care. Do not go to the specialist for return visits unless your primary care physician gives you a referral. However, female members may see an
obstetrician/ gynecologist (OB/ GYN), also known as a "woman's principal health care provider", who is in the Plan's network and has been designated by
the member, without a referral. Although a woman may directly see her "woman's principal health care provider," a referral arrangement must exist
between that provider and her PCP so her care can be coordinated. This will also eliminate any potential billing issues. Female members must call the

2003 UNICARE HMO Section 3 9 14.
14 Page 15 16
Plan's Customer Services Department for assistance in designating a provider where the referral arrangement exists.
. Here are other things you should know about specialty care:

. If you need to see a specialist frequently because of a chronic, complex, or
serious medical condition, your primary care physician will develop a treatment plan that allows you to see your specialist for a certain number of

visits without additional referrals. Your primary care physician will use our criteria when creating your treatment plan (the physician may have to
get an authorization or approval beforehand).
. If you are seeing a specialist when you enroll in our Plan, talk to your
primary care physician. Your primary care physician will decide what treatment you need. If he or she decides to refer you to a specialist, ask if

you can see your current specialist. If your current specialist does not participate with us, you must receive treatment from a specialist who does.
Generally, we will not pay for you to see a specialist who does not participate with our Plan.

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

arrangements for you to see someone else.
. If you have a chronic or disabling condition and lose access to your
specialist because we:

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

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

If you are in the hospital when your enrollment in our Plan begins, call our Customer Services Department immediately at 312/ 234-8855. If you are new
to the FEHB Program, we will arrange for you to receive care.

2003 UNICARE HMO Section 3 10 15.
15 Page 16 17
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 prior approval Your primary care physician has authority to refer you for most services. For
certain services, however, your physician must obtain approval from us. Before giving approval, we consider if the service is covered, medically
necessary, and follows generally accepted medical practice.
We call this review and approval process precertification. Your physician must obtain preauthorization for the following services:

. Surgical procedures that must be performed in ambulatory surgery unit or
hospital operating room, or if the procedure requires anesthesia; . 23 hour hospital observations;

. Skilled Nursing Facility Care .
Home health care; . Durable medical equipment and prosthetic devices;

. Certain prescription drugs such as human growth hormone or drugs to treat
sexual dysfunction; and . Any services performed by a non-participating provider.

. Temporomandibular joint dysfunction treatment

2003 UNICARE HMO Section 3 11 16.
16 Page 17 18
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 $15 per office visit.

. Deductible The calendar year deductible is a fixed expense you must incur for certain
covered services and supplies before we start paying benefits for them. Copayments do not count toward any deductible.

. We have a deductible for Durable Medical Equipment and prosthetic
devices.

NOTE: If you change plans during open season, you do not have to start a new deductible under your old plan between January 1 and the effective date
of your new plan. If you change plans at another time during the year, you must begin a new deductible under your new plan.

And, if you change options in this Plan during the year, we will credit the amount of covered expenses already applied toward the deductible of your old
option to the deductible of your new option.

. Coinsurance Coinsurance is the percentage of charges that you must pay for your care.
Coinsurance doesn't begin until you meet your deductible.

Example: In our Plan, you pay 20% of our allowance for durable medical equipment after you have satisfied the durable medical equipment deductible.

Your catastrophic protection After your copayments and coinsurance total $2, 900 per person or out-of-pocket maximum for $7, 000 per family enrollment in any calendar year, you do not have to
deductibles, coinsurance, and pay any more for covered services. However, copayments for the copayments following services do not count toward your catastrophic protection out-of-pocket
maximum, and you must continue to pay copayments for these services:

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

2003 UNICARE HMO Section 4 12 17.
17 Page 18 19
Section 5. Benefits --OVERVIEW
(See page 8 for how our benefits changed this year and page 57 for a benefits summary.)

NOTE: This benefits section is divided into subsections. Please read the important things you should keep in mind at the beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the
following subsections. To obtain claim forms, claims filing advice, or more information about our benefits, contact us at 312/ 234-8855 or at our website at www. unicare. com.
(a) Medical services and supplies provided by physicians and other health care professionals ........................... 14-22
. 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........................ 23-26
. Surgical procedures .
Reconstructive surgery . Oral and maxillofacial surgery . Organ/ tissue transplants . Anesthesia

(c) Services provided by a hospital or other facility, and ambulance services...................................................... 27-29
. Inpatient hospital
. Outpatient hospital or ambulatory surgical
center

. Extended care benefits/ skilled nursing care
facility benefits . Hospice care

. Ambulance
(d) Emergency services/ accidents ......................................................................................................................... 30-31 . Medical emergency
. Ambulance
(e) Mental health and substance abuse benefits .................................................................................................... 32-33

(f) Prescription drug benefits................................................................................................................................ 34-37
(g) Special features..................................................................................................................................................... 38 . Flexible benefits options

. Services for deaf and hearing impaired
(h) Dental benefits...................................................................................................................................................... 39
(i) Non-FEHB benefits available to Plan members ................................................................................................... 40

Summary of benefits.................................................................................................................................................... 59

2003 UNICARE HMO Section 5 13 18.
18 Page 19 20
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 a $100 calendar year deductible per person for durable medical equipment and
prosthetic devices.

. 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
. Office Medical consultations
. Second Surgical Opinion

$15 per office visit

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

Nothing

At home $15 per visit
Lab, X-ray and other diagnostic tests
Laboratory tests, such as:
. Blood tests
. Urinalysis
. Non-routine pap tests
. Pathology
. X-rays
. Non-routine Mammograms
. Cat Scans/ MRI
. Ultrasound
. Electrocardiogram and EEG

Nothing

2003 UNICARE HMO 14 Section 5( a) 19.
19 Page 20 21
Preventive care, adult You Pay
Routine screenings, such as:
. Chlamydial Infection Screening
. Total Blood Cholesterol once every three years
. Colorectal Cancer Screening, including
. . Fecal occult blood test

$15 per office visit

. . Sigmoidoscopy, screening every five years starting at age 50
Prostate Specific Antigen (PSA test) one annually for men age 40 and older $15 per office visit
Routine pap test
Note: The office visit is covered if pap test is received on the same day; see Diagnosis and Treatment, above.
$15 per office visit

Mammograms covered for women age 35 and older, as follows:
. From age 35 through 39, one baseline mammogram during this five year
period

. At age 40 and older, one routine mammogram every calendar year

$15 per office visit

Not covered: Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, or travel. All charges
Routine immunizations, such as:
. Tetanus-diphtheria (Td) booster once every 10 years, ages 19 and over
(except as provided for under Childhood immunizations)

. Influenza vaccines, annually

. Pneumococcal vaccine, age 65 and over

$15 per office visit

Not covered: Immunizations required for obtaining or continuing employment or insurance, attending schools or camp, or travel All charges
Preventive care, children
. Childhood immunizations recommended by the American Academy of
Pediatrics $15 per office visit

. Well-child care charges for routine examinations, immunizations and
care (up to age 22)

. Examinations, such as:
-Eye exams through age 17 to determine the need for vision correction.

-Ear exams through age 17 to determine the need for hearing correction
-Examinations done on the day of immunizations (up to age 22)

$15 per office visit

2003 UNICARE HMO 15 Section 5( a) 20.
20 Page 21 22
Maternity care You pay
Complete maternity (obstetrical) care, such as:
. Prenatal care
. Delivery
. Postnatal care
Note: Here are some things to keep in mind:
. You may remain in the hospital up to 48 hours after a regular delivery and 96
hours after a cesarean delivery. 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).

$15 for initial maternity office visit and nothing for
subsequent maternity office visits

Not covered: Routine sonograms to determine fetal age, size or sex All charges
Family planning
A range of voluntary family planning services, limited to:
. Voluntary sterilization (See Surgical procedures Section 5 (b))
. 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

$15 per office visit

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

2003 UNICARE HMO 16 Section 5( a) 21.
21 Page 22 23
Infertility services You pay
Diagnosis and treatment of infertility, such as:
. In vitro fertilization
. Uterine embryo lavage
. Embryo transfer
. Gamete intrafallopian tube transfer
. Zygote intrafallopian tube transfer
. Low tubal ovum transfer
. Artificial insemination:
. . intravaginal insemination (IVI)
. . intracervical insemination (ICI)
. . intrauterine insemination (IUI)
. Fertility drugs
Note: We cover injectable fertility drugs under medical benefits when administered in the doctor's office (not self-injected) subject to the $15 office

visit copay. Non-fertility self-injectables and oral fertility drugs are covered under the prescription drug benefit.

$15 per office visit

Not covered:
. Collection and storage of sperm, oocytes (eggs), or embryos for later use
. Services and supplies in connection with the reversal of voluntary sterilization
or sex change

. Cost of donor sperm
. Cost of donor egg

All charges

Allergy care
Testing and treatment
Allergy injection
$15 per office visit

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

2003 UNICARE HMO 17 Section 5( a) 22.
22 Page 23 24
Treatment therapies You pay
. Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone marrow transplant is 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
Note: Growth hormone therapy (GHT) is covered under Prescription Drug Benefits (Section 5f) as self-injectable drug.

$15 per office visit

Physical and occupational therapies
. Sixty (60) visits per condition per calendar year for the services of each of the
following:

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

. Cardiac rehabilitation following a heart transplant, bypass surgery or a
myocardial infarction, is provided up to sixty visits if determined to be medically necessary.

Note: Occupational therapy is limited to services that assist the member to achieve and maintain self-care and improved functioning in other activities of
daily living. Rehabilitation is based on medical necessity.

$15 per office or outpatient visit
Nothing per visit during covered inpatient admission.

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

All charges

Speech Therapy
. Sixty (60) visits per condition per calendar year for the services of a qualified
speech therapist $15 per office or outpatient visit

Hearing services (testing, treatment, and supplies)
. Hearing testing only when necessitated by accidental injury
. Hearing testing for children through age 17 (see Preventive care, children)
$15 per office visit

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

All charges

2003 UNICARE HMO 18 Section 5( a) 23.
23 Page 24 25
Vision services (testing, treatment, and supplies) You pay
. Eye exam to determine the need for vision correction for children
through age 17 (see preventive care) . One eye refraction every 24 months for enrollees age 18 and older $15 per office visit

Not covered:
. Eyeglasses or contact lenses or the fitting of either
. 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.
$15 per office visit

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

2003 UNICARE HMO 19 Section 5( a) 24.
24 Page 25 26
Orthopedic and prosthetic devices You pay
. External prosthetic devices, such as artificial limbs and eyes and
lenses (following cataract removal); stump hoses; and

. Externally worn breast prostheses and surgical bras, including
necessary replacements, following a mastectomy

. Internal prosthetic devices, such as artificial joints, pacemakers,
insulin pumps, and surgically implanted breast implant( s) 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. The internal prosthetic device must be medically necessary to restore bodily function and require a surgical
incision (as opposed to an external prosthetic device).
Note: Call us at 312/ 234-8855 as soon as your Plan physician prescribes this equipment. We will arrange with a health care provider

to rent or sell you durable medical equipment at discounted rates and will tell you more about this service when you call.

20% of the charges after you have satisfied a calendar year
deductible of $100 per Self Only enrollment and $300 per Self and
Family enrollment.

Not covered:
. orthopedic and corrective shoes (unless permanently attached to an
approved device)

. arch supports
. foot orthotics
. braces
. heel pads and heel cups
. lumbosacral supports
. cochlear implant devices
. corsets, trusses, elastic stockings, support hose, and other supportive
devices

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

. all ostomy supplies including bags, adhesives and skin protectants

All charges

2003 UNICARE HMO 20 Section 5( a) 25.
25 Page 26 27
Durable medical equipment (DME) You pay
Rental or purchase, at our option, of durable medical equipment prescribed by your Plan physician, such as oxygen and dialysis

equipment. Under this benefit, we also cover:
. hospital beds;
. wheelchairs;
. crutches;
. walkers; and
. blood glucose monitors
Note: Call us at 312/ 234-8855 as soon as your Plan physician prescribes this equipment. We will arrange with a health care provider

to rent or sell you durable medical equipment at discounted rates and will tell you more about this service when you call.

20% of the charges after you have satisfied a calendar year
deductible of $100 per Self Only enrollment or $300 per Self and
Family enrollment

Not covered:
. CAM walkers
. Scooters
. Blood Pressure cuffs
. Breast pumps

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;

. services primarily for hygiene, feeding, exercising, moving the
patient, homemaking, companionship or giving oral medication.

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

All charges

2003 UNICARE HMO 21 Section 5( a) 26.
26 Page 27 28
Chiropractic You Pay
. Manipulation of the spine and extremities
. Adjunctive procedures such as ultrasound, electrical muscle
stimulation, vibratory therapy, and cold pack application

$15 per office visit

Alternative treatments
No benefit All charges

Educational classes and programs
Coverage is limited to:
. Diabetes self-management
$15 per office visit if performed in physician's office

. Smoking cessation classes in the service area. Members should call
312/ 234-7037 for times and locations. Nothing

2003 UNICARE HMO 22 Section 5( a) 27.
27 Page 28 29
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
I M
P O
R T
A N
T

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

. Plan physicians must provide or arrange your care.
. 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.).

. YOUR PHYSICIAN MUST GET PRECERTIFICATION OF SOME SURGICAL
PROCEDURES. Please refer to the precertification information shown in Section 3 to be sure which services require precertification and identify which surgeries require precertification.

I M
P O
R T
A N
T

Benefit Description You pay
Surgical procedures
A comprehensive range of services, such as:
. Operative procedures
. Treatment of fractures, including casting
. Normal pre-and post-operative care by the surgeon
. Correction of amblyopia and strabismus
. Endoscopy procedures
. Biopsy procedures
. Removal of tumors and cysts
. Correction of congenital anomalies (see reconstructive surgery)
. Surgical treatment of morbid obesity --a condition in which an
individual weighs 100 pounds or 100% over his or her normal weight according to current underwriting standards; eligible members must

be age 18 or over
. Insertion of internal prosthetic devices. See 5( a) Orthopedic and
prosthetic devices for device coverage information.

Nothing

Surgical procedures continued on next page.
2003 UNICARE HMO 23 Section 5( b) 28.
28 Page 29 30
Surgical procedures (Continued) You pay
. Voluntary sterilization (e. g., Tubal ligation, Vasectomy)
. 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.

Nothing

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.
. 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

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, services, drugs and supplies related to sex transformation

All charges

2003 UNICARE HMO 24 Section 5( b) 29.
29 Page 30 31
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.

Nothing

. Surgical treatment of temporomandibular joint (TMJ) pain
dysfunction syndrome due to acute trauma or systemic disease

Note: We must approve your treatment TMJ plan in advance.

50% of charges for approved treatment of TMJ pain dysfunction
syndrome

Not covered:
. Oral implants and transplants
. Procedures that involve the teeth or their supporting structures (such
as the periodontal membrane, gingiva, and alveolar bone)

. Any dental care involved in the treatment of temporomandibular joint
(TMJ) pain dysfunction syndrome

All charges

2003 UNICARE HMO 25 Section 5( b) 30.
30 Page 31 32
Organ/ tissue transplants You pay
Transplants are covered when approved by the Plan's Medical Director. Transplants are limited to:

. Cornea
. Heart
. Heart/ lung
. Kidney
. Kidney/ Pancreas
. Liver
. Allogeneic (donor) bone marrow transplants
. Autologous bone marrow transplants (autologous stem cell and
peripheral stem cell support) for the following conditions: acute lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's

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

. Intestinal transplants (small intestine) and the small intestine with the
liver or small intestine with multiple organs such as the liver, stomach and pancreas

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

Nothing

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)
. Hospital outpatient department
. Skilled nursing facility
. Ambulatory surgical center
. Office

Nothing

2003 UNICARE HMO 26 Section 5( b) 31.
31 Page 32 33
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
I M
P O
R T
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 PRECERTIFICATION OF HOSPITAL STAYS. Please refer to Section 3 to be sure which services require

precertification

I M
P O
R T
A N
T

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.
. Private accommodations or private duty nursing care when a Plan
doctor determines it is medically necessary

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

Nothing

Inpatient hospital continued on next page.

2003 UNICARE HMO 27 Section 5( c) 32.
32 Page 33 34
Inpatient hospital (Continued) You pay
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
. Dressings, splints, casts, and sterile tray services
. Medical supplies and equipment, including oxygen
. Anesthetics, including nurse anesthetist services
. Medical supplies, appliances, medical equipment, and any covered
items billed by a hospital for use at home

Nothing

Not covered:
. Custodial care
. Non-covered facilities, such as nursing homes, schools
. Personal comfort items, such as telephone, television, barber
services, guest meals and beds

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
. 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
2003 UNICARE HMO 28 Section 5( c) 33.
33 Page 34 35
Extended care benefits/ skilled nursing care facility benefits You pay
Skilled nursing facility (SNF):
We cover up to 120 days of skilled nursing facility care per calendar year when we determined that full-time skilled nursing care is medically

necessary. You and your Plan doctor must obtain our prior approval. All necessary services are covered, including:

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

Nothing

Not covered: custodial care, rest cures, domiciliary or convalescent care All charges
Hospice care
We cover support and palliative care for a terminally ill member in the home or hospice facility. Coverage is provided up to a maximum

benefit of $10,000 per period of care. Services include:
. Inpatient and outpatient care
. Family counseling
Note: Covered hospice 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 ordered or authorized by a Plan doctor. Nothing

2003 UNICARE HMO 29 Section 5( c) 34.
34 Page 35 36
Section 5 (d). Emergency services/ accidents
I M
P O
R T
A N
T

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

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

I M
P O
R T
A N
T
What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or could result in serious injury or disability, and requires immediate medical or

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

What to do in case of emergency:
Emergencies within our service area: If you are in an emergency situation, please call your primary care doctor. In extreme emergencies, if you are unable to contact your doctor, contact the local

emergency system (e. g. the 911 telephone system) or go to the nearest hospital emergency room. Be sure to tell the emergency room personnel that you are a Plan member so they can notify us. You or a family
member must notify us within 48 hours unless it was not reasonably possible to do so. It is your responsibility to ensure that we have been timely notified.

If you need to be hospitalized in a non-Plan facility, we must be notified within 48 hours or on the first working day following admission, unless it was not reasonably possible to notify us within that time. If
you are hospitalized in a non-Plan facility and Plan doctors believe care can be provided in a Plan hospital, we will transfer to a Plan facility when medically feasible. We will cover any ambulance charges in full.

Benefits are available for care from non-Plan providers in a medical emergency only if delay in reaching a Plan provider would result in death, disability or significant jeopardy to your condition.

To be covered by this Plan, any follow-up care recommended by non-Plan providers must be approved by the Plan or provided by Plan providers.
Emergencies outside our service area: Benefits are available for any medically necessary health service that is immediately required because of injury or unforeseen illness.
If you need urgent or emergency medical care when you're away from home, you should call UNICARE HMO AT 800/ 782-0180. Service is available 24 hours a day, 7 days a week. If your unexpected illness is
not an emergency, you must call this number before seeking treatment. For life-threatening medical emergencies, you should seek treatment from the nearest medical facility and inform the hospital or
physician that you are a member of UNICARE HMO. You should then contact the Plan at 800/ 782-0180 within 24 hours after medical care begins.

If you need to be hospitalized, you must notify us within 48 hours or on the first working day following your admission, unless it was not reasonably possible to do so within that time. If a Plan doctor believes
care can be provided in a Plan hospital, we will transfer you to a Plan facility at our expense. We must approve all follow-up care recommended by a non-Plan provider or you must receive the follow-up care
from a Plan provider.

2003 UNICARE HMO 30 Section 5( d) 35.
35 Page 36 37
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 in a hospital emergency room
Note: We waive the copay if you are admitted as an inpatient to the hospital.

Note: We pay reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers

$15 per office visit
$50 per urgent care center visit
$50 per hospital emergency room visit.

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 in a hospital emergency room
Note: We waive the copay if you are admitted as an inpatient to the hospital.

Note: We pay reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers

$15 per office visit
$50 per urgent care center visit

$50 per hospital emergency room visit.

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 full-term delivery of a
baby outside the service area

All charges

Ambulance
Professional ambulance service when medically appropriate.
See 5( c) for non-emergency service.
Nothing

Not covered: air ambulance All charges

2003 UNICARE HMO 31 Section 5( d) 36.
36 Page 37 38
Section 5 (e). Mental health and substance abuse benefits
I M
P O
R T
A N
T

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

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

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

I M
P O
R T
A N
T

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

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

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

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

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

. Medication management

$15 per office visit

Mental health and substance abuse benefits -Continued on next page

2003 UNICARE HMO 32 Section 5( e) 37.
37 Page 38 39
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

Nothing

Not covered:
. Services we have not approved
. Psychiatric evaluation or therapy on court order or as a condition of
parole or probation unless determined by a Plan doctor to be necessary and appropriate.

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

All charges

Preauthorization To be eligible to receive these benefits you must obtain a treatment plan and the follow the following authorization process:
You must contact Magellan Behavioral Health at 1-800-746-6294 before seeking Mental Health or Substance Abuse treatment. Magellan Behavioral
Health will review your treatment needs. They will provide you and the provider with written authorization (certification letter) for your initial visit
and any ongoing care.

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

2003 UNICARE HMO 33 Section 5( e) 38.
38 Page 39 40
Section 5 (f). Prescription drug benefits
I M
P O
R T
A N
T

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

. All benefits are subject to the definitions, limitations and exclusions in this brochure and
are payable only when we determine they are medically necessary.

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

I M
P O
R T
A N
T
. There are important features you should be aware of. These include:
. Who can write your prescription. A plan physician or referral doctor must write the prescription.
. Where you can obtain them. You must fill the prescription at a plan pharmacy, or by mail for a
maintenance medication. To obtain a list of Plan pharmacies call UNICARE's Customer Services Department at 312/ 234-8855 or 888/ 234-8855 (outside the Ameritech local calling area). To order

maintenance medications by mail, call UNICARE's Customer Services Department to obtain the necessary forms. Complete or have your Plan doctor complete the prescription order form. Mail the
Plan doctor's written prescription for up to a 90-day supply of the maintenance drug, along with the completed prescription order form and the appropriate copay amount to the mail order pharmacy
provider. Additional refills may be obtained the same way provided the strength and dosage of the medication remain the same.

. We use a formulary. A formulary is a list of prescription medications that we cover when your
doctor prescribes them for you. These drugs were selected because they have been proven safe and effective. They are included in the formulary because most doctors prefer them to other choices.

Drugs are dispensed in accordance with the Plan's drug formulary. However, we do cover non-formulary drugs when prescribed by a Plan doctor. Your physician must obtain our approval for
non-formulary drugs.
We have an open formulary. If your physician believes a name brand product is necessary or there is no generic available, your physician may prescribe a name brand drug from a formulary list. This

list of name brand drugs is a preferred list of drugs that we selected to meet patient needs at a lower cost. To order a prescription drug brochure, call UNICARE Customer Services at 312/ 234-8855 or
888/ 234-8855 (outside the Ameritech local calling area).
. These are the dispensing limitations.
Pharmacy supply limits:
. . up to a 30-day supply or 100-unit supply whichever is less; or
. . 240 milliliters of liquid (8oz); or
. . 60 grams of ointment, creams or topical preparation; or
. . or one commercially prepared unit (i. e. one inhaler)
You pay a $5 copay per prescription unit or refill of generic formulary drugs and $15 per prescription unit or refill of name brand formulary drugs. If a generic drug is available and your doctor does not

require the use of a name brand drug, you pay the $15 name brand copay plus the difference in cost between the generic and name brand drugs. When generic substitution is not available, you pay the
brand name copay.
For non-formulary drugs obtained at a Plan pharmacy you pay a $25 copay. When generic substitution is permissible (e. g. 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 $25 non-formulary copay plus the difference between the cost of the generic drug and the cost of the name brand drug.

2003 UNICARE HMO 34 Section 5( f) 39.
39 Page 40 41
Mail Order:
You may obtain up to a 90-day supply of formulary maintenance drugs from our mail order pharmacy program. You pay 2 times the per unit copay.

Maintenance medications are drugs used on a continual basis for treatment of chronic health conditions, such as high blood pressure, ulcers or diabetes and that are packaged and intended for
self-administration by the patient. Additionally, you may obtain insulin and select oral contraceptives may be obtained through the pharmacy mail order program.

To order maintenance medications by mail, call UNICARE'S Customer Services Department to obtain the necessary forms. Complete or have your Plan doctor complete the prescription order
form. Mail the Plan doctor's written prescription for up to a 90-day supply of the maintenance drug, along with the completed prescription order form and the appropriate copay amount to the mail order
pharmacy provider. Additional refills may be obtained the same way provided the strength and dosage of the medication remain the same.

All drugs are not available by mail order. You cannot obtain antibiotics, cough syrup, and self-injected drugs (except insulin) by mail.
Please note that we will only refill prescriptions within 12 months of the date of the initial prescription from your Plan doctor. Also, we will not refill a prescription less than 10 days prior to its completion
Drugs to treat sexual dysfunction have dispensing limits and require prior approval. Please contact us for details.
A generic equivalent will be dispensed if it is available, unless your physician specifically requires a name brand. If you receive a name brand drug when a Federally-approved generic drug is available, and
your physician has not specified Dispense as Written for the name brand drug, you have to pay the difference in cost between the name brand drug and the generic.

. Why use generic drugs? Generic drugs are lower-priced drugs that are the therapeutic equivalent to
more expensive brand-name drugs. They must contain the same active ingredients and must be equivalent in strength and dosage to the original brand-name product. Generics cost less than the equivalent brand-name

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

. When you have to file a claim. You normally won't have to submit claims to us unless you receive
emergency services from a provider who doesn't contract with us. If you file a claim, please 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. Either OPM or we can extend this deadline if you show that circumstances beyond your control prevented you from filing on time. Please mail your claims to
UNICARE HMO, P. O. Box 5597, Chicago, Illinois 60680-5597.

Prescription drug benefits begin on the next page.

2003 UNICARE HMO 35 Section 5( f) 40.
40 Page 41 42
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 Federal law of the United States require
a physician's prescription for their purchase, except as excluded below.

. Insulin
. Disposable needles and syringes for the administration of covered
medications

. Drugs for sexual dysfunction
. Oral contraceptive drugs
. Smoking cessation prescription drugs and medication, including but
not limited to nicotine patches and sprays

Note: Drugs for sexual dysfunction have pill limits and require preauthorization.

$ 5 per generic formulary prescription unit or refill
$ 15 per name brand formulary prescription unit or refill
$ 25 per generic or name brand non-formulary prescription unit or
refill

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

. Self-injectable drugs
. Self-injectable fertility drugs
Note: Fertility drugs administered in the doctor's office (not self-injected), intravenous fluids and medication for home use, implantable drugs,

contraceptive devices, and injectable drugs that can only be administered by a physician are covered under Medical and Surgical Benefits.

Note: Drugs prescribed for sexual dysfunction have dispensing limitations. For complete details, please call UNICARE Customer Services.

50% of the cost of the drug up to the $2, 500 catastrophic protection out-of-pocket
maximum per calendar year. We then cover self-injectable drugs at
100% for the rest of that year.

2003 UNICARE HMO 36 Section 5( f) 41.
41 Page 42 43
Covered medications and supplies (continued) You pay
Not covered:
. Drugs and supplies for cosmetic purposes
. Vitamins, nutrients and food supplements even if a physician
prescribes or administers them

. Nonprescription medicines or medicines for which there is a non-prescription
equivalent

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

. Medical supplies such as dressings and antiseptics
. Drugs to enhance athletic performance
. Drugs consumed in an inpatient setting
. Replacement of lost or stolen medications or the replacement of
medications damaged by improper storage

. Drugs used for the purpose of weight loss or weight gain

All Charges

2003 UNICARE HMO 37 Section 5( f) 42.
42 Page 43 44
Section 5 (g). Special features
Feature Description
Flexible benefits option Under the flexible benefits option, we determine the most effective way to provide services.
. We may identify medically appropriate alternatives to
traditional care and coordinate other benefits as a less costly alternative benefit.

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

. The decision to offer an alternative benefit is solely ours, and
we may withdraw it at any time and resume regular contract benefits.

. Our decision to offer or withdraw alternative benefits is not
subject to OPM review under the disputed claims process.

Services for deaf and hearing impaired UNICARE's TDD (Telecommunication Device for the Deaf) machine is available to communicate with our hearing-impaired members. Messages received by our TDD machine are returned
and resolved quickly by a Customer Services Representative. The TDD telephone number is 312/ 234-7770.

2003 UNICARE HMO 38 Section 5( g) 43.
43 Page 44 45
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.

. 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. Restorative services must be initiated within 60 days of the reported injury, unless the member's medical
condition is such that a delay in initiating treatment is required. The injury must be reported to the Plan as soon as reasonably possible after
the accident.

Nothing

Dental benefits
We do not cover any other dental benefits.

2003 UNICARE HMO Section 5( h) 39 44.
44 Page 45 46

Section 5 (i). Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed claim about them. Fees you pay for these services do not count toward FEHB deductibles or catastrophic protection
out-of-pocket maximums.
Dental Benefits
As a UNICARE HMO member, you and your family are automatically eligible for participation in the UNICARE Dental Network. By taking advantage of this non-FEHB benefit, you and your family will be able to choose a dental provider
from an extensive network of participating, credentialed dental providers in the Chicagoland area. And you can realize discounts averaging around 20% on a wide range of preventive and specialty care services from participating dental
providers, including orthodontists. After you enroll in UNICARE HMO we will send you a an identification card that provides both HMO and Dental information. You can either call 800-627-0004 or check our website at
http:// www. unicare. com to select a convenient dental office near you. Written inquires or correspondence should be directed to P. O. Box 9201, Oxnard, CA 93031-9021. If you have questions you may also contact UNICARE HMO
Customer Services at 312/ 234-8855 or 888/ 234-8855 (outside of the Ameritech local calling area).
Vision Care
As a UNICARE HMO member, you and your family are entitled to discounts off the retail price on eye wear from more than 50 Cole Vision Centers in the Chicagoland area. These discounts are in addition to any covered eye refraction
explained in the previous pages. Cole Vision Centers are conveniently located in most Sears, Montgomery Ward, JC Penney and Carson Pirie Scott stores. Call the Cole Vision Customer Service Center at 800/ 334-7591 to find a convenient
location near you. Then just present your HMO ID card at a Cole Vision Center to receive your discount. If you have questions you may also contact UNICARE HMO Customer Services at 312/ 234-8855 or 888/ 234-8855 (outside of the
Ameritech local calling area).

2003 UNICARE HMO Section 5( i) 40 45.
45 Page 46 47
Section 6. General exclusions --things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not cover it unless your Plan doctor determines it is medically necessary to prevent, diagnose, or
treat your illness, disease, injury, or condition, and we agree, as discussed under Services Requiring our Prior Approval on page 11.

We do not cover the following:
. Care by non-Plan providers except for authorized referrals or emergencies (see Emergency Benefits);
. Services, drugs, or supplies you receive while you are not enrolled in this Plan;
. Services, drugs, or supplies that are not medically necessary;
. 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.
. Services, drugs, or supplies you receive without charge while in active military service.

2003 UNICARE HMO Section 6 41 46.
46 Page 47 48
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at Plan pharmacies, you will not have to file claims. Just present your identification card and pay your copayment,
coinsurance, or deductible.
You will only need to file a claim when you receive emergency services from non-plan providers. Sometimes these providers bill us directly. Check with the provider. If you need to file the claim, here is the process:

Medical, hospital and drug benefits
In most cases, providers and facilities file claims for you. Physicians must file on the form HCFA-1500, Health Insurance Claim Form.
Facilities will file on the UB-92 form. For claims questions and assistance relating to medical and hospital claims, call us at 312/ 234-
8855 or 888/ 234-8855 (outside the local Ameritech calling area) and for prescription drugs claims questions call us at 888/ 218-4844.

When you must file a claim --such as for services you receive outside of the Plan's service area --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:
Medical and hospital UNICARE HMO, P. O. Box 06200, Chicago, IL 60606-6309
Submit your claims to:

Prescription drugs UNICARE HMO, P. O. Box 9085, Claim Services, Oxnard, CA 93031-9085

2003 UNICARE HMO 42 Section 7 47.
47 Page 48 49
Other supplies or services In most cases, you will not have to file a claim because our providers will handle the process for you. If you must file a claim for services such as
durable medical equipment or prosthetic devices, use the procedure and address above.

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.

2003 UNICARE HMO 43 Section 7 48.
48 Page 49 50
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: UNICARE HMO, Attn: Appeals Department, 233 S. Wacker Drive, Suite 3900, Chicago, IL 60606-6309; 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 2, 1900 E Street, NW, Washington, DC 20415-3620.

2003 UNICARE HMO 44 Section 8 49.
49 Page 50 51
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 more than one claim, 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.
If you do not agree with OPM's decision, your only recourse is to sue. If you decide to sue, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received
the disputed services, drugs, or supplies, or from the year in which you were denied precertification or prior approval. This is the only deadline that may not be extended.

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

NOTE: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and
(a) We haven't responded yet to your initial request for care or preauthorization/ prior approval, then call us at 312/ 234-8855 or 888/ 234-8855 (outside of the local Ameritech calling area) 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 may call OPM's Health Benefits Contracts Division 2 at 202/ 606-3818 between 8 a. m. and 5 p. m.
eastern time.

2003 UNICARE HMO 45 Section 8 50.
50 Page 51 52
Section 9. Coordinating benefits with other coverage
When you have other You must tell us if you or a covered family member have coverage under health coverage another group health plan or have automobile insurance that pays

healthcare expenses without regard to fault. This is called "double coverage."

When you have double coverage, one plan normally pays its benefits in full as the primary payer and the other plan pays a reduced benefit as the
secondary payer. We, like other insurers, determine which coverage is primary according to the National Association of Insurance
Commissioners' guidelines.
When we are the primary payer, we will pay the benefits described in this brochure.

When we are the secondary payer, we will determine our allowance. After the primary plan pays, we will pay what is left of our allowance, up
to our regular benefit. We will not pay more than our allowance.
What is Medicare? Medicare is a Health Insurance Program for:

. People 65 years of age and older
. Some people with disabilities, under 65 years of age
. People with End-Stage Renal Disease (permanent kidney failure
requiring dialysis or a transplant).

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

Part A insurance. (Someone who was a Federal employee on January 1, 1983 or since automatically qualifies.) Otherwise, if you are age 65
or older, you may be able to buy it. Contact 1-800-MEDICARE for more information.

. Part B (Medical Insurance). Most people pay monthly for Part B.
Generally, Part B premiums are withheld from your monthly Social Security check or your retirement check.

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

. The Original Medicare Plan The Original Medicare Plan (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 care must continue to be authorized by your primary care physician. We will not waive copayments, deductibles, or coinsurance.

2003 UNICARE HMO 46 Section 9 51.
51 Page 52 53
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 at 312/ 234-8855 or 888/ 234-8855
(outside the local Ameritech calling area).
We do not waive any costs if the Original Medicare Plan is your primary payer.

(Primary payer chart begins on next page.)

2003 UNICARE HMO 47 Section 9 52.
52 Page 53 54
The following chart illustrates whether the Original Medicare Plan or this Plan should be the primary payer for you according to your employment status and other factors determined by Medicare. It is critical that you tell us if you or
a covered family member has Medicare coverage so we can administer these requirements correctly.
Primary Payer Chart
Then the primary payer is A. When either you --or your covered spouse --are age 65 or over and

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

because of a disability),

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

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

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

(for other services)

6) Are a former Federal employee receiving Workers' Compensation and the Office of Workers' Compensation Programs has determined
that you are unable to return to duty,

(except for claims related to Workers'

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

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

b) Are an active employee, or

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

Please note: if your Plan physician does not participate in Medicare, you will have to file a claim with Medicare.

2003 UNICARE HMO 48 Section 9 53.
53 Page 54 55

. Medicare managed care plan If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from 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, coinsurance, or
deductibles. If you enroll in a Medicare managed care plan, tell us. We will need to know whether you are in the Original Medicare Plan or in a
Medicare managed care plan so we can correctly coordinate benefits with Medicare.

Suspended FEHB coverage and 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.

2003 UNICARE HMO 49 Section 9 54.
54 Page 55 56
TRICARE and CHAMPVA TRICARE is the health care program for members, eligible dependents of military persons, and retirees of the military. TRICARE includes the
CHAMPUS program. CHAMPVA provides health coverage to disabled Veterans and their eligible dependents. If TRICARE or CHAMPVA and
this Plan cover you, we pay first. See your TRICARE or CHAMPVA Health Benefits Advisor if you have questions about these programs.

Suspended FEHB coverage and to enroll in TRICARE OR CHAMPVA: If you are an annuitant or former spouse, you can suspend
your FEHB coverage to enroll in one of these programs, 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.

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

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

2003 UNICARE HMO 50 Section 9 55.
55 Page 56 57
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 12.

Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 12.
Covered services Care we provide benefits for, as described in this brochure.
Custodial care Care that provides a level of routine maintenance for the purpose of meeting personal needs. This is care that can be provided by a layperson
who does not have professional qualifications, skills, or training. Examples include help in walking, dressing, getting in to and out of bed,
and help in functions of daily living. Custodial care that lasts 90 days or most is sometimes known as Long term care.

Deductible A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for
those services. See page 12.

Experimental or investigational services A procedure that is determined to be experimental or investigational
based on Plan review of medical records, current reviews of medical literature and scientific evidence, results of current studies or clinical
trials, research protocols, reports or opinions of authoritative medical bodies, and opinions of independent outside experts and approvals
granted by regulatory bodies.

Medical necessity Medical services provided for the diagnosis or the treatment of a sickness or injury or for the maintenance of a person's good health. Also, the
medical services are furnished by a provider with the appropriate training, experience, staff and facilities to furnish the service. And the
established opinion with the appropriate specialty of the United States medical profession is that the services are safe and effective for the
intended use.

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 the reasonable and customary charge.

Us/ We Us and we refer to UNICARE Health Plans of the Midwest, Inc.
You You refers to the enrollee and each covered family member.

2003 UNICARE HMO 51 Section 10 56.
56 Page 57 58
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 your FEHB coverage. These
materials tell you:
. 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.

2003 UNICARE HMO 52 Section 11 57.
57 Page 58 59

Annotations

Children's Equity Act OPM has implemented the Federal Employees Health Benefits Children's Equity Act of 2000. This law mandates that you be enrolled for Self and
Family coverage in the Federal Employees Health Benefits (FEHB) Program, if you are an employee subject to a court or administrative
order requiring you to provide health benefits for your child( ren).
If this law applies to you, you must enroll for Self and Family coverage in a health plan that provides full benefits in the area where your children
live or provide documentation to your employing office that you have obtained other health benefits coverage for your children. If you do not
do so, your employing office will enroll you involuntarily as follows:
. If you have no FEHB coverage, your employing office will enroll
you for Self and Family coverage in the Blue Cross and Blue Shield Service Benefit Plan's Basic Option,

. if you have a Self Only enrollment in a fee-for-service plan or in an
HMO that serves the area where your children live, your employing office will change your enrollment to Self and Family in the same

option of the same plan; or . if you are enrolled in an HMO that does not serve the area where the
children live, your employing office will change your enrollment to Self and Family in the Blue Cross and Blue Shield Service Benefit
Plan's Basic Option.
As long as the court/ administrative order is in effect, and you have at least one child identified in the order who is still eligible under the FEHB
Program, you cannot cancel your enrollment, change to Self Only, or change to a plan that doesn't serve the area in which your children live,
unless you provide documentation that you have other coverage for the children. If the court/ administrative order is still in effect when you
retire, and you have at least one child still eligible for FEHB coverage, you must continue your FEHB coverage into retirement (if eligible) and
cannot make any changes after retirement. Contact you employing office for further information.

When benefits and The benefits in this brochure are effective on January 1. If you joined premiums start this Plan during Open Season, your coverage begins 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.

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. This is the case even when the court has ordered your former spouse to supply

2003 UNICARE HMO 53 Section 11 58.
58 Page 59 60

health coverage to you. But, you may be eligible for your own FEHB coverage under the spouse equity law or Temporary Continuation of
Coverage (TCC). 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. You can also download the guide from OPM's website, www. opm. gov/ insure.

. Temporary continuation If you leave Federal service, or if you lose coverage because you no
of 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.

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.
2003 UNICARE HMO 54 Section 11 59.
59 Page 60 61

For more information, get OPM pamphlet RI 79-27, Temporary Continuation of Coverage (TCC) under the FEHB Program. See also
the FEHB website 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 it has information about Federal and State agencies you can contact for more information.

2003 UNICARE HMO 55 Section 11 60.
60 Page 61 62

Long Term Care Insurance Is Still Available!
Open Season for Long Term Care Insurance
. You can protect yourself against the high cost of long term care by applying for insurance in the Federal
Long Term Care Insurance Program. . Open Season to apply for long term care insurance through LTC Partners ends on December 31, 2002.

. If you're a Federal employee, you and your spouse need only answer a few questions about your health
during Open Season. . If you apply during the Open Season, your premiums are based on your age as of July 1, 2002. After pen

Season, your premiums are based on your age at the time LTC Partners receives your application.

FEHB Doesn't Cover It
. Neither FEHB plans nor Medicare cover the cost of long term care. Also called "custodial care", long term
care helps you perform the activities of daily living such as bathing or dressing yourself. It can also provide help you may need due to a severe cognitive impairment such as Alzheimer's disease.

You can Also Apply Later, But,,,
. Employees and their spouses can still apply for coverage after the Federal Long Term Care Insurance
Program Open Season ends, but they will have to answer more health-related questions. . For annuitants and other qualified relatives, the number of health-related questions that you need to answer is

the same during and after the Open Season.
You Must Act to Receive an Application
. Unlike other benefit programs, YOU have to take action you won't receive an application automatically.
You must request one through the toll-free number or website listed below. . Open Seasons ends December 31, 2002 act NOW so you won't miss the abbreviated underwriting available

to employees and their spouses, and the July 1 "age freeze"!
Find Out More Contact LTC Partners by calling 1-800- LTC-FEDS (1-800-852-3337) (TDD for the hearing impaired: 1-800-843-3557) or visiting www. ltcfeds. com to get more information and to request an application.

2003 UNICARE HMO 56 Long Term Care Insurance 61.
61 Page 62 63
Index Do not rely on this page; it is for your convenience and does not explain your benefit coverage.
Family planning 16 Accidental injury 39 Outpatient facility care 29 Oxygen 21 Fecal occult blood test 15 Allergy tests 17
Pap test 15 General Exclusions 41 Alternative treatment 22 Hearing services 18 Physical examination 15 Allogeneic donor) bone marrow
transplant 26 Physical therapy 18 Home health services 21 Physician 9 Hospice care 29 Ambulance 29
Pre-admission testing 28 Home nursing care 29 Anesthesia 26 Precertification 11 Hospital 10 Autologous bone marrow
transplant 26 Immunizations 15 Preventive care, adult 15 Biopsies 23 Preventive care, children 15 Infertility 17
Prescription drugs 34 Inhospital physician care 14 Blood and blood plasma 28 Preventive services 15 Inpatient Hospital Benefits 27 Breast cancer screening 16
Prior approval 11 Insulin 36 Casts 29 Laboratory and pathological
services 14 Prostate cancer screening 15 Catastrophic protection 11 Prosthetic devices 20 Changes for 2003 8 Psychologist 32 Long Term Care 56 Chemotherapy 18
Radiation therapy 18 Machine diagnostic tests 14 Childbirth 16 Renal dialysis 18 Magnetic Resonance Imagings
(MRIs) 14 Cholesterol tests 15 Room and board 27 Claims 43 Second surgical opinion 14 Mail Order Prescription Drugs 35 Coinsurance 12
Skilled nursing facility care 29 Mammograms 15 Colorectal cancer screening 15 Maternity Benefits 16 Congenital anomalies 23
Smoking cessation 36 Medicaid 49 Contraceptive devices and drugs 16 Speech therapy 18 Medically necessary 51
Splints 28 Medicare 46 Coordination of benefits 46 Sterilization procedures 16 Members 9 Covered charges 12
Subrogation 50 Mental Conditions/ Substance Abuse Benefits 32 Covered providers 9 Substance abuse 32 Crutches 21
Neurological testing 33 Surgery 23 Deductible 12 . Anesthesia 26 Newborn care 16 Definitions 51
. Oral 25 Non-FEHB Benefits 40 Dental care 39 . Outpatient 28 Nurse
Diagnostic services 14 . Reconstructive 24 Licensed Practical Nurse 21 Disputed claims review 44

Syringes 36 Nurse Anesthetist 28 Donor expenses (transplants) 26 Temporary continuation of
coverage 54 Registered Nurse 21 Dressings 28 Nursery charges 16 Durable medical equipment (DME) 21 Obstetrical care 16 Transplants 26
Treatment therapies 18 Occupational therapy 18 Educational classes and programs 22 Vision services 19 Office visits 14
Well child care 15 Oral and maxillofacial surgery 25 Effective date of enrollment 54 Wheelchairs 21 Orthopedic devices 20 Emergency 30
Workers' compensation 50 Ostomy and catheter supplies 20 Experimental or investigational 51 X-rays 14 Out-of-pocket expenses 12 Eyeglasses 19

2003 UNICARE HMO 57 Index 62.
62 Page 63 64
NOTES:
2003 UNICARE HMO Notes 58 63.
63 Page 64 65
Summary of benefits for the UNICARE HMO -2003
. 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: $15 primary care; $15 specialist 14

Services provide d by a hospital:
. Inpatient ...........................................................................................

. Outpatient.........................................................................................

Nothing
Nothing

27

28
Emergency benefits:
. In-area .............................................................................................

. Out-of-area ......................................................................................

$50 per emergency room visit

$50 per emergency room visit

30
31
Mental health and substance abuse treatment ..................................... Regular cost sharing. 32
Prescription drugs................................................................................. $5 per generic formulary prescription unit or refill /$ 15 per
name brand formulary prescription unit or refill
formulary/$ 25 per name brand non-formulary prescription unit or
refill

34

Dental Care.......................................................................................
Accidental injury benefit only
No benefit 39

Vision Care.......................................................................................
One eye refraction every 24 months
$15 copay 19

Protection against catastrophic costs (your catastrophic protection out-of-pocket maximum)................... Nothing after $2, 900/ Self Only or $7,000/ Family enrollment per year
Some costs do not count toward this protection
12

2003 UNICARE HMO Summary 59 64.
64 Page 65
2003 Rate Information for UNICARE HMO
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 171 $ 91. 67 $ 30. 55 $198. 61 $ 66. 20 $108. 47 $ 13. 75
Self and Family 172 $249. 62 $100. 57 $540. 84 $217. 91 $294. 70 $ 55. 49

2003 UNICARE HMO Rates 60
UHP 0005445 65.

Page Navigation Panel