KPS Health Plans

Federal Employees Health Benefits Program
2003 Plan Brochure
Accessible Version

Pages 1--64

Page 1


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

KPS Health Plans 2003 www. kpshealthplans. com
A Prepaid Comprehensive Medical Plan

For changes
in benefits
see page 7.

Serving: Most of Western Washington.
Enrollment in this Plan is limited. You must live or work in our Geographic Service area to enroll. See page 6 for requirements.

Enrollment codes for this Plan:
High Option VT1 Self Only

VT2 Self and Family
Standard Option VT4 Self Only
VT5 Self and Family

RI 73-051 1.
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2.
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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 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). 3.
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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.
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Table of Contents
Introduction. ..................................................................................... 4
Plain Language..................................................................................... 4
Stop Health Care Fraud!...................................................................................................................................................................... 4
Section 1. Facts about this HMO plan................................................................................................................................................ 6
How we pay providers....................................................................................................................................................... 6
Your Rights ....................................................................................................................................................................... 6
Service Area ...................................................................................................................................................................... 6
Section 2. How we change for 2003............................................................................................................................................... 7
Program-wide changes ...................................................................................................................................................... 7
Changes to this Plan .......................................................................................................................................................... 7
Section 3. How you get care ... ........................................................................................................................................... 8
Identification cards ............................................................................................................................................................ 8
Where you get covered care .............................................................................................................................................. 8
Plan providers ..................................................................................................................................................... 8
Plan facilities....................................................................................................................................................... 8
What you must do to get covered care............................................................................................................................... 8
Primary care ........................................................................................................................................................ 8
Specialty care ...................................................................................................................................................... 8
Hospital care ....................................................................................................................................................... 9
Circumstances beyond our control .................................................................................................................................... 9
Services requiring our prior approval.............................................................................................................................. 10
Help us control costs ....................................................................................................................................................... 10
Outpatient surgery............................................................................................................................................. 10
Pre-admission testing ........................................................................................................................................ 10
Pre-admission certification................................................................................................................................ 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 ............................. 25
(c) Services provided by a hospital or other facility, and ambulance services........................................................... 29
(d) Emergency services/ accidents .............................................................................................................................. 32

2003 KPS Health Plans 2 Table of Contents
(e) Mental health and substance abuse benefits ......................................................................................................... 34 5.
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(f) Prescription drug benefits ..................................................................................................................................... 36
(g) Dental benefits ...................................................................................................................................................... 38
Section 6. General exclusions things we don't cover..................................................................................................................... 43
Section 7. Filing a claim for covered services.................................................................................................................................. 44
Section 8. The disputed claims process ............................................................................................................................................ 45
Section 9. Coordinating benefits with other coverage...................................................................................................................... 47
When you have other health coverage............................................................................................................................. 47
What is Medicare .............................................................................................................................................. 47
Medicare managed care plan............................................................................................................................. 50
TRICARE and CHAMPVA.............................................................................................................................. 50
Workers' Compensation .................................................................................................................................... 51
Medicaid............................................................................................................................................................ 51
Other Government agencies .............................................................................................................................. 51
When others are responsible for injuries ........................................................................................................... 51
Section 10. Definitions of terms we use in this brochure ................................................................................................................. 53
Section 11. FEHB facts .................................................................................................................................................................... 55
Coverage information .................................................................................................................................................... 55
No pre-existing condition limitation ................................................................................................................. 55
Where you get information about enrolling in the FEHB Program................................................................... 55
Types of coverage available for you and your family ....................................................................................... 55
Children's Equity Act ....................................................................................................................................... 55
When benefits and premiums start .................................................................................................................... 56
When you retire................................................................................................................................................. 56
When you lose benefits.................................................................................................................................................. 56
When FEHB coverage ends .............................................................................................................................. 56
Spouse equity coverage..................................................................................................................................... 56
Temporary Continuation of Coverage (TCC) ................................................................................................... 56
Converting to individual coverage .................................................................................................................... 57
Getting a Certificate of Group Health Plan Coverage....................................................................................... 57
Long term care insurance is still available ........................................................................................................................................ 58
Index.................................................................................................................................................................................................. 59
Summary of benefits ......................................................................................................................................................................... 60
Rates.................................................................................................................................................................................... Back cover

2003 KPS Health Plans 3 Table of Contents 6.
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Introduction
This brochure describes the benefits of KPS Health Plans under our contract (CS 1767) with the Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. The address for KPS Health Plans administrative offices is:
KPS Health Plans 400 Warren Avenue, P. O. Box 339
Bremerton, Washington 98337
This brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations, and exclusions 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 7. Rates are shown at the end of this brochure.

Plain Language
All FEHB brochures are written in plain language 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 KPS Health Plans.
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.

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.

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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 360-478-6796 or toll free at 800-552-7114 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 age 22 or older (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.

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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 our 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.
Comprehensive Individual-practice Prepaid Medical Plans:

We are a Comprehensive Individual-practice Prepaid Medical Plan. This means that we offer health services in whole or substantial part on a prepaid basis, with professional services provided by individual physicians who agree, under certain
conditions approved by OPM, to accept the payments provided by the Plan and the members' cost-sharing amounts as full payment for covered services.

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. We pay dental providers
based on a scheduled allowance amount, and you will only be responsible for charges over the scheduled allowance amount.
We emphasize comprehensive medical and surgical care in Plan doctors' offices and hospitals. A Plan doctor is a Medical Doctor (MD) or Doctor of Osteopathy (DO) participating with KPS, and includes doctors participating in the First Choice Health Network
(FCHN) and MultiPlan Network. A Plan dentist is any licensed dentist within the State of Washington.
For the purposes of a dependent child or when you are on temporary duty assignment residing outside the state of Washington, a Plan doctor or Plan dentist is a MultiPlan provider. If a MultiPlan provider is not available in your or your dependent's temporary county
of residence, then you or your dependent may see any doctor or dentist practicing within the temporary county of residence at no penalty. (See Service Area)

We arrange with doctors (2548 primary care physicians and 5994 specialists) and hospitals (60), and make referrals to nonparticipating doctors, to provide medical care for both the prevention of disease and the treatment of serious illness.
Your rights
OPM requires that all FEHB Plans to provide certain information to their FEHB members. You may get information about us, our networks, providers, and facilities. OPM's FEHB website (www. opm. gov/ insure) lists the specific types of information that we must
make available to you.
If you want more information about us, call 360-478-6796 or toll free 800-552-7114, or write to P. O. Box 339, Bremerton, Washington 98337. You may also contact us by fax at 360-415-6514 or visit our website at www. kpshealthplans. com.

Service Area
To enroll in this Plan, you must live or work in our service area. This is where our providers practice. Our service area covers the counties of Clallam, Grays Harbor, Jefferson, King, Kitsap, Mason, Pierce and Thurston in Northwest Washington.

Ordinarily, you must get your care from providers who contract with us. If you receive care from non-Plan providers outside the State of Washington, we will pay only benefits for emergency care. We will not pay for any other health care services out of our service
area unless the services have prior plan approval. Exceptions: eligible dependent children away at school and you on temporary duty assignment outside our service area may receive benefits for other than emergency care when arrangements are made with us.

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

2003 KPS Health Plans 6 Section 1 9.
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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
Under High Option, your share of the non-Postal premium will increase by 40.8% for Self Only or 43.4% for Self and Family.
Under Standard Option, your share of the non-Postal premium will increase by 30.4% for Self Only or 26.1% for Self and Family.
Under High Option, the hospital copayment will increase from $200 per admission with a $600 per member annual maximum to $100 per day with a $1,000 per member annual maximum.

Under Standard Option, you will now pay $20 for an office visit or urgent care center visit. The annual deductible has been waived for office or urgent care facility visits.
Under Standard Option, your annual out-of-pocket maximum will increase from $2,000 per person or $4,000 per family enrollment to $3,000 per person or $6,000 per family enrollment.
Under both High Option and Standard Option, you will now be covered for up to 60 visits combined per calendar year for physical, occupational and speech therapy.
Under both High Option and Standard Option, all organ/ tissue transplants will now be covered at 80%.
Under both High Option and Standard Option, organ transplant costs in excess of $100,000 will now count toward your out-of-pocket maximum.

Under High Option, for prescription drugs, you will now pay a $5 copayment for Tier 1 (Generic) drugs. Tier 2 (Preferred) and Tier 3 (Non-preferred) drugs are still subject to the $600 annual deductible and covered at 50%.
Under Standard Option, your copayment for Tier 2 (Preferred) drugs will increase from $15 per prescription or refill to $20 per prescription or refill.
Under Standard Option, your dental benefits for preventive care will now be paid at 100% of the scheduled allowance.
You may now enroll in this Plan if you live or work in King County.
We have clarified that Temporomandibular Joint (TMJ) disorders are covered up to $1,000 per year for physician services under the medical benefit.

We have clarified which tests are covered under the Preventive Care benefit.
We have clarified our role when another party is responsible for your injuries.
We have clarified that a complete eye examination is covered.

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Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services from a Plan
provider or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits
enrollment confirmation (for annuitants), or your Employee Express confirmation letter.
If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 360-478-6796 or toll free at 800-
552-7114 or write us at KPS Health Plans, P. O. Box 339, Bremerton, Washington 98337.

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

Plan providers Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our members. We credential Plan
providers according to national standards.
Our provider directory lists primary care doctors (generally family practitioners, pediatricians, and internists) with their locations and phone numbers. Directories are
updated on a regular basis and are available at the time of enrollment or upon request by calling the Member Services Department at 360-478-6796 or toll free at 800-552-7114.
You can also find out if your doctor participates with us by calling these numbers. If you are interested in receiving care from a specific provider who is listed in the directory, call
the provider to verify that he or she still participates with us and is accepting new patients.

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. This information is also on our website at www. kpshealthplans. com.

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

If, in our medical director's opinion, your utilization of covered benefits appears to be excessive for proper medical care, you may be required to designate a Plan doctor of your
choice who will arrange for coordination of your medical care and for referral to other providers. It is the responsibility of your doctor to obtain any necessary authorizations
from us before referring you to a specialist or making arrangements for hospitalization.

Primary care Your primary care physician can be any physician you choose (generally 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 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. However, a woman may see her Plan women's health professional for her annual routine examination
without referral.
Here are other things you should know about specialty care:

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If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician and the specialist 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, and will obtain any necessary Plan authorization.
If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician. Your primary care physician will decide what treatment you need. If he
or she decides to refer you to a specialist, ask if you can see your current specialist. If your current specialist does not participate with us, you must receive treatment
from a specialist who does. Generally, we will not pay for you to see a specialist who does not participate with our Plan.

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

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

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

Hospital care Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled nursing or other type of
facility.
If you are in the hospital when your enrollment in our Plan begins, call our Member Services Department immediately at 360-478-6796 or toll free at 800-552-7114. If you
are new to the FEHB Program, we will arrange for you to receive care.
If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:

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

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

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Services requiring our prior approval Your primary care physician has authority to refer you for most services. For certain services, however, you or 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 pre-authorization

or pre-certification.

Your physician must obtain pre-authorization for the following services: Inpatient Services
Hospitalization Organ transplants
Home health services Skilled nursing facility confinements
Sleep disorders
This list is not a complete list of services requiring pre-authorization. You should review Section 5 for additional information regarding pre-authorization.

Help us control costs
Outpatient Surgery Hospitalization is no longer necessary for many surgical and diagnostic procedures. These procedures can be performed safely and less expensively on an outpatient basis

without sacrificing quality of care.
Listed elective surgeries and diagnostic procedures must be performed in a hospital outpatient unit, surgical center, or Plan doctor's office. These facilities are more
convenient than a hospital because surgery can be scheduled easily and quickly, and the patient can return home sooner. The cost of surgery is reduced because hospital room
and board charges are eliminated.
If circumstances indicate that it is medically necessary to perform a procedure on an inpatient basis, full Plan benefits will be provided.

If a procedure is performed on an inpatient basis when hospitalization is not medically necessary, benefits for the surgical fee will be reduced by 20% and benefits for the
hospital stay will be denied. No reduction in benefits will occur for emergency admissions.

The following procedures must be performed on an outpatient basis:
Biopsy procedures Hemorrhoid surgery Breast surgery (minor) (However,
anyone who undergoes a mastectomy may, at their option,
have this procedure performed on an inpatient basis and remain in the
hospital up to 48 hours after the procedure)
Diagnostic examination with scopes Dilation and curettage (D & C)
Ear surgery (minor) Facial reconstruction surgery
Tonsillectomy and adenoidectomy

Inguinal hernia surgery Knee surgery
Nose surgery Removal of bunions, nails,
hammertoes, etc. Removal of cataracts
Removal of cysts, ganglions, and lesions
Sterilization procedures Tendon, bone, and joint
surgery of the hand and foot.

Pre-Admission Testing Pre-admission testing requires that necessary routine diagnostic tests be performed on an outpatient basis before you are hospitalized for elective non-emergency care. These must
be performed within three days of the scheduled admission. Failure to obtain testing prior to admission will result in a 20% reduction of benefits for the testing charges. Pre-admission
testing is less expensive when done on an out-patient basis and is usually more convenient.

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When inpatient hospitalization is recommended for you, ask your Plan doctor to schedule diagnostic tests on an outpatient basis within three days of admission. Pre-admission
certification provides advanced confirmation for benefits from us before you are admitted to a hospital or skilled nursing facility.

Pre-Admission Certification Pre-admission certification authorizes inpatient hospital benefits and is valid for six months. Approval for each admission or re-admission is required. We will provide
coverage only for the number of hospital days that are medically necessary and appropriate for your condition. If your hospital stay is extended due to complications,
your Plan doctor must obtain benefit authorization for the extension.
After your Plan doctor notifies you that hospitalization or skilled nursing care is necessary, ask your Plan doctor to obtain pre-admission certification. You and your Plan
doctor must request pre-admission certification before hospitalization. This is a feature that allows you to know, prior to hospitalization, which services are considered medically
necessary and eligible for payment under this Plan. If the hospitalization and treatment is not pre-certified, the admitting physician's fees will be reduced by 20% and benefits for
the hospital stay will be reduced by $500.
We will send you written confirmation of the approved admission, once certification is obtained. If an emergency admission occurs, have your attending physician and the
hospital contact us within 48 hours of admission, or as soon as reasonably possible, to complete the certification process.

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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.

Examples: Under High Option, when you see your primary care physician you pay a copayment of $10 per office visit, and when you go in the hospital you pay $100 per day
to a maximum of $1,000 per calendar year. Under Standard Option you pay a copayment of $20 per office visit.

Deductible A 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.
The calendar year deductible is $0 per person under High Option and $200 per person under Standard Option. Under a family enrollment, the deductible is

considered satisfied and benefits are payable for all family members when the combined covered expenses applied to the calendar year deductible for family
members reach $0 under High Option and $400 under Standard Option. This deductible is waived for preventive care and accidental injuries on the Standard
Option.
We also have a separate deductible for Prescription Drugs under High Option of $600 per family member for Tier 2 (Preferred) and Tier 3 (Non-Preferred) drugs.

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 our negotiated fee that you must pay for your care. Coinsurance doesn't begin until you meet your deductible. Under Standard Option you

pay 20% coinsurance for most services.
Example: In our Plan, you pay 50% of our allowance for infertility services, sleep disorders and treatment of morbid obesity.

High Option After your hospital copayments total $1,000 per family member you do not have to pay any more inpatient hospital copayments. Your catastrophic protection out-of-pocket maximum for
deductibles, coinsurance, and copayments Standard Option After your coinsurance totals $3,000 per person or $6,000 per family
enrollment in any calendar year, you do not have to pay any more for covered services. However, copayments or coinsurance for the following services do not count toward your
out-of-pocket maximum, and you must continue to pay copayments or coinsurance for these services:

Prescription drugs Dental services
Services of non-Plan providers Diagnosis and treatment of infertility
Surgical treatment of morbid obesity Diagnosis and treatment of sleep disorders

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

2003 KPS Health Plans 12 Section 4 15.
15 Page 16 17

Section 5. Benefits OVERVIEW
(See page 7 for how our benefits changed this year and page 60 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 360-478-6796 or toll free at 800-552-7114 or at our website at www. kpshealthplans. com.

(a) Medical services and supplies provided by physicians and other health care professionals ................................................ 14-24
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............................................. 25-28
Surgical procedures Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility and ambulance services ........................................................................... 29-31
Inpatient hospital Outpatient hospital or ambulatory surgical
center
Extended care benefits/ skilled nursing care facility benefits Hospice care
Ambulance

(d) Emergency services/ accidents.............................................................................................................................................. 32-33 Medical emergency Ambulance
(e) Mental health and substance abuse benefits......................................................................................................................... 34-35
(f) Prescription drug benefits .................................................................................................................................................... 36-37
(g) Dental benefits ..................................................................................................................................................................... 38-42
Summary of benefits ......................................................................................................................................................................... 60

2003 KPS Health Plans 13 Section 5 16.
16 Page 17 18
Section 5 (a). Medical services and supplies provided by physicians and other health care professionals
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Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

Plan physicians must provide or arrange your care.
Under Standard Option The calendar year deductible is $200 per person ($ 400 per family). The calendar year deductible applies to almost all benefits in this Section. We added "( No deductible)"

to show when the calendar year deductible does not apply.
Under High Option We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including

with Medicare.

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

Diagnostic and treatment services You pay Standard Option You pay High Option

Professional services of physicians
In physician's office
In an urgent care center
Office medical consultations
Second surgical opinion
Note: Under Standard Option, you pay a $20 copay for office visits billed with codes corresponding to

these services. All other services are subject to the coinsurance or benefit limitations as referenced in
this brochure.
Note: Treatment of impotence is covered when medically necessary.

$20 per office visit
(No deductible)
$10 per office visit
(No deductible)

Professional services of physicians
During a hospital stay
In a skilled nursing facility
Initial exam of a newborn child covered under a family enrollment

20% Nothing

At home 20% $15 per visit
(No deductible)

Not covered:
Non-surgical treatment of morbid obesity
Hearing aids

All charges All charges

2003 KPS Health Plans 14 Section 5( a) 17.
17 Page 18 19
Lab, X-ray and other diagnostic tests You pay Standard Option You pay High Option
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG

20% Nothing

Preventive care, adult
Routine screenings, such as:
Complete Blood Count one annually
Total Blood Cholesterol once every three years
A fasting lipoprotein profile (total cholesterol, LDL, HDL and triglycerides) once every 5 years

for adults 20 or over
Colorectal cancer screening, including
Fecal occult blood test
Sigmoidoscopy, screening every five years starting at age 50; or

Colonoscopy once every 10 years starting at age 50; or
Double contrast barium enema (DCBE) once every 5 to 10 years starting at age 50

20%
(No deductible)
Nothing

Routine Prostate Specific Antigen (PSA) test one annually for men age 40 and older 20%
(No deductible)
Nothing

Routine pap test
Note: The office visit is covered if pap test is received on the same day; see Diagnosis and

Treatment, above.

20%
(No deductible)
Nothing

Preventive care, adult Continued on next page

2003 KPS Health Plans 15 Section 5( a) 18.
18 Page 19 20
Preventive care, adult (Continued) You payStandardOption You pay High Option
Routine mammogram covered for women age 35 and older, as follows:

From age 35 through 39, one during this five-year period
From age 40 through 64, one every calendar year
At age 65 and older, one every two consecutive calendar years

Note: In addition to routine mammograms, mammograms are covered when prescribed by the doctor as necessary to
diagnosis or treat your illness.

20%
(No deductible)
Nothing

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

Routine immunizations, limited to:
Tetanus-diphtheria (Td) booster once every 10 years, ages 19 and over (except as provided for under

Childhood immunizations)
Influenza vaccine, annually, age 65 and over
Pneumococcal vaccines, age 65 and over

Nothing Nothing

Preventive care, children
Childhood immunizations recommended by the American Academy of Pediatrics Nothing Nothing

Well-child care charges for routine examinations, immunizations and care (through age 21) Nothing Nothing
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

20%
(Nodeductible)
$10 per office visit
(Nodeductible)

2003 KPS Health Plans 16 Section 5( a) 19.
19 Page 20 21
Maternity care You pay Standard Option You pay High Option
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Certified nurse midwife and licensed midwife
Birthing centers
Postnatal care
Note: Here are some things to keep in mind:
You do not need to pre-certify your normal delivery; see page 11 for other circumstances, such

as extended stays for you or your baby.
You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean

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

Hospital benefits (Section 5( c).) and Surgery benefits (Section 5( b).)

20% $100 per day to a maximum of $1,000 per
member per calendar year.
(No deductible)

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

Surgically implanted contraceptives
Injectable contraceptive drugs (such as Depo provera)

Intrauterine devices (IUDs)
Diaphragms
NOTE: We cover oral contraceptives under the prescription drug benefit.

20% $10 per office visit
(No deductible)

Family planning continued on next page
2003 KPS Health Plans 17 Section 5( a) 20.
20 Page 21 22
Family planning (continued) You pay Standard Option You pay High Option
Not covered:
Reversal of voluntary surgical sterilization
Genetic counseling
Drugs and 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

All charges All charges

Infertility services
Diagnosis and treatment of infertility, such as:
Artificial insemination: Intravaginal insemination (IVI)

Intracervical insemination (ICI)

50% 50%
(No deductible)

Not covered:
Assisted reproductive technology (ART) procedures, such as:

In vitro fertilization
Embryo transfer, gamete GIFT and zygote ZIFT

Zygote transfer
Intrauterine insemination (IUI)
Services and supplies related to excluded ART procedures

Cost of donor sperm
Cost of donor egg
Fertility drugs

All charges All charges

Allergy care
Testing and treatment
Allergy injection
20% $10 per office visit

(No deductible)

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

2003 KPS Health Plans 18 Section 5( a) 21.
21 Page 22 23
Treatment therapies You payStandardOption You pay High Option
Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those

transplants listed under Organ/ Tissue Transplants on page 27.

Respiratory and inhalation therapy
Dialysis hemodialysis and peritoneal dialysis
Intravenous (IV)/ Infusion Therapy Home IV and antibiotic therapy. Pre-authorization required

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

Note: We will only cover GHT when we pre-authorize the treatment. It is covered under your pharmacy benefit.
Call MedImpact at 800-788-2949 for pre-authorization. They will ask you to submit information that establishes
that GHT is medically necessary. Ask us to authorize GHT before you begin treatment; otherwise, we will only
cover GHT services from the date you submit the information. If you do not ask or if we determine GHT is
not medically necessary, we will not cover GHT or related services and supplies. See Services requiring our
prior approval in Section 3.

20% $10 per office visit
(Nodeductible)

Physical and occupational therapies
Up to 60 visits per year combined for speech therapy (see below) and for the services 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.

20% $10 per office visit
(Nodeductible)

Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction, is
provided for up to $500
20% Nothing

Not covered:
Long-term rehabilitative therapy
Exercise programs

All charges All charges

Speech therapy
Licensed speech therapist
Note: Speech therapy is combined with 60 visits per year for the services of physical therapy and/ or

occupational therapy (see above)

20% $10 per office visit
(No deductible)

2003 KPS Health Plans 19 Section 5( a) 22.
22 Page 23 24
Hearing services (testing, treatment, and supplies) You pay Standard Option You pay High Option
Hearing testing for children through age 17 (see Preventive care, children) 20%
(No deductible)
$10 per office visit
(No deductible)

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

Vision services (testing, treatment, and supplies)
One pair of eyeglasses or contact lenses to correct an impairment directly caused by accidental ocular
injury or intraocular surgery (such as for cataracts)
20% Nothing

Annual eye exam 20% $10 per office visit
(No deductible)

Eye exams to determine the need for vision correction for children through age 17 (see
Preventive care)
20%
(No deductible)
$10 per office visit
(No deductible)

Not covered:
Eyeglasses or contact
Eye exercises and orthoptics
Radial keratotomy and other refractive surgery

All charges 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.

20% $10 per office visit
(No deductible)

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 All charges

2003 KPS Health Plans 20 Section 5( a) 23.
23 Page 24 25
Orthopedic and prosthetic devices You pay Standard Option You pay High Option
Artificial limbs and eyes; stump hose
Externally worn breast prostheses and surgical bras, including necessary replacements, following a

mastectomy
Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain

dysfunction syndrome
Note: This benefit combined with the Durable Medical Benefit on page 22 is limited to a

maximum payment of $2,500 per calendar year and $50,000 maximum per lifetime.

Internal prosthetic devices, such as artificial joints, pacemakers, and surgically implanted breast
implant following mastectomy.
Note: We pay internal prosthetic devices as hospital benefits; see Section 5( c). for payment

information. See section 5( b). for coverage of the surgery to insert the device.

20% Nothing

Not covered:
Orthopedic and corrective shoes
Arch supports
Foot orthotics
Heel pads and heel cups
Lumbosacral supports
Corsets, trusses, elastic stockings, support hose, and other supportive devices

Cochlear implants
Prosthetic replacements provided less than 3 years after the last one we covered

All charges All charges

2003 KPS Health Plans 21 Section 5( a) 24.
24 Page 25 26
Durable medical equipment (DME) You pay Standard Option You pay High Option
Rental or purchase, at our option, including repair and adjustment, 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
Blood glucose monitors
Insulin pumps
Motorized wheel chairs
Note: This list is not complete. For more details please call Member Services.

Note: This benefit combined with the Orthopedic and prosthetic devices benefit on page 21 is limited to a
maximum payment of $2,500 per calendar year and $50,000 maximum per lifetime.

20% Nothing

Not covered:
Exercise equipment such as Nordic Track and/ or exercise bicycles

Equipment which is primarily used for non-medical purposes such as hot tubs and massage
pillows
Convenience items

All charges 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. Up to two hours per
visit.
Services include oxygen therapy, intravenous therapy and medications.

Note: These services require pre-certification. Please refer to the pre-certification information shown in
Section 3 for pre-certification guidelines.

20% Nothing

Not covered:
Nursing care requested by, or for the convenience of, the patient or the patient's family

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

All charges All charges

2003 KPS Health Plans 22 Section 5( a) 25.
25 Page 26 27
Chiropractic You pay Standard Option You pay High Option
Up to 12 treatments per calendar year for manipulation of the spine and extremities 20% $10 per office visit
(No deductible)

Not covered:
Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy

and cold pack application.

All charges All charges

Alternative treatments
Acupuncture up to 12 treatments per calendar year when treatment is received by a licensed Plan

provider
20% $10 per office visit
(No deductible)

Not covered:
Herbs prescribed by an acupuncturist or naturopath

Naturopathic services
Hypnotherapy
Biofeedback

All charges All charges

Educational classes and programs
Coverage is limited to:

Smoking Cessation Up to $150 for one smoking cessation program per member per lifetime.
Approved medications obtained at a Plan pharmacy will be covered under the Prescription Drug
Benefit to a lifetime maximum of $350 per member.

20%
(No deductible)
$10 per office visit
(No deductible)

Outpatient nutritional guidance counseling services by a registered dietitian for the following
conditions: diabetes, cancer, endocrine conditions, swallowing conditions after stroke, and
hyperlipidemia. Up to a maximum benefit of $400 per member per year.

20% $10 per office visit
(No deductible)

2003 KPS Health Plans 23 Section 5( a) 26.
26 Page 27 28
Sleep disorders You pay Standard Option You pay High Option
Sleep studies (including polysomnograph, multiple sleep latency tests, continuous positive airway

pressure (CPAP) studies, and durable medical equipment and supplies) will be covered for the
following sleep disorders when diagnosed and referred by a Plan physician: narcolepsy and sleep
apnea syndrome (such as obstructive upper airway and/ or central sleep apnea). Other conditions may be
payable upon review by the Medical Director. Sleep studies are limited to a lifetime maximum of $5,000.

Surgical treatment of the above listed sleep disorders will be limited to a lifetime maximum of
$3,000.

50% 50%
(No deductible)

Not covered: Any service not listed above for the purpose of studying, monitoring and/ or treating sleep disorders. All charges All charges
Temporomandibular joint (TMJ) disorders
We cover care by a physician or licensed dentist (D. D. S.) for the medical and/ or dental diagnosis and non-surgical

treatment of TMJ disorders.
This benefit is limited to a maximum of $1,000 per year

20% Nothing

Not covered: Services primarily for cosmetic purposes All charges All charges

2003 KPS Health Plans 24 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
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Plan physicians must provide or arrange your care.
Under Standard Option the calendar year deductible is $200 per person ($ 400 per family). The calendar year deductible applies to almost all benefits in this Section. We added "( No

deductible)" to show when the calendar year deductible does not apply.
Under High Option there is no deductible for these services

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 PRE-CERTIFICATION FOR SOME SURGICAL PROCEDURES. Please refer to the pre-certification information shown in Section 3 to be

sure which services require pre-certification and identify which surgeries require pre-certification.

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

Surgical procedures You pay Standard Option You pay High Option
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) Insertion of internal prosthetic devices. See
Section 5( a) Orthopedic and prosthetic devices for device coverage information.
Circumcision from birth to one month old or as medically necessary

20% Nothing

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

50% 50%
(No deductible)

Surgical procedures Continued on next page
2003 KPS Health Plans 25 Section 5( b) 28.
28 Page 29 30
Surgical procedures (Continued) You pay Standard Option You pay High Option
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.

20% $10 per office visit
(No deductible)

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

Foot care, Section 5( a).

All charges 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.

20% 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 related to sex transformation

All charges All charges

2003 KPS Health Plans 26 Section 5( b) 29.
29 Page 30 31
Oral and maxillofacial surgery You pay Standard Option You pay High Option
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.

20% Nothing

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

and alveolar bone)

All charges All charges

Organ/ tissue transplants
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ pancreas
Pancreas
Liver
Lung: Single Double
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; multiple myeloma; epithelial ovarian cancer; and
testicular, mediastinal, retroperitoneal and ovarian germ cell tumors

Intestinal transplants (small intestine) and the small intestine with the liver or small intestine with multiple
organs such as the liver, stomach, and pancreas. Limited to those transplants that meet our protocols.

Limited Benefits Treatment for breast cancer, multiple myeloma, and epithelial ovarian cancer may be provided in an
NCI or NIH approved clinical trial at a Plan-designated center of excellence and if approved by our medical director in
accordance with the our protocols.
Note: We cover related medical and hospital expenses of the donor when we cover the recipient.

20%. 20%
(No deductible)

2003 KPS Health Plans 27 Section 5( b) Organ/ tissue transplant continued on next page 30.
30 Page 31 32
Organ/ tissue transplants (continued) You Pay Standard Option You Pay High Option
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 All charges

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

Skilled nursing facility Ambulatory surgical center
Office

20% Nothing

2003 KPS Health Plans 28 Section 5( b) 31.
31 Page 32 33
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
I M
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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.

In this Section, unlike Sections (a) and (b), the calendar year deductible applies to only a few benefits. In that case, we added "( calendar year deductible applies)".
Under Standard Option the calendar year deductible is $200 per person ($ 400 per family).
Under High Option there is no deductible for these services
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other

coverage, including with Medicare.
The amounts listed below are for the charges billed by the facility (i. e., hospital or surgical center) or ambulance service for your surgery or care. Any costs associated with

the professional charge (i. e., physicians, etc.) are covered in Section 5( a) or (b).
YOUR PHYSICIAN MUST GET PRE-CERTIFICATION FOR HOSPITAL STAYS. Please refer to Section 3 to be sure which services require pre-certification.

I M
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Benefit Description You pay
NOTE: The calendar year deductible applies to all services on the Standard Option.
The High Option does not have a deductible:

Inpatient hospital You pay Standard Option You pay High Option
Room and board, such as
Ward, semiprivate, or intensive care accommodations;

General nursing care; and Meals and special diets.

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

20%
(Calendar year deductible applies)
$100 per day to a maximum of $1,000 per member per
calendar year.

Inpatient hospital continued on next page

2003 KPS Health Plans 29 Section 5( c) 32.
32 Page 33 34
Inpatient hospital (Continued) You pay Standard Option You pay High Option
Other hospital services and supplies, such as:
Operating, recovery, maternity, and other treatment rooms

Prescribed drugs and medicines Diagnostic laboratory tests and X-rays
Administration of blood and blood products Blood or blood plasma, if not donated or replaced
Dressings, splints, casts, and sterile tray services Medical supplies and equipment, including oxygen
Anesthetics, including nurse anesthetist services Take-home items
Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home
Private nursing care