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HMO Blue Texas

Federal Employees Health Benefits Program
2003 Plan Brochure
Accessible Version

Document Outline

Introduction
Plain Language
Stop Health Care Fraud!
Section 1. Facts about this HMO Plan
Section 2. How we change for 2003
- Program-wide changes
- Changes to this Plan
Section 3. How you get care
Section 4. Your costs for covered services
Section 5. Benefits OVERVIEW
Section 6. General exclusions -- things we dont cover
Section 7. Filing a claim for covered services
Section 8. The disputed claims process
Section 9. Coordinating benefits with other coverage
Section 10. Definitions of terms we use in this brochure
Section 11. FEHB facts
- Coverage Information
- When you lose benefits
Long Term Care Insurance Is Still Available
Index
Summary of benefits for HMO Blue Texas 2003
2003 Rate Information for HMO Blue Texas

Pages 1--63

Page 1 2

HMO Blue Texas
2003 http:// www. bcbstx. com
Health Maintenance Organization

Serving: Houston metropolitan area
Enrollment in this Plan is limited. You must live or work in our geographic service area; see page 7 for requirements.

Enrollment codes for this Plan:
Houston area
YM1 Self Only
YM2 Self and Family

RI 73-264

For changes
in benefits,
see page 8.

The Southwest Texas HMO Plan
has full accreditation from the
NCQA. See the 2003 Guide for
more information on NCQA. 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

Plan providers........................................................................................................................................ 9
Plan facilities ......................................................................................................................................... 9
What you must do to get covered care ......................................................................................................... 9

Prenatal Education 5.
5 Page 6 7

2003 HMO Blue Texas 4 Section 1
Introduction
This brochure describes the benefits of HMO Blue Texas under our contract (CS 1951) with the Office of Personnel Management
(OPM), as authorized by the Federal Employees Health Benefits law. The address for HMO Blue Texas administrative offices is:

Southwest Texas HMO, Inc. d/ b/ a HMO Blue Texas
P. O. Box 660044
Dallas, TX 75266-0044

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 8. 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 HMO Blue Texas.

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 (FEHBP) 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. 7.
7 Page 8 9
2003 HMO Blue Texas 5 Section 1
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 877/ 299-2377 and explain the situation.
If we do not resolve the issue:

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.

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 8.
8 Page 9 10

2003 HMO Blue Texas 6 Section 1
Section 1. Facts about this HMO Plan
This Plan is a health maintenance organization (HMO). We require you to seek care from 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
and coinsurance described in this brochure. When you receive emergency services from non-Plan providers, you may have to submit
claim forms.

You should join an HMO because you prefer the Plan's benefits, not because a particular provider is available. You cannot
change plans because a provider leaves our Plan. We cannot guarantee that any one physician, hospital, or other provider will
be available and/ or remain under contract with us.

How we pay providers
We contract with individual physicians, medical groups and hospitals to provide the benefits in this brochure. These Plan providers
accept a negotiated payment from us, and you will only be responsible for your copayments or coinsurance. Some Primary Care
Physicians (PCP) are paid under a method known as capitation. Capitation pre-pays a physician based on a fixed monthly amount per
person, no matter how few or many services a patient uses.

Most specialists are paid on a fee-for service basis (as set for specific services).
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.

HMO Blue Texas began in 1983 as a for-profit health maintenance organization under the name Sanus Corp Health Systems. Sanus Corp received Federal Qualification in 1984.
Licenses to operate were received for Texas in 1984. Southwest Texas HMO received full NCQA accreditation in 1994, 1997, and 2000 for three years each.
Texas Gulf Coast HMO received full NCQA accreditation in 1997 and 2001 for three years each. On July 15, 1998, Aetna U. S. Healthcare purchased NYLCare Health Plans, the parent company of NYLCare Health Plans of
the Southwest, Inc. and NYLCare Health Plans of the Gulf Coast, Inc.
On April 1, 2000, Health Care Service Corporation, which does business in Texas as Blue Cross and Blue Shield of Texas, purchased NYLCare Health Plans of the Southwest, Inc. and NYLCare Health Plans of the Gulf Coast, Inc. The names of the

purchased entities were changed, respectively, to Southwest Texas HMO, Inc. d/ b/ a HMO Blue Texas and Texas Gulf Coast
HMO, Inc. d/ b/ a HMO Blue Texas.
September 1, 2001, Gulf Coast HMO, Inc. d/ b/ a HMO Blue Texas, and Rio Grande HMO, Inc. merged with Southwest Texas HMO, Inc. d/ b/ a HMO Blue Texas. The surviving entity is named Southwest Texas HMO, Inc. and does business as HMO Blue

Texas. HMO Blue Texas is a wholly owned subsidiary of Health Care Services Corporation, an independent licensee of the
Blue Cross and Blue Shield Association.

If you want more information about us, call (877) 299-2377. Or write to HMO Blue Texas at P. O. Box 660044, Dallas, TX 75266-
0044. You may also visit our website at www. bcbstx. com. 9.
9 Page 10 11
2003 HMO Blue Texas 7 Section 1
Service Area
To enroll in this plan, you must live in or work in our Service Area. This is where our providers practice. Our service
areas is:

Houston Territory The Texas counties of: Austin, Brazoria, Chambers, Colorado, Fort Bend, Galveston, Grimes, Harris, Liberty,
Matagorda, Montgomery, San Jacinto, Walker, Waller, Washington, and Wharton.
Ordinarily, if you live within our service area, you must get care from providers who contract with us in this particular
service area. If you receive care outside your service area, we will pay only 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.

If you or a covered family member move outside of our service area, you can enroll in another plan. If your
dependents live out of the area (for example, if your child goes to college in another state), you should consider
enrolling in a fee-for-service plan or an HMO that has agreements with affiliates in other areas. If you or a family
member move, you do not have to wait until Open Season to change plans. Contact your employing or retirement
office. 10.
10 Page 11 12
2003 HMO Blue Texas 8 Section 2
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 15. 8% for Self Only or 22. 1% for Self and Family.
We changed the amount that you pay for an office visit from $10 to $20. (Section 5( a, b, e, h))
We changed the amount that you pay for In-patient hospital care from $100 per admission to $100 per day up to a maximum of $400 per admission. (Section 5( a, c, e, h))

We changed the amount that you pay for an Emergency Room visit from $75 to $100. (Section 5( d))
We changed the amount that you pay for Urgent Care from $15 to $35. (Section 5( a, d))
We now require that "Bioequivalent Generic Drugs" be dispensed with this plan. If the member request a name brand when a generic is available, the member will pay the generic copayment plus the difference between the

cost of the generic and the cost of the name brand product. (Section 5( f))
We changed the amount that you pay for a 30-day supply of preferred brand name drugs from $10 to $25. (Section 5( f))

We changed the amount that you pay for a 30-day supply of non-preferred brand name drugs from $25 to $40. (Section 5( f))
We changed the amount that you pay for a 90-day mail order supply of generic drugs from $5 for each 30-day supply to $20 for a 90 day supply. (Section 5( f))
We changed the amount that you pay for a 90-day mail order supply of preferred brand name drugs from $10 for each 30-day supply to $40 for a 90 day supply (Section 5( f))
We changed the amount that you pay for a 90-day mail order supply of non-preferred brand drugs from $25 for each 30-day supply to $80 for a 90 day supply (Section 5( f))
We changed the amount that you pay for Durable Medical Equipment from "Nothing" to "20% of the allowed amount. (Section (a))
We changed the amount you pay for out-patient hospital services from "Nothing" to $150 per surgery. (Section 5( c))
We changed the amount of your catastrophic protection or the out-of-pocket maximum for copayments from $650 to $1,000 for the individual and from $1,500 to $3,000 for each family. (Section 4) 11.
11 Page 12 13

2003 HMO Blue Texas 9 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it
whenever you receive services from a Plan provider, or 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
Customer Service at (877) 299-2377 or write to us at PO Box 660044;
Dallas, Texas 75266-0044. You may also request replacement cards
through our website at www. bcbstx. com.

Where you get covered care You get care from "Plan providers" and "Plan facilities." You will only pay copayments and you will not have to file claims.
Plan providers Plan providers are physicians and other health care professionals in our service areas that we contract with to provide covered services to our
members. We credential Plan providers according to national standards.
We list Plan providers in the provider directory, which we update
periodically. The list is also on our website, www. bcbstx. com.

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

What you must do to It depends on the type of care you need. First, you and each family get covered care member must choose a Primary Care Physician (PCP). This decision is
important since your PCP provides or arranges for most of your health
care. To select a PCP, refer to the provider directory or website to find a
doctor that meets your personal criteria and preferences (provider type,
location, etc.).

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

If you want to change PCPs or if your PCP leaves the Plan, call us. We
will help you select a new one.

Specialty care Your PCP will refer you to a specialist for needed care. When you receive a referral from your PCP, you must return to the PCP after the
consultation, unless your PCP authorized a certain number of visits
without additional referrals. The PCP must provide or authorize all
follow-up care. Do not go to the specialist for return visits unless your
PCP gives you a referral. However, you may see a Plan OB/ GYN or
plan mental health substance abuse provider without a referral. 12.
12 Page 13 14
2003 HMO Blue Texas 10 Section 3
Here are other things you should know about specialty care:
If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your PCP will work with the
specialist to develop a treatment plan that allows you to see your
specialist for a certain number of visits without additional referrals.
Your PCP 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 PCP. Your PCP 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 PCP to arrange 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 PCP or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled nursing or
other type of facility.
If you are in the hospital when your enrollment in our Plan begins, call
our Customer Service department immediately at (877) 299-2377. 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 13.
13 Page 14 15
2003 HMO Blue Texas 11 Section 3
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.

Services requiring our prior approval Your PCP 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 practices.

We call this review and approval process precertification. Your
physician must obtain precertification for the following services that
include, but are not limited to the following:

Hospitalization Outpatient Facility
Ancillary Facility Referral to non-participating provider
Surgical procedures 14.
14 Page 15 16
2003 HMO Blue Texas 12 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc. when you receive services.

Example: When you see your PCP you pay a copayment of $20 per
office visit. When you go in the hospital, you pay $100 per admission.

Deductible We do not have a deductible.
Coinsurance We do not have coinsurance.

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

Prescription Drugs Durable Medical Equipment
Dental Vision
Blood and Blood Products Prosthetic Devices
Allergy Serum and Injections
Be sure to keep accurate records of your copayments since you are
responsible for informing us when you reach the maximum. 15.
15 Page 16 17

2003 HMO Blue Texas 13 Section 5
Section 5. Benefits OVERVIEW
(See Page 8 for how our benefits changed this year and Page 63 for a benefits summary.)

NOTE: This benefits section is divided into subsections. Please read the important things you should keep in mind at
the beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in
the following subsections. To obtain claims forms, claims filing advice, or more information about our benefits,
contact us at (877) 299-2377, or visit our website at www. bcbstx. 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............................................................................................................................... 34-36
(g) Special features..................................................................................................................................................... 37
Flexible Benefits Option Prenatal Education

(h) Dental benefits ................................................................................................................................................ 38-40
(i) Non-FEHB benefits available to Plan members ................................................................................................... 41

Summary of benefits .................................................................................................................................................... 59 16.
16 Page 17 18
2003 HMO Blue Texas 14 Section 5( a)
Section 5 (a) Medical services and supplies provided by physicians and other health care professionals
I M
P O
R T
A N
T

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

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

coverage, including with Medicare.

I M
P O
R T
A N
T

Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
In physician's office
Consultations by specialists
Office medical consultations
Second surgical opinion

$20 per office visit

In an urgent care center $35 per office visit
During a hospital stay
In a skilled nursing facility
Nothing

At home (within Service Area)
House calls provided at Plan doctor's discretion if such case is necessary and appropriate

Visits by nurses and health aides

$20 per visit

Lab, X-ray and other diagnostic tests You pay
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG

Nothing if you receive these
services during your office visit or
at lab facility; otherwise $20 per
office visit 17.
17 Page 18 19
2003 HMO Blue Texas 15 Section 5( a)
Preventive care, adult
Routine screenings, such as:
Periodic Health Assessments
Total Blood Cholesterol once every year
Colorectal Cancer Screening, including
-Fecal occult blood test

Nothing, based on physician's
recommended schedule

-Sigmoidoscopy, screening every five years starting at age 50
Chlamydial infection screening

Routine Prostate Specific Antigen (PSA ) Test one annually for men age 40 and older

Note: Preventive care is provided on the schedule recommended by the
examining physician, based on guidelines we provide the physician.

Routine pap test Nothing, for annual exam;
otherwise $20 for each additional
visit

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

Nothing

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

Treatment for work related injury (if covered by workman's compensation), educational testing and therapy, and nutritional
counseling and diet planning.

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
Pneumococcal vaccine, age 65 and over

Nothing 18.
18 Page 19 20
2003 HMO Blue Texas 16 Section 5( a)
Preventive care, children You pay
Childhood immunizations recommended by the American Academy of Pediatrics 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

-Examinations done on the day of immunizations (through age 22)

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

Note: Your PCP decides how frequent and extensive these check-ups
should be, based on guidelines we provide the physician.

Nothing

Maternity care
Complete outpatient maternity (obstetrical) care, such as:
Prenatal care
Postnatal care

$20 for initial visit only

Complete inpatient maternity (obstetrical) care such as:
Delivery

Note: Here are some things to keep in mind:
Plan physicians must provide or arrange your care and you must be hospitalized in a Plan facility.

You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will extend your inpatient
stay if medically necessary.
We cover routine nursery care of the newborn child during the covered portion of the mother's maternity stay. We will cover other care of an

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

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

benefits (Section 5b).

Nothing

Not covered:
Routine sonograms to determine fetal age, size or sex.
Charges for normal delivery outside of the service area

All chares 19.
19 Page 20 21
2003 HMO Blue Texas 17 Section 5( a)
Family planning You pay
A range of voluntary family planning services, limited to:
Voluntary sterilization (See surgical procedures Section 5( b))
Injectable contraceptive drugs (such as Depo Provera)
Intrauterine devices (IUDs)

$20 per office visit plus $25 per
procedure

Surgically implanted contraceptives (such as Norplant) $20 per office visit plus 50% of the usual and customary charge, as
determined by us.

Note: A diaphragm and oral contraceptives are covered under
prescription drugs.
See page 34 for prescription drug
benefit.

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

Infertility services
Diagnostic testing to determine the cause of infertility. $20 per office visit

Treatment of infertility such as:
Artificial insemination:
-intravaginal insemination (IVI)
-intracervical insemination (ICI)
-intrauterine insemination (IUI)

$20 per office visit plus 50% of the
usual and customary charges for
each service as determined by us,
including physician office visit and
laboratory testing

Oral Fertility drugs Note: See page 34 for prescription drug benefit
Not covered:
Assisted reproductive technology (ART) procedures, such as:
-in vitro fertilization
-embryo transfer, gamete GIFT and zygote ZIFT
-zygote transfer (ZIFT)

Services and supplies related to excluded ART procedures
Donation, preservation, analysis and storage of sperm, eggs or embryos
Cost of sperm
Injectable Fertility Drugs
Infertility services after voluntary sterilization

All charges

Allergy care
Testing and treatment $25 for each session of testing;
$20 copay for treatment

Allergy injection $20 copay 20.
20 Page 21 22
2003 HMO Blue Texas 18 Section 5( a)
Allergy care (continued) You pay
Allergy serum Nothing

Not covered:
Provocative food testing and sublingual allergy desensitization
All charges

Treatment therapies
Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone
marrow transplants are limited to those transplants listed under
Organ/ Tissue Transplants on page 25.

Respiratory and inhalation therapy
Dialysis hemodialysis and peritoneal dialysis
Intravenous (IV)/ Infusion Therapy Home IV and antibiotic therapy

$20 per office visit

Growth hormone therapy (GHT)
Note: We will only cover GHT when we preauthorize the treatment.
The attending physician must obtain preauthorization. We will ask
your physician to submit information that establishes that the 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 the GHT or
related services and supplies. See Services requiring our prior
approval in Section 3.

See page 35 for prescription drug
benefit.

Physical and occupational therapies
Services for each of the following:
-qualified physical therapists;
-occupational therapists, and
-chiropractic care as physical therapy

Note: Physical and 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.

Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction is also provided subject to the limitations below.

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.

Note: Your coverage is limited to services that continue to meet or
exceed the treatment goals established for you by your physician.
For the physically disabled maintenance of functioning or
prevention of or slowing of further deterioration.

Outpatient: $20 per office visit
Inpatient: Nothing included in
admission 21.
21 Page 22 23
2003 HMO Blue Texas 19 Section 5( a)
Physical and occupational therapies (continued) You pay
Not covered:
Long-term rehabilitative therapy
Exercise programs

All charges

Speech therapy
Services of a Speech Therapist
Note: Speech therapy includes coverage for rehabilitation or
developmental medical care.

Note: Your coverage is limited to services that continue to be medically
necessary.

$20 per office visit

Hearing services (testing, treatment, and supplies)
One audiogram if medically indicated per year
Initial placement of hearing aid when medically necessary
Note: Limit $800 for hearing aids, one cleaning of the hearing device per
year, and replacement every 4 years if medically indicated.

Hearing testing for children through age 17 (see Preventive care, children)

Nothing

Not covered:
Replacement for loss, damage or functional defect
All charges

Vision services (testing, treatment, and supplies)
Eye exam (vision screening) to determine the need for vision correction for children through age 17 (see preventive care) Nothing

Implantable lenses following intraocular surgery for cataracts. Nothing
Not covered:
Eye exercises and orthoptics
Radial keratotomy and other refractive surgery

Eyeglasses or contact lenses and examinations for them (See page 41, Non-FEHB Benefits)

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 per office visit 22.
22 Page 23 24
2003 HMO Blue Texas 20 Section 5( a)
Foot care (continued) You pay
Not covered:
Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except

as stated above
Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the treatment

is by open cutting surgery)
Corrective orthopedic shoes, arch supports, braces, splints or other foot care items.

All charges

Orthopedic and prosthetic devices
Artificial limbs and eyes; stump hose
Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy

Terminal devices such as hand or hook.
Braces for arms, legs, back or neck.
External cardiac pacemaker.
Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implant following

mastectomy. Note: We pay internal prosthetic devices as hospital
benefits; see Section 5 (c) for payment information. See 5( b) for
coverage of the surgery to insert the device.

Foot orthotics when medically necessary.
Note: Coverage is limited to the initial device.

Nothing

Not covered:
Corrective and orthopedic shoes (unless built into a leg brace) or other foot care items

Arch supports
Heel pads and heel cups
Lumbosacral supports
Corsets, trusses, elastic stockings, support hose, and other supportive devices

Replacement of external prosthetic devices, except for standard replacements needed because of physical growth by members who are
under 18 years of age
Repair or periodic maintenance of any external prosthetic device
Devices provided solely for cosmetic purposes that have no functional applications.

Dentures
Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.

All charges 23.
23 Page 24 25
2003 HMO Blue Texas 21 Section 5( a)
Durable medical equipment (DME) You pay
Rental or purchase, at our option, including repair and adjustment, of
durable medical equipment prescribed by your Plan physician, such as
oxygen and dialysis equipment. Under this benefit, we also cover:

Hospital Beds;
Standard Wheelchairs;
Crutches;
Walkers;
Blood Glucose Monitors;
Insulin Pumps;
Bedside Commodes;
Suction Machines;
Orthopedic Tractions;
Oxygen; and
Annual audiogram (if medically indicated)
Note: Call the Plan as soon as your physician prescribes the equipment.
Blood Glucose Monitors and Insulin Pumps are covered under
your pharmacy benefits.

20% of the allowed amount

Not covered:
Motorized wheel chairs
Deluxe equipment such as motor driven hospital beds.
Comfort items
Bed boards
Bathtub lifts
Over bed tables
Air Purifiers
Disposable supplies
Elastic stockings
Sauna baths
Repair, replacement or maintenance of equipment purchased by Plan
Exercise equipment
Stethoscopes
Sphygmomanometers

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.

$20 per visit. 24.
24 Page 25 26
2003 HMO Blue Texas 22 Section 5( a)
Home health services (continued) You pay
Not covered:
Nursing care requested by, or for the convenience of, the patient or the patient's family;

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

All charges

Chiropractic
No benefit

Note: Chiropractic care for physical therapy is included in Physical and
Occupational Therapies on page 18.

All charges

Alternative treatments
No benefit All charges

Educational classes and programs
Coverage is limited to classes and programs for the following conditions:
Diabetes
Asthma
Congestive heart failure
Mothers-to-be program (pregnancy management)

Note: Programs must be provided or arranged by our Plan.

Nothing 25.
25 Page 26 27
2003 HMO Blue Texas 23 Section 5( b)
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
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Plan physicians must provide or arrange your care (precertification).
We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about Coordinating benefits with other

coverage, including with Medicare.
The amounts listed below are for the charges billed by a physician or other health care professional for your surgical care. Any costs associated with the facility charge (i. e.

hospital, surgical center, etc.) are covered in Section 5 (c).
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.

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

according to current underwriting standards; eligible members must be
age 18 or over.

Insertion of internal prosthetic devices. See 5( a) Orthopedic and prosthetic devices for device coverage information.

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

Voluntary sterilization (e. g. Tubal ligation, Vasectomy) $20 office visit plus $25 per procedure 26.
26 Page 27 28
2003 HMO Blue Texas 24 Section 5( b)
Surgical procedures (continued) You pay
Treatment of burns $20 per office visit
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; birthmarks; webbed fingers; and webbed toes.

$20 per office visit

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.

See above

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

Oral and maxillofacial surgery
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 per office visit 27.
27 Page 28 29
2003 HMO Blue Texas 25 Section 5( b)
Oral and maxillofacial surgery (continued) You pay
Not covered:
Oral implants and transplants
Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone)

Dental care or dental appliances involved in treatment of TMJ
Procedures to improve the appearance of a functioning structure

All charges

Organ/ tissue transplants
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single Double
Pancreas
Allogenic (donor) bone marrow transplants
Autologous bone marrow transplants (autologous stem cell and peripheral stem cell support) for the following conditions: 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, and

pancreas.
National Transplant Program (NTP) A nationally recognized medical facility designated by our Plan must evaluate the case and determine

that the proposed transplant is appropriate for treatment of the
condition and has agreed to perform the transplant.

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

Note: We cover related medical and hospital expenses of a live 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 28.
28 Page 29 30
2003 HMO Blue Texas 26 Section 5( b)
Anesthesia You pay
Professional services provided in
Hospital (inpatient)
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center
Office

Nothing 29.
29 Page 30 31
2003 HMO Blue Texas 27 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
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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 (precertification) and you must be hospitalized in a Plan facility.

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

associated with the professional charge (i. e., physicians, etc.) are covered in
Section 5( a) or (b).

YOUR PHYSICIAN MUST GET PRECERTIFICATION OF HOSPITAL STAYS. Please refer to Section 3 to be sure which services require

precertification.

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Benefit Description You pay
Inpatient hospital
Room and board, such as
Ward, Semiprivate, Or Intensive Care Accommodations;
General Nursing Care; and
Meals and special diets.

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

$100 per day with a maximum of
$400 per admission

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.

Note: Take home drugs are covered under the prescription drug benefit.
For more information, see Section 5( f).

Nothing 30.
30 Page 31 32
2003 HMO Blue Texas 28 Section 5( c)
Inpatient hospital (continued) You pay
Not covered:
Custodial care, rest cures, or domiciliary care.
Non-covered facilities, such as nursing homes, schools
Personal comfort items, such as telephone, television, barber services, guest meals and beds

Private nursing care

All charges

Outpatient hospital or ambulatory surgical center
Operating, recovery, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology services
Administration of blood, blood plasma, and other biologicals
Blood and blood plasma
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 other dental inpatient procedures.

$150 per surgery

Extended care benefits/ skilled nursing care facility benefits
Extended care benefit in a Skilled Nursing Facility (SNF):
Up to 60 days consecutive days for each illness or injury when:

Full-time skilled nursing care is necessary and confinement in a skilled nursing facility is medically appropriate as determined by the Plan

doctor.
All necessary services are covered, including:

Bed, board, general nursing care, drugs, biologicals, supplies, and equipment ordinarily provided or arranged by the skilled nursing

facility when prescribed by a Plan doctor.

$25 per day

Not covered:
Custodial care, rest cures, care for persistent illness and disorders.
All charges

Hospice care
Supportive and palliative care for the terminally ill is covered in the
home or hospice facility. Services include inpatient and outpatient care
and family counseling; these services are provided under the direction of
a Plan doctor who certifies the terminal stages of illness, with a life
expectancy of approximately six months or less.

Nothing 31.
31 Page 32 33
2003 HMO Blue Texas 29 Section 5( c)
Hospice care (continued) You pay
Not covered:
Independent nursing, homemaker services, custodial care.
All charges

Ambulance
Local professional ambulance service when medically appropriate. $25 per service 32.
32 Page 33 34
2003 HMO Blue Texas 30 Section 5( d)
Section 5 (d). Emergency services/ accidents
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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.
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.

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What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe
endangers your life or could result in serious injury or disability, and requires immediate medical or surgical
care. Some problems are emergencies because, if not treated promptly, they might become more serious;
examples include deep cuts and broken bones. Others are emergencies because they are potentially life
threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or sudden inability to breathe. There
are many other acute conditions that we may determine are medical emergencies what they all have in
common is the need for quick action.

What to do in case of emergency:
Call 911 or your local emergency number or go to the nearest emergency room. If reasonably possible, call your PCP first. In a true emergency, you can use any hospital or emergency room worldwide.
Show your HMO Blue Texas member ID card to the emergency room staff.
If you are not sure whether an emergency exists, call your PCP.
If you need quick medical attention but the situation is not a true emergency, call your PCP, even at night and on the weekends. All HMO Blue Texas PCPs are required to have 24-hour on-call coverage.

You or a family member must notify the Plan within 48 hours unless it was not reasonably possible to do so. It is your responsibility to ensure that the Plan has been timely notified.
Benefits are available for 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.
If you need to be hospitalized in a non-Plan facility, you or a family member must notify the Plan immediately, unless it was not reasonably possible to do so.
If you are hospitalized in a non-Plan facility and Plan doctors believe care can be better provided in a Plan hospital, you will be transferred when medically feasible. A $25 copay for ambulance services will apply.
Any follow-up care recommended by non-Plan providers must be approved by the Plan or provided by Plan providers.

For emergencies outside the service area, benefits are available for any medically necessary health service that is immediately required because of injury or unforeseen illness. 33.
33 Page 34 35
2003 HMO Blue Texas 31 Section 5( d)
Benefit Description You pay
Emergency within our service area

Emergency care at a doctor's office $35 per office visit after normal business hours

Emergency care at an urgent care center $35 per office visit
Emergency care as an outpatient or inpatient at a hospital, including doctors'services $100 per office visit

Note: Copayment waived when admitted to a hospital. If admitted, refer
to Section 5( c) on Inpatient Hospitalization.

Not covered:
Elective care or non-emergency care.
All charges

Emergency outside our service area
Emergency care at a doctor's office $35 per office visit after normal business hours

Emergency care at an urgent care center $35 per office visit
Emergency care as an outpatient or inpatient at a hospital, including doctors'services $100 per office visit

Note: Copayment waived when admitted to hospital. If admitted, refer to
Section 5( c) on Inpatient Hospitalization.

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

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

All charges

Ambulance
Professional ambulance service when medically appropriate.
Air Ambulance if medically necessary.
See Section 5( c) on Non-emergency services.

$25 per service 34.
34 Page 35 36
2003 HMO Blue Texas 32 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
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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.

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

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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

$20 per office visit.

Diagnostic tests $20 per office visit.
Services provided by a hospital or other facility
Services in approved alternative care settings such as partial hospitalization, residential treatment, full-day hospitalization, facility

based intensive outpatient treatment

$100 per day with a
maximum of $400 per
admission. 35.
35 Page 36 37
2003 HMO Blue Texas 33 Section 5( e)
Mental health and substance abuse benefits (continued) You pay
Not covered:

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

All charges

Preauthorization To be eligible to receive these benefits you must obtain a treatment Plan and follow all of the following authorization processes
If you need treatment, you may contact your PCP and he or she will assist you in obtaining care.
A referral from your PCP for mental health and chemical dependency services is not needed. Precertification for the mental health/ chemical
dependency provider that delivers these services must be obtained by
telephone prior to the delivery of all behavioral health care, including
chemical dependency, by calling toll-free (800) 729-2422.

Certain medical groups or Independent Physician Associations (IPAs) may have selected a different provider for mental health/ chemical

dependency services.
Members who wish to verify that their mental health/ chemical dependency provider is a Network Provider need to call Magellan

Behavioral Health at (800) 729-2422.
Limitation We may limit your benefits if you do not obtain a treatment plan. 36.
36 Page 37 38

2003 HMO Blue Texas 34 Section 5( f)
Section 5 (f). Prescription drug benefits
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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.
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.

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There are important features you should be aware of. These include:
Who can write your prescription. A Plan physician must write the prescription except for emergency care.

Where you can obtain them. You may use the services of a Participating Pharmacy or our Mail Order Pharmacy by presenting or mailing your new prescription (or refill request) prescribed by a Participating
Physician or Participating Dentist to the Participating Pharmacy or Mail Order Pharmacy. Texas Law
requires that our Mail Order Pharmacy receive the original prescription in order to fill any C-II medication
(for example: Ritalin, Tylox, Dexedrine, Demerol, Dilaudid, Percodan or Morphine).

We use a preferred drug list. "Member Preferred Drug List" (also known as a formulary) is a listing published by HMO Blue Texas of prescribed medications listed as Generic Prescription Drugs and Preferred

Brand Name Prescription Drugs. Non-preferred Brand Name prescriptions are those not included in the list
of Generic Prescription Drugs and Preferred Brand Name Prescription Drugs. These are covered at the
highest copayment. HMO Blue Texas Preferred Drug List is subject to periodic review.

We have an open preferred drug list. 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 preferred drug list. This list
of name brand drugs is a preferred list of drugs that we selected to meet patient needs at a lower cost. Name
Brand Prescription drugs not on the preferred list are subject to the highest copayment. To request a copy of
our Member Preferred Drug List, call Customer Service at (877) 299-2377, or visit our website at
www. bcbstx. com.

If a Generic Prescription Drug is available and you request a Name Brand Drug, you will the charged the
Generic copayment and will be required to pay the difference in the cost of the Generic and the Name Brand.

These are the dispensing limitations. Members are limited to a thirty-(30) day supply or 100-unit supply, whichever is less, of Prescription Drugs from the Participating Pharmacy, subject to any applicable
copayments listed on the next page. When using the services of our Mail Order Pharmacy for Maintenance
Medications, members are limited to the lesser of a ninety-(90) day supply or the number of days supply
from the date the prescription is filled to the termination date of the Group Contract, subject to the
copayments listed on Page 35. The initial prescription of certain classes of drugs is limited to a thirty-(30)
day supply.

Note: Medications purchased as a result of a medical emergency that occurs outside the Plan's service area
will be reimbursed for up to a 10 day supply, minus the applicable copay. 37.
37 Page 38 39
2003 HMO Blue Texas 35 Section 5( f)
Why use generic drugs? By using generic instead of brand name products, you keep down your costs and ours, without compromising on quality.
When you have to file a claim. If you purchase items covered by this benefit from a non-participating pharmacy for out of area emergency care prescriptions, you have to submit a reimbursement request to HMO
Blue Texas in order to get your benefits. See Section 7, Filing a claim for covered services.
Note: Coverage for items obtained from non-participating pharmacies is limited to items obtained in
connection with covered Emergency and Out-of-Area Urgent Care services.

Benefit Description You pay
Covered medications and supplies

We cover the following medications and supplies prescribed by a Plan
physician and obtained from Participating pharmacies for up to a 30-day
supply

or
through our Mail Order service for up to a 90-day supply:

Drugs for which a prescription is required by State law; Oral contraceptive drugs;
FDA approved prescriptions for birth control; Intravenous fluids and medications for home use;
Oral fertility drugs; Smoking cessation drugs, limited to $185. 00 lifetime maximum;
Disposable needles and syringes needed to inject covered prescribed medication;
Drugs to treat sexual dysfunction (limited benefits); and Insulin (including prescription and non-prescription oral agents for
controlling blood glucose levels, and glucagon emergency kits).
Note: "Bioequivalent Generic Drugs will be dispensed with this
Plan. If the member request a name brand when a generic is
available, the member will pay the generic copayment plus the
difference between the cost of the generic and the cost of the
name brand product.

Note: Drugs to treat sexual dysfunction have limited benefits, contact
Plan for dose limits; for these medications, you pay the applicable
copay up to the dose limit and all charges thereafter. Injectible
contraceptives, birth control devices (except diaphrams) covered
under family planning. Diabetic supplies, equipment, and education
are covered as basic Plan benefits, even though they may be
received from Participating pharmacies. See section below.

$10 per 30 day supply for generic
$25 per 30 day supply for preferred
brand name

$40 per 30 day supply for non-preferred
brand name

$20 per 90 day supply for generic
$50 per 90 day supply for preferred
brand name

$80 per 90 day supply for non-preferred
brand name 38.
38 Page 39 40
2003 HMO Blue Texas 36 Section 5( f)
Covered medications and supplies (continued) You pay
Diabetic supplies
Blood glucose test strips
Lancets
Lancet devices
Insulin syringes and needles
Urine test strips
Visual reading

$10 up to a 30-day supply at
participating pharmacy or $80 for
up to a 90-day supply through mail
order service

Diabetic equipment
Insulin pump and associated appurtenances
Insulin infusion device
Blood glucose monitor
Podiatric appliance for the intervention of complications associated with diabetes.

Nothing

Not covered:
Drugs and supplies for cosmetic purposes
Vitamins, nutrients and food supplements even if a physician prescribes or administers them

Non-prescription drugs
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
Implanted time-release medications, except Norplant
Injectables, aerosol inhalers and inhalant solutions except when purchased through the Home Delivery Pharmacy Service

Fertility drugs other than oral
Topical fluoride
Prescription Drugs prescribed as anorexients (appetite suppressants) or for weight reduction

Blood and urine testing devices
Oxygen gas
Prescription drugs intended for use in a practitioner's office or a clinical setting

Prescription drugs which a member is entitled to receive without charge from any worker's compensation laws, or similar municipal,
state or federal programs
Prescription drugs dispensed prior to the effective date of coverage
Therapeutic devices or appliances, including hypodermic needles and syringes, support garments, and drug infusion/ metering devices

All charges 39.
39 Page 40 41
2003 HMO Blue Texas 37 Section 5( g)
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.

Prenatal Education Our prenatal education program, Special Beginnings
, is designed to
promote specialty care, education, and monitoring to help you toward
the goal of delivering a healthy, full-term baby.

Special Beginnings offers pregnant HMO Blue Texas members:
the support of an obstetrical nurse throughout your pregnancy,
risk screening and ongoing monitoring and evaluation,
educational materials designed to help you understand each stage of your pregnancy,

nutritional advice, and
coordination of your prenatal care under the HMO Blue Texas Plan with your participating doctor. 40.
40 Page 41 42
2003 HMO Blue Texas 38 Section 5( h)
Section 5 (h). Dental benefits
I M
P O
R T
A N
T

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

the patient; See Section 5 (c) for inpatient hospital benefits. We do not cover the dental
procedure unless it is described below.

There are no calendar year deductibles.
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 directly result
from an accidental injury, not biting or chewing.
Treatment must be initiated within 72 hours of the
accident.

Outpatient: $20 per visit.
Inpatient: $100 per day with a maximum of $400 per
admission

Dental Benefits
Service You pay

Diagnostic/ preventive dentistry by Primary Dentist
Initial/ periodic oral examination
Treatment Plan
Oral cancer exam
Visual aids
Consultations

Nothing

X-rays Bitewing
Single
Other X-rays (one each 36 months)

Full Mouth Panoramic

$2
$1

$12
$6

Prophylaxis (cleaning every 6 months)
Child (to age 15)
Adult (age 15+)

$5
$8

Oral hygiene instruction
Fluoride treatment (once each 6 months)
Nothing

Sealant treatment (per tooth) $7
Infection control fee (per visit) (By Primary Dentist) $6 41.
41 Page 42 43
2003 HMO Blue Texas 39 Section 5( h)
Dental Benefits
Service You pay
Non-routine and emergency dentistry X-rays, single (per film) $3

Non-routine and emergency office visits During regular office hours
Not during regular office hours
Note: The office visit copayment is in addition to the
applicable copayment( s) for treatment

$9
$15

Missed appointment (By Primary Dentist) Without 24-hour notice except in case of unforeseen
emergency
$15

Restorative (fillings) by Primary Dentist Amalgam (silver) restorations
1 surface (primary of permanent)
2 surfaces (primary or permanent)
3 or more surfaces (primary or permanent)

$10
$15
$18

Composite resin (white) restorations (anterior teeth only)
1 surface
2 surfaces
3 or more surfaces

$18
$21
$26

Cosmetic by Primary Dentist Acid etch bonding for repair of incisal edge $50

Endodontics (Root canal therapy) by Primary Dentist 1 canal (anterior)
2 canals (bicuspid)
3 or more canals (molar)

(per tooth)
$170
$200
$260

Oral surgery by Primary Dentist Single tooth extraction

Each additional tooth
Surgical extraction erupted tooth
Surgical extraction soft tissue impaction
Surgical extraction partial bony impaction
Surgical extraction full bony impaction

(per tooth)
$35
$35
$40
$55
$75
$100

Anesthesia by Primary Dentist Nitrous Oxide (per 1/ 2 hour)

Local Anesthetic
$10
Nothing

Periodontics (Gum treatment) by Primary Dentist Osseous surgery (per quadrant)

Occlusal Adjustment Limited
Occlusal Adjustment Complete

Periodontal scaling and root planing (per quadrant)

$280
$60
$130
$70

Major restorative dentistry by Primary Dentist Crown and Bridge (per unit)

All gold is charged at market price
Porcelain veneer crown (with non-precious) $235
Full-cast crown (non-precious) $225
Inlay 2 surfaces $175
Inlay 3 surfaces $200
Re-cement crown/ bridge $10
Post for crown $60
Stainless steel crown $60 42.
42 Page 43 44
2003 HMO Blue Texas 40 Section 5( h)
Dental Benefits
Service You pay
Prosthodontics (dentures) by Primary Dentist Complete Dentures (upper or lower; plus lab fee)

Partial Denture (plus lab fee)
$235 plus lab fee
$320 plus lab fee

Orthodontics (braces) by Primary Dentist Note: Patient pays 20% in advance of treatment. The

balance is to be paid in equal monthly installment
during course of treatment. Treatment schedule for
more than 24 months is to be paid at $65.00 per
month.

75% of Dentist's Usual and customary fee**

The copayments listed above apply when services are performed by your Primary Dentist. Any unlisted procedures and services provided by your Primary Dentist will be charged to the Member at 75% of
the Dentist's usual and customary fees.
All procedures and services provided by a Specialist Dentist will be charged to you at 75% of the Specialist Dentist's usual and customary fees.

Primary and Specialist Dentist services may not be available in your immediate area. If you reside in the Corpus
Christi vicinity, you may travel to other provider locations within the Southeast regional service area to receive
dental services from affiliated providers. Refer to your provider directory or call Customer Service at
(877) 299-2377 to find out where Primary and Specialist Dentists are located.

General Provisions No referral is needed to see a Participating Specialist Dentist.
Each family member may select a different Primary Dentist.
Scheduled appointments must be canceled at least 24 hours in advance or the member may be liable for a missed
appointment fee, as charged by the dentist.
In case of an emergency, contact your Primary Dentist if possible or obtain services from any licensed dentist.
HMO Blue Texas will reimburse the member for the actual cost of such emergency dental services, less
applicable copayments, and are limited to palliative treatment to control pain, bleeding or infection. (See
"exclusions")

Not covered The following are not covered:
Emergency services provided at a hospital, outpatient care facility or otherwise than in a dentist's office.
Non-emergency services provided by a non-participating dentist.
Services and related fees for services performed any place other than a dental office, except the oral surgery
services described in the Schedule of Dental Benefits.
Services and supplies ordered or received when the person is not a member. 43.
43 Page 44 45
2003 HMO Blue Texas 41 Section 5( i)
Section 5 (i). Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed
claim about them. Fees you pay for these services do not count toward FEHB out-of-pocket maximums.

Vision Benefits
Enrollees are entitled to the following vision benefits from Plan optometrists:
One eye examination for eyeglasses every 12 months; you pay a $10 copay; Eyeglass lenses and frames available at discount prices;

Contact lenses and materials are also available at discount prices; and One eye examination for contact lenses every 12 months; you pay a $20 copay.

Note: Coverage is for routine eye examination only when conducted in a single visit. Benefits for medical treatment
of eye disease are provided under your basic medical plan when deemed medically necessary by your PCP.
Your Cole Managed Vision provider will provide you with information regarding the cost of contact lenses and
fitting services.

Vision Providers
To be covered, the exam must be provided by a Cole Managed Vision provider unless your designated PCP is with a
Medical Group/ IPA that is responsible for providing that service. The prescription for lenses (or contacts) must be
filled by a participating Cole Managed Vision provider in order to receive the reduced rates. A referral from your
PCP is not necessary. However, if your designated PCP is with a Medical Group/ IPA that provided the exam, you
must obtain the eyeglass prescription from the Medical Group/ IPA vision provider to present to a participating Cole
Managed Vision provider in order to receive glasses or contacts at the reduced rates.

What to do
When vision services are needed, call Customer Service at (877) 299-2377 or Cole Managed Vision at (800) 228-2020
for assistance in locating a participating vision provider close to you. Again, if you are assigned to a Medical
Group/ IPA that is responsible for providing the eye exam, you must obtain your eye exam through the Medical
Group/ IPA vision provider.

Schedule an appointment if you need an eye exam by calling a participating provider, otherwise simply go to the
provider's office for services.

Areas Not Included in Your Coverage
Medical treatment of eyes, or special procedures, such as orthoptics training; Eyeglass lenses, eyeglass frames or contact lenses;
Contact lens fitting services; Eye examinations required by an employer or services for which no charge is made;
Vision examinations performed more frequently than every twelve (12) months; Vision examinations performed by non participating providers; and
Special purpose vision aids. 44.
44 Page 45 46
2003 HMO Blue Texas 42 Section 6
Section 6. General exclusions --things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we
will not cover it unless your Plan doctor determines it is medically necessary to prevent, diagnose, or treat
your illness, disease, injury or condition.

We do not cover the following:

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

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

Services, drugs, or supplies related to sex transformations;
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program;
Services, drugs, or supplies you receive without charge while in active military service; or 45.
45 Page 46 47
2003 HMO Blue Texas 43 Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at
Plan pharmacies, you will not have to file claims. Just present your identification card and pay your 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 and hospital benefits In most cases, providers and facilities file claims for you. Physicians must file on the form HCFA-1500, Health Insurance Claim Form.
Facilities will file on the UB-92 form. For claims questions and
assistance, call us at (877) 299-2377.

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:
HMO Blue Texas
Claims Dept.
P. O. Box 660044
Dallas, TX 75266-0044 46.
46 Page 47 48
2003 HMO Blue Texas 44 Section 7
Prescription drugs If you purchase items covered by this benefit from a non-participating pharmacy, you have to submit a reimbursement request to HMO Blue
Texas in order to get your benefits.
Submit your claims to:
HMO Blue Texas
P. O. Box 660044
Dallas, Texas 75266-0044

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. 47.
47 Page 48 49
2003 HMO Blue Texas 45 Section 8
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on
your claim or request for services, drugs, or supplies including a request for preauthorization:

Step Description

. 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: P. O. Box 25916 Houston, TX 77265; and
(c) Include a statement about why you believe our initial decision was wrong, based on specific benefit
provisions in this brochure; and

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

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

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

. If you do not agree with our decision, you may ask OPM to review it. You must write to OPM within:
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. 48.
48 Page 49 50
2003 HMO Blue Texas 46 Section 8
The disputed claims process (continued)
Send OPM the following information:
A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;

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

Note: If you want OPM to review 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.

. 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
(800) 441-9188. 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. 49.
49 Page 50 51
2003 HMO Blue Texas 47 Section 9
Section 9. Coordinating benefits with other coverage
When you have other health coverage You must tell us if you or a covered family member have coverage under another group health plan or have automobile insurance that pays health
care expenses without regard to fault. This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in
full as the primary payer and the other plan pays a reduced benefit as the
secondary payer. We, like other insurers, determine which coverage is
primary according to the National Association of Insurance
Commissioners' guidelines.

When we are the primary payer, we will pay the benefits described in this
brochure.

When we are the secondary payer, we will determine our allowance.
After the primary plan pays, we will pay what is left of our allowance, up
to our regular benefit. We will not pay more than our allowance. Visit
limits will apply even when the plan is the secondary payer.

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 show how we coordinate benefits with
Medicare, depending on the type of Medicare managed care plan you
have.

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

The Original Medicare Plan (Part A or Part B) 50.
50 Page 51 52
2003 HMO Blue Texas 48 Section 9
When you are enrolled in Original Medicare along with this plan, you
still need to follow the rules in this brochure for us to cover your care.
Your care must continue to be authorized by your Plan PCP, or
precertified as required.

Medicare managed care plan If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from another 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. 51.
51 Page 52 53
2003 HMO Blue Texas 49 Section 9
The following chart illustrates whether the Original Medicare Plan or this Plan should be the primary payer for you
according to your employment status and other factors determined by Medicare. It is critical that you tell us if you or
a covered family member has Medicare coverage so we can administer these requirements correctly.

Primary Payer Chart
Then the primary payer is A. When either you --or your covered spouse --are age 65 or over and

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

2) Are an annuitant,

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

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

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

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

(for other
services)

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

(except for claims
related to Workers'
Compensation.)

B. When you --or a covered family member --have Medicare based on end stage renal disease (ESRD) and
1) Are within the first 30 months of eligibility to receive Part A benefits
solely because of ESRD,

2) Have completed the 30-month ESRD coordination period and are still
eligible for Medicare due to ESRD,

3) Become eligible for Medicare due to ESRD after Medicare became
primary for you under another provision,

C. When you or a covered family member have FEHB and
1) Are eligible for Medicare based on disability, and
a) Are an annuitant, or

b) Are an active employee, or
c) Are a former spouse of an annuitant, or
d) Are a former spouse of an active employee 52.
52 Page 53 54
2003 HMO Blue Texas 50 Section 9
TRICARE and CHAMPVA TRICARE is the health care program for 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 to enroll in TRICARE or CHAMPVA: If
you are an annuitant or former spouse, you can suspend your FEHB
coverage to enroll in a one of these programs, eliminating your FEHB
premium. (OPM does not contribute to any applicable plan premiums.)
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 under the program.

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.
Suspended FEHB coverage to enroll in Medicaid or a similar State-sponsored program of medical assistance: If you are an annuitant or
former spouse, you can suspend your FEHB coverage to enroll in a one
of these State programs, eliminating your FEHB 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 under the State program.

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 care for injuries 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. 53.
53 Page 54 55
2003 HMO Blue Texas 51 Section 10
Section 10. Definitions of terms we use in this brochure
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on
December 31 of the same year.

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 primarily helps with or supports daily living activities (such as bathing, dressing, eating and eliminating body wastes) and can be given
by people other than trained medical personnel. Custodial care that lasts
90 days or more is sometimes known as Long term care.

Experimental or Experimental or Investigational drugs, devices, treatments or procedures Investigational services includes any drug, device, treatment or procedure that would not be used
in the absence of the experimental or investigation al drug, device,
treatment or procedure. We consider a drug, device, treatment or
procedure to be experimental or investigational if:

It cannot be lawfully marketed without the approval of the U. S. Food and Drug Administration, and approval for marketing has been given
at the time it is provided; or

It was reviewed and approved by the treating facility's Institutional Review Board or similar committee, or if federal law requires it to
be reviewed and approved by that committee. This exclusion also
applies if the informed consent form used with the drug, device,
treatment or procedure was (or was required by federal law to be)
reviewed and approved by that committee; or

Reliable evidence shows that the drug, device, treatment or procedure is the subject of ongoing Phase I or Phase II clinical trials;
is the research, experimental, study or investigational arm of
ongoing Phase III clinical trials; or is otherwise under study to
determine its maximum tolerated dose, its toxicity, its safety, its
effectiveness, or its effectiveness compared to a standard method of
treatment or diagnosis.

Reliable evidence shows that the prevailing opinion among experts is that further studies or clinical trials of the drug, device, treatment
or procedure are needed to determine its maximum tolerated dose, its
toxicity, its safety, its effectiveness, or its ineffectiveness compared
to a standard method of treatment or diagnosis.

(" Reliable evidence" includes only published reports and articles in
authoritative medical and scientific literature, and written protocols and
informed consent forms used by the treating facility or by another facility
studying substantially the same drug, device, treatment or procedure.) 54.
54 Page 55 56
2003 HMO Blue Texas 52 Section 10
Medical necessity By "medically necessary," we mean that the service meets all of the following conditions:
The service is required for diagnosing, treating or preventing an illness or injury, or a medical condition such as pregnancy;
If you are ill or injured, it is a service you need in order to improve your condition or to keep your condition from getting worse;
It is generally accepted as safe and effective under standard medical practice in your community; and
The service is provided in the most cost-efficient way, while still giving you an appropriate level of care.
Not every service that fits this definition is covered under your Plan. To
be covered, a service that is medically necessary must also be described
in this document. For example, we do not cover any preventative, family
planning or infertility services that are not specified. Just because a
physician or other health care provider has performed, prescribed or
recommended a service does not mean it is medically necessary or that it
is covered under your Plan.

Us/ We Us and we refer to HMO Blue Texas.
You You refers to the enrollee and each covered family member. 55.
55 Page 56 57

2003 HMO Blue Texas 53 Section 11
Section 11. FEHB facts
No pre-existing condition We will not refuse to cover the treatment of a condition that you had limitation before you enrolled in this Plan solely because you had the condition
before you enrolled.
Where you can get information See www. opm. gov/ insure. Also, your employing or retirement office about enrolling in the can answer your questions, and give you a Guide to Federal Employees

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

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.

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) 56.
56 Page 57 58
2003 HMO Blue Texas 54 Section 11
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 option of 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 on the first day of
your first pay period that starts on or after January 1. Annuitants'
coverage and premiums begin on January 1. If you joined at any other
time during the year, your employing office will tell you the effective
date of coverage.

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
continuation (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. 57.
57 Page 58 59

2003 HMO Blue Texas 55 Section 11
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
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 of coverage (TCC) If you leave Federal service, or if you lose coverage because you no
longer qualify as a family member, you may be eligible for Temporary
Continuation of Coverage (TCC). For example, you can receive TCC if
you are not able to continue your FEHB enrollment after you retire, if
you lose your job, if you are a covered dependent child and you turn 22
or marry, etc.

You may not elect TCC if you are fired from your Federal job due to
gross misconduct.

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 58.
58 Page 59 60

2003 HMO Blue Texas 56 Section 11
you enroll within 63 days of losing coverage under this Plan. If you have been enrolled with us for less than 12 months, but were previously
enrolled in other FEHB plans, you may also request a certificate from those plans.

For more information, get OPM pamphlet RI 79-27, Temporary Continuation of Coverage (TCC) under the FEHB Program. See also the
FEHB web site (www. opm. gov/ insure/ health); refer to the "TCC and HIPAA" frequently asked question. These highlight HIPAA rules, such
as the requirement that Federal employees must exhaust any TCC eligibility as one condition for guaranteed access to individual health
coverage under HIPAA, and have information about Federal and State agencies you can contact for more information. 59.
59 Page 60 61

2003 HMO Blue Texas 57 Long Term Care Insurance
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 Open 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 Season 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 (1-800-582-3337) (TDD for the hearing
impaired: 1-800-843-3557) or visiting www. ltcfeds. com to get more information and to request an application.

. 60.
60 Page 61 62
2003 HMO Blue Texas 58 Index
Index
Do not rely on this page; it is for your convenience and may not show all pages where the terms appear.

Accidental injury 24, 38 Allergy tests 17
Allogenetic (donor) bone marrow transplant 25
Alternative treatment 17, 22, 32 Ambulance 27, 29, 30, 31
Anesthesia 23, 26, 28, 39 Autologous bone marrow
transplant 18, 25 Blood and blood plasma 12, 15,
21, 27, 28 Bone Marrow transplants 18, 25
Breast cancer screening 25 Casts 27, 28
Changes for 2003 8 Chemotherapy 18
Chiropractic 18, 22 Cholesterol tests 8, 15
Claims 8, 9, 13, 43 -46, 50, 55 Coinsurance 6, 12, 43, 50
Colorectal cancer screening 15 Congenital anomalies 23, 24
Contraceptive devices and drugs 17, 35
Coordination of benefits 8, 47, 50 Covered providers 6, 7, 9, 50, 51
Crutches 21
Deductible 12, 43, 50 Dental care 12, 20, 25, 28, 38, 39,

40, 42 Diagnostic services 14, 15, 17, 27,
28, 32, 38 Disputed claims review 8, 41, 45,
46 Donor expenses (transplants) 25
Dressings 27, 28, 36 Durable medical equipment
(DME) 12, 21 Educational classes and programs
22, 37 Emergency 6, 7, 30, 31, 34, 35,
39, 40, 42, 43 Experimental or Investigational
14, 42, 52 Eyeglasses 19, 41
Fecal occult blood test 15

General Exclusions 12, 42 Hearing services 16, 19
High Risk Pregnancies 37
Hospice care 28, 29, 57 Home nursing care 57

Hospital 5, 6, 9, 10, 11, 12, 14, 16, 20, 23 -28, 30 -32, 40,
43, 47, 48, 50, 51 Immunizations 6, 15, 16
Infertility 8, 13, 16, 17, 53 Insulin 21, 35
Laboratory and pathological services 15, 17, 27, 28, 40
Magnetic Resonance Imagings (MRIs) 15
Mail Order Prescription Drugs 34, 35
Mammograms 15 Maternity Benefits 16, 27
Medicaid 51 Medically necessary 11, 16, 18,
19, 20, 27, 30, 31, 33, 41, 42, 53
Medicare 8, 47, 48, 49, 50 Mental Conditions/ Substance
Abuse Benefits 9, 33, 33 Newborn care 14, 16
Non-FEHB Benefits 19, 41, 56 Nurse
Licensed Practical Nurse 21 Nurse Anesthetist 27
Registered Nurse 21 Nursery charges 16
Obstetrical care 16, 37 Occupational therapy 18, 19
Office visits 6, 12, 14, 15, 31, 39, 41
Oral and maxillofacial surgery 24, 25 Orthopedic devices 19, 20, 21, 23
Out-of-pocket expenses 12, 41 Outpatient facility care 11, 13,
26, 28, 31, 40 Oxygen 21, 27, 28, 36
Pap test 15 Physical exam 6, 15

Physical therapy 18 Physician 5, 6, 9, 10, 11, 14,
15, 16, 17, 18, 21, 23, 34, 35, 36, 43, 49, 53
Precertification 11, 33, 46 Preventive care, adult 6, 8, 15
Preventive care, children 6, 16, 19
Prescription drugs 2, 34-36, 44, 48, 50
Preventive services 15, 38 Prior approval 11
Prostate cancer screening 15 Prosthetic devices 12, 19, 20,
23, 24 Psychologist 32
Radiation therapy 18 Reciprocity Program 37
Renal dialysis 47 Room and board 27
Second surgical opinion 14 Skilled nursing facility care
10, 14, 26, 28, 57 Smoking cessation 35
Speech therapy 8, 19 Splints 20, 27
Sterilization procedures 17, 24
Subrogation 51 Substance abuse 9, 32, 33
Surgery 23-26 Anesthesia 26
Oral 25 Outpatient 28
Reconstructive 24 Syringes 35, 36
Temporary continuation of coverage 55, 56
Transplants 8, 18, 24, 25 Treatment therapies 18
Vision services 19, 41 Well child care 14, 16
Wheelchairs 21 Workers' compensation 51,
55 X-rays 15, 27, 28, 38, 39 61.
61 Page 62 63
2003 HMO Blue Texas 59 Summary
Summary of benefits for HMO Blue Texas 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: $20 primary
care; $20 specialist 14

Services provided by a hospital:
Inpatient............................................................................................

Outpatient .........................................................................................
$100 per day with a maximum of
$400 per admission

$150 per surgery

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

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

$100 per visit
$100 per visit
31
31
Mental health and substance abuse treatment....................................... Regular cost sharing 32
Prescription drugs .................................................................................. $10 per generic
$25 per preferred brand
$40 per non-preferred brand

Dental Care ............................................................................................ Nothing for preventive services;
scheduled cost for other services 38

Vision Care ............................................................................................ One eye examination for
eyeglasses every 12 months; you
pay a $10 copay; Eyeglass lenses
and frames available at discount
prices;

Contact lenses and materials are
also available at discount prices;
and One eye examination for
contact lenses every 12 months;
you pay a $20 copay.

Special features: Reciprocity Program and High Risk Pregnancies Program 37
Protection against catastrophic costs
(your catastrophic protection out-of-pocket maximum) ...................

Nothing after $1,000/ Self Only or
$3,000/ Family enrollment per year

Some costs do not count toward
this protection

12 62.
62 Page 63
2003 HMO Blue Texas Rate Information
2003 Rate Information for
HMO Blue Texas

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 a special FEHB guide is published for Postal Service Inspectors and
Office of Inspector General (OIG) employees (see RI 70-2IN).

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

Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly

Type of
Enrollment
Code Gov't
Share
Your
Share
Gov't
Share
Your
Share
USPS
Share

Your
Share

Houston area
Self Only YM1 103.87 34.62 225.05 75.01 122.91 15.58

Self and Family YM2 249.62 89.38 540.84 193.66 294.70 44.30

Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company*
HMO plans offered by Southwest Texas HMO, Inc.* d/ b/ a HMO Blue Texas
*Independent Licensees of the Blue Cross and Blue Shield Association 63.

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