Pages 1--64

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

This Plan has excellent accreditations from
the NCQA. See the 2003 Guide for more
information on NCQA.

Enrollment codes for this Plan:
ED1 Self Only
ED2 Self and Family

Authorized for distribution by the:
United States Office of Personnel Management

Retirement and Insurance Service
http:// www. opm. gov/ insure RI 73-483

Keystone Health Plan East 2003 http:// www. ibx. com/ fep
For changes in benefits
see page 12 1.
1 Page 2 3
UNITED STATES OFFICE OF PERSONNEL MANAGEMENT
WASHINGTON, DC 20415-0001
OFFICE OF THE DIRECTOR

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 and tell you how OPM may use and give out (" disclose") your personal medical information
held by OPM.

OPM will use and give out your personal medical information:
To you or someone who has the legal right to act for you (your personal representative), To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is
protected,
To law enforcement officials when investigating and/ or prosecuting alleged or civil or criminal actions, and Where required by law.

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

To communicate with your FEHB health plan when you or someone you have authorized to act on your behalf asks for our assistance regarding a benefit or customer service issue.
To review, make a decision, or litigate your disputed claim. For OPM and the General Accounting Office when conducting audits.

OPM may use or give out your personal medical information for the following purposes under limited circumstances:
For Government healthcare oversight activities (such as fraud and abuse investigations), For research studies that meet all privacy law requirements (such as for medical research or education), and
To avoid a serious and imminent threat to health or safety.
By law, OPM must have your written permission (an "authorization") to use or give out your personal medical
information for any purpose that is not set out in this notice. You may take back (" revoke") your written permission
at any time, except if OPM has already acted based on your permission.

By law you have the right to:
See and get a copy of your personal medical information held by OPM. Amend any of your personal medical information created by OPM if you believe that it is wrong or if
information is missing, and OPM agrees. If OPM disagrees, you may have a statement of your disagreement
added to your personal medical information.
Get a listing of those getting your personal medical information from OPM in the past 6 years. The listing will not cover your personal medical information that was given to you or your personal representative, any

information that you authorized OPM to release, or that was given out for law enforcement purposes or to
pay for your health care or a disputed claim. 3.
3 Page 4 5
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
2003 Keystone Health Plan East 5 Table of Contents
Table of Contents
Introduction ................................................................................................................................................................. 7
Plain Language ............................................................................................................................................................. 7
Stop Health Care Fraud! ............................................................................................................................................... 8
Section 1. Facts about this HMO plan ......................................................................................................................... 9
How we pay providers ................................................................................................................................ 9
Who provides my health care? .................................................................................................................. 11
Your Rights................................................................................................................................................ 11
Service Area............................................................................................................................................... 11
Section 2. How we change for 2003 ........................................................................................................................... 12
Program-wide changes............................................................................................................................... 12
Changes to this Plan................................................................................................................................... 12
Section 3. How you get care ...................................................................................................................................... 13
Identification cards..................................................................................................................................... 13
Where you get covered care....................................................................................................................... 13

Plan providers...................................................................................................................................... 13
Plan facilities ....................................................................................................................................... 13
What you must do to get covered care ....................................................................................................... 13

Primary care......................................................................................................................................... 14
Specialty care....................................................................................................................................... 14
Hospital care ........................................................................................................................................ 15
Circumstances beyond our control............................................................................................................. 15
Services requiring our prior approval ........................................................................................................ 16
Section 4. Your costs for covered services ................................................................................................................. 17

Copayments ......................................................................................................................................... 17
Deductible............................................................................................................................................ 17
Coinsurance ......................................................................................................................................... 17
Your catastrophic protection out-of-pocket maximum.............................................................................. 17
Section 5. Benefits ...................................................................................................................................................... 18
Overview.................................................................................................................................................... 18
(a) Medical services and supplies provided by physicians and other health care professionals ........... 19
(b) Surgical and anesthesia services provided by physicians and other health care professionals........ 28
(c) Services provided by a hospital or other facility, and ambulance services ..................................... 32
(d) Emergency services/ accidents ......................................................................................................... 35
(e) Mental health and substance abuse benefits .................................................................................... 37
(f) Prescription drug benefits................................................................................................................ 39 5.
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2003 Keystone Health Plan East 6 Table of Contents
(g) Special features ............................................................................................................................... 42
..Services for deaf and hearing impaired...................................................................................... 42
..Urgent care/ travel benefit .......................................................................................................... 42
(h) Dental benefits ................................................................................................................................ 43
(i) Non-FEHB benefits available to Plan members.............................................................................. 45
Section 6. General exclusions things we don't cover ............................................................................................ 46
Section 7. Filing a claim for covered services ............................................................................................................ 47
Section 8. The disputed claims process ...................................................................................................................... 48
Section 9. Coordinating benefits with other coverage ................................................................................................ 50
When you have other health coverage ...................................................................................................... 50

What's Medicare ............................................................................................................................ 50
Medicare managed care plan........................................................................................................... 51
TRICARE/ CHAMPVA................................................................................................................... 53
Workers' Compensation.................................................................................................................. 53
Medicaid ........................................................................................................................................ 53
Other Government agencies ............................................................................................................ 53
When others are responsible for injuries.................................................................................................... 53
Section 10. Definitions of terms we use in this brochure ........................................................................................... 54
Section 11. FEHB facts............................................................................................................................................... 55
Coverage information ................................................................................................................................ 55

No pre-existing condition limitation ............................................................................................... 55
Where you can get information about enrolling in the FEHB Program.......................................... 55
Types of coverage available for you and your family..................................................................... 55
Children's Equity Act ..................................................................................................................... 56
When benefits and premiums start .................................................................................................. 57
When you retire............................................................................................................................... 57
When you lose benefits.............................................................................................................................. 57

When FEHB coverage ends............................................................................................................... 57
Spouse equity coverage .................................................................................................................... 57
Temporary Continuation of Coverage (TCC) ................................................................................... 57
Converting to individual coverage.................................................................................................... 58
Getting a Certificate of Group Health Plan Coverage ...................................................................... 58
Long Term Care Insurance is still available ................................................................................................................ 59
Index ............................................................................................................................................................................ 60
Summary of benefits.................................................................................................................................................... 63
Rates .............................................................................................................................................................. Back cover 6.
6 Page 7 8
2003 Keystone Health Plan East 7 Introduction/ Plain Language
Introduction
This brochure describes the benefits of Keystone Health Plan East under our contract (CS 2339) with the Office of
Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law.

The address for Keystone Health Plan East administrative offices is:
Keystone Health Plan East, Inc.
1901 Market Street
Philadelphia, PA 19103

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 for Self
and Family coverage, each eligible family member is also entitled to these benefits. You do not have a right to
benefits that were available before January 1, 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 12. 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 Keystone Health Plan East.

We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the Office of Personnel Management. If we use others, we tell you what they mean first.
Our brochure and other FEHB plans' brochures have the same format and similar descriptions to help you compare plans.
If you have comments or suggestions about how to improve the structure of this brochure, let OPM know. Visit
OPM's "Rate Us" feedback area at www. opm. gov/ insure or e-mail OPM at fehbwebcomments@ opm. gov. You may
also write to OPM at the Office of Personnel Management, Office of Insurance Planning and Evaluation Division,
1900 E Street, NW, Washington, DC 20415-3650. 7.
7 Page 8 9
2003 Keystone Health Plan East 8 Advisory
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 FEHBP
Program regardless of the agency that employs you or from which you retired.

Protect Yourself From Fraud Here are some things you can do to prevent fraud:

Be wary of giving your plan identification (ID) number over the telephone or to people you do not know, except to your doctor, other provider, or authorized plan or OPM representative.
Let only the appropriate medical professionals review your medical record or recommend services.
Avoid using health care providers who say that an item or service is not usually covered, but they know how to bill us to get it paid.
Carefully review explanations of benefits (EOBs) that you receive from us. Do not ask your doctor to make false entries on certificates, bills or records in order to get us to
pay for an item or service.
If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or misrepresented any information, do the following:

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

Do not maintain as a family member on your policy: your former spouse after a divorce decree or annulment is final (even if court
orders stipulate otherwise); or
your child over age 22 (unless he/ she is disabled and incapable of 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 FEHBP 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
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 Keystone Health Plan East 9 Section 1
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and
other providers that contract with us. These Plan providers coordinate your health care services. 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 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
Our reimbursement programs for health care providers are intended to encourage the provision of quality, cost-effective
care for our Members. Set forth below is a general description of our reimbursement programs, by type of
participating health care provider. These programs vary by state. Please note that these programs may change from
time to time, and the arrangements with particular providers may be modified as new contracts are negotiated. If after
reading this material you have any questions about how your health care provider is compensated, please speak with
them directly or contact us.

Professional Providers
Primary Care Physicians: Most Primary Care Physicians (PCPs) are paid in advance for their services, receiving
a set dollar amount per Member, per month for each Member selecting that PCP. This is called a "capitation"
payment and it covers most of the care delivered by the PCP. Covered Services not included under capitation are
paid fee-for-service according to the HMO fee schedule. Many PCPs are eligible to receive additional payments
for meeting certain medical quality, patient service, and other performance standards. By far the largest incentive
component is related to quality and is based on compliance with preventive and chronic care guidelines. Other
incentive payments are available for practices that have extended office hours or submit encounter and referral
data electronically. There is also an incentive that is based on the extent to which a PCP prescribes generic drugs
(when available and appropriate) relative to similar PCPs.

Referred Specialists: Most specialists are paid on a fee-for-service basis, meaning that payment is made
according to Keystone's fee schedule for the specific medical services that the Referred Specialist performs.
Obstetricians are paid global fees that cover most of their professional services for prenatal care and for delivery.
PCP referrals to Pennsylvania based cardiologists or gastroenterologists are valid for ninety (90) days and apply
to all Covered Services provided by the gastroenterologist or cardiologist in his/ her office.

Designated Providers: For a few specialty services (for example, certain rehabilitation therapy, podiatry and
radiology services), PCPs are required to select a Designated Provider to which they refer their patients for those
particular services. Designated Providers usually receive a set dollar amount per Member per month (capitation)
for their services based on the PCPs that have selected them. Before selecting a PCP, Members may want to
speak to the PCP regarding the Designated Provider that PCP has chosen.

Institutional Providers
Hospitals: For most inpatient medical and surgical Covered Services, Hospitals are paid per diem rates, which
are specific amounts paid for each day a Member is in the Hospital. These rates usually vary according to the
intensity of services provided. Some Hospitals are also paid case rates, which are set dollar amounts paid for a
complete hospital stay related to a specific procedure or diagnosis, e. g., transplants. For most outpatient and
emergency Covered Services and procedures, most Hospitals are paid specific rates based on the type of service
performed. Hospitals are also paid a global rate for certain outpatient services (e. g., lab and radiology) that 9.
9 Page 10 11
2003 Keystone Health Plan East 10 Section 1
includes both the facility and professional component. For a few Covered Services, Hospitals are paid based on a
percentage of billed charges. Most Hospitals are paid through a combination of the above payment mechanisms
for various Covered Services.

Skilled Nursing Homes, Rehabilitation Hospitals, and other care facilities: Most Skilled Nursing Facilities and
other special care facilities are paid per diem rates, which are specific amounts paid for each day a Member is in
the facility. These amounts may vary according to the intensity of services provided.

Ambulatory Surgical Centers (ASCs)
Most ASCs are paid specific rates based on the type of service performed. For a few Covered Services, some
ASCs are paid based on a percentage of billed charges.

Integrated Delivery Systems
In a few instances, global payment arrangements are in place with integrated hospital/ physician organizations
called Integrated Delivery Systems (IDS). In these cases the IDS provides or arranges for some of the Hospital,
physician and ancillary Covered Services provided to some of our Members who select PCPs which are employed
by or otherwise participate with the IDS. The IDS is paid a global fee to cover all such Covered Services,
whether provided by the IDS or other providers. These IDSs are therefore "at risk" for the cost of these Covered
Services. Some of these IDSs may provide incentives to their IDS-affiliated professional providers for meeting
certain quality, service or other performance standards.

Physician Group Practices and Physician Associations
Certain physician group practices and independent physician associations (IPAs) employ or contract with
individual physicians to provide medical Covered Services. These groups are paid as outlined above. These
groups may pay their affiliated physicians a salary and/ or provide incentives based on quality, production,
service, or other performance standards. In addition, we have entered into a joint venture with an IPA. This IPA
is paid a global fee to cover the cost of all Covered Services, including Hospital, professional and ancillary
Covered Services provided to Members who choose a PCP in this IPA. This IPA is therefore "at risk" for the cost
of these Covered Services. This IPA provides incentives to its affiliated physicians for meeting certain quality,
service and other performance standards.

Ancillary Service Providers
Some ancillary service providers, such as Durable Medical Equipment and Home Health Care Providers, are paid
fee-for-service payments according to the HMO fee schedule for the specific medical services performed. Other
ancillary service providers, such as those providing laboratory, dental and vision Covered Services, receive a set
dollar amount per Member per month (capitation). Capitated ancillary service vendors are responsible for paying
their contracted providers and do so on a fee-for-service basis.

Mental Health
A behavioral health management company administers most of our behavioral health/ substance Covered
Services, provides a network of participating Mental Health Care Providers and processes related claims. A
Designated Provider is selected for each PCP practice to which all of the PCP's Members are directed for these
Covered Services. The behavioral health company receives a set dollar amount per Member per month amount
(capitation) for each Member and is responsible for paying its contracted providers on a fee-for-service or
capitated basis. The contract with the behavioral health company includes performance-based payments related
to quality, provider access, service, and other such parameters. A subsidiary of Independence Blue Cross has less
than a three percent ownership interest in this behavioral health management company.

Pharmacy
A pharmacy benefits management company (PBM) administers our pharmacy benefits, provides a network of
Participating Pharmacies and processes pharmacy claims. The PBM also processes and provides all mail order
Prescription Orders, negotiates price discounts with pharmaceutical manufacturers and provides drug utilization
and quality reviews. Price discounts may include rebates from a drug manufacturer based on the volume
purchased. These rebates and discounts reduce the overall cost of pharmacy benefits. Most outpatient
Prescription Drugs are purchased on a fee-for-service basis from pharmacies. The PBM is paid an administrative
fee for processing each pharmacy claim and providing the other pharmacy related services. Most regional
network pharmacies also have the opportunity to receive a small incentive payment each quarter if their generic
drug-dispensing rate is better than the network average. 10.
10 Page 11 12
2003 Keystone Health Plan East 11 Section 1
Who provides my health care?
Keystone Health Plan East, a wholly owned subsidiary of Independence Blue Cross, is an individual practice
prepayment (IPP) plan that provides access to care throughout the greater Philadelphia area. Members and their
family members may select their own primary care doctor from among the 2,611 who practice within the Plan's
service area. There are approximately 9,700 specialty care doctors who participate with the Plan. Your primary care
doctor will arrange for the necessary specialty and hospital care you need at one of the Plan's participating specialist
offices or at a participating Plan hospital throughout the Plan's service area.

Your Rights
OPM requires that all FEHB Plans provide certain information to their FEHB members. You may get information
about us, our networks, providers, and facilities. OPM's FEHB website (www. opm. gov/ insure) lists the specific types
of information that we must make available to you

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

Service Area
To enroll in this Plan, you must live in or work in our Service Area. This is where our providers practice. Our
service area is: The Pennsylvania counties of Bucks, Chester, Montgomery, Delaware and Philadelphia.

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

Ordinarily, you must get your care from providers who contract with us, except for emergency care required while
you are outside our Service Area. However, as a Keystone Health Plan East member, you have access to urgent care
and urgent follow-up care through a nationwide network of Blue Cross and Blue Shield providers. If you become
ill while visiting outside our Service Area, call 1-800/ 810-BLUE to find names and addresses of nearby participating
Blue Cross and Blue Shield providers. This number is also found on the back of your ID card. Before you obtain
urgent care, call Patient Care Management at the phone number on your ID Card to have the care preauthorized. An
office visit copayment will be collected when the service is rendered. You will not need to file a claim.

If you or a covered family member move outside of our Service Area, you can enroll in another plan. If your
dependents live out of the area (for example, if your child goes to college in another state), you should consider
enrolling in a fee-for-service plan or an HMO that has agreements with affiliates in other areas. Through our Guest
Membership benefit, members who are away from home for at least 90 days may temporarily enroll in another Blue
Cross and Blue Shield network HMO. Members are also eligible for Guest Membership for up to six months if,
for example, they are assigned out-of-area temporarily. Guest Membership enables members to receive the full range
of HMO benefits and services offered by the hosting HMOs. To enroll, members simply contact their Guest
Membership Coordinator in advance. The phone number is on the back of the ID Card. The Coordinator will make
all the necessary arrangements for Guest Membership and take care of all the billing details. Also, your prescription
drug card works in more than 52,000 pharmacies in the United States. If you or a family member move, you do not
have to wait until Open Season to change plans. Contact your employing or retirement office. 11.
11 Page 12 13
2003 Keystone Health Plan East 12 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 16. 1% for Self Only or 18. 7% for Self and Family.

1. Prescription drugs prescribed by a Plan physician and obtained at a participating Plan retail
pharmacy now will be dispensed for up to a 30-day supply per prescription unit or refill, subject to
the following copays:

A $5 copay for formulary generic drugs; A $15 copay for formulary name brand drugs; and

A $25 copay for covered non-formulary drugs.
Previously, for up to a 34-day supply per prescription unit or refill obtained at a participating retail
pharmacy, there was a $5 copay for generic or name brand drugs. Up to a 90 day supply of
maintenance medications were available for a $15 copay for generic or brand name drugs through the
plan.

2. Prescription drugs prescribed by a Plan physician and obtained at a participating Plan mail order
pharmacy now will be dispensed for up to a 90-day supply for maintenance medications for two
copays per prescription unit or refill and will be subject to the following copays:

A $10 copay for formulary generic drugs; A $30 copay for formulary name brand drugs; and

A $50 copay for covered non-formulary drugs.
Previously, for up to a 90-day supply per prescription unit or refill for maintenance medications
obtained at a participating Plan mail order pharmacy, there was a $5 copay for generic or name brand
drugs.

3. Prescription drugs prescribed by a Plan physician and obtained at a non-Plan pharmacy are now
covered at 30% of the total cost of the drug except emergency purchases which are covered at
100% less the appropriate copay. Previously, coverage was only available for emergency non-Plan
pharmacy purchases which were covered at 100% less the appropriate copay.

4. Emergency care at an urgent care center or at the outpatient department of a hospital now will be
subject to a $50 copay, which will be waived if admitted. Previously, emergency care at an urgent
care center or at the outpatient department of a hospital was subject to a $35 copay, which was
waived if admitted. 12.
12 Page 13 14
2003 Keystone Health Plan East 13 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it
whenever you receive services from a Plan provider, or fill a prescription
at a Plan pharmacy. Until you receive your ID card, use your copy of the
Health Benefits Election Form, SF-2809, your health benefits enrollment
confirmation (for annuitants), or your Employee Express confirmation
letter.

If you do not receive your ID card within 30 days after the effective
date of your enrollment, or if you need replacement cards, call us at
1-800/ 227-3114. You may also request replacement cards through our
web site at www. ibx. 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 area that we contract with to provide covered services to our
members. We credential Plan providers according to national standards.
We list Plan providers in the provider directory, which we update
periodically. The list is also on our website.

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

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

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

Treatment for mental conditions and substance abuse may be obtained
directly from Magellan Behavioral Health. Magellan Behavioral Health,
or any other mental health administrator for Keystone Health Plan East,
manage all care related to mental health and substance abuse services and
will determine what specialty care is appropriate and which specialists
will be utilized. Questions about related benefits and precertification
should be directed to Magellan Behavioral Health at 1-800/ 688-1911. 13.
13 Page 14 15
2003 Keystone Health Plan East 14 Section 3
If you enroll, you will be asked to complete a primary care doctor
selection form and send it directly to the Plan, indicating the name of the
primary care doctor selected for you and each member of your family.
You are required to select a personal doctor from among participating
plan primary care doctors located within the Plan's service area. Please
note that if you reside in New Jersey and work in Pennsylvania within
our service area, you must select a primary care doctor whose practice is
in Pennsylvania within our service area. Your dependents may select a
personal doctor from among participating plan primary care doctors in
Pennsylvania or New Jersey. You and your dependents may have only
one dentist who must be selected from a list of participating plan dentists
located within the Plan's service area.

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

Specialty care Your primary care physician will refer you to a specialist for needed care. When you receive a referral from your primary care physician, you must
return to the primary care physician after the consultation, unless your
primary care physician authorized a certain number of visits without
additional referrals. The primary care physician must provide or
authorize all follow-up care. Do not go to the specialist for return visits
unless your primary care physician gives you a referral. However, you
may get dental care, vision care, mammograms, and see an obstetrician/
gynecologist for preventive care, and for routine maternity care or
problems related to gynecological conditions when medically necessary,
without a referral.

Here are other things you should know about specialty care:

If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician
will develop a treatment plan that allows you to see your specialist for
a certain number of visits without additional referrals. Your primary
care physician will use our criteria when creating your treatment plan
(the physician may have to get an authorization or approval
beforehand).

If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician. Your primary care physician will decide
what treatment you need. If he or she decides to refer you to a
specialist, ask if you can see your current specialist. If your current
specialist does not participate with us, you must receive treatment
from a specialist who does. Generally, we will not pay for you to see
a specialist who does not participate with our Plan.

If you are seeing a specialist and your specialist leaves the Plan, call your primary care physician, who will arrange for you to see another
specialist. You may receive services from your current specialist
until we can make arrangements for you to see someone else. 14.
14 Page 15 16
2003 Keystone Health Plan East 15 Section 3
If you have a chronic or disabling condition and lose access to your specialist because we:
terminate our contract with your specialist for other than cause; or
drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB Plan; or
reduce our service area and you enroll in another FEHB Plan,
you may be able to continue seeing your specialist for up to 90 days
after you receive notice of the change. Contact us or, if we drop out of
the Program, contact your new plan.

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

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

If you changed from another FEHB plan to us, your former plan will pay
for the hospital stay until:

You are discharged, not merely moved to an alternative care center; or
The day your benefits from your former plan run out; or
The 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. 15.
15 Page 16 17
2003 Keystone Health Plan East 16 Section 3
Services requiring our Your primary care physician has authority to refer you for most services.
prior approval For certain services, however, your physician must obtain approval from us. Before giving approval, we consider if the service is covered,

medically necessary, and follows generally accepted medical practice.

We call this review and approval process preauthorization. Your
physician must obtain preauthorization for the following services
such as:

All non-emergency hospital admissions All obstetrical admissions
All same day surgery/ short procedure unit admissions Outpatient therapies: speech, cardiac, pulmonary, respiratory, home
infusion
Other facility services: skilled nursing, home health, hospice, birthing center

Rental/ purchase of durable medical equipment and prostheses (purchases over $100.00 and all rentals)
Non-emergency ambulance services Spinal manipulation services
Inpatient psychiatric care Inpatient alcohol and substance abuse treatment
Some medications that have specific uses and are administered in outpatient settings or physician offices

Members are not responsible for payment of services if the provider does
not obtain preauthorization of services. 16.
16 Page 17 18
2003 Keystone Health Plan East 17 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive services.

Example: When you see your primary care physician you pay a
copayment of $10 per office visit or a copayment of $15 per office visit
when you see a specialist.

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 $2,000 per family out-of-pocket maximum for enrollment in any calendar year, you do not have to pay any more for

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

Prescription drugs Dental services

Be sure to keep accurate records of your copayments since you are
responsible for informing us when you reach the maximum. 17.
17 Page 18 19
2003 Keystone Health Plan East Section 5 18
Section 5. Benefits --OVERVIEW
(See page 12 for how our benefits changed this year and page 63 for a benefits summary.)

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

(a) Medical services and supplies provided by physicians and other health care professional.. 19-27

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, occupational, and hand 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....................... 28-31
Surgical procedures Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services..................................................... 32-34

Inpatient hospital Outpatient hospital or ambulatory surgical
center
Extended care benefits/ skilled nursing care facility benefits
Hospice care
Ambulance

(d) Emergency services/ accidents ........................................................................................................................ 35-36
Medical emergency Ambulance

(e) Mental health and substance abuse benefits ................................................................................................... 37-38
(f) Prescription drug benefits ............................................................................................................................... 39-41
(g) Special features..................................................................................................................................................... 42

Services for deaf and hearing impaired Urgent care/ travel benefit

(h) Dental benefits................................................................................................................................................ 43-44
(i) Non-FEHB benefits available to Plan members ................................................................................................... 45

Summary of benefits.................................................................................................................................................... 63 18.
18 Page 19 20
2003 Keystone Health Plan East Section 5( a) 19
Section 5 (a). Medical services and supplies provided by physicians and other health care professionals
I M
P O
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A N
T

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

Plan physicians must provide or arrange your care.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other

coverage, including with Medicare.

I M
P O
R T
A N
T

Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
In physician's office
Office medical consultations

Second surgical opinion

$10 per visit to your primary care
physician

$15 per visit to a specialist

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

Nothing

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

All charges. 19.
19 Page 20 21
2003 Keystone Health Plan East Section 5( a) 20
Lab, X-ray and other diagnostic tests You pay
Laboratory tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
CAT Scans/ MRI
Ultrasound
Electrocardiogram and EEG

Nothing.

Preventive care, adult
Routine screenings, based on medical necessity and risk such as:
Total Blood Cholesterol once every three years, ages 19 through 64
Colorectal Cancer Screening, including
Fecal occult blood test

$10 per visit

Sigmoidoscopy, screening every five years starting at age 50
Colonoscopy once every 10 years starting at age 50
Double contrast barium enema (DCBE) once every 5-10 years starting at
age 50.

Prostate Specific Antigen (PSA test) one annually for men age 40 and older
Routine pap test $10 per visit to your primary care
physician; $15 per visit to a
specialist; nothing for the test 20.
20 Page 21 22
2003 Keystone Health Plan East Section 5( a) 21
Preventive care, adult (Continued) You pay
Routine mammogram covered for women Nothing
Not covered: Physical exams required for obtaining or continuing
employment or insurance, attending schools or camp, or travel.
All charges.

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

Influenza vaccine, annually
Pneumococcal vaccine, annually, age 65 and over
Other adult immunizations as recommended by the Center for Disease Control and approved by Keystone

$10 per visit

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

Well-child care charges for routine examinations, immunizations and care (up to age 22)
Examinations, such as:
Eye exams through age 17 to determine the need for
vision correction.

Ear exams through age 17 to determine the need for
hearing correction

Examinations done on the day of immunizations
(up to age 22)

$10 per visit 21.
21 Page 22 23
2003 Keystone Health Plan East Section 5( a) 22
Maternity care You pay
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Note: Here are some things to keep in mind:

You do not need to precertify your normal delivery; see page 15 for other circumstances, such as extended stays for you or your baby.

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

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

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

benefits (Section 5b).

$15 only applies to first visit

Not covered: Routine sonograms to determine fetal age, size or sex All charges.
Family planning
A range of voluntary family planning services, limited to:
Voluntary sterilization (See Surgical procedures Section 5 (b))
$15 per specialist office visit

Surgically implanted contraceptives

Injectable contraceptive drugs (such as Depo provera)
Intrauterine devices (IUDs)
Diaphragms
Note: We cover oral contraceptives under the prescription drug benefit.

$5 prescription drug copay for the
implant, plus $15 per specialist office
visit; nothing when the device is
implanted during a covered
hospitalization.

$5 prescription drug copay for up to a
three-cycle supply, plus $15 per
specialist office visit.

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

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

Not covered: reversal of voluntary surgical sterilization, genetic counseling All charges. 22.
22 Page 23 24
2003 Keystone Health Plan East Section 5( a) 23
Family planning (Continued) You pay
Not covered:
Reversal of voluntary surgical sterilization
Genetic counseling
Removal of surgically implanted time-release medication before the end of the expected life, unless medically necessary and approved by

the Plan.

All charges.

Infertility services
Diagnosis and treatment of infertility, such as:
Artificial insemination:
intravaginal insemination (IVI)
intracervical insemination (ICI)
intrauterine insemination (IUI)

Fertility drugs
Note: We cover non-injectable and oral fertility drugs under the
Prescription drug benefit.

$15 per specialist office visit

Not covered:
Assisted reproductive technology (ART) procedures, such as:
in vitro fertilization
embryo transfer, gamete GIFT and zygote ZIFT
zygote transfer

Services and supplies related to excluded ART procedures

Cost of donor sperm
Cost of donor egg

All charges.

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

Allergy serum Nothing
Not covered: provocative food testing and sublingual allergy
desensitization
All charges. 23.
23 Page 24 25
2003 Keystone Health Plan East Section 5( a) 24
Treatment therapies You pay
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 30.

Respiratory and inhalation therapy
Dialysis Hemodialysis and peritoneal dialysis
Intravenous (IV)/ Infusion Therapy Home IV and antibiotic therapy
Growth hormone therapy (GHT)
Note: We will only cover GHT when we preauthorize the treatment. If
we determine GHT is not medically necessary, we will not cover the
GHT or related services and supplies. See Services requiring our prior
approval in Section 3.

Nothing

Physical, occupational, and hand therapies
60 consecutive days per condition for the services of each of the following if significant improvement can be expected within 2
months
qualified physical therapists;
occupational therapists; and
hand therapists
Note: We only cover therapy to restore bodily function when there
has been a total or partial loss of bodily function due to illness or
injury.

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

Nothing

Not covered:
long-term rehabilitative therapy
exercise programs

All charges.

Speech therapy
60 consecutive days per condition for the services of qualified speech therapists Nothing 24.
24 Page 25 26
2003 Keystone Health Plan East Section 5( a) 25
Hearing services (testing, treatment, and supplies) You pay
Hearing testing for children through age 17 (see Preventive care, children) $10 per office visit

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

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

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

One pair of eyeglasses or contact lenses to correct an impairment directly caused by accidental ocular injury or intraocular surgery
(such as for cataracts)

Nothing

Eye exam to determine the need for vision correction for children through age 17 (see preventive care) $10 per office visit
Not covered:
Contact lens fittings
Eye exercises and orthoptics
Radial keratotomy and other refractive surgery

All charges.

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

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

$10 per office visit

Not covered:
Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot,

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

treatment is by open cutting surgery)

All charges. 25.
25 Page 26 27
2003 Keystone Health Plan East Section 5( a) 26
Orthopedic and prosthetic devices You pay
Artificial limbs; limited to initial device only; stump hose
Artificial lenses following cataract surgery
Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy

Internal prosthetic devices, such as artificial joints, pacemakers, and surgically implanted breast implant following mastectomy.
Note: See 5( b) for coverage of the surgery to insert the device.
Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.

Braces; limited to initial purchase and fitting

Nothing

Not covered:
cost of a cochlear implanted device
orthopedic and corrective shoes
arch supports
foot orthotics, unless for treatment of diabetes
heel pads and heel cups
lumbosacral supports
corsets, trusses, elastic stockings, support hose, and other supportive devices

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

All charges.

Durable medical equipment (DME)
Rental, or at our option, the initial purchase per medical episode,
including repair and adjustment, of standard durable medical equipment
prescribed by your Plan physician, such as oxygen and dialysis
equipment. Under this benefit, we also cover:

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

Nothing

Not covered:
Motorized wheelchairs Customized durable medical equipment

Replacements of DME

All charges. 26.
26 Page 27 28
2003 Keystone Health Plan East Section 5( a) 27
Home health services You pay
Home health care ordered by a Plan physician and provided by a registered nurse (R. N.), licensed practical nurse (L. P. N.), licensed
vocational nurse (L. V. N.), or home health aide.
Services include oxygen therapy, intravenous therapy and medications.

Nothing

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

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

All charges.

Chiropractic
Spinal manipulation will be provided for up to 60 consecutive days per
condition if significant improvement can be expected in the two month
period.

Nothing

Alternative treatments
Not covered:
naturopathic services hypnotherapy

biofeedback acupuncture

All charges.

Educational classes and programs
Coverage is limited to:

Diabetes self-management training and education through community-based programs certified by the American Diabetes
Association or Pennsylvania Department of Health. Covered
services may also be provided by these contracted providers; a
licensed health care professional; or at a hospital on an outpatient
basis.

Nothing 27.
27 Page 28 29
2003 Keystone Health Plan East Section 5( b) 28
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
I M
P O
R T
A N
T

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

necessary.
Plan physicians must provide or arrange your care.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with

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

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

I M
P O
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A N
T

Benefit Description You pay
Surgical procedures
A comprehensive range of services, such as:
Operative procedures
Treatment of fractures, including casting
Normal pre-and post-operative care by the surgeon
Correction of amblyopia and strabismus
Endoscopy procedures
Biopsy procedures
Removal of tumors and cysts
Correction of congenital anomalies (see reconstructive surgery)
Surgical treatment of morbid obesity
Insertion of internal prosthetic devices. See 5( a) -Orthopedic and prosthetic devices for device coverage information.

Nothing

Surgical procedures continued on next page. 28.
28 Page 29 30
2003 Keystone Health Plan East Section 5( b) 29
Surgical procedures (Continued) You pay
Voluntary sterilization (e. g., Tubal ligation, Vasectomy)
Treatment of burns

Note: Generally, we pay for internal prostheses (devices) according to
where the procedure is done. For example, we pay Hospital benefits for
a pacemaker and Surgery benefits for insertion of the pacemaker.

Nothing

Not covered:
Reversal of voluntary sterilization Routine treatment of conditions of the foot; see Foot care.
All charges.

Reconstructive surgery
Your physician must obtain approval from us before providing service.
Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if:
the condition produced a major effect on the member's
appearance and

the condition can reasonably be expected to be corrected by such
surgery

Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of

congenital anomalies are: protruding ear deformities; cleft lip; cleft
palate; birth marks; webbed fingers; and webbed toes.

Nothing

Reconstructive surgery continued on next page 29.
29 Page 30 31
2003 Keystone Health Plan East Section 5( b) 30
Reconstructive surgery (Continued) You pay
All stages of breast reconstruction surgery following a mastectomy, such as:

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

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

Nothing

Not covered:
Cosmetic surgery any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance

through change in bodily form, except repair of accidental injury
Surgeries related to sex transformation

All charges.

Oral and maxillofacial surgery
Oral surgical procedures require preapproval by the Plan, and are 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 absences when done as independent procedures; and

Other surgical procedures that do not involve the teeth or their supporting structures.

Nothing

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

All charges. 30.
30 Page 31 32
2003 Keystone Health Plan East Section 5( b) 31
Organ/ tissue transplants You pay
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single Double
Pancreas
Allogeneic (donor) bone marrow transplants

Autologous bone marrow transplants (autologous stem cell and peripheral stem cell support) for the following conditions:

autologous tandem transplants as accepted treatment for testicular
and other germ cell tumors; acute lymphocytic or non-lymphocytic
leukemia; advanced Hodgkin's lymphoma; advanced non-Hodgkin's
lymphoma; advanced neuroblastoma; breast cancer; multiple
myeloma; epithelial ovarian cancer; and testicular, mediastinal,
retroperitoneal and ovarian germ cell tumors

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

Nothing

Not covered:
Donor screening tests and donor search expenses, except those performed for the actual donor

Implants of artificial organs
Transplants not listed as covered

All charges.

Anesthesia
Professional services provided in
Hospital (inpatient)
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center
Office

Nothing 31.
31 Page 32 33
2003 Keystone Health Plan East 32 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
I M
P O
R T
A N
T

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

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

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

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

I M
P O
R T
A N
T

Benefit Description You pay
Inpatient hospital
Room and board, such as
ward, semiprivate, or intensive care or cardiac care accommodations;

general nursing care; and
meals and special diets.

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

Nothing

Inpatient hospital continued on next page. 32.
32 Page 33 34
2003 Keystone Health Plan East 33 Section 5( c)
Inpatient hospital (Continued) You pay
Other hospital services and supplies, such as:
Operating, recovery, maternity, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays
Administration of blood and blood products
Blood or blood plasma
Dressings, splints, casts, and sterile tray services
Medical supplies and equipment, including oxygen
Anesthetics, including nurse anesthetist services
Take-home items
Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home

Nothing

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

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

All charges.

Outpatient hospital or ambulatory surgical center
Operating, recovery, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology services
Administration of blood, blood plasma, and other biologicals
Blood and blood plasma, if not donated or replaced
Pre-surgical testing
Dressings, casts, and sterile tray services
Medical supplies, including oxygen
Anesthetics and anesthesia service

Note: We cover hospital services and supplies related to dental
procedures when necessitated by a non-dental physical impairment. We
do not cover the dental procedures.

Nothing

Not covered: blood and blood derivatives not replaced by the member All charges. 33.
33 Page 34 35
2003 Keystone Health Plan East 34 Section 5( c)
Extended care benefits/ skilled nursing care facility benefits You pay
Extended care benefit:
We provide a comprehensive range of benefits for up to 180 days per
calendar year when full-time skilled nursing care is necessary and
confinement in a skilled nursing facility is medically appropriate as
determined by a Plan doctor and approved by the Plan.

Nothing

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

Hospice care
Supportive and palliative care for a terminally ill member 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 that the patient is in the terminal
stages of illness, with a life expectancy of approximately six months or
less.

Nothing

Not covered: Independent nursing, homemaker services All charges.
Ambulance
Local professional ambulance service when medically appropriate and authorized by a Plan doctor. Nothing 34.
34 Page 35 36
2003 Keystone Health Plan East 35 Section 5( d)
Section 5 (d). Emergency services/ accidents
I M
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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.

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
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T

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

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

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

If you need to be hospitalized, the Plan must be notified. If a Plan doctor believes care can be better provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges
covered in full.
To be covered by this Plan, any follow up care recommended by non-Plan providers must be approved by
the Plan or provided by Plan providers. 35.
35 Page 36 37
2003 Keystone Health Plan East 36 Section 5( d)
Benefit Description You pay
Emergency within our service area

Emergency care at a doctor's office $10 per office visit

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

$50 per visit; waived if
admitted to a hospital or if
you are referred to the ER
by your PCP and services
could have been provided
by your doctor.

Not covered: Elective care or non-emergency care All charges.
Emergency outside our service area

Emergency care at a doctor's office $10 per office visit
Emergency care at an urgent care center
Emergency care as an outpatient or inpatient at a hospital, including doctors' services

$50 per visit; waived if
admitted to hospital

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

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

All charges.

Ambulance
Professional ambulance, or air ambulance service, when medically
appropriate.

See 5( c) for non-emergency service.

Nothing 36.
36 Page 37 38
2003 Keystone Health Plan East 37 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
I M
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T

When you get our approval for services and follow a treatment plan we approve, cost-sharing
and limitations for Plan mental health and substance abuse benefits will be no
greater than for similar benefits for other illnesses and conditions.

Here are some important things to keep in mind about these benefits.
All benefits are subject to the definitions, limitations, and exclusions in this brochure.

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with
other coverage, including with Medicare.
YOU MUST GET PREAUTHORIZATION OF THESE SERVICES. See the instructions after the benefits description below.

I M
P O
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A N
T

Benefit Description You pay
Mental health and substance abuse benefits

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

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

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

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

Medication management

$15 per specialist office visit

Mental health and substance abuse benefits continued on next page. 37.
37 Page 38 39
2003 Keystone Health Plan East 38 Section 5( e)
Mental health and substance abuse benefits (Continued) You pay
Diagnostic tests Services provided by a hospital or other facility
Services in approved alternative care settings such as partial hospitalization, full-day hospitalization, facility based intensive
outpatient treatment

Nothing

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

All charges.

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

Limitation We may limit your benefits if you do not obtain a treatment plan. 38.
38 Page 39 40
2003 Keystone Health Plan East 39 Section 5( f)
Section 5 (f). Prescription drug benefits
I
M
P
O
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A
N
T

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

All benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically
necessary.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about

coordinating benefits with other coverage, including with Medicare.

I
M
P
O
R T

A
N
T

There are important features you should be aware of. These include:
Who can write your prescription. A licensed Plan physician or licensed Plan dentist must write the prescription.

Where you can obtain them. You may fill the prescription at a Plan pharmacy, or by mail at a Plan mail order pharmacy for maintenance medications, except for prescriptions required because
of an out-of-area emergency.
We use a formulary. Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan's formulary. A formulary is a list of selected drugs that have been evaluated for their medical

effectiveness and value. Plan formulary is designed to include all therapeutic categories, provide
coverage for all types of drugs and provide physicians with prescribing options.

Prior Authorization. Your pharmacy benefits plan requires prior authorization of certain covered drugs to ensure that the drug prescribed is medically necessary and appropriate and is being prescribed

according to the food and Drug Administration (FDA) guidelines. The approval criteria was developed
and endorsed by the Independence Blue Cross Pharmacy and Therapeutics Committee which is an
established group of pharmacists, Medical Directors and representatives from the physician and
pharmacy communities.

These are the dispensing limitations. Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed for up to a 30-day supply, or the maximum

allowed dosage as prescribed by law, whichever is less. Covered maintenance drugs may be
obtained through the Plan Mail Order pharmacy for up to a 90-day supply. Prescription refills will
not be provided beyond six (6) months from the most recent dispensing date. Prescription refills
will be dispensed only if 75% of the previously dispensed quantity has been consumed based on the
dosage prescribed.

Why use generic drugs? Generic drugs are lower-priced drugs that are the therapeutic equivalent to more expensive name brand drugs. They must contain the same active ingredients and must be

equivalent in strength and dosage to the original name brand product. Generics cost less than the
equivalent name brand product. The U. S. Food and Drug Administration sets quality standards for
generic drugs to ensure that these drugs meet the same standards of quality and strength as name
brand drugs. You can save money by using generic drugs. However, you and your physician have
the option to request a name brand, even if a generic option is available. Using the most cost-effective
medication saves money.

When you have to file a claim. Prescription drugs obtained from a non-Plan pharmacy are eligible with a higher out of pocket expense, except for an out of area emergency which will be

reimbursed after your copay. You must submit acceptable proof-of-payment with a direct
reimbursement form. All claims for payment must be received within ninety (90) days of
the date of proof-of-purchase. Direct reimbursement forms may be obtained by calling
1-800/ 227-3114.

Prescription drug benefits begin on the next page. 39.
39 Page 40 41
2003 Keystone Health Plan East 40 Section 5( f)
Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan
physician, or licensed Plan dentist, and obtained from a Plan pharmacy
or through our mail order program:

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

listed as Not covered.
Oral and formulary injectable contraceptive drugs up to a three-cycle supply for a single copay.

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

equivalent, acetone test tablets, diabetic blood testing strips, lancets
and glucometers. Copay applies to each diabetic supply, except
lancets and glucometers obtained through a Plan Participating
Pharmacy.

Disposable needles and syringes for the administration of covered medications.

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

At a Plan Retail Pharmacy:
$5 per covered generic formulary
prescription/ refill (up to a 30 day
supply)

$15 per covered brand formulary
prescription/ refill (up to a 30 day
supply)

$25 per covered non-formulary
prescription/ refill (up to a 30 day
supply)

Through Mail Order:
$10 per covered generic formulary
prescription/ refill for a 31 to 90 day
supply through mail order
(maintenance medications only)

$30 per covered brand formulary
prescription/ refill for a 31 to 90 day
supply through mail order
(maintenance medications only)

$50 per covered non-formulary
prescription/ refill for a 31 to 90 day
supply through mail order
(maintenance medications only) 40.
40 Page 41 42
2003 Keystone Health Plan East 41 Section 5( f)
Covered medications and supplies (continued) You pay
Not covered:
Drugs and supplies used for cosmetic purposes
Vitamins and nutritional substances that can be purchased without a prescription, except for prenatal and pediatric vitamins

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

Injectable fertility drugs
Pharmacological therapy for weight reduction or diet agents, except for treatment of Morbid Obesity

All charges. 41.
41 Page 42 43
2003 Keystone Health Plan East 42 Section 5( g)
Section 5 (g). Special features
Feature Description

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

Urgent care/ travel benefit Ordinarily, you must get your care from providers who contract with us. As a Keystone Health Plan East member, you have access to urgent care
through a nationwide network of Blue Cross and Blue Shield
providers. Urgent care includes covered services provided in order to
treat an unexpected illness or injury that is not life-threatening. The
services must be required in order to prevent a serious deterioration in
your or a covered family member's health if treatment were delayed.

If you become ill or injured while visiting outside the service area, call
1-800-8100-BLUE to find names and addresses of nearby participating
Blue Cross and Blue Shield Traditional (BlueCard providers).
Before you obtain any urgent care, call Patient Care Management at the
phone number on our ID Card to have care preauthorized. An office
visit copayment will be collected when the service is rendered. You will
not need to file a claim.

No coverage will be provided for urgent care that has not been
preauthorized. 42.
42 Page 43 44
2003 Keystone Health Plan East 43 Section 5( h)
Section 5 (h). Dental benefits
I M
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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 dentists must provide or arrange your care.
We cover hospitalization for dental procedures only when a nondental physical impairment exists which makes hospitalization necessary to safeguard the health of

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

other coverage, including with Medicare.

I M
P O
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T

Benefit Description You pay
Accidental injury benefit

We cover restorative services and supplies necessary to promptly repair
(but not replace) sound natural teeth. The services are covered if they are
initiated within 6 months after the accident, or as other medical conditions
permit, and are provided by participating Plan dentists. The need for these
services must result from an accidental injury.

$15 copay per visit

Dental benefits are continued on next page. 43.
43 Page 44 45
2003 Keystone Health Plan East 44 Section 5( h)
Dental benefits
Service You Pay
The following dental services are covered when provided by
participating Plan general dentists:

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

Topical fluoride (include child and adult)
Oral hygiene instruction

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

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

Pin restoration
Sedative restoration (per tooth)
Emergency treatment for covered restorative services (palliative)

$5 copay per office visit

Other services
Endodontic
Orthodontic
Oral surgery
Single unconnected crowns
Prosthodontic

A discounted amount; what you pay may
change periodically, so call us for the
amounts you pay for these dental services.

Out-of-area dental services:
We will provide coverage for covered dental services in connection
with dental emergencies for palliative treatment (to relieve pain). To
receive payment for these services, you must submit a receipt to
Member Services. The receipt must be itemized and show the dental
services performed and the charge for each service.

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

Not covered: Other dental services not shown as covered All charges. 44.
44 Page 45 46
2003 Keystone Health Plan East 45 Section 5( i)
Section 5 (i). Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB
disputed claim about them. Fees you pay for these services do not count toward FEHB deductibles or
out-of-pocket maximums.

Keystone Health Plan East also offers members these Distinct Health Enhancement Opportunities:

Weight Management Program Keystone and Weight Watchers have a special offer for those who want to lose weight and keep it off! Keystone Members receive 100% reimbursement up to $200 on Weight
Watchers 1 or a network hospital program of their choice.
New Fitness Reimbursement Program To give members added incentive to maintain an active lifestyle, we will reimburse members up to $150 of their annual fitness club fees. Members can now enjoy the
flexibility of joining any fitness club and working out at multiple fitness clubs. Visits can be recorded by
swipe-card, computer printout, telephone or logbook. Members must complete 120 visits per 365 day
enrollment period to receive reimbursement.

Smoking Cessation Program If you smoke, quitting is one of the best things you can do for your health. Better yet, when you kick the habit, we'll help foot the bill! You can get up to $200 back when you complete
your choice of a variety of proven smoking cessation programs. And to give you more incentive, we now will
reimburse you the costs of nicotine replacement products. If you choose a smoking cessation program that costs
less than $200, you use the difference toward the purchase of nicotine replacement products, such as "the patch"
or chewing gum.

Red Cross CPR and First Aid Course Discounts Keystone Health Plan East members will receive up to $25 reimbursement for any course offered by the American Red Cross.

Child Safety Program Offers tips on how to reduce children's risk for household accidents such as burns, injuries from firearms, choking, and accidental poisonings. Our newly enhanced Family Health Portfolio
includes "Mr. Yuk" stickers to place on poisonous substances, a coupon for a free bottle of Syrup of Impecac,
reimbursement up to $25 for a bike helmet, tips for safe bicycling and more.

Baby Blueprints Our maternity program helps identify possible risk factors during pregnancy. It also offers educational materials and up to $50 back for the cost of any childbirth class.

For more information Call the Health Resource Center 1-800/ 275-2583 or 215/ 241-3367 in the Philadelphia area. 45.
45 Page 46 47
2003 Keystone Health Plan East 46 Section 6
Section 6. General exclusions things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will
not cover it unless your Plan doctor determines it is medically necessary to prevent, diagnose, or treat your illness, disease, injury, or condition and we agree, as discussed under What Services Require Our Prior Approval

on page 16.
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; or
Services, drugs or supplies you receive without charge while in active military service. 46.
46 Page 47 48
2003 Keystone Health Plan East 47 Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or fill your prescription drugs at Plan
pharmacies, you will not have to file claims. Just present your identification card and pay your copayment.

You will only need to file a claim when you receive emergency services from non-Plan providers or non-Plan
pharmacies. Sometimes these providers bill us directly. Check with the provider. If you need to file the claim, here
is the process:

Medical, hospital, and drug In most cases, providers and facilities file claims for you. Physicians
benefits must file on the form HCFA-1500, Health Insurance Claim Form. Facilities will file on the UB-92 form. For claims questions and

assistance, call us at 1-800/ 227-3114.

When you must file a claim such as for 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: Keystone Health Plan East
1901 Market Street
Philadelphia, PA 19103.

Deadline for filing your claim Send us all of the documents for your claim as soon as possible. You must submit the claim by December 31 of the year after the year you
received the service, unless timely filing was prevented by administrative
operations of Government or legal incapacity, provided the claim was
submitted as soon as reasonably possible. .

When we need more information Please reply promptly when we ask for additional information. We may delay processing or deny your claim if you do not respond. 47.
47 Page 48 49
2003 Keystone Health Plan East 48 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: 1901 Market Street, Philadelphia, PA 19103; and
(c) Include a statement about why you believe our initial decision was wrong, based on specific benefit
provisions in this brochure; and

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

. 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 medical 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 3,
1900 E Street, NW, Washington, D. C. 20415-3630.

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

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

Note: If you want OPM to review different claims, you must clearly identify which documents apply to
which claim. 48.
48 Page 49 50
2003 Keystone Health Plan East 49 Section 8
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 or supplies or from the year in which you were denied
precertification or prior approval. This is the only deadline that may not be extended.

OPM may disclose the information it collects during the review process to support their disputed claim
decision. This information will become part of the court record.

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

NOTE: If you have a serious or life threatening condition (one that may cause permanent loss of bodily
functions or death if not treated as soon as possible), and

(a) We haven't responded yet to your initial request for care or preauthorized/ prior approval, then call us at
1-800/ 227-3114 and we will expedite our review; or

(b) We denied your initial request for care or preauthorization/ prior approval, then:
If we expedite our review and maintain our denial, we will inform OPM so that they can give your
claim expedited treatment too, or

You can call OPM's Health Benefits Contracts Division 3 at 202/ 606-0755 between 8 a. m. and 5 p. m.
eastern time. 49.
49 Page 50 51
2003 Keystone Health Plan East 50 Section 9
Section 9. Coordinating benefits with other coverage
When you have other health coverage You must tell us if you are covered or a family member is covered under another group health plan or have automobile insurance that pays health
care expenses without regard to fault. This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in full as the primary payer and the other plan pays a reduced benefit as the
secondary payer. We, like other insurers, determine which coverage is primary according to the National Association of Insurance
Commissioners' guidelines.
When we are the primary payer, we will pay the benefits described in this brochure.

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

Medicare has two parts:
Part A (Hospital Insurance). Most people do not have to pay for Part A. If you or your spouse worked for at least 10 years in Medicare-covered
employment, you should be able to qualify for premium-free Part A insurance. (Someone who was a Federal employee on January 1, 1983
or since automatically qualifies.) Otherwise, if you are age 65 or older, you may be able to buy it. Contact 1-800-MEDICARE for more
information.
Part B (Medical Insurance). Most people pay monthly for Part B. Generally, Part B premiums are withheld from your monthly Social
Security check or your retirement check.
If you are eligible for Medicare, you may have choices in how you get your health care. Medicare + Choice is the term used to describe the
various health plan choices available to Medicare beneficiaries. The information in the next few pages show how we coordinate benefits with
Medicare, depending on the type of Medicare managed care plan you have.
The Original Medicare Plan The Original Medicare Plan (Original Medicare) is a plan that is (Part A or Part B) 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.
When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care.
Your care must continue to be authorized by your Plan PCP. We will not waive any of our copayments.
(Primary payer chart begins on next page.) 50.
50 Page 51 52
2003 Keystone Health Plan East 51 Section 9
Claims process when you have the Original Medicare Plan You probably will never have to file a claim
form when you have both our Plan and the Original Medicare Plan.

When we are the primary payer, we process the claim first.
When Original Medicare is the primary payer, Medicare processes your claim first. In most cases, your claims will be coordinated automatically and we will pay the balance of covered

charges. You will not need to do anything. To find out if you need to do something about
filing your claims, call us at 1-800/ 227-3114.

We do not waive any costs when you have Medicare.
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 familymember 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 . 51.
51 Page 52 53
2003 Keystone Health Plan East 52 Section 9
Medicare managed care plan If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare managed care plan. These are
health care choices (like HMOs) in some areas of the country. In most
Medicare managed care plans, you can only go to doctors, specialists,
or hospitals that are part of the plan. Medicare managed care plans
provide all the benefits that Original Medicare covers. Some cover
extras, like prescription drugs. To learn more about enrolling in a
Medicare managed care plan, contact Medicare at 1-800-MEDICARE
(1-800-633-4227) or at www. medicare. gov.

If you enroll in a Medicare managed care plan, the following options are
available to you:

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

This Plan and another plan's Medicare managed care plan: You
may enroll in another plan's Medicare managed care plan and also
remain enrolled in our FEHB plan. We will still provide benefits when
your Medicare managed care plan is primary, even out of the managed
care plan's network and/ or service area (if you use our Plan providers),
but we will not waive any of our copayments. If you enroll in a
Medicare managed care plan, tell us. We will need to know whether you
are in the Original Medicare Plan or a Medicare managed care plan so we
can correctly coordinate benefits with Medicare.

Suspended FEHB coverage to enroll in a Medicare managed care plan: If you are an annuitant or former spouse, you can suspend your
FEHB coverage to enroll in a Medicare managed care plan, eliminating
your FEHB premium. (OPM does not contribute to your Medicare
managed care plan premium.) For information on suspending your
FEHB enrollment, contact your retirement office. If you later want to
re-enroll in the FEHB Program, generally you may do so only at the next
open season unless you involuntarily lose coverage or move out of the
Medicare managed care plan's service area.

If you do not enroll in If you do not have one or both parts of Medicare, you can still be covered Medicare Part A or Part B under the FEHB Program. We will not require you to enroll in Medicare
Part B and, if you can't get premium-free Part A, we will not ask you to
enroll in it. 52.
52 Page 53 54
2003 Keystone Health Plan East 53 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 CAMPVA and this Plan cover
you, we pay first. See your TRICARE or CHAMPVA Health Benefits
Advisor if you have any questions about these programs.

Suspended FEHB coverage to enroll in TRICARE or CHAMPA: 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 en-roll 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 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 your
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 Keystone Health Plan East 54 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 17.

Covered services Care we provide benefits for, as described in this brochure.
Custodial Care Care provided primarily for maintenance of the patient or care which is
(Domiciliary Care) designed essentially to assist the patient in meeting his/ her activities of daily living and which is not primarily provided for its therapeutic value

in the treatment of an illness, disease, bodily injury, or condition.
Custodial care includes, but is not limited to, help in walking, bathing,
dressing, feeding, preparation of special diets and supervision of self-administration
of medications which do not require the technical skills or
professional training of medical or nursing personnel in order to be
performed safely and effectively. Custodial care that lasts 90 days or
more is sometimes known as Long term care.

Experimental or To establish if a biological, medical device, drug or procedure is or is not
investigational services experimental/ investigational, a technology assessment is performed. The results of the assessment provide the basis for the determination of the

service's status (e. g., medically effective, experimental, etc.).
Technology assessment is the review and evaluation of available data
from multiple sources using industry standard criteria to assess the
medical effectiveness of the service. Sources of data used in technology
assessment include, but are not limited to, clinical trials, position papers,
articles published by local and/ or nationally accepted medical
organizations or peer-reviewed journals, information supplied by
government agencies, as well as regional and national experts and/ or
panels and, if applicable, literature supplied by the manufacturer.

Us/ We Us and we refer to Keystone Health Plan East.
You You refers to the enrollee and each covered family member. 54.
54 Page 55 56
2003 Keystone Health Plan East 55 Section 11
Section 11. FEHB facts
No pre-existing condition We will not refuse to cover the treatment of a condition that you had
limitation before you enrolled in this Plan solely because you had the condition before you enrolled.

Where you can get information See www. opm. gov/ insure. Also, your employing or retirement office
about enrolling in the can answer your questions, and give you a Guide to Federal Employees
FEHB Program Health Benefits Plans, brochures for other plans, and other materials you need to make an informed decision about:

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

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

Types of coverage available Self Only coverage is for you alone. Self and Family coverage is for
for you and your family you, your spouse, and your unmarried dependent children under age 22, including any foster children or stepchildren your employing or

retirement office authorizes coverage for. Under certain circumstances,
you may also continue coverage for a disabled child 22 years of age or
older who is incapable of self-support.

If you have a Self Only enrollment, you may change to a Self and Family
enrollment if you marry, give birth, or add a child to your family. You
may change your enrollment 31 days before to 60 days after that event.
The Self and Family enrollment begins on the first day of the pay period
in which the child is born or becomes an eligible family member. When
you change to Self and Family because you marry, the change is effective
on the first day of the pay period that begins after your employing office
receives your enrollment form; benefits will not be available to your
spouse until you marry.

Your employing or retirement office will not notify you when a family
member is no longer eligible to receive health benefits, nor will we.
Please tell us immediately when you add or remove family members
from your coverage for any reason, including divorce, or when your child
under age 22 marries or turns 22.

If you or one of your family members is enrolled in one FEHB plan, that
person may not be enrolled in or covered as a family member by another
FEHB plan. 55.
55 Page 56 57
2003 Keystone Health Plan East 56 Section 11
Children's Equity Act OPM has implemented the Federal Employees Health Benefits Children's Equity Act of 2000. This law mandates that you be enrolled
for self and family coverage in the Federal Employees Health Benefits
(FEHB) Program, if you are an employee subject to a court or
administrative order requiring you to provide health benefits for your
child( ren).

If this law applies to you, you must enroll for self and family coverage in
a health plan that provides full benefits in the area where your children
live or provide documentation to your employing office that you have
obtained other health benefits coverage for your children. If you do not
do so, your employing office will enroll you involuntarily as follows:

If you have no FEHB coverage, your employing office will enroll you for self and family coverage in the option of the Blue Cross and
Blue Shield Service Benefit Plan that provides the lower level
coverage:

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 lower option of the Blue Cross
and Blue Shield Service Benefit Plan.

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 your employing
office for further information. 56.
56 Page 57 58
2003 Keystone Health Plan East 57 Section 11
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
coverage (TCC).

When you lose benefits
When FEHB coverage ends You will receive an additional 31 days of coverage, for no additional premium, when:

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

Spouse equity If you are divorced from a Federal employee or annuitant, you may not coverage continue to get benefits under your former spouse's enrollment. This is

the case even when the court has ordered your former spouse to supply
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 If you leave Federal service, or if you lose coverage because you no Coverage (TCC) longer qualify as a family member, you may be eligible for Temporary
Continuation of Coverage (TCC). For example, you can receive TCC if
you are not able to continue your FEHB enrollment after you retire, if
you lose your job, if you are a covered dependent child and you turn 22
or marry, etc.

You may not elect TCC if you are fired from your Federal job due to
gross misconduct. 57.
57 Page 58 59
2003 Keystone Health Plan East 58 Section 11
Enrolling in TCC. Get the RI 79-27, which describes TCC, and the RI
70-5, the Guide to Federal Employees Health Benefits Plans for
Temporary Continuation of Coverage and Former Spouse Enrollees,
from your employing or retirement office or from www. opm. gov/ insure.
It explains what you have to do to enroll.

Converting to You may convert to a non-FEHB individual policy if: individual coverage
Your coverage under TCC or the spouse equity law ends (If you canceled your coverage or did not pay your premium, you cannot
convert);
You decided not to receive coverage under TCC or the spouse equity law; or

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

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

Getting a Certificate of The Health Insurance Portability and Accountability Act of 1996 Group Health Plan Coverage (HIPAA) is a Federal law that offers limited Federal protections for
health coverage availability and continuity to people who lose employer
group coverage. If you leave the FEHB Program, we will give you a
Certificate of Group Health Plan Coverage that indicates how long you
have been enrolled with us. You can use this certificate when getting
health insurance or other health care coverage. Your new plan must
reduce or eliminate waiting periods, limitations, or exclusions for health
related conditions based on the information in the certificate, as long as
you enroll within 63 days of losing coverage under this Plan. If you have
been enrolled with us for less than 12 months, but were previously
enrolled in other FEHB plans, you may also request a certificate from
those plans.

For more information, get OPM pamphlet RI 79-27, Temporary
continuation of Coverage (TCC) under the FEHB Program. See also the
FEHB web site (www. opm. gov/ insure/ health); refer to the "TCC and
HIPAA" frequently asked questions. These highlight HIPAA rules, such
as the requirement that Federal employees must exhaust any TCC
eligibility as one condition for guaranteed access to individual health
coverage under HIPAA, and have information about Federal and State
agencies you can contact for more information. 58.
58 Page 59 60
2003 Keystone Health Plan East 59 Long Term Care Insurance
Long Term Care Insurance Is Still Available!
Open Season The Federal Long Term Care Insurance Program's open season for enrollment ends on December 31, 2002. If you're a Federal employee, this is the chance for
you and your spouse to apply by answering only a few questions about your health.

You Can Also Apply Later You and your qualified relatives can still apply for coverage after open season ends. The difference for employees and their spouses is that they won't have the
advantage of open season's abbreviated underwriting, so they'll have to answer more health-related questions. For annuitants and other qualified relatives, there's
no difference in the underwriting requirements during and after the open season.

FEHB Doesn't Cover It It's important to keep in mind that neither your FEHB plan nor Medicare covers the cost of long term care. Also called "custodial care," it's care you receive
when you need help performing activities of daily living such as bathing or dressing yourself. This need can strike any one at any age and the cost of care can
be substantial.

It's Not Too Late! It's not too late to protect yourself against the high cost of long term care by applying for the Federal Long Term Care Insurance Program. Don't delay if
you apply during open season, your premiums will be based on your age as of July 1, 2002. After open season, your premiums are based on your age at the time your
application for enrollment is received by LTC Partners.

Find Out More Call 1-800-LTC-FEDS (1-800-582-3337) or visit www. ltcfeds. com to get more information and to request an application. 59.
59 Page 60 61
2003 Keystone Health Plan East 60 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 35 Allergy tests 23
Allogeneic (donor) bone marrow transplant 31
Alternative treatment 27 Ambulance 32
Anesthesia 31 Autologous bone marrow
transplant 31 Biopsies 28
Birthing centers 16 Blood and blood plasma 31
Breast cancer screening 21 Casts 33
Catastrophic protection 17 Changes for 2002 12
Chemotherapy 24 Childbirth 22
Chiropractic 27 Cholesterol tests 20
Circumcision 22 Claims 47
Coinsurance 17 Colorectal cancer screening 20
Congenital anomalies 29 Contraceptive devices and drugs 22
Coordination of benefits 50 Covered charges 13
Covered providers 13
Crutches 26
Deductible 17 Definitions 54

Dental care 43 Diagnostic services 19
Disputed claims review 48 Donor expenses (transplants) 31
Dressings 33 Durable medical equipment
(DME) 26 Educational classes and programs 27
Effective date of enrollment 57 Emergency 33
Experimental or investigational 46 Eyeglasses 25
Family planning 22 Fecal occult blood test 20

General Exclusions 46 Hand therapy 24
Hearing services 25 Home health services 27
Hospice care 34 Home nursing care 27
Hospital 13 Immunizations 21
Infertility 23 Inhospital physician care 19
Inpatient Hospital Benefits 32 Insulin 40
Laboratory and pathological services 20
Machine diagnostic tests 20 Magnetic Resonance Imagings
(MRIs) 20 Mail Order Prescription Drugs 40
Mammograms 21 Maternity Benefits 22
Medicaid 53 Medically necessary 13
Medicare 50 Members 13
Mental Conditions/ Substance Abuse Benefits 37
Neurological testing 20 Newborn care 22
Non-FEHB Benefits 45 Nurse
Licensed Practical Nurse 27 Nurse Anesthetist 33
Nurse Midwife 22 Nurse Practitioner 27
Psychiatric Nurse 38 Registered Nurse 27
Nursery charges 22 Obstetrical care 22
Occupational therapy 24 Ocular injury 25
Office visits 19 Oral and maxillofacial surgery 30
Orthopedic devices 26 Ostomy and catheter supplies 33
Out-of-pocket expenses 17 Outpatient facility care 33
Oxygen 33

Pap test 20 Physical examination 21
Physical therapy 24 Physician 14
Pre-admission testing 33 Precertification 16
Preventive care, adult 20 Preventive care, children 21
Prescription drugs 39 Preventive services 20
Prior approval 16 Prostate cancer screening 20
Prosthetic devices 26 Psychologist 37
Psychotherapy 37 Radiation therapy 24
Renal dialysis 24 Room and board 32
Second surgical opinion 19 Skilled nursing facility care 34
Smoking cessation 45 Speech therapy 24
Splints 33 Sterilization procedures 22
Subrogation 53 Substance abuse 37
Surgery 28
Anesthesia 31 Oral 30

Outpatient 31 Reconstructive 29
Syringes 40 Temporary continuation of
coverage 57 Transplants 31
Treatment therapies 24 Urgent care/ travel benefit 42
Vision services 25 Well child care 21
Wheelchairs 26 Workers' compensation 53
X-rays 20 60.
60 Page 61 62
2003 Keystone Health Plan East 61 Summary
NOTES 61.
61 Page 62 63
2003 Keystone Health Plan East 62 Summary
NOTES 62.
62 Page 63 64
2003 Keystone Health Plan East 63 Summary
Summary of Benefits for Keystone Health Plan East 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.

Benefit Description You pay Page
Medical services provided by physicians
Diagnostic and treatment services provided in the office
Office visit copay: $10
primary care; $15
specialist
19

Services provided by a hospital:
Inpatient. Outpatient.. Nothing Nothing 32 33

Emergency benefits:
In-area

Out-of-area

$50 per emergency room
visit; waived if admitted

$50 per emergency room
visit; waived if admitted

36
36

Mental health and substance abuse treatment. Regular costs sharing 37
Prescription drugs
Drugs prescribed by any doctor and obtained at a participating pharmacy

A Mail Order program is available for up to a 90 day supply of maintenance medications
Non-plan Retail Pharmacy..

$5 copay per prescription
or refill for Formulary
Generic Drugs: $15 copay
for Formulary Brand Name
Drugs; $25 copay for
covered non-formulary
drugs; 2 copays per 90 day
supply at mail order

70% of the total cost of the
drug except for emergency
prescription purchases
which are covered at 100%
less the appropriate copay
as indicated above.

40

Dental Care
Accidental injury benefit....
Preventive, Diagnostic, and Restorative dental care..
$15 copay per visit
$5 copay per visit

43

Vision Care
One eye exam and refraction every two years $15 copay per visit
25

Special Features: Services for deaf and hearing impaired; and Urgent
care/ travel benefit.
42

Protection against catastrophic costs
(your out-of-pocket maximum).
Nothing after $1,000/ Self
Only or $2,000/ Family
enrollment per year

Some costs do not count
toward this protection.

17 63.
63 Page 64
2003 Keystone Health Plan East
007667

2003 Rate Information for Keystone Health Plan East
Non-Postal rates apply to most non-Postal enrollees. If you are in a special enrollment category, refer to the FEHB
Guide for that category or contact the agency that maintains your health benefits enrollment.

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

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

Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly
Type of
Enrollment Code

Gov't
Share
Your
Share
Gov't
Share
Your
Share
USPS
Share
Yours
Share

Self Only ED1 109.30 37.33 236.82 80.88 129.03 17.60
Self and Family ED2 249.62 137.07 540.84 296.99 294.70 91.99 64.

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