Pages 1--62

Serving: Grand Rapids, Michigan Area
Enrollment in this Plan is limited; see page 6 for requirements.

Enrollment codes for this Plan:
RL1 Self Only RL2 Self and Family

RI 73-567

GVHP has a 4 star, excellent
accreditation from the NCQA. See the 2003 Guide for more information on

NCQA.

For changes in benefits
see page 7. 1.
1 Page 2 3
Dear Federal Employees Health Benefits Program Participant:
I am pleased to present this Federal Employees Health Benefits (FEHB) Program plan brochure for 2003. The brochure explains all the benefits this health plan offers to its enrollees. Since
benefits can vary from year to year, you should review your plan's brochure every Open Season. Fundamentally, I believe that FEHB participants are wise enough to determine the care
options best suited for themselves and their families.
In keeping with the President's health care agenda, we remain committed to providing FEHB members with affordable, quality health care choices. Our strategy to maintain quality and cost
this year rested on four initiatives. First, I met with FEHB carriers and challenged them to contain costs, maintain quality, and keep the FEHB Program a model of consumer choice and
on the cutting edge of employer-provided health benefits. I asked the plans for their best ideas to help hold down premiums and promote quality. And, I encouraged them to explore all
reasonable options to constrain premium increases while maintaining a benefits program that is highly valued by our employees and retirees, as well as attractive to prospective Federal
employees. Second, I met with our own FEHB negotiating team here at OPM and I challenged them to conduct tough negotiations on your behalf. Third, OPM initiated a comprehensive
outside audit to review the potential costs of federal and state mandates over the past decade, so that this agency is better prepared to tell you, the Congress and others the true cost of mandated
services. Fourth, we have maintained a respectful and full engagement with the OPM Inspector General (IG) and have supported all of his efforts to investigate fraud and waste within the
FEHB and other programs. Positive relations with the IG are essential and I am proud of our strong relationship.

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

Sincerely,

Kay Coles James Director 2.
2 Page 3 4
Notice of the Office of Personnel Management's
Privacy Practices

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

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

criminal actions, and Where required by law.

OPM has the right to use and give out your personal medical information to administer the FEHB Program. For example:
To communicate with your FEHB health plan when you or someone you have authorized
to act on your behalf asks for our assistance regarding a benefit or customer service issue. To review, make a decision, or litigate your disputed claim.

For OPM and the General Accounting Office when conducting audits.
OPM may use or give out your personal medical information for the following purposes under limited circumstances:

For Government healthcare oversight activities (such as fraud and abuse investigations),
For research studies that meet all privacy law requirements (such as for medical research or
education), and To avoid a serious and imminent threat to health or safety.

By law, OPM must have your written permission (an "authorization") to use or give out your personal medical information for any purpose that is not set out in this notice. You may take back 3.
3 Page 4 5
(" revoke") your written permission at any time, except if OPM has already acted based on your permission.
By law, you have the right to:
See and get a copy of your personal medical information held by OPM.
Amend any of your personal medical information created by OPM if you believe that it is
wrong or if information is missing, and OPM agrees. If OPM disagrees, you may have a statement of your disagreement added to your personal medical information.

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

that was given out for law enforcement purposes or to pay for your health care or a disputed claim.
Ask OPM to communicate with you in a different manner or at a different place (for
example, by sending materials to a P. O. Box instead of your home address). 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 Grand Valley Health Plan 1 Introduction/ Plain Language/ Advisory
Table of Contents
Introduction ...................................................................................................................................................................................... 3
Plain Language.................................................................................................................................................................................. 3
Stop Health Care Fraud .................................................................................................................................................................. 4
Section 1. Facts about this HMO plan ......................................................................................................................................... 5
How we pay providers ................................................................................................................................................. 5
Your Rights.................................................................................................................................................................... 5
Service Area................................................................................................................................................................... 6
Section 2. How we change for 2003............................................................................................................................................. 7
Program-wide changes................................................................................................................................................. 7
Changes to this Plan ..................................................................................................................................................... 7
Section 3. How you get care ... .................................................................................................................................... 8
Identification cards....................................................................................................................................................... 8
Where you get covered care........................................................................................................................................ 8

Plan providers......................................................................................................................................................... 8
Plan facilities .......................................................................................................................................................... 8
What you must do to get covered care ...................................................................................................................... 8

Primary care ............................................................................................................................................................ 8
Specialty care ......................................................................................................................................................... 8
Hospital care ........................................................................................................................................................... 9
Circumstances beyond our control........................................................................................................................... 10
Services requiring our prior approval...................................................................................................................... 10
Section 4. Your costs for covered services................................................................................................................................ 11

Copayments .......................................................................................................................................................... 11
Deductible ............................................................................................................................................................. 11
Coinsurance.......................................................................................................................................................... 11
Your out-of-pocket maximum.................................................................................................................................. 11
Section 5. Benefits....................................................................... 12
Overview...................................................................................................................................................................... 12
(a) Medical services and supplies provided by physicians and other health care professionals ............. 13
(b) Surgical and anesthesia services provided by physicians and other health care professionals ......... 23
(c) Services provided by a hospital or other facility, and ambulance services........................................... 27
(d) Emergency services/ accidents ...................................................................................................................... 30
(e) Mental health and substance abuse benefits............................................................................................... 32
(f) Prescription drug benefits.............................................................................................................................. 34
(g) Special features ............................................................................................................................................... 36
Flexible Benefits Option 5.
5 Page 6 7
2003 Grand Valley Health Plan 2 Introduction/ Plain Language/ Advisory
24 Hour Nurse/ Provider Line
(h) Dental benefits................................................................................................................................................. 37
(i) Non-FEHB benefits available to Plan members ........................................................................................ 38
Section 6. General exclusions --things we don't cover......................................................................................................... 39
Section 7. Filing a claim for covered services .......................................................................................................................... 40
Section 8. The disputed claims process..................................................................................................................................... 41
Section 9. Coordinating benefits with other coverage............................................................................................................. 43
When you have other health coverage

What is Medicare ............................................................................................................................................... 43
Medicare managed care .................................................................................................................................... 46
TRICARE and CHAMPVA/ Workers' Compensation/ Medicaid ....................................................................... 46
Other Government agencies...................................................................................................................................... 47
When others are responsible for injuries ................................................................................................................ 47
Section 10. Definitions of terms we use in this brochure ....................................................................................................... 48
Section 11. FEHB facts................................................................................................................................................................. 50
Coverage information................................................................................................................................................. 50
No pre -existing condition limitation ................................................................................................................ 50
Where you get information about enrolling in the FEHB Program............................................................ 50
Types of coverage available for you and your family ................................................................................... 50
Children's Equity Act ............................................................................................................................................... 50

When benefits and premiums start.................................................................................................................... 52
When you retire................................................................................................................................................... 52
When you lose benefits.............................................................................................................................................. 52

When FEHB coverage ends............................................................................................................................... 52
Spouse equity coverage ..................................................................................................................................... 52
Temporary Continuation of Coverage (TCC)................................................................................................ 52
Converting to individual coverage................................................................................................................... 52
Getting a Certificate of Group Health Plan Coverage.................................................................................. 53
Long term care is still available ................................................................................................................................................... 54
Index .................................................................................................................................................................................... 55
Summary of benefits ...................................................................................................................................................................... 57
Rates .................................................................................................................................................................... Back cover 6.
6 Page 7 8
2003 Grand Valley Health Plan 3 Introduction/ Plain Language/ Advisory
Introduction
This brochure describes the benefits of Grand Valley Health Plan under our contract (CS 2632) with the Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. The address for Grand
Valley Health Plan administrative offices is:
Grand Valley Health Plan
829 Forest Hill Ave., SE Grand Rapids, MI 49546

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 7. Rates are shown at the end of this brochure.

Plain Language
All FEHB brochures are written in plain language to make them responsive, accessible, and understandable to the
public. For instance,

Except for necessary technical terms, we use common words. For instance, "you" means the enrollee or family
member; "we" means Grand Valley Health Plan.

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 us know. Visit OPM's
"Rate Us" feedback area at www. opm. gov/ insure or e-mail us at fehbwebcomments@ opm. gov. You may also write to OPM at the Office of Personnel Management, Office of Insurance Planning and Evaluation Divis ion, 1900 E Street,

NW, Washington, DC 20415-3650. 7.
7 Page 8 9
2003 Grand Valley Health Plan 4 Introduction/ Plain Language/ Advisory
Stop Health Care Fraud!
Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits (FEHB)
Program premium

OPM's Office of Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program
regardless of the agency that employs you or from which you retired.

Protect Yourself From Fraud Here are some things you can do to prevent fraud:
Be wary of giving your plan identification (ID) number over the telephone or to people you do not know, except to your doctor, other provider, or authorized plan or OPM representative.
Let only the appropriate medical professionals review your medical record or recommend services.
Avoid using health care providers who say that an item or service is not usually covered, but they know how to bill us to get it paid.

Carefully review explanations of benefits (EOBs) that you receive from us.
Do not ask your doctor to make false entries on certificates, bills or records in order to get us to pay for an item or service.

If you suspect that a provider has charged you for services you did not receive, billed you twice for the same
service, or misrepresented any information, do the following:
Call the provider and ask for an explanation. There may be an error.
If the provider does not resolve the matter, call us at 616/ 949-2410 and explain the situation.
If we do not resolve the issue:

Do not maintain as a family member on your policy:
your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise); or
your child over age 22 (unless he/ she is disabled and incapable of self support).
If you have any questions about the eligibility of a dependent, check with your personnel office if you are employed or with OPM if you are retired.

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

CALL --THE HEALTH CARE FRAUD HOTLINE 202-418-3300
OR WRITE TO: The United States Office of Personnel Management
Office of the Inspector General Fraud Hotline 1900 E Street, NW, Room 6400
Washington, DC 20415 8.
8 Page 9 10
2003 Grand Valley Health Plan 5 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, and coinsurance described in this brochure. When you receive emergency services from non-Plan
providers, you may have to submit claim forms.

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

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

Your Rights
OPM requires that all FEHB Plans provide certain information to their FEHB members. You may get information about us, our networks, providers, and facilities. OPM's FEHB website (www. opm. gov/ insure) lists the specific types
of information that we must make available to you. Some of the required information is listed below.
Grand Valley Health Plan is a Staff Model Health Maintenance Organization (HMO) that provides a wide variety of
primary medical services at its health centers. In addition to health care providers (such as physicians, physician assistants, nurse practitioners, clinical social workers, and registered dieticians), lab, and pharmacy services are

conveniently located at each health center. The Plan also arranges and covers care through specialists, hospitals and
other health care professionals. Different family members may see different primary care providers at their health center. Women who wish to see a Plan Gynecologist for their annual routine examination should contact their Health

Center to obtain a list of Plan providers.
We are a for-profit plan that has been in existence since 1982.
If you want more information regarding case management practices, staff provider credentials, contracted provider credentials, and health center and other facility information, call 616/ 949-2410, or write to Grand Valley Health Plan,
829 Forest Hill Ave., SE, Grand Rapids, MI 49546. You may also contact us by fax at 616/ 949-4978 or visit our
website at www. gvhp. com. 9.
9 Page 10 11
2003 Grand Valley Health Plan 6 Section 1
Service Area
To enroll with us and maintain membership, you must live or work in our service area. This is where our providers practice. Our service area is:

All of Kent County and portions of Allegan, Ionia, and Ottawa Counties defined by the following zip codes:
Allegan County --49311, 49323, 49355, and 49348
Ionia County --48815
Ottawa County --49401, 49403, 49404, 49426, 49427, 49428, 49430, and 49435.
Ordinarily, you must get your care from providers who staffed or contracted with us. If you receive care outside our service area, we will pay only for emergency care. We will not pay for any other health care services out of our
service area unless the services have prior plan approval.
If you or a covered family member moves outside of our service area, you must enroll in another plan within 30 days of this move. If your dependents live out of the area (for example, if your child goes to college in another state), you
should consider enrolling in a fee-for-service plan or an HMO that has agreements with affiliates in other areas. If you or a family member moves, you do not have to wait until Open Season to change plans. Contact your employing
or retirement office. 10.
10 Page 11 12
2003 Grand Valley Health Plan 7 Section 2
Section 2. How we change for 2003
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5
Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here is a clarification that does not change benefits.

Program-wide changes
A Notice of the Office of Personnel Management's Privacy Practices is included.
A section on the Children's Equity Act describes when an employee is required to maintain Self and Family coverage.

Program information on TRICARE and CHAMPVA explains how annuitants or former spouses may suspend their FEHB Program enrollment.
Program information on Medicare is revised.
By law, the DoD/ FEHB Demonstration project ends on December 31, 2002.

Changes to this Plan
Your share of the non-Postal premium will increase by 15.1% for Self Only or 21.8 % for Self and Family.
Allergy Serum is now limited up to a maximum of $500 per member per contract year.
Hearing testing, treatment, and supplies are now covered. Audiometric exam and evaluation is covered up to $100 per exam. Hearing Aid provided once every 36 months, up to $700 per ear. Basic models only.

Foot orthotics copay will increase from zero to 50% of the charges.
Cochlear implants are no longer covered 11.
11 Page 12 13
2003 Grand Valley Health Plan 8 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 (616) 949-2410.

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 Grand Valley Health Plan is a Staff Model Health Maintenance Organization (HMO) that provides a wide variety of primary medical services at its health
centers. In addition to health care providers (such as physicians, physician assistants, nurse practitioners, clinical social workers, and registered dieticians),
lab, and pharmacy services are conveniently located at each health center. The
Plan also arranges and covers care through specialists, hospitals and other health care professionals. Different family members may see different primary care

providers at their health center. Women who wish to see a Plan Gynecologist for their annual routine examination should contact their Health Center to obtain
a list of Plan providers.

We list Plan providers in the provider directory, which we update periodically. The list is also on our website.

Plan facilities Plan facilities are our Health Centers, or 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.

It depends on the type of care you need. First, you and each family member must choose a Health Center. This decision is important since your Health
Center provides or arranges for most of your health care. You choose your Health Center when you enroll in the plan.

Primary care Primary Care Providers at your Health Center are Family Practice Physicians, Physicians Assistants and Nurse Practitioners. These Primary Care Providers
will provide most of your health care, or give you a referral to see a specialist.
If you want to change Health Centers, call us. We will help you select a new one.

Specialty care Except in a medical emergency, you must receive a referral from your primary care doctor before seeing any other doctor or obtaining special services. 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. 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.

Here are other things you should know about specialty care:

What you must do
to get covered care 12.
12 Page 13 14
2003 Grand Valley Health Plan 9 Section 3
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 and authorization that allows you to see your specialist for a
certain number of visits. Your primary care physician will use our criteria when creating your treatment plan. All visits to specialists must first be

arranged and authorized by your primary care physician. Authorizations
will be made for the adequate number of visits under an approved treatment plan. Any visits beyond that which is stated in the treatment plan will not be

covered unless further authorization is obtained from your GVHP Primary
Care Provider.

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 they decide to refer you to a specialist, ask if you can

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

Plan.

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

If you have a chronic or disabling condition and lose access to your specialist because we:

-terminate our contract with your specialist for other than cause; or
-drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB Plan; or

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

Hospital care Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled
nursing or other type of facility.
If you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at (616) 949-2410. 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 13.
13 Page 14 15
2003 Grand Valley Health Plan 10 Section 3
The day your benefits from your former plan run out; or
The 92 nd day after you become a member of this Plan, whichever happens first.

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

Services requiring our Your primary care physician has authority to refer you for most prior approval services. For certain services, however, your physician must obtain approval
from us. Before giving approval, we consider if the service is covered,
medically necessary, and follows generally accepted medical practice.

We call this the Medical Opinion Review process. The Medical Opinion Review team, headed by the Vice President of Medical Affairs, will review all
information pertaining to the requested services. The team will review factors
such as whether the service is a covered benefit, medically necessary, or experimental, to make this decision.

If we deny the service, you have the right to pursue resolution through the disputed claims process (see Section 8). 14.
14 Page 15 16
2003 Grand Valley Health Plan 11 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay to the provider, facility,
pharmacy, etc., when you receive services.

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

Deductible We do not have a deductible

Coinsurance Coinsurance is the percentage of our negotiated fee that you must pay for your care.
Example: In our Plan, you pay 50% of our allowance for fertility drugs and growth hormone.

Your catastrophic protection out-of-pocket maximum We do not have an out-of-pocket maximum. 15.
15 Page 16 17
2003 Grand Valley Health Plan 12 Section 5
Section 5. Benefits --OVERVIEW
(See page 7 for how our benefits changed this year and page 66 for a benefits summary.)

NOTE: This benefits section is divided into subsections. Please read the important things you should keep in mind at the beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the
following subsections. To obtain claims filing advice, or more information about our benefits, contact us at (616) 949-2410.

(a) Medical services and supplies provided by physicians and other health care professionals ........................................... 13-22
Diagnostic and treatment services
Lab, X-ray, and other diagnostic tests
Preventive care, adult
Preventive care, children
Maternity care
Family planning
Infertility services
Allergy care
Treatment therapies
Physical and occupational therapies

Speech therapy
Hearing services (testing, treatment, and supplies)

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

(b) Surgical and anesthesia services provided by physicians and other health care professionals ........................... 23-26
Surgical procedures
Reconstructive surgery
Oral and maxillofacial surgery
Organ/ tissue transplants
Anesthesia

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

Hospice care
Ambulance

(d) Emergency services/ accidents ................................................................................................................................ 30-31
Medical emergency Ambulance

(e) Mental health and substance abuse benefits......................................................................................................... 32-33
(f) Prescription drug benefits................................................................................................................................................ 34-35
(g) Special features ....................................................................................................................................................................... 36
Flexible benefits option

24 Hour Nurse/ Provider Line

(h) Dental benefits......................................................................................................................................................................... 37
(i) Non-FEHB benefits available to Plan members ................................................................................................................ 38

Summary of benefits ...................................................................................................................................................................... 57 16.
16 Page 17 18
2003 Grand Valley Health Plan 13 Section 5( a)
Section 5 (a) Medical services and supplies provided by physicians and other health care professionals
I M
P O
R T
A N
T

Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
Plan physicians must provide or arrange your care.
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
At the GVHP Urgent Care Center

Office medical consultations

Second surgical opinion

$10 per office visit

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

Nothing

At home Nothing
Diagnostic and treatment services --Continued on next page 17.
17 Page 18 19
2003 Grand Valley Health Plan 14 Section 5( a)
Lab, X-ray and other diagnostic tests
Laboratory tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG

Nothing

Preventive care, adult
Routine screenings, such as: Routine Examinations, Physicals
Total Blood Cholesterol once every three years
Colorectal Cancer Screening, including

-Fecal occult blood test
-Sigmoidoscopy, screening every five years starting at age 50 Prostate Specific Antigen (PSA) test) one annually for men age 40 and

older
Routine pap test

$10 per office visit

Routine mammogram covered for women age 35 and older, as follows:
From age 35 through 39, one during this five year period
From age 40 through 64, one every calendar year
At age 65 and older, one every two consecutive calendar years

Routine Immunizations, limited to:
Tetanus-diphtheria (Td) booster once every 10 years, ages19 and over (except as provided for under Childhood immunizations)

Influenza/ Pneumococcal vaccines, annually, age 65 and over
Not covered: Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, or travel. All charges. 18.
18 Page 19 20
2003 Grand Valley Health Plan 15 Section 5( a)
Preventive care, children You pay
Childhood immunizations recommended by the American Academy of Pediatrics $10 per office visit

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

$10 per office visit

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

Delivery
Note: Here are some things to keep in mind:
You do not need to pre-certify your normal delivery; see page 9 for other circumstances, such as extended stays for you or your baby.

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

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

benefits (Section 5b).

Nothing

Not covered: Routine sonograms to determine fetal age, size or sex All charges 19.
19 Page 20 21
2003 Grand Valley Health Plan 16 Section 5( a)
Family planning
A range of voluntary family planning services, limited to:
Voluntary sterilization (See Surgical procedures Section 5 (b))
Surgically implanted contraceptives )
Injectable contraceptive drugs (such as Depo provera)
Intrauterine devices (IUDs)
Diaphragms
NOTE: We cover oral contraceptives under the prescription drug benefit.

$10 per office visit

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

Infertility services You pay
Diagnosis and treatment of infertility, such as:
Artificial insemination:

-intrauterine insemination (IUI)

$10 per visit

Fertility drugs
Note: Please see Section 5 (f) Prescription drug benefits

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

-in vitro fertilization
-embryo transfer and GIFT
-Zygote transfer
Services and supplies related to excluded ART procedures

Cost of donor sperm
Cost of donor egg

All charges. 20.
20 Page 21 22
2003 Grand Valley Health Plan 17 Section 5( a)
Allergy care
Testing and treatment
Allergy injection
$10 per office visit; nothing for allergy injections

Allergy serum, covered up to $500 per member per contract year Nothing
Not covered: provocative food testing and sublingual allergy desensitization All charges.

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 25.
Respiratory and inhalation therapy
Dialysis Hemodialysis and peritoneal dialysis
Intravenous (IV)/ Infusion Therapy Home IV and antibiotic therapy

$10 per visit

Growth hormone therapy (GHT)
Note: We cover Growth Hormone under the Prescription drug benefit
Note: We will only cover GHT when we preauthorize the treatment. Call your health center for preauthorization. We will ask you to submit
information that establishes that the GHT is medically necessary. Ask us to
authorize GHT before you begin treatment; otherwise, we will only cover GHT services from the date you submit the information. If you do not ask

or if we determine GHT is not medically necessary, we will not cover the
GHT or related services and supplies. See Services requiring our prior approval in Section 3.

$10 per visit 21.
21 Page 22 23
2003 Grand Valley Health Plan 18 Section 5( a)
Physical and occupational therapies
Covered for up to two consecutive months per condition this language was deleted in 2001; shouldn't have appeared in last year's brochure.

-qualified physical therapists and -occupational therapists.

Note: We only cover therapy to restore bodily function when there has been a total or partial loss of bodily function due to illness or injury.
Cardiac rehabilitation following a heart transplant, bypass surgery or a
myocardial infarction, is provided for up to two months per condition.

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

Not covered:
long-term rehabilitative therapy
exercise programs

All charges.

Speech therapy
Covered for up to two consecutive months per condition Same as above $10 per outpatient visit
Nothing per visit during covered inpatient admission

Not covered:
Exercise programs
All charges. 22.
22 Page 23 24
2003 Grand Valley Health Plan 19 Section 5( a)
Hearing services (testing, treatment, and supplies)
Audiometric exam and evaluation covered up to $100 per exam. Hearing Aid provided once every 36 months, up to $700 per ear.
Basic models only.
Hearing testing for children through age 17 (see Preventive care, children)

$10 per visit

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

All charges.

Vision services (testing, treatment, and supplies) You pay
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)

Annual eye refractions

$10 per visit

Not covered:
Eyeglasses or contact lenses and, after age 17, examinations for them

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 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. 23.
23 Page 24 25
2003 Grand Valley Health Plan 20 Section 5( a)
Orthopedic and prosthetic devices You pay
Artificial limbs and eyes; stump hose
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 devices for the non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.

Nothing

Foot orthotics 50% of charges
Not covered:
orthopedic and corrective shoes
arch supports
heel pads and heel cups
lumbosacral supports
corsets, trusses, elastic stockings, support hose, and other supportive
devices

cochlear implants

All charges.

Durable medical equipment (DME)
Rental or purchase, at our option, including repair and adjustment, of durable medical equipment prescribed by your Plan physician, such as
oxygen and dialysis equipment. Under this benefit, we also cover:
hospital beds;
wheelchairs;
crutches;
walkers;
motorized wheelchairs when medically necessary
blood glucose monitors; and
insulin pumps.

Nothing

Not covered:
luxury or deluxe items, such as bath tub seats, reachers, raised
toilet seat
devices, braces used to affect performance in sport related activities

All charges. 24.
24 Page 25 26
2003 Grand Valley Health Plan 21 Section 5( a)
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, rehabilitative

All charges.

Chiropractic and Alternative Integrative Holistic Health
Acupuncture, chiropractic, and therapeutic massage services are covered up to a combined level of 20 visits per contract year, contingent
upon assessment and authorization within the Integrative Holistic Health Program.
$10 per visit

Not covered:
naturopathic services
hypnotherapy
biofeedback

All charges. 25.
25 Page 26 27
2003 Grand Valley Health Plan 22 Section 5( a)
Educational classes and programs You pay
Population Based Programs: Any members who fall into the following categories can participate in the appropriate program

Diabetes Program
Asthma Program
Depression Program
Congestive Heart Failure Program
Obstetrical Program

$10 copay for visits with practitioners, $5 copay for
prescription drugs, you pay
nothing for obstetrical visits

Health Education Classes: Classes are free to members. A minimal charge for
materials may be required for some classes.
Intuitive Eating: This 8-10 class series will help you say good-bye to dieting forever. Learn to make peace with food while honoring

healthful eating. Start developing a healthier relationship with food
and your body now!
Managing your Cholesterol: A Registered Dietitian will help you evaluate you overall risk, interpret cholesterol numbers, and suggest

ways to eat healthier and fit exercise into you life.
Practical Stress Management: This 2 session class is designed to help you handle stress overloads that often happen in daily life. Situations

from home to work and families to co-workers will be covered. You will learn a number of different methods to help you cope and take
control.
Asthma Classes: Learn and discuss: "What is asthma?," "What causes asthma?," "Medications used to treat asthma," and "How to get

asthma under control."
Back Education: Got back pain? Learn correct body mechanics, appropriate exercises and stretching techniques.

Tobacco Free for Good: This class, consisting of 7 sessions, is
designed to help tobacco users deal with triggers, withdrawal symptoms, daily stress and weight control.

Prepared Childbirth Classes: This 5 class series prepares both the
mother and her coach for a special, shared birth experience. Topics include labor and delivery, hospital procedures, breast and

bottle feeding and much more. The classes also include practice
sessions in breathing and relaxation techniques. Refresher Childbirth Classes are available as well.

Breast Feeding Classes: This 1 session class offers information and support to foster a positive breastfeeding experience. Before
your baby arrives, learn the "how-to's" of breast feeding and how to avoid common difficulties.

Nothing 26.
26 Page 27 28
2003 Grand Valley Health Plan 23 Section 5( b)
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
I M
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A N
T

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

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

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

$10 per office visit; nothing for surgical center or hospital visits

Surgical procedures continued on next page. 27.
27 Page 28 29
2003 Grand Valley Health Plan 24 Section 5( b)
Surgical procedures (Continued) You pay
Voluntary sterilization (i. e., 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.

$10 per office visit; nothing for surgical center or hospital visits

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

All charges.

Reconstructive surgery
Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if:

-the condition produced a major effect on the member's appearance and

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

Nothing

All stages of breast reconstruction surgery following a mastectomy,
such as:

-surgery to produce a symmetrical appearance on the other breast;

-treatment of any physical complications, such as lymph edemas;
-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 28.
28 Page 29 30
2003 Grand Valley Health Plan 25 Section 5( b)
Oral and maxillofacial surgery
Oral surgical procedures, limited to:
Reduction of fractures of the jaws or facial bones;
Surgical correction of cleft lip, cleft palate or severe functional malocclusion;

Removal of stones from salivary ducts;
Excision of leukoplakia or malignancies;
Excision of cysts and incision of abscesses when done as independent procedures; and

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

$10 per office visit

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. 29.
29 Page 30 31
2003 Grand Valley Health Plan 26 Section 5( b)
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: 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
National Transplant Program (NTP)
Limited Benefits -Treatment for breast cancer, multiple myeloma, and
epithelial ovarian cancer may be provided in an NCI-or NIH-approved clinical trial at a Plan-designated center of excellence and if approved

by the Plan's medical director in accordance with the Plan's protocols.

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

Nothing

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 You pay
Professional services provided in

Hospital (inpatient)
Hospital outpatient department
Skilled nursing facility
Ambulatory Surgical Center
Office

Nothing 30.
30 Page 31 32
2003 Grand Valley Health Plan 27 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
I M
P O
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A N
T

Here are some important things to remember about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are
medically necessary.
Plan physicians must provide or arrange your care and you must be hospitalized in a Plan facility.

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

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

I M
P O
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T

Benefit Description You pay
Inpatient hospital
Room and board, such as
ward, semiprivate, or intensive care accommodations;
general nursing care; and
meals and special diets.

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. 31.
31 Page 32 33
2003 Grand Valley Health Plan 28 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, if not donated or replaced
Dressings, splints, casts, and sterile tray services
Medical supplies and equipment, including oxygen
Anesthetics, including nurse anesthetist services
Medical supplies, appliances, medical equipment, and any covered
items billed by a hospital for use at home

Nothing

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

All charges.

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

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

Nothing

Extended care benefits/ skilled nursing care facility benefits You pay
Extended care benefit: We provide a comprehensive range of benefits for up to 45 days per member in a contract year with no dollar limit
when full-time skilled nursing care is necessary and confinement in a
skilled nursing facility is medically appropriate as determined by a Plan doctor. We cover all necessary services including:

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

prescribed by a Plan doctor.

Nothing

Not covered: custodial care All charges 32.
32 Page 33 34
2003 Grand Valley Health Plan 29 Section 5( c)
Hospice care
We cover supportive and palliative care for a terminally ill member 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 participating professional ambulance service when medically appropriate Nothing 33.
33 Page 34 35
2003 Grand Valley Health Plan 30 Section 5( d)
Section 5 (d). Emergency services/ accidents
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.

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

I M
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A N
T
What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe
endangers your life or could result in serious injury or disability, and requires immediate medical or surgical care. Some problems are emergencies because, if not treated promptly, they might become more

serious; examples include deep cuts and broken bones. Others are emergencies because they are
potentially life-threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or sudden inability to breathe. There are many other acute conditions that we may determine are medical emergencies what

they all have in common is the need for quick action.

What to do in case of emergency:
Emergencies within our service area: If you are in an emergency situation, please call your primary care doctor. In extreme emergencies, if you are unable to contact your doctor, contact the local emergency system
(e. g., the 911 telephone system) or go to the nearest hospital emergency room. Be sure to tell the emergency room personnel that you are a Plan member so they can notify the Plan. You or a family member should notify the Plan
within 48 hours. It is your responsibility to ensure that the Plan has been timely notified.
If you need to be hospitalized, the Plan must be notified within 48 hours or on the first working day following your admission, unless it was not reasonably possible to notify the Plan within that time. 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 within 48 hours or on the first working day following your admission, unless it was not reasonably possible to notify the Plan within that time. 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. 34.
34 Page 35 36
2003 Grand Valley Health Plan 31 Section 5( d)
Benefit Description You pay
Emergency within our service area

Emergency care at a Grand Valley Health Plan doctor's office
Emergency care at a Grand Valley Health Plan urgent care center
$10 per visit

Emergency care at a non-Grand Valley Health Plan urgent care center or doctor's office $25 per visit
Emergency care at a hospital, including doctors' services
Note: If emergency results in admission to a hospital, we waive the
emergency room copay.

$50 per visit

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

Emergency care at an urgent care center or doctor's office $25 per visit

Emergency care at a hospital, including doctors' services
Note: If emergency results in admis sion to a hospital, we waive the
emergency room copay.

$50 per visit

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

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

All charges.

Ambulance
Professional participating ambulance service in the service area when
medically appropriate.
Nothing

Professional ambulance service outside the service area when medically
appropriate

See 5( c) for non-emergency service.

$50 per service 35.
35 Page 36 37
2002 Grand Valley Health Plan 32 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
I M
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A N
T

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

conditions.

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

Medication management

$10 per visit

Mental health and substance abuse benefits -continued on next page 36.
36 Page 37 38
2002 Grand Valley Health Plan 33 Section 5( e)
Mental health and substance abuse benefits (continued) You pay
Diagnostic tests $10 per visit

Services provided by a hospital or other facility
Services in approved alternative care settings such as partial
hospitalization, residential treatment, full-day hospitalization, facility
based intensive outpatient treatment

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 follow your treatment plan and all the following authorization processes:
Please contact your Grand Valley Health Plan health center for services.

Limitation We may limit your benefits if you do not obtain a treatment plan. 37.
37 Page 38 39
2003 Grand Valley Health Plan 34 Section 5( f)
Section 5 (f). Prescription drug benefits
I M
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A N
T

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

All benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically
necessary.
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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A N
T
There are important features you should be aware of. These include:
Who can write your prescription. A licensed practitioner must write the prescription
Where you can obtain them. You must fill the prescription at a plan pharmacy, or by mail for a maintenance medication

These are the dispensing limitations. All prescriptions will be filled at a 30 day supply unless noted on approved 90-day drug list
A generic equivalent will be dispensed if it is available, unless your physician specifically requires a name brand. If you receive a name brand drug when a Federally-approved generic drug is available,
and your physician has not specified Dispense as Written for the name brand drug, you have to pay the
difference in cost between the name brand drug and the generic, plus the copay amount.

Why us Generic Drugs. Generic drugs contain the same active ingredients and are equivalent in strength and dosage to the original brand name product. Generic drugs cost you and your plan less

money than a name-brand drug.

Prescription drug benefits begin on the next page. 38.
38 Page 39 40
2003 Grand Valley Health Plan 35 Section 5( f)
Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan physician and obtained from a Plan pharmacy or through our mail order
program:

Drugs and medicines that by Federal law of the United States require a physician's prescription for their purchase, except those
listed as Not covered.
Insulin
Disposable needles and syringes for the administration of covered
medications

Diabetes supplies, including insulin syringes, needles, glucose test tablets and test tape

Drugs for sexual dysfunction
Contraceptive drugs and devices

$5 per prescription, you pay nothing for supplies

Fertility Drugs
Growth Hormone
50% of charges

Not covered:
Drugs and supplies for cosmetic purposes
Vitamins and nutritional supplements that can be administered without a prescription

Drugs to enhance athletic performance
Drugs obtained at a non-Plan pharmacy; except for out-of-area emergencies

Nonprescription medicines
Smoking Cessation drugs and medication, including nicotine patches
Medications for Travel

All charges. 39.
39 Page 40 41
2003 Grand Valley Health Plan 36 Section 5( g)
Section 5 (g). Special features
Feature Description

Flexible benefits option Under the flexible benefits option, we determine the most effective way to provide services.
We may identify medically appropriate alternatives to traditional
care and coordinate other benefits as a less costly alternative benefit.

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

The decision to offer an alternative benefit is solely ours, and we may withdraw it at any time and resume regular contract benefits.
Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process.

24 hour nurse/ provider line For any of your health concerns, 24 hours a day, 7 days a week, you may call your Health Center number, and talk with a provider who will discuss treatment options and answer your health questions. The
Health Center phone numbers are listed below.
Beckwith Health Center (616) 224-1515
Cascade Health Center (616) 949-6003 Jenison Health Center (616) 457-3830

Kentwood Health Center (616) 534-8323
Rockford Health Center (616) 866-9568 Walker Health Center (616) 784-4717

Wyoming Health Center (616) 532-1100 40.
40 Page 41 42
2003 Grand Valley Health Plan 37 Section 5( h)
Section 5 (h). Dental benefits
I M
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A N
T

Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure 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 non-dental physical impairment exists which makes hospitalization necessary to safeguard the health of the patient; we do not

cover the dental procedure unless it is described below.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage,

including with Medicare.

I M
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T
Accidental injury benefit You pay

We cover restorative services and supplies necessary to promptly repair (but not replace) sound natural teeth. The need for these services must

result from an accidental injury.
$10 per office visit

Dental benefits
We cover the following dental services when provided by participating Plan dentists:

Oral exam; two in 12 months
Prophylaxis (cleaning); two in 12 months
Topical applications of fluoride to age 19
Oral cancer exam
Study models
Emergency services and supplies necessary to promptly relieve pain

Nothing 41.
41 Page 42 43
2003 Grand Valley Health Plan 38 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.

Expanded Dental Care
Basic services are covered at 50% after an annual deductible of $50.00 per person (maximum of three deductibles per family). Coverage would include fillings, root canals, X-rays, periodontic

services and oral surgery. Maximum benefit of $500.00 per member per year.

Expanded Vision Care
Discounts are available through SVS Shoppes for Grand Valley Health Plan members. 42.
42 Page 43 44
2003 Grand Valley Health Plan 39 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 or condition.

We do not cover the following:
Care by non-Plan providers except for authorized referrals or emergencies (see Emergency Benefits);

Services, drugs, or supplies you receive while you are not enrolled in this Plan;
Services, drugs, or supplies that are not medically necessary;
Services, drugs, or supplies not required according to accepted standards of medical, dental, or
psychiatric practice;

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

incest
Services, drugs, or supplies related to sex transformations;
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program; or
Services, drugs, or supplies you receive without charge while in active military service. 43.
43 Page 44 45
2003 Grand Valley Health Plan 40 Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at
Plan pharmacies, you will not have to file claims. Just present your identification card and pay your copayment.

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

Medical, hospital and In most cases, providers and facilities file claims for you. Physicians drug 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 (616) 949-2410.

When you must file a claim --such as for out-of-area care --submit it on
the HCFA-1500 or a claim form that includes the information shown below. Bills and receipts should be itemized and show:

Covered member's name and ID number;
Name and address of the physician or facility that provided the service or supply;

Dates you received the services or supplies;
Diagnosis;
Type of each service or supply;
The charge for each service or supply;
A copy of the explanation of benefits, payments, or denial from any
primary payer --such as the Medicare Summary Notice (MSN); and

Receipts, if you paid for your services.

Submit your claims to: Grand Valley Health Plan
829 Forest Hill Ave., SE Grand Rapids, MI 49546

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. 44.
44 Page 45 46
2003 Grand Valley Health Plan 41 Section 8
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on
your claim or request for services, drugs, or supplies including a request for preauthorization:

Step Description
1 Ask us in writing to reconsider our initial decision. You must:
(a) Write to us within 6 months from the date of our decision; and
(b) Send your request to us at: Grand Valley Health Plan, 829 Forest Hill Ave. SE, Grand Rapids, MI 49546; and

(c) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure; and
(d) Include copies of documents that support your claim, such as physicians' letters, operative reports, bills,
medical records, and explanation of benefits (EOB) forms.

2 We have 30 days from the date we receive your request to:
(a) Pay the claim (or 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.

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

We will write to you with our decision.

4 If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
90 days after the date of our letter upholding our initial decision; or
120 days after you first wrote to us --if we did not answer that request in some way within 30 days; or
120 days after we asked for additional information.

Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Contracts Division 3, 1900 E Street, NW, Washington, DC 20415-3630 45.
45 Page 46 47
2003 Grand Valley Health Plan 42 Section 8
Send OPM the following information:
A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;

Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms;
Copies of all letters you sent to us about the claim;
Copies of all letters we sent to you about the claim; and
Your daytime phone number and the best time to call.
Note: If you want OPM to review different claims, you must clearly identify which documents apply to which claim.

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

5 OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct. OPM will send you a final decision within 60 days. There are no
other administrative appeals.

If you do not agree with OPM's decision, your only recourse is to sue. If you decide to sue, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received
the disputed services, drugs, or supplies, or from the year in which you were denied pre-certification or prior approval. This is the only deadline that may not be extended.

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

You may not sue until you have completed the disputed claims process. Further, Federal law governs your lawsuit, benefits, and payment of benefits. The Federal court will base its review on the record that was

before OPM when OPM decided to uphold or overturn our decision. You may recover only the amount of benefits in dispute.

NOTE: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and
(a) We haven't responded yet to your initial request for care or preauthorization/ prior approval, then call us at
616/ 949/ 2410 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. 46.
46 Page 47 48
2003 Grand Valley Health Plan 43 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
medical expenses without regard to fault. This is called "double
coverage."

When you have double coverage, one plan normally pays its benefits in
full as the primary payer and the other plan pays a reduced benefit as the secondary payer. We, like other insurers, determine which coverage is

primary according to the National Association of Insurance
Commissioners' guidelines.

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

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

What is Medicare? Medicare is a Health Insurance Program for:
People 65 years of age and older.
Some people with disabilities, under 65 years of age.
People with End-Stage Renal Disease (permanent kidney failure
requiring dialysis or a transplant).

Medicare has two parts:
Part A (Hospital Insurance). Most people do not have to pay for Part A. If you or your spouse worked for at least 10 years in

Medicare-covered employment, you should be able to qualify for
premium-free Part A insurance. (Someone who was a Federal employee on January 1, 1983 or since automatically qualifies.)

Otherwise, if you are age 65 or older, you may be able to buy it.
Contact 1-800-MEDICARE for more information.

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

Security check or your retirement check.

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

The Original Medicare Plan The Original Medicare Plan is available everywhere in the United States. It
(Part A or Part B) 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. Medicare pays its
share and you pay your share. Some things are not covered under Original Medicare, like prescription drugs. 47.
47 Page 48 49
2003 Grand Valley Health Plan 44 Section 9
When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care.
Your care must be authorized and coordinated by your health center team in order for you to be covered.

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 claim will be
coordinated automatically and we will then provide secondary
benefits for covered charges. You will not need to do anything. To find out if you need to do something to file your claim, call

us at 616/ 949-2410

We do not waive any costs if the Original Medicare Plan is your
primary payer.

[Primary payer chart begins on next page.) 48.
48 Page 49 50
2003 Grand Valley Health Plan 45 Section 9
The following chart illustrates whether the Original Medicare Plan or this Plan should be the primary payer for you according to your employment status and other factors determined by Medicare. It is critical that you tell us if you or
a covered family member has Medicare coverage so we can administer these requirements correctly.
Primary Payer Chart
Then the primary payer is A. When either you --or your covered spouse --are age 65 or over and

OriginalMedicare This Plan
1) Are anactiveemployeewith theFederalgovernment(including whenyouora familymemberare eligibleforMedicaresolely becauseofadisability),

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,

(exceptforclaims
relatedtoWorkers' 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 49.
49 Page 50 51
2003 Grand Valley Health Plan 46 Section 9
Medicare managed care If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare managed care plan. These are health
care choices (like HMOs) in some areas of the country. In most Medicare managed care plans, you can only go to doctors, specialists, or
hospitals that are part of the plan. Medicare managed care plans provide
all the benefits that Original Medicare covers. Some cover extras, like prescription drugs. To learn more about enrolling in a Medicare managed

care plan, contact Medicare at 1-800-MEDICARE (1-800-633-4227) or
at www. medicare. gov.

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

This Plan and another plan's Medicare managed care plan: You may
enroll in another plan's Medicare managed care plan and also remain enrolled in our FEHB plan. We will still provide benefits when your

Medicare managed care plan is primary, if you use our Plan providers,
but we will not waive any of our copayments, coinsurance, or deductibles. If you enroll in a Medicare managed care plan, tell us. We

will need to know whether you are in the Original Medicare Plan or in a
Medicare managed care plan so we can correctly coordinate benefits with Medicare.

Suspended FEHB coverage 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 service area.
If you do not enroll in Medicare Part A or Part B If you do not have one or both Parts of Medicare, you can still be covered
under the FEHB Program. We will not require you to enroll in Medicare Part B and, if you can't get premium-free Part A, we will not ask you to
enroll in it.
TRICARE and CHAMPVA TRICARE is the health care program for eligible dependents of military persons, and retirees of the military. TRICARE includes the CHAMPUS
program. CHAMPVA provides health coverage to disabled Veterans and their eligible dependents. If TRICARE or CHAMPVA and this Plan
cover you, we pay first. See your TRICARE or CHAMPVA Health
Benefits Advisor if you have questions about these programs.

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

premium. (OPM does not contribute to any applicable plan premiums.)
For information on suspending your FEHB enrollment, contact your retirement office. If you later want to re-enroll in the FEHB Program,

generally you may do so only at the next Open Season unless you
involuntarily lose coverage under the program.

Workers' Compensation We do not cover services that: 50.
50 Page 51 52
2003 Grand Valley Health Plan 47 Section 9
you need because of a workplace-related illness or injury that the Office of Workers' Compensation Programs (OWCP) or a similar
Federal or State agency determines they must provide; or

OWCP or a similar agency pays for through a third party injury settlement or other similar proceeding that is based on a claim you
filed under OWCP or similar laws.
Once OWCP or similar agency pays its maximum benefits for your
treatment, we will cover your care. You must use our providers.

Medicaid When you have this Plan and Medicaid, we pay first.

Suspended FEHB coverage to enroll in Medicaid or a similar State-sponsored program of medical assistance: If

you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in a one of these State programs,
eliminating your FEHB premium. For information on suspending your FEHB enrollment, contact your retirement
office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless
you involuntarily lose coverage under the State program.

When other Government agencies We do not cover services and supplies when a local, State,
are responsible for your care or Federal Government agency directly or indirectly pays for them.

When others are responsible When you receive money to compensate you for
for injuries medical or hospital care for injuries or illness caused by another person, you must reimburse us for any expenses we paid. However, we will

cover the cost of treatment that exceeds the amount you received in the
settlement.

If you do not seek damages you must agree to let us try. This is called
subrogation. If you need more information, contact us for our subrogation procedures. 51.
51 Page 52 53
2003 Grand Valley Health Plan 48 Section 10
Section 10. Definitions of terms we use in this brochure
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on
December 31 of the same year.
Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. See page 11.

Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 11.
Covered services Care we provide benefits for, as described in this brochure.
Custodial care Room and board, nursing care, and personal care designed to assist a person in the activities of daily living. Custodial care that lasts 90 days
or more is sometimes known as Long term care.
Deductible A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for
those services. See page 11.
Experimental or A procedure, drug, device or biological product is experimental or
investigational services investigational when: a. There is not sufficient outcome data available from

controlled clinical trials published in the peer reviewed
literature to substantiate its safety and effectiveness for the disease or injury involved, or:

b. Required FDA approval has not been granted for
marketing; or c. A recognized national medical or dental society or

regulatory agency has determined, in writing, that it is
experimental or for research purposes; or d. The written protocol( s) used by the treating facility or the

protocol( s) of any other facility studying substantially the
same drug, device, procedure or treatment or the written informed consent used by the treating facility or by another

facility studying the same drug, device, procedure or
treatment states that it is experimental or for research purposes; or it is not of proven benefit for the specific

diagnosis or treatment of a member's particular condition;
or e. It is not generally recognized by the medical community as

effective or appropriate for the specific diagnosis or
treatment of a member's particular condition; or it is provided or performed in special settings for research

purposes.
Medical necessity A service, procedure, treatment, supply or accommodation prescribed, ordered, supplied, authorized or provided to you, which has been
determined by your Health Center Team to be necessary for your general care and well being, and which is generally acceptable according to the
standards of medical practice. 52.
52 Page 53 54
2003 Grand Valley Health Plan 49 Section 10
Us/ We Us and we refer to Grand Valley Health Plan
You You refers to the enrollee and each covered family member. 53.
53 Page 54 55
2003 Grand Valley Health Plan 50 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.

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 54.
54 Page 55 56
2003 Grand Valley Health Plan 51 Section 11
to your employing office that you have obtained other health benefits coverage for your children. If you do not do so, your employing office will enroll you involuntarily as
follows:

If you have no FEHB coverage, your employing office will enroll you for Self and Family coverage in the option of the Blue Cross and Blue Shield Service Benefit
Plan's Basic Option;
if you have a Self Only enrollment in a fee-for-service plan or in an HMO that serves the area where your children live, your emp loying office will change your enrollment

to Self and Family in the same option of the same plan; or
if you are enrolled in an HMO that does not serve the area where the children live, your employing office will change your enrollment to Self and Family in the Blue

Cross and Blue Shield Service Benefit Plan's Basic Option.
As long as the court/ administrative order is in effect, and you have at least one child
identified in the order who is still eligible under the FEHB Program, you cannot cancel your enrollment, change to Self Only, or change to a plan that doesn't serve the area in

which your children live, unless you provide documentation that you have other coverage
for the children. If the court/ administrative order is still in effect when you retire, and you have at least one child still eligible for FEHB coverage, you must continue your

FEHB coverage into retirement (if eligible) and cannot make any changes after
retirement. Contact you employing office for further information. 55.
55 Page 56 57
2003 Grand Valley Health Plan 52 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 coverage (TCC) If you leave Federal service, or if you lose coverage because you no longer qualify as a family member, you may be eligible for Temporary Continuation of Coverage (TCC).

For example, you can receive TCC if you are not able to continue your FEHB enrollment
after you retire, if you lose your job, if you are a covered dependent child and you turn 22 or marry, etc.

You may not elect TCC if you are fired from your Federal job due to gross misconduct.
Enrolling in TCC. Get the RI 79-27, which describes TCC, and the RI 70-5, the Guide
to Federal Employees Health Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees, from your employing or retirement office or from

www. opm. gov/ insure. It explains what you have to do to enroll.

Converting to You may convert to a non-FEHB individual policy if: individual coverage

Your coverage under TCC or the spouse equity law ends. If you canceled your coverage or did not pay your premium, you cannot convert;
You decided not to receive coverage under TCC or the spouse equity law; or
You are not eligible for coverage under TCC or the spouse equity law. 56.
56 Page 57 58
2003 Grand Valley Health Plan 53 Section 11
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. Also, see 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. 57.
57 Page 58 59
2003 Grand Valley Health Plan 54 Index
Long Term Care Insurance Is Still Available!
Open Season for Long Term Care Insurance
You can protect yourself against the high cost of long term care by applying for insurance in the Federal Long Term Care Insurance Program.
Open Season to apply for long term care insurance through LTC Partners ends on December 31, 2002.
If you're a Federal employee, you and your spouse need only answer a few questions about your health during Open Season.

If you apply during the Open Season, your premiums are based on your age as of July 1, 2002. After Open Season, your premiums are based on your age at the time LTC Partners receives your application.

FEHB Doesn't Cover It
Neither FEHB plans nor Medicare cover the cost of long term care. Also called "custodial care", long term care helps you perform the activities of daily living such as bathing or dressing yourself. It can also provide
help you may need due to a severe cognitive impairment such as Alzheimer's disease.
You Can Also Apply Later, But
Employees and their spouses can still apply for coverage after the Federal Long Term Care Insurance Program Open Season ends, but they will have to answer more health-related questions.
For annuitants and other qualified relatives, the number of health-related questions that you need to answer is
the same during and after the Open Season.

You Must Act to Receive an Application

Unlike other benefit programs, YOU have to take action you won't receive an application automatically. You must request one through the toll-free number or website listed below.
Open Season ends December 31, 2002 act NOW so you won't miss the abbreviated underwriting available to employees and their spouses, and the July 1 "age freeze"!

Find Out More Contact LTC Partners by calling 1-800-LTC-FEDS (1-800-582-3337) (TDD for the hearing impaired: 1-800-843-3557) or visiting www. ltcfeds. com to get more information and to request an application. 58.
58 Page 59 60
2003 Grand Valley Health Plan 55 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 19, 24, 37 Alternative treatment 12, 21
Ambulance 2, 12, 27, 29, 30, 31 Anesthesia 2, 12, 21, 23, 26, 28
Autologous bone marrow transplant 17, 26
Blood and blood plasma 28 Casts 28
Chemotherapy 17 Claims 2, 8, 10, 12, 36, 40, 41, 42,
45, 51 Coinsurance 2, 5, 11, 46, 48
Colorectal cancer screening 14 Congenital anomalies 23, 24
Crutches 20 Deductible 2, 5, 11, 38, 46, 48
Definitions 2, 13, 23, 27, 30, 32, 34, 37, 48
Dental care 38, 55 Diagnostic services 12, 13, 14, 28,
32, 33, 55 Disputed claims 2, 10, 36, 41, 42
Dressings 28 Durable medical equipment
(DME) 12, 20 Educational classes and programs
12, 22 Emergency 2, 5, 6, 8,12, 30, 31,
37, 39, 40 Experimental or investigational
10, 39, 48 Eyeglasses 19
Family planning 12, 16 Fecal occult blood test 14
General Exclusions 2, 12, 39 Hearing services 12, 19
Home health services 12, 21 Hospice care 12, 29

Hospital 2, 4, 5, 7, 8, 9, 10, 12, 13, 15, 20, 22, 23, 24, 26, 27,
28, 30, 31, 33, 37, 40, 43, 47, 48
Immunizations 5, 14, 15 Infertility 12, 16
Insulin 20, 35 Mammograms 14
Maternity Benefits 12, 15, 28 Medicaid 2, 46
Medically necessary 10, 13, 15, 17, 20, 23, 27, 30, 34, 37, 39
Medicare 2, 13, 23, 27, 30, 32, 34, 37, 40, 43, 44-46
Members 2, 5, 8, 12, 22, 23, 38, 48, 50, 57
Mental Conditions/ Substance Abuse Benefits 1, 12, 32, 33,
56 Newborn care 15
Non-FEHB Benefits 2, 38 Nurse
Licensed Practical Nurse 21 Nurse Anesthetist 28
Nurse Practitioner 5, 8 Registered Nurse 21
Obstetrical care 22 Occupational therapy 18
Ocular injury 19 Office visits 5
Oral and maxillofacial surgery 12 Orthopedic devices 20
Oxygen 20, 21, 28 Pap test 14
Physical examination 5, 12, 14 Physical therapy 18
Physician 1, 4, 5, 8, 9, 10, 12, 13, 21, 23, 27, 34, 35, 40, 41, 42

Preventive care, adult 12, 14, 15
Preventive care, children 12, 15, 19
Prescription drugs 22, 40, 43 Preventive services 5, 12-15,
19 Prior approval 1, 10, 17, 42
Prosthetic devices 12, 19, 20, 23, 24
Psychologist 32 Radiation therapy 17
Room and board 27, 48 Second surgical opinion 13
Skilled nursing facility care 9, 12, 13, 26, 28
Smoking cessation 35 Speech therapy 7, 12, 18
Splints 28 Subrogation 47
Substance abuse 1, 12, 32, 33 Surgery 12, 15, 18, 19, 23,
24, 25, 27, 38 Anesthesia 1, 12, 21, 23,
26, 28 Oral 12, 25, 37
Reconstructive 12, 23, 24 Syringes 35
Temporary continuation of coverage 2, 51, 52
Transplants 7, 12, 17, 25, 26 Treatment therapies 12, 18
Vision services 12, 17 Wheelchairs 20
Workers' compensation 45, 46, 51
X-rays 14, 28, 38 59.
59 Page 60 61
2003 Grand Valley Health Plan 56 Index 60.
60 Page 61 62
2003 Grand Valley Health Plan 57 Summary
Summaryof benefits for Grand Valley Health Plan-2003
Do not rely on this chart alone. All benefits are provided in full unless indicated and are subject to the
definitions, limitations, and exclusions in this brochure. On this page we summarize specific expenses we cover; for more detail, look inside.

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

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

Benefits You Pay Page
Medical services provided by physicians:
Diagnostic and treatment services provided in the office ................... Office visit copay: $10 primary care; $10 specialist 13-22

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

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

Nothing
In office: $10 copay Surgical Center: Nothing
27-29
23-26

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

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

$50 per visit
$50 per visit

30-31
30-31
Mental health and substance abuse treatment .......................................... $10 per visit 32-33
Prescription drugs........................................................................................... $5 per prescription 34-35
Dental Care .................................................................................................. Nothing for preventive services;
scheduled allowance for other services 37-38

Vision Care .................................................................................................. $10 per visit 19
Special features: Flexible Benefits, 24 Hour Health Center Line 36
Protection against catastrophic costs (your out-of-pocket maximum) ................................................................
No out-of-pocket maximums 61.
61 Page 62
2003 Rate Information for
Grand Valley Health Plan

Non-Postal rates apply to most non-Postal enrollees. If you are in a special enrollment category, refer to the FEHB Guide for that category or contact the agency that maintains your
health benefits enrollment.
Postal rates apply to career Postal Service employees. Most employees should refer to the FEHB Guide for United States Postal Service Employees, RI 70-2. Different postal rates apply
and a special FEHB guide is published for r Postal Service Inspectors and Office of Inspector General (OIG) employees (see RI 70-2IN).

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

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

Self Only RL1 $100.97 $33.65 $218.76 $72.92 $119.48 $15.14
Self and Family RL2 $249.62 $128.36 $540.84 $278.12 $294.70 $83.28 62.

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