Pages 1--55

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

Serving: Connecticut and Hampden, Hampshire and Franklin
Counties in Massachusetts

Enrollment in this Plan is limited. You must live or work in our
Geographic service area to enroll. See page 6 for requirements.

Enrollment codes for this Plan:
TE1 Self Only
TE2 Self and Family

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

For changes in benefits
see page 7.

A Health Maintenance Organization

RI 73-599 1.
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2.
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Notice of the Office of Personnel Management s
Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT
CAREFULLY.

By law, the Office of Personnel Management ( OPM) , which administers the Federal Employees Health Benefits ( FEHB) Program, is required to protect the privacy of your personal medical information. OPM is also required to give you this notice to tell you how
OPM may use and give out ( disclose ) your personal medical information held by OPM.
OPM will use and give out your personal medical information:
To you or someone who has the legal right to act for you ( your personal representative) , To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is protected,
To law enforcement officials when investigating and/ or prosecuting alleged or civil or criminal actions, and Where required by law.

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

OPM may use or give out your personal medical information for the following purposes under limited circumstances:
For Government healthcare oversight activities ( such as fraud and abuse investigations) , For research studies that meet all privacy law requirements ( such as for medical research or education) , and
To avoid a serious and imminent threat to health or safety.
By law, OPM must have your written permission ( an authorization ) to use or give out your personal medical information for any purpose that is not set out in this notice. You may take back ( revoke ) your written permission at any time, except if OPM h s
already acted based on your permission. 3.
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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.
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2003 ConnectiCare Inc. 2 Table of Contents
Table of Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Plain Language. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Stop Health Care Fraud! . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Section 1. Facts about this HMO plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
How we pay providers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Who provides my health care? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . 6
Your Rights. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . 6
Service Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . 6
Section 2. How we change for 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Program-wide changes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Changes to this Plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Section 3. How you get care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Identification cards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . 8
Where you get covered care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . 8
Plan providers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Plan facilities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . 8
What you must do to get covered care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Primary care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . 8
Specialty care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Hospital care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . 9
Circumstances beyond our control. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Services requiring our prior approval. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Section 4. Your costs for covered services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . 11
Copayments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . 11
Deductible. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Coinsurance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . 11
Your catastrophic protection 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. . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
( c) Services provided by a hospital or other facility, and ambulance services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
( d) Emergency services/ accidents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
( e) Mental health and substance abuse benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
( f) Prescription drug benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
( g) Special features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Flexible benefits, services for deaf and hearing impaired, ConnectiCare website, alternative treatments
( h) Dental benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . 35 5.
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2003 ConnectiCare Inc. 3 Table of Contents
Section 6. General exclusions things we don' t cover. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Section 7. Filing a claim for covered services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Section 8. The disputed claims process. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Section 9. Coordinating benefits with other coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
When you have other health coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
What is Medicare? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Medicare managed care plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
TRICARE and CHAMPVA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Worker s Compensation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . 42
Other Government agencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
When others are responsible for injuires . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Section 10. Definitions of terms we use in this brochure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43Section
11. FEHB facts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . 44
Coverage information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
No pre-existing condition limitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Where you get information about enrolling in the FEHB Program. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Types of coverage available for you and your family . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Children s Equity Act . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
When benefits and premiums start . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
When you retire. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . 45
When you lose benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

When FEHB coverage ends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Spouse equity coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Temporary Continuation of Coverage ( TCC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Converting to individual coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Getting a Certificate of Group Health Plan Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Long term care insurance is still available . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Summary of benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Back cover 6.
6 Page 7 8
2003 ConnectiCare Inc. 4 Introduction/ Plain Language/ Advisory
Introduction
This brochure describes the benefits of ConnectiCare, Inc. under our contract ( CS2662) with the Office of Personnel Management ( OPM) , as authorized by the Federal Employees Health Benefits law. The address for administrative offices is:

ConnectiCare, Inc. 30 Batterson Park Road, Farmington, CT 06032-2574
This brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations, and exclusions of this brochure. It is your responsibility to be informed about your health benefits.
If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in Self and Family coverage, each eligible family member is also entitled to these benefits. You do not have a right to benefits that were available
before January 1, 2003, unless those benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2003, and changes are summarized on page 7. Rates are shown at the end of this brochure.

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

Except for necessary technical terms, we use common words. For instance, you means the enrollee or family member; ;
" we" means ConnectiCare, Inc.

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 Division, 1900 E Street, NW Washington, DC 20415-3650.

Stop Health Care Fraud!
Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits ( FEHB) Program premium.
OPM' s Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program regardless of the agency that employs you or from which you retired.

Protect Yourself From Fraud -Here are some things you can do to prevent fraud:
Be wary of giving your plan identification ( ID) number over the telephone or to people you do not know, except to your doctor, other provider, or authorized plan or OPM representative.
Let only the appropriate medical professionals review your medical record or recommend services. Avoid using health care providers who say that an item or service is not usually covered, but they know how to bill us to
get it paid.
Carefully review explanations of benefits ( EOBs) that you receive from us. Do not ask your doctor to make false entries on certificates, bills or records in order to get us to pay for an item or service.

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: 7.
7 Page 8 9
2003 ConnectiCare Inc. 5 Introduction/ Plain Language/ Advisory
Call the provider and ask for an explanation. There may be an error. If the provider does not resolve the matter, call us at 800/ 251-7722 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 ConnectiCare Inc. 6 Section 1
This Plan is a health maintenance organization ( HMO) . We require you to see specific physicians, hospitals, and other providers that contract with us. These Plan providers coordinate your health care services. The Plan is solely responsible for the selection of these
providers in your area. Contact the Plan for a copy of their most recent provider directory.
HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in addition to treatment for illness and injury. Our providers follow generally accepted medical practice when prescribing any course of treatment.

When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You only pay the copayments, coinsurance, and deductibles described in this brochure. When you receive emergency services from non-Plan providers, you may
have to submit claim forms.
You should join an HMO because you prefer the plan s benefits, not because a particular provider is available. You cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician, hospital, or other provider
will be available and/ or remain under contract with us.
How we pay providers We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure. These Plan providers
accept a negotiated payment from us, and you will only be responsible for your copayments or coinsurance.

Who provides my health care ConnectiCare is an Independent Practice Association ( IPA) model Health Maintenance Organization ( HMO) . It offers you the services
of more than 8,300 physicians, including general practitioners and specialists. For Plan records, all members and each family member must select a primary care doctor. However, members are free to choose the services of any participating doctor, including specialists,
except as noted below ( see What you must do, specialty care) . Your personal doctor may already participate in ConnectiCare. If so, you may receive comprehensive coverage with no change in your established doctor/ patient relationship. Also, a wide range of
hospitals, laboratories and pharmacies participate with ConnectiCare.
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.

ConnectiCare complies with all State and Federal health care regulations.
Years in existence: 21
Profit status: For-profit

If you want more information about us, call 1-800-251-7722, or write to ConnectiCare, Inc. , 30 Batterson Park Road, Farmington, CT 06032-2574. You may also contact our Member Services Department by fax at 860-674-2232 or visit our website at
www. connecticare. com

Service Area To enroll in this Plan, you must live in or work in our Service Area. This is where our providers practice. Our service area is: the
state of Connecticut along with Hampden, Hampshire and Franklin Counties in Massachusetts.
Ordinarily, you must get your care from providers who contract with us. If you receive care outside our service area, we will pay only for emergency care benefits. We will not pay for any other health care services out of our service area unless the services have prior
plan approval.
If you or a covered family member move outside of our service area, you can enroll in another plan. If your dependents live out of the area ( for example, if your child goes to college in another state) , you should consider enrolling in a fee-for-service plan or an HMO
that has agreements with affiliates in other areas. If you or a family member move, you do not have to wait until Open Season to change plans. Contact your employing or retirement office.

Section 1. Facts about this HMO plan 9.
9 Page 10 11
2003 ConnectiCare Inc 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 20.1% for Self Only or 40.4% for Self and Family. 10.
10 Page 11 12
2003 ConnectiCare Inc. 8 Section 3
Section 3. How you get care
Identification cards We will send you an identification ( ID) card. 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.
To get your cards quickly, fax us a copy of your Health Benefits Election Form with the payroll code printed on the bottom. List your PCP and provider number for you and each
family member on a separate page.
Fax everything to ConnectiCare s Enrollment Department at 860-409-8991. If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you
need replacement cards, call us at 1-800-251-7722. Replacement cards can be ordered by calling us or going to our Web site, www. connecticare. com

Where you get covered care You get care from Plan providers and Plan facilities. You will only pay copayments and/ or coinsurance, and you will not have to file claims.
Plan providers Plan providers are physicians and other health care professionals in our service area with whom we contract to provide covered services to our members. We credential Plan
providers according to national standards. We list Plan providers in the provider directory, which we update periodically. The list is also on our website. Since this list
changes, it s best to contact us to confirm that a provider participates.
Plan facilities Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members. We list these in the provider directory, which
we update periodically. The list is also on our website.

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

directory. If you don t provide us with your PCP, we will select one for you, which you can change at any time by calling 1-800-251-7722.

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

Specialty care Members may see any participating doctor for covered services without a referral with the following exceptions. You must get a referral from a participating doctor for:
cardiovascular lab, cardiac rehabilitation, lab work, pain management and behavioral medicine, pulmonary rehabilitation, radiology, radiation therapy, and physical, speech
and occupational therapy.
Your doctor will both refer you and get Plan authorization for: hospital admissions ( except out-of-service area emergencies) , use of surgical facilities, outpatient alcohol and
substance abuse treatment, durable medical equipment, prostheses, orthopedic devices, home health care, speech therapy, occupational therapy, out-of-Plan services ( non-
participating providers) , human organ transplants, skilled nursing facilities and surgical treatment of morbid obesity. 11.
11 Page 12 13
2003 ConnectiCare Inc. 9 Section 3
For information on how to obtain specialty care services, contact us at 1-800-251-7722. A Plan doctor can make arrangements for appropriate referrals. Do not go to a specialist
for services listed above unless a referral or an authorization and a referral has been issued in advance.

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

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

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

reduce our service area and you enroll in another FEHB Plan,
you may be able to continue seeing your specialist for up to 90 days after you receive notice of the change. Contact us or, if we drop out of the Program, contact your new

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

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

If you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at 1-800-251-7722. If you are new to the FEHB
Program, we will arrange for you to receive care.
If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:

You are discharged, not merely moved to an alternative care center; or
The day your benefits from your former plan run out; or
The 92nd day after you become a member of this Plan, whichever happens first.
These provisions apply only to the benefits of the hospitalized person. 12.
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2003 ConnectiCare Inc. 10 Section 3
Circumstances beyond Under certain extraordinary circumstances, such as natural disasters, we may have to
our control 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 or specialist has authority to refer you for most services. For
prior approval certain services, however, your physician must obtain approval from us. Before giving approval, we consider if the service is covered, medically necessary, and follows

generally accepted medical practice.
We call this review and approval process Plan authorization.
Your doctor will both refer you and get Plan authorization for: hospital admissions ( except out-of-service area emergencies) , outpatient alcohol and substance abuse
treatment, durable medical equipment, prostheses, orthopedic devices, home health care, out-of-Plan services ( non-participating providers) , human organ transplants, skilled
nursing facilities and surgical treatment of morbid obesity. For a complete listing, call our Member Services Department at 1-800-251-7722.

For information on how to obtain specialty care services, contact us at 1-800-251-7722. A Plan doctor can make arrangements for appropriate referrals. Do not go to a specialist
for services listed above unless a referral or an authorization and a referral has been issued in advance. Otherwise, the services may not be covered. 13.
13 Page 14 15
2003 ConnectiCare Inc. 11 Section 4
Section 4. Your costs for covered services
You must share the cost of You are responsible for:
some services.

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 and when you go in the hospital, you pay $ 100 per admission.

Deductible The only deductible this plan has is for Durable Medical Equipment ( DME) . For example, DME would consists of oxygen and dialysis equipment, crutches, disposable
medical supplies, ostomy equipment, etc. , the ( DME) benefit.

Coinsurance Coinsurance is the percentage of our negotiated fee that you must pay for your care. DME has coinsurance.
Your catastrophic
Protection out-of-pocket
maximum for deductibles,
coinsurance, and
copayments We do not have a catastrophic protection out-of-pocket maximum. 14.
14 Page 15 16
2003 ConnectiCare Inc. 12 Section 5
Section 5. Benefits OVERVIEW
( See page 5 for how our benefits changed this year and page 47 for a benefits summary. )

NOTE : This benefits section is divided into subsections. Please read the important things you should keep in mind at the beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the following subsections. To obtain
claims forms, claims filing advice, or more information about our benefits, contact us at 1-800-251-7722 or at our Web site at www. connecticare. com

( a) Medical services and supplies provided by physicians and other health care professionals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-21
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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22-25
Surgical procedures Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue transplants
Anesthesia
( ) Services provided by a hospital or other facility, and ambulance services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26-27

Inpatient hospital Outpatient hospital or ambulatory surgical center Extended care benefits/ skilled nursing care facility benefits Hospice care
Ambulance
( d) Emergency services/ accidents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28-29
Medical emergency Ambulance

( e) Mental health and substance abuse benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
( f) Prescription drug benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31-33
( g) Special features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Flexible benefits option, services for deaf and hearing impaired, our website, alternative treatments

( h) Dental benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Summary of benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . 49 15.
15 Page 16 17
2003 ConnectiCare Inc. 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 for your care.
We have no calendar year deductible, except for DME.
Be sure to read Se tion 4, You cost s f o covered services, for valuable information about how ost sharing works. Also read Se tion 9 about oordinating benefits with other overage, including

Medi care.

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 $ 10 per offi e visit

Professional services of physicians
In an urgent care center
During a hospital stay
In a skilled nursing facility
Office medical consultations
Second surgical opinion

$ 20 per office visit
Nothing.
Nothing for up to 90 days per calendar year.
$ 10 per office visit.
$ 10 per office visit.

At home $ 10 per house call by a doctor.

Diagnosis and treatment of illness or injury in physician s office, Including specialty care $ 10 per office visit.

Diagnostic tests in hospital Nothing.
Vaccines for pediatric and adult immunizations Nondental treatment of temporomandibular joint ( TMJ) syndrome
Services for which a member has no responsibility to pay Services for intentionally inflicted injuries
Services for injuries resulting from hazardous activities

Nothing if you receive these services during your office visit.

Injuries received in connection with the commission of a felony All charges. 16.
16 Page 17 18
2003 ConnectiCare Inc. 14Section 5( a)
Lab, X-ray and other diagnostic tests
Tests, such as: Cardiovascular lab
Blood tests Cardiac rehabilitation
Urinalysis Lab work
Non-routine pap tests Pain management and
Pathology behavioral medicine
X-rays Pulmonary rehabilitation
Non-routine Mammograms Radiology
Cat Scans/ MRI Radiation therapy
Ultrasound Physical, speech and
Electrocardiogram and EEG occupational therapy

Nothing if you receive these services during your office visit; otherwise, $ 10 per offi e
visit

Preventive care, adult
Routine screenings, such as periodic check-ups and routine immunizations including these tests as ordered by your doctor

Total Blood Cholesterol
Colorectal Cancer Screening, including

Fecal occult blood test
Sigmoidos opy, s reening

$ 10 per offi e visit

Prostate Spe ifi Antigen ( PSA test) one annually for men age 40 and older $ 10 per offi e visit
Routine pap test
Note: The office visit is covered if pap test is received on the same day; see Diagnosis and Treatment , above.
Nothing if you receive these services during your office visit; otherwise, $ 10 per 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

$ 10 per offi e visit.

Preventive Care continued on next page 17.
17 Page 18 19
2003 ConnectiCare Inc. 15 Section 5( a)
Preventive care, adult ( continued) You pay
Not covered: Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, or travel. All charges.

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

Influenza vaccine, annually
Pneumococcal vaccine, age 65 and over

Nothing if you receive these services during your office visit; otherwise $ 10 per visit.

Check with your doctor to see if this plan covers other immunizations.
Preventive care, children
Childhood immunizations recommended by the American Academy of Pediatrics Nothing if you receive these services during your office visit; otherwise $ 10 per visit.

Well-child care charges for routine examinations, immunizations and care ( up to age 22)
Examinations, such as:
Eye exams to determine the need for vision correction. Ear exams up to age 18 to determine the need for hearing

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

$ 10 per office visit

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

Postnatal care
Note: Here are some things to keep in mind:

You do not need to precertify your normal delivery. This is done by your Plan Provider.

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) .

$ 10 for initial visit, then nothing.

Not covered: Routine sonograms to determine fetal age, size or sex. All charges. 18.
18 Page 19 20
2003 ConnectiCare Inc. 16 Section 5( a)
Family planning You pay
A range of voluntary family planning services, limited to:
Voluntary sterilization ( See Surgical procedures Section 5 ( b) )
Surgically implanted contraceptives ( such as Norplant)
Injectable contraceptive drugs ( such as Depo provera)
Intrauterine devices ( IUDs)
NOTE: We cover oral contraceptives, injectable contraceptive and diaphragms under the prescription drug benefit.

$ 10 per office visit

Not covered: reversal of voluntary surgical sterilization, genetic counseling All charges.
Infertility services
Diagnosis and treatment of infertility, such as:
Artificial insemination:
intravaginal insemination ( IVI) intracervical insemination ( ICI)

intrauterine insemination ( IUI) Fertility drugs
Note: We cover injectable fertility drugs under medical benefits and oral fertility drugs under the prescription drug benefit ( up to $ 1,500 per
calendar year. )

$ 10 per office visit

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

Zygote transfer Services and supplies related to excluded ART procedures
Cost of donor sperm Cost of donor egg

All charges.

Allergy care
Testing and treatment $ 10 per office visit

Allergy injection/ serum Nothing
Not covered: provocative food testing and sublingual allergy desensitization All charges. 19.
19 Page 20 21
2003 ConnectiCare Inc. 17 Section 5( a)
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 24.

Respiratory and inhalation therapy
Dialysis hemodialysis and peritoneal dialysis
Intravenous ( IV) / Infusion Therapy Home IV and antibiotic therapy
Growth hormone therapy ( GHT)
Note: We will only cover GHT when we pre-authorize the treatment. Your doctor would have to submit your case in writing to the Plan.

Your case will be reviewed for medical necessity and, if approved, you may then seek treatment.

Nothing.

Not covered: Vision Therapies
Physiotherapy ( such as therapeutic muscle exercises, galvanic or thanscutaneous nerve stimulation, vapocoolant sprays, ultrasound
or diathermy)

All charges.

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

qualified physical therapists and occupational therapists.

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

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

Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction, is provided as part of your rehabilitation. Nothing.
Chiropractic manipulation therapy is provided on an outpatient basis for up to 20 visits per calendar year. $ 10 copayment per visit.
Not covered:
long-term rehabilitative therapy
exercise programs

All charges.

Speech therapy
60 visits per condition per calendar year $ 10 per outpatient visit.
Nothing per visit during covered inpatient admission.

Not covered:
Non-authorized, non-medically necessary treatment All charges. 20.
20 Page 21 22
2003 ConnectiCare Inc. 18 Section 5( a)
Hearing services ( testing, treatment, and supplies) You pay
First hearing aid and testing only when necessitated by accidental injury

Hearing testing for children through age 18 ( see Preventive care, children )
$ 10 per office visit

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

All charges.

Vision services ( testing, treatment, and supplies)
Our vision program includes: frames and lenses, prescription contact lenses available only at Plan routine vision providers ( offered at
various discounts, not at $ 10 copay) . For a full description of the Vision Care Coverage, please see the routine vision information
located in the enrollment packet.

25% discount on frames and lenses at or below $ 250; 30% discount over $ 250 at
plan routine vision providers

Eye exam to determine the need for vision correction for children ( see Preventive care, children)
Annual eye refractions once per calendar year, when obtained by Plan providers
$ 10 per office visit
$ 10 per office visit

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

All charges.

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

See orthopedic and prosthetic devices for information on podiatric shoe inserts.
$ 10 per office visit

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

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

treatment is by open cutting surgery)

All charges. 21.
21 Page 22 23
2003 ConnectiCare Inc. 19 Section 5( a)
Orthopedic and prosthetic devices You pay
Artificial limbs and eyes; stump hose
Note: Plan authorization is required and coverage is limited to the initial acquisition. This benefit paid under Durable Medical Equipment.

Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy
Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implant
following mastectomy. Note: See 5( b) for coverage of the surgery to insert the device.

$ 10 per office visit

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

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

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 ( Motorized chairs covered only with plan approval
of doctors written request detailing medical necessity. )

crutches;
walkers;
blood glucose monitors; and
insulin pumps.
You must get your equipment from our vendors. Your doctor can help you or you can call member services at 1-800-251-7722.

$ 100 deductible per calendar year and 20% of charges up to a maximum Plan payment
of $ 1,500 per calendar year.

Note: Prior Plan authorization is required and coverage is limited to the initial
acquisition. 22.
22 Page 23 24
2003 ConnectiCare Inc. 20 Section 5( a)
Disposable medical supplies You pay
Certain disposable medical supplies, which are used in conjunction with covered durable medical equipment or covered medical treatment received
in the home are covered. Examples: BiPAP, CPAP masks.
Not all disposable medical supplies are covered. See your doctor or call Member Services.

$ 100 deductible and 20% of charges up to a maximum Plan payment of $ 300 per
calendar year.
Note: Prior plan authorization is required.

Ostomy equipment and supplies
Ostomy equipment and supplies prescribed by your Plan physician. $ 100 deductible per calendar year and 20% of charges up to a maximum Plan payment
of $ 1,000 per calendar year.

Note: Prior Plan authorization is required and coverage is limited to the initial
acquisition.

Home health services
Home health care ordered by a Plan physician and provided by a registered nurse ( R. N. ) , licensed practical nurse ( L. P. N. ) , licensed
vocational nurse ( L. V. N. ) , or home health aides when prescribed by your Plan doctor, who will periodically review the program for
continuing appropriateness and need.
Services include oxygen therapy, intravenous therapy and medications.

Nothing.

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

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

All charges.

Chiropractic
Manipulation of the spine and extremities
Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack application

$ 10 per office visit
20 visits per calendar year. 23.
23 Page 24 25
2003 ConnectiCare Inc. 21 Section 5( a)
Alternative treatments You pay
Naturopathic Doctors if Plan Doctors $ 10 per office visit

Not covered:
hypnotherapy biofeedback
All charges.

Educational classes and programs
Coverage is limited to: Diabetes, Heart, Asthma and Smoking Cessation programs are available. Information can be obtained by
calling Member Services at 1-800-251-7722.
Nothing. 24.
24 Page 25 26
2003 ConnectiCare Inc. 22 Section 5( b)
Section 5 ( b) . Surgical and anesthesia services provided by physicians and other health care professionals
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ere are some i mportant thi ngs to keep i n mi nd about these benefi ts:
Please remember that all benefits are subje t to the definitions, limitations, and ex lusions in this bro hure and are payabl e onl y when we det ermi ne t hey are medi call y necessary.

Plan physi ians must provide or arrange your are.
We have no alendar year deductible.
Be sure to read Se tion 4, Your costs for covered services, for valuable information about how ost sharing works. Also read Se tion 9 about oordinating benefits with other overage, including with

Medi care.
The amounts listed below are for the harges billed by a physi ian or other health are professional for your surgi al are. Look in Se tion 5( ) for harges asso iated with the fa ility ( i. e. hospital,

surgi cal cent er, et . ) .
YOU MUST GET PRECERTIFICATION OF SOME SURGICAL PROCEDURES. Please refer t o t he precert i fi cati on i nformati on shown i n Secti on 3 t o be sure whi ch services requi re

precert i fi cati on and i dent i fy whi h surgeri es requi re precert i fi cati on.

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Benefit Description You pay
Surgical procedures
A comprehensive range of services, such as :
Operative procedures Treatment of fractures, including casting

Normal pre-and post-operative care by the surgeon Correction of amblyopia and strabismus
Endoscopy procedures Biopsy procedures
Removal of tumors and cysts Correction of congenital anomalies ( see reconstructive surgery)

$ 10 per office visit

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 and Plan must approve in advance.
Nothing when approved in advance by Plan.

Insertion of internal prosthetic devices must be medically necessary to restore bodily function and require a surgical incision ( as opposed
to an external prosthetic device) .
Examples: artificial joints, pacemakers, defibrillators and penile implants.

Nothing.

Surgical procedures continued on next page. 25.
25 Page 26 27
2003 ConnectiCare Inc. 23 Section 5( b)
Surgical procedures ( continued) You pay
Voluntary sterilization ( e. g. , Tubal ligation, Vasectomy) Treatment of burns

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

$ 10 per office visit

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

Skin Tag removal

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.

$ 10 per office visit

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

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

See above.

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

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

All charges. 26.
26 Page 27 28
2003 ConnectiCare Inc. 24Section 5( b)
Oral and maxillofacial surgery You pay
Oral surgical procedures, limited to:
Reduction of fractures of the jaws or facial bones; Surgical correction of cleft lip, cleft palate or severe functional

malocclusion;
Removal of stones from salivary ducts; Excision of leukoplakia or malignancies;

Excision of cysts and incision of abscesses when done as independent procedures; and
Other surgical procedures that do not involve the teeth or their supporting structures.
Oral surgery services: Medically necessary oral surgical services for the treatment of tumors, cysts ( of non-dental origin) , injuries of the
facial bones and for the treatment of fractures and dislocations involving the face and jaw, including temporamandibular joint ( TMJ)
dysfunction surgery ( for demonstrable joint disease only) provided by a Participating Physician are covered. Certain oral surgery requires
Pre-Authorization.

$ 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.

Organ/ tissue transplants
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
Note: Plan authorization is required at the time of diagnosis, prior to any evaluative
services and will only be authorized at Plan facilities, contracted Centers of Excellence. 27.
27 Page 28 29
2003 ConnectiCare Inc. 25 Section 5( b)
Organ/ tissue transplants You pay
Not covered:
Donor screening tests and donor search expenses, except those performed for the actual donor

Implants of artificial organs
Transplants not listed as covered

All charges.

Anesthesia
Professional services provided in
Hospital ( inpatient)
Nothing.

Professional services provided in
Hospital outpatient department Skilled nursing facility

Ambulatory surgical center Office

Nothing when prescribed by a Plan doctor. 28.
28 Page 29 30
2003 ConnectiCare Inc. 26 Section 5( c)
Section 5 ( c) . Services provided by a hospital or other facility, and ambulance services
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Here are some important things to remember about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

Plan physicians must provide or arrange your care 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) .

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

meals and special diets.

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

Nothing

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

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

Nothing

Not covered:
Custodial care Non-covered facilities, such as nursing homes, schools

Personal comfort items, such as telephone, television, barber services, guest meals and beds
Private nursing care

All charges. 29.
29 Page 30 31
2003 ConnectiCare Inc. 27 Section 5( c)
Outpatient hospital or ambulatory surgical center You pay
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

Skilled nursing facility ( SNF) : The Plan provides a comprehensive range of benefits for up to 90 days when full-time skilled nursing care
is necessary and confinement in a skilled nursing facility is medically appropriate as determined by a Plan doctor and approved by the Plan.
All necessary services are covered, including:

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

Nothing for up to 90 days per calendar year. Prior authorization required.

Not covered: custodial care All charges.
Hospice care
Hospice Care: Supportive and palliative care for a terminally ill member is covered in the home or hospice facility. Services include inpatient
and outpatient care, and family counseling; these services are provided under the direction of a Plan doctor who certifies that the patient is in
the terminal stages of illness, with a life expectancy of approximately six months or less.

Nothing.

Not covered: Independent nursing, homemaker services All charges.
Ambulance
Emergency Ambulance services are covered
Non-Emergency use must be requested by your doctor and pre-approved by the Plan
Nothing 30.
30 Page 31 32
2003 ConnectiCare Inc. 28 Section 5( d)
Section 5 ( d) . Emergency services/ accidents
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Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subje t to the definitions, limitations, and ex lusions in this brochure.

We have no alendar year deductible.
Be sure to read Se tion 4, Your costs for covered services, for valuable information about how ost sharing works. Also read Se tion 9 about oordinating benefits with other overage, including with

Medi care

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What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or could result in serious injury or disability, and requires immediate medical or surgical care. Some problems are emergencies

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

What to do in case of emergency:
Emergencies within our service area: If you are in an urgent care situation within our service area, please call your primary care doctor ( available 24 hours a day through their answering service) . In extreme emergencies, 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
24 hours of an admission to the hospital unless it was not reasonably possible to do so. It is your responsibility to ensure that the Plan has been timely notified.

If you need to be hospitalized in a non-Plan facility, the Plan must be notified within 24 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.
The Plan pays reasonable charges for emergency services to the extent the services would have been covered if received from 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 24 hours of an admission 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. 31.
31 Page 32 33
2003 ConnectiCare Inc. 29 Section 5( d)
Benefit Description You pay
Emergency within our service area
Emergency care at a doctor' s office
Emergency care at an urgent care center within the service area

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

$ 10 per office visit.
$ 20 for emergency services that are covered benefits of this Plan. Copayment waived if

emergency results in hospital admission.
$ 40 for emergency services that are covered benefits of this Plan. Copayment waived if

emergency results in hospital admission.

Not covered: Elective care or non-emergency care All charges.
Emergency outside our service area
Emergency care at a doctor' s office
Emergency care at an urgent care center outside of the service area

Emergency care outside of the service area, at an outpatient or inpatient at a hospital, including doctors' services

$ 10 per office visit.
$ 20 for emergency services that are covered benefits of this Plan. Copayment waived if

emergency results in hospital admission.
$ 40 for emergency services that are covered benefits of this Plan. Copayment waived if

emergency results in hospital admission.

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

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

All charges.

Ambulance
Professional ambulance service when medically appropriate. See 5( c) for non-emergency service. Nothing. 32.
32 Page 33 34
2003 ConnectiCare Inc. 30 Section 5( e)
Section 5 ( e) . Mental health and substance abuse benefits
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When you get our approval for services and follow a treatment plan we approve, cost-sharing and limitations for Plan mental health and substance abuse benefits will be no greater than for similar benefits for other
illnesses and conditions.
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
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Benefit Description You pay
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 offi e visit.

Diagnostic tests Nothing.
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
$ 10 per office visit or nothing depending on service.

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 call 1-800-424-5669 for all mental health
requests. This number is printed on the back of your ConnectiCare, Inc. member card as well.

Limitation We may limit your benefits if you do not obtain a treatment plan. 33.
33 Page 34 35
2003 ConnectiCare Inc. 31 Section 5( f)
Section 5 ( f) . Prescription drug benefits
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ere are some i mportant thi ngs to keep i n mi nd about these benefi ts:
We over pres ribed drugs and medi ations, as des ribed in the hart beginning on the next page.
All benefits are subje t to the definitions, limitations and ex lusions in this bro hure and are payable onl y when we det ermi ne t hey are medi call y necessary.

Be sure to read Se tion 4, Your costs for covered services, for valuable information about how ost sharing works. Also read Se tion 9 about oordinating benefits with other overage, including with
Medi care.

A generic equivalent will be dispensed if it is available. If you receive a name brand drug when a Federally-approved generic drug is available, you have to pay the difference in cost between the name
brand drug and the generic.
We have an open formulary. If your physician believes a name brand product is necessary or there is no generic available, your physician may prescribe a name brand drug from a formulary list. This list of

name brand drugs is a preferred list of drugs that we selected to meet patient needs at a lower cost. To order a formulary listing, go to our web site www. connecticare. com.

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2003 ConnectiCare Inc. 32 Section 5( f)
There are important features you should be aware of. These include:
Who can write your prescription. A licensed physician must write the prescription.
Where you can obtain them. You must fill the prescription at a Express Scripts pharmacy, or by mail for a maintenance medication. The only exception is for out-of-area emergencies.

Pharmacy: You may obtain your pres riptions at any Express S ripts, Inc. pharma y. ( in 98% of US Pharmacies)
Mail order: Maintenance medication, those medications needed for conditions such as diabetes, high blood pressure, epilepsy and heart conditions, can be obtained either via mail order or at the pharmacy in a 100-day
supply. If you choose mail order at 2 times the copay, call Member Services at 1-800-251-7722 to request and order form. If you choose to go to your pharmacy, the co-pay will be 3 times the co-pay. All rules that
apply to the regular Prescription Plan apply to the Mail Order Program as well. Note: Not all drugs are
available via mail order and your doctor must write a maintenance prescription

We use a formulary. We work with our network physicians and our pharmacy network, Express Scripts, Inc. , to build a Formulary Drug List. This Formulary Drug List includes over 80% of the drugs currently

available in the market, including all generic and some name brand drugs. Formulary and Non-Formulary drugs are available at a cost difference when a generic is available. Our Formulary is available by calling
Member Services at 1-800-251-7722 or on the Web at www. connecticare. com
All members receive educational information describing the Formulary drug program. Members using non-Formulary drugs are sent a series of letters recommending that they speak to their physician about preferred

alternatives.
We have an open formulary. If your physician believes a name brand product is necessary or there is no generic available, your physician may prescribe a name brand drug from a formulary list. This list of name

brand drugs is a preferred list of drugs that we selected to meet patient needs at a lower cost. To order a prescription drug brochure, call 1-800-251-7722.

These are the dispensing limitations. Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed for up to a 34-day supply; 240 milliliters of liquid ( 8oz. ) ;
60 grams of ointment, creams or topical preparation; or one commercially prepared unit ( i. e. , one inhaler, one vial ophthalmic medication or Insulin) of medication per prescription or refill. You pay a $ 10 copay
per prescription unit or refill for generic drugs or a $ 20 copay for name brand Formulary drugs when generic substitution is not permissible. When generic substitution is permissible and, you or your doctor
request the Formulary name brand drug, you pay the price difference between the generic and name brand drug as well as the $ 10 copay per prescription unit or refill. Drugs are prescribed by Plan doctors and
dispensed in accordance with the Plan s drug Formulary. Non-Formulary drugs will be covered when prescribed by a Plan doctor, but at a higher copay.

Why use generic drugs? Per the FDA ( Federal Drug Administration) , generic drugs and name brand drugs share identical basic ingredients. The color and shape may differ but the result should be the same. Many
generic patents are owned by the name brand drug companies. Generic drugs are an affordable alternative. You can always get the name brand, you just pay more.

NOTE: Not all prescriptions are available through the Maintenance Mail Order Program depending on the type of drug, etc. We follow FDA dispensing guidelines. If you send in your order too soon, it can t be
filled. Maintenance Mail Order refills should be requested after 75% of the prescription is used. Over the counter when you have 5 days left. If your prescription is for more than 34 days ( 1 month) prescription, you
will be charged two and sometime three copays depending on how much was dispensed.
If you choose a non-Formulary drug when a generic or Formulary name brand drug is available, you pay a $ 10 copayment in addition to the cost difference between the Formulary and non-Formulary drug, up to

50% of the cost of the drug. If the cost is less than the copayment, you pay the lesser amount.
When you have to file a claim. There are no claims to file for prescription services received at Express Scripts, Inc. drug stores. If you are new to the plan and don t have your card when you first join and need a
prescription, you must pay for it and call Member Services at 1-800-251-7722 for a prescription reimbursement form. Refunds take up to 8 weeks so always use your card when you get it. 35.
35 Page 36 37
2003 ConnectiCare Inc. 33 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

Drugs for sexual dysfunction ( contact the plan for dose limits)
Contraceptive drugs and devices ( oral and injectable plus diaphragms)

Fertility drugs are subject to $ 1,500 per calendar year
Intraveneous fluids and medicine for home use ( covered implantable drugs and covered injectable drugs are covered under medical and

surgical benefits) .

You pay a $ 10 copay per prescription unit or refill for generic drugs, a $ 20 copay for name brand
Formulary drugs and a $ 35 copay for non-Formulary drugs. When a generic drug is
available, but you or your doctor request the Formulary name brand drug, or non-Formulary
brand drug, you pay the price difference between the generic and name brand drug as well as the $ 10
copay per prescription unit or refill. Drugs are prescribed by Plan doctors and dispensed in
accordance with the Plan s drug Formulary. Our Formulary is open and available by calling
Member Services at 800-251-7722 or by going to our website www. connecticare. com . Mail Order
forms are also available by calling Member Services. Mail Order follows the same rules ( cost
sharing) and provides a 100 day supply for 2 times the copay.

Not covered:
Drugs and supplies for cosmetic purposes
Drugs to enhance athletic performance
Drugs obtained at a non-Plan pharmacy; except for out-of-area emergencies

Vitamins, nutrients and food supplements even if a physician prescribes or administers them
Nonprescription medicines

All charges. 36.
36 Page 37 38
2003 ConnectiCare Inc. 34 Section 5( g) ( h)
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 reviews.
By approving an alternative benefit, we cannot guarantee you will get it in the future.

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

Services for deaf and
hearing impaired

Call the TDD/ TTY number for the hearing impaired: 1-800-251-7722.

Our website
www. connecticare. com

You can change or add your PCP, look up a doctor or check our drug formulary at our website.

Alternative treatments Discounts on homeopathic treatments, massage therapy, etc. See flyer enclosed in your enrollment kit or, call Member Services at 1-800-251-7722 and ask for a Healthy Alternatives brochure. .
Section 5 ( h) . Dental benefits
I M
P O
R T
A N
T

ere are some i mportant thi ngs to keep i n mi nd about these benefi ts:
Please remember that all benefits are subje t to the definitions, limitations, and ex lusions in this bro hure and are payabl e onl y when we det ermi ne t hey are medi call y necessary.

Plan dentists must provide or arrange your are.
We have no calendar year dedu t i bl e .
We over hospitalization for dental pro edures only when a nondental physi al impairment exists whi h makes hospitalization ne essary to safeguard the health of the patient. See Se tion 5 ( ) for inpatient

hospital benefits. We do not over the dental procedure unless it is des ribed below.
Be sure to read Se tion 4, You cost s f o covered services, for valuable information about how ost sharing works. Also read Se tion 9 about oordinating benefits with other overage, including with

Medi care.

I M
P O
R T
A N
T

Dental benefits
We have no other dental benefits. 37.
37 Page 38 39
2003 ConnectiCare Inc. 35 Section 6
Section 6. General exclusions things we don t cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not cover it unless your Plan doctor determines it is medically necessary to prevent, diagnose, or treat your illness, disease,
injury or condition and we agree, as discussed under What Services Require Our Prior Approval on page 10.
We do not cover the following:
Care by non-Plan providers except for authorized referrals or emergencies ( see Emergency Benefits) ;
Services, drugs, or supplies you receive while you are not enrolled in this Plan;
Services, drugs, or supplies that are not medically necessary;
Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice;
Experimental or investigational procedures, treatments, drugs or devices;
Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest

Services, drugs, or supplies related to sex transformations;
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program;
Services, drugs, or supplies you receive without charge while in active military service; or
Expenses you incurred while you were not enrolled in this Plan. 38.
38 Page 39 40
2003 ConnectiCare Inc. 36 Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at Plan pharmacies, you will not have to file claims. Just present your identification card and pay your copayment, coinsurance, or deductible.

You will only need to file a claim when you receive emergency services from non-plan providers. Sometimes these providers bill us directly. Check with the provider. If you need to file the claim, call Member Servicers at 800 251-7722 to obtain an out-of-area claim
form. Then, here is the process:

Medical, hospital, and In most cases, providers and facilities file claims for you. Physicians must file on the
drug benefits form HCFA-1500, Health Insurance Claim Form. Facilities will file on the UB-92 form. For claim questions and assistance, call us at 1-800-251-7722.

When you must file a claim such as for services you receive outside of the Plan s service area submit it on the HCFA-1500 or a claim form that includes the information
shown below. Bills and receipts should be itemized and show:
Covered member s name and ID number;
Name and address of the physician or facility that provided the service or supply;
Dates you received the services or supplies;
Diagnosis;
Type of each service or supply;
The charge for each service or supply;
A copy of the explanation of benefits, payments, or denial from any primary payer such as the Medicare Summary Notice ( MSN) ; and Receipts, if you paid for

your services.
Submit your claims to: Member Services
ConnectiCare, Inc. 30 Batterson Park Road
Farmington, CT 06032-2574

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. 39.
39 Page 40 41
2003 ConnectiCare Inc. 37 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: Member Services, 30 Batterson Park Road, Farmington, CT 06032-2574; and
( ) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure; and

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

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

step 3.

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

4 If you do not agree with our decision, you may ask OPM to review it. You must write to OPM within:

90 days after the date of our letter upholding our initial decision; or 120 days after you first wrote to us --if we did not answer that request in some way within 30 days; or
120 days after we asked for additional information.
Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Health Benefits Contracts Division 3, 1900 E Street, NW, Washington, DC 20415-3630.

Send OPM the following information:
A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;
Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits ( EOB) forms;

Copies of all letters you sent to us about the claim;
Copies of all letters we sent to you about the claim; and
Your daytime phone number and the best time to call.

Note: If you want OPM to review more than one claim, you must clearly identify which documents apply to which claim.
Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representative, such as medical providers, must include a copy of your specific written consent with the review request.

Note: The above deadlines may be extended if you show that you were unable to meet the deadline because of reasons beyond your control. 40.
40 Page 41 42
2003 ConnectiCare Inc. 38 Section 8
5 OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct. OPM will send you a final decision within 60 days. There are no other administrative appeals.
If you do not agree with OPM s decision, your only recourse is to sue. If you decide to sue, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services, drugs, or
supplies or from the year in which you were denied precertification or prior approval. This is the only deadline that may not be extended.

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

NOTE: If you have a serious or life threatening condition ( one that may cause permanent loss of bodily functions or death if not treated as soon as possible) , and
( a) We haven' t responded yet to your initial request for care or preauthorization/ prior approval, then call us at 1-800-251-7722 and we will expedite our review; or
( b) We denied your initial request for care or preauthorization/ prior approval, then:
If we expedite our review and maintain our denial, we will inform OPM so that they can give your claim expedited treatment too, or

You may call OPM' s Health Benefits Contracts Division 3 at 202/ 606-0755 between 8 a. m. and 5 p. m. eastern time. 41.
41 Page 42 43
2003 ConnectiCare Inc. 39 Section 9
Section 9. Coordinating benefits with other coverage
When you have other health You must tell us if you or a covered family member have coverage under another group
coverage health plan or have automobile insurance that pays health care expenses without regard to fault. This is called double coverage.

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

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

What i s Medi care? 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.

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

When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care. Your care must continue to be
authorized by your Plan PCP, or precertified as required .
When Medicare is primary, we will cover what they don t assuming all other rules have been followed. 42.
42 Page 43 44
2003 ConnectiCare Inc. 40 Section 9
In most cases, if you inform your provider that your have two coverages, they will send the claims to the carriers. But, this is something they do as a convenience. You are
always ultimately responsible to submit your claims to the carriers you deal with.
Claims process when you have the Original Medicare Plan You probably will never have to file a claim form when you have both our Plan and the Original Medicare
Plan.
When we are the primary payer, we process the claim first.
When Original Medicare is the primary payer, Medicare processes your claim first. In
most cases, your claims will be coordinated automatically and we will 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 claims, call us at 1-800-251-7722.
We do not waive any costs if the Original Medicare Plan is your primary payer.

Medicare managed care plan If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare managed care plan. These are health care choices ( like HMOs) in
some areas of the country. In most Medicare managed care plans, you can only go to doctors, specialists, or hospitals that are part of the plan. Medicare managed care plans
provide all the benefits that Original Medicare covers. Some cover extras, like prescription drugs. To learn more about enrolling in a Medicare+ Choice 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 and also remain enrolled in our FEHB plan. We
will still provide benefits when your Medicare managed care plan is primary and will supplement that plan assuming you went to our providers and follow our rules. 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 and enroll in a
Medicare managed care plan. For information on suspending your FEHB enrollment, contact your retirement office. If you later want to re-enroll in the FEHB Program,
generally you may do so only at the next open season unless you involuntarily lose coverage or move out of the Medicare managed care plan s service area.

If you do not enroll in 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.

Primary payer chart begins on next page. 43.
43 Page 44 45
2003 ConnectiCare Inc. 41 Section 9
The following chart illustrates whether the Original Medicare Plan or this Plan should be the primary payer for you according to your employment status and other factors determined by Medicare. It is critical that you tell us if you or a covered family member
has Medicare coverage so we can administer these requirements correctly.

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

Original Medicare This Plan
1) Are an active employee with the Federal government ( in luding when you or a family member are eligible for Medicare solely be ause of a
disability) ,
.

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

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

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

covered spouse is this type of judge) , .

5) Are enrolled in Part B only, regardless of your employment status, . ( for Part B services) . ( for other services)
6) Are a former Federal employee receiving Workers Compensation and the Office of Workers Compensation Programs has determined that
you are unable to return to duty,

. ( ex ept for laims
related to Workers Compensation. )

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

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

b) Are an active employee, or .
c) Are a former spouse of an annuitant, or .
d) Are a former spouse of an active employee . 44.
44 Page 45 46
2003 ConnectiCare Inc. 42 Section 9
TRICARE and CHAMPVA TRICARE is the health care program for eligible dependents of military persons, and retirees of the military. TRICARE includes the CHAMPUS program. CHAMPVA
provides health coverage to disabled Veterans and their eligible dependents. If TRICARE or CHAMPVA and this Plan cover you, we pay first. See your TRICARE or
CHAMPVA Health Benefits Advisor if you have questions about these programs.
Suspended FEHB coverage to enroll in TRICARE or CHAMPVA: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in a one of
these programs, eliminating your FEHB premium. ( OPM does not contribute to any applicable plan premiums. ) For information on suspending your FEHB enrollment,
contact your retirement office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose
coverage under the program.

Workers Compensation We do not cover services that: you need because of a workplace-related illness or injury that the Office of Workers
Compensation Programs ( OWCP) or a similar Federal or State agency determines they must provide; or

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

Medicaid When you have this Plan and Medicaid, we pay first.
Suspended FEHB coverage to enroll in Medicaid or a similar State-sponsored program of medical assistance: If you are an annuitant or former spouse, you can
suspend your FEHB coverage to enroll in a one of these State programs, eliminating your FEHB premium. For information on suspending your FEHB enrollment, contact
your retirement office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage under the
State program.

Whe n ot he r Gove rnme nt We do not cover services and supplies when a local, State, or Federal Government
agencies are responsible for agency directly or indirectly pays for them.
your care

When others are responsible When you receive money to compensate you for medical or hospital care for injuries or for injuries 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. 45.
45 Page 46 47
2003 ConnectiCare Inc. 43 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 Home Health Care, light duty services at your home 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 How do you decide if a service is experimental or investigational?
investigational services ConnectiCare uses outside medical experts and scientific literature reviews for determining whether a medical service is considered investigational and/ or experimental.

Group health coverage Health Insurance sold only to group employers.
Medical necessity Medical care provided for illness or injury that is determined by national standards to be Medically Necessary. Like a Mammogram, etc.
Us/ We Us and we refer to ConnectiCare, Inc.
You You refers to the enrollee and each covered family member. 46.
46 Page 47 48
2003 ConnectiCare Inc. 44 Section 11
Section 11. FE B 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 can answer your
about enrolling in the and questions, give you a Guide to Federal Employees Health Benefits Plans
FEHB Program brochures for other plans, and other materials you need to make an informed decision about your FEHB coverage. These materials tell you:

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

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

Types of coverage available Self Only coverage is for you alone. Self and Family coverage is for you, your spouse,
for you and your family 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
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: 47.
47 Page 48 49
2003 ConnectiCare Inc. 45 Section 11
If you have no FEHB coverage, your employing office will enroll you for Self and Family coverage in the Blue Cross and Blue Shield Service Benefit Plan s Basic Option,
if you have a Self Only enrollment in a fee-for-service plan or in an HMO that serves the area where your children live, your employing office will change your enrollment to Self
and Family in the same option of the same plan; or
if you are enrolled in an HMO that does not serve the area where the children live, your employing office will change your enrollment to self and family in the Blue Cross and

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

When benefits and The benefits in this brochure are effective on January 1. If you joined this Plan
premiums start 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 coverage If you are divorced from a Federal employee or annuitant, you may not continue to get benefits under your former spouses 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. 48.
48 Page 49 50
2003 ConnectiCare Inc. 46 Section 11
Coverting to You may convert to a non-FEHB individual policy if: individual coverage Your coverage under TCC or the spouse equity law ends ( If you canceled your
coverage or did not pay your premium, you cannot convert) ;
You decided not to receive coverage under TCC or the spouse equity law; or

You are not eligible for coverage under TCC or the spouse equity law.
If you leave Federal service, your employing office will notify you of your right to convert. You must apply in writing to us within 31 days after you receive this notice.

However, if you are a family member who is losing coverage, the employing or retirement office will not notify you. You must apply in writing to us within 31 days
after you are no longer eligible for coverage.
Your benefits and rates will differ from those under the FEHB Program; however, you will not have to answer questions about your health, and we will not impose a waiting
period or limit your coverage due to pre-existing conditions.

Getting a Certificate of The Health Insurance Portability and Accountability Act of 1996 ( HIPAA) is a Federal
Group Health Plan Coverage law that offers limited Federal protections for health coverage availability and continuity to people who lose employer group coverage. If you leave the FEHB Program, we will

give you a Certificate of Group Health Plan Coverage that indicates how long you have been enrolled with us. You can use this certificate when getting health insurance or other
health care coverage. Your new plan must reduce or eliminate waiting periods, limitations, or exclusions for health related conditions based on the information in the
certificate, as long as you enroll within 63 days of losing coverage under this Plan. If you have been enrolled with us for less than 12 months, but were previously enrolled in
other FEHB plans, you may also request a certificate from those plans.
For more information, get OPM pamphlet RI 79-27, Temporary Continuation of Coverage ( TCC) under the FEHB Program. See also the FEHB web site
( www. opm. gov/ insure/ health) ; refer to the " TCC and HIPAA" frequently asked question.
These highlight HIPAA rules, such as the requirement that Federal employees must exhaust any TCC eligibility as one condition for guaranteed access to individual health

coverage under HIPAA, and have information about Federal and State agencies you can contact for more information. 49.
49 Page 50 51
2003 ConnectiCare Inc. 47 Long Term Care Insurance
Long Term Care Insurance Is Still Available!
Open Season for Long Term Care Insurance
You can protect yourself against the high cost of long term care by applying for insurance in the Federal Long Term Care Insurance Program.
Open Season to apply for long term care insurance through LTC Partners ends on December 31, 2002. If you' re a Federal employee, you and your spouse need only answer a few questions about your health during Open Season.
If you apply during the Open Season, your premiums are based on your age as of July 1, 2002. After Open Season, your premiums are based on your age at the time LTC Partners receives your application.

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

You Must Act to Receive an Application
Unlike other benefit programs, YOU have to take action you won t receive an application automatically. You must request one through the toll-free number or website listed below.
Open Season ends December 31, 2002 act NOW so you won t miss the abbreviated underwriting available to employees and their spouses, and the July 1 age freeze !

Find Out More Contact LTC Partners by calling 1-800-LTC-FEDS ( 1-800-582-3337) ( TDD for the hearing impaired: 1-800-843-3557) or visiting www. ltcfeds. com to get more information and to request an application. 50.
50 Page 51 52
2003 ConnectiCare Inc. 48 Index
Index
Do not rely on this page; it is for your convenience may not show all pages where the terms appear.
Accidental injury 28 Allergy tests 16
Alternative treatment 21 Allogenic ( donor) bone marrow
transplant 24 Ambulance 29
Anesthesia 25 Autologous bone marrow
transplant 24 Biopsies 22
Birthing centers 15 Blood and blood plasma 26
Breast cancer screening 14 Casts 26
Catastrophic protection 11 Changes for 2003 7
Chemotherapy 17 Childbirth 15
Chiropractic 20 Cholesterol tests 14
Circumcision 22 Claims 37
Coinsurance 11 Colorectal cancer screening 14
Congenital anomalies 22 Contraceptive devices and drugs 33
Coordination of benefits 39 Covered providers 8
Crutches 19 Deductible 11
Definitions 43 Diagnostic services 13
Disputed claims review 37 Donor expenses ( transplants) 25
Dressings 26 Durable medical equipment ( DME)
19 Educational classes and programs 21
Effective date of enrollment 45 Emergency 28

Experimental or investigational 43 Eyeglasses 18
Family planning 16 Fecal occult blood test 17
General Exclusions 35 Hearing services 18
Home health services 20 Hospice care 26
Home nursing care 20 Hospital 25
Immunizations 14 Infertility 16
Inhospital physician care 13 Inpatient Hospital Benefits 26
Insulin 33 Laboratory and pathological
services 14 Machine diagnostic tests 13
Magnetic Resonance Imagings ( MRIs) 14
Mail Order Prescription Drugs 32 Mammograms 14
Maternity Benefits 15 Medicaid 42
Medically necessary 43 Medicare 39
Mental Conditions/ Substance Abuse Benefits 30
Neurological testing 14 Newborn care 15
Nursery charges 15 Obstetrical care 15
Occupational therapy 17 Ocular injury 13
Office visits 13 Oral and maxillofacial surgery 24
Orthopedic devices 19 Ostomy and catheter supplies 20
Out-of-pocket expenses 11 Outpatient facility care 27

Oxygen 19 Pap test 14
Physical examination 14 Physical therapy 17
Physician 8 Precertification 10
Preventive care, adult 14 Preventive care, children 15
Prescription drugs 31 Preventive services 14
Prior approval 10 Prostate cancer screening 14
Prosthetic devices 19 Psychologist 30
Psychotherapy 30 Radiation therapy 14
Room and board 25 Skilled nursing facility care 26
Speech therapy 27 Splints 26
Sterilization procedures 23 Subrogation 42
Substance abuse 30 Surgery 22
Anesthesia 25 Oral 24
Outpatient 27 Reconstructive 23
Syringes 33 Temporary continuation of
coverage 46 Transplants 24
Treatment therapies 17 Vision services 18
Well child care 15 Wheelchairs 19
Workers compensation 42 X -rays 14 51.
51 Page 52 53
Summary of benefits for ConnectiCare, Inc. 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

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

Nothing
Day surgery, Nothing Walk-In, $ 20 copay
26-27

Emergency benefits:
In-area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Out-of-area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$ 40 per visit
$ 40 per visit

28
28
Mental health and substance abuse treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 10 copay outpatient 100% inpatient 30

Prescription drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 10 Generic $ 20 Name Brand Formulary
$ 35 Name Brand Non-Formulary Cost-sharing applies when generic is available
31-33

Dental Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No benefit.
Vision Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 10 Routine Exam, Discounts available on eyewear and contacts 18

Special features: Flexible benefits, services for deaf and hearing impaired,
ConnectiCare website, alternative treatments . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Nothing 34

Protection against catastrophic costs ( your out-of-pocket maximum) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . You must share the cost of some services. This is called either a copayment ( a set dollar
amount) or coinsurance ( a set percentage of charges) . Please remember you must pay this

amount when you receive services. All catastrophic costs are paid by the Plan. .

11

2003 ConnectiCare Inc. 49 Summary 52.
52 Page 53 54
Notes:
2003 ConnectiCare Inc. 50 Notes 53.
53 Page 54 55
Notes:
2003 ConnectiCare Inc. 51 Notes 54.
54 Page 55
2003 ConnectiCare, Inc. 52 Rate information
2003 Rate Information for
ConnectiCare, Inc.

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

Postal rates apply to career Postal Service employees. Most employees should refer to the FEHB Guide for
United States Postal Service Employees, RI 70-2. Different postal rates apply and a special FEHB guide is
published for Postal Service Inspectors and Office of Inspector General ( OIG) employees ( see RI 70-2IN) .

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

Type of
Enrollment Code

Non-Postal Premium
Biweekly Monthly
Gov' t Your Gov' t Your
Share Share Share Share

Postal Premium
Biweekly

USPS You
Share Share

All of Connecticut
High Option Self Only

High Option
Self & Family

TE1
TE2
$ 101.00 $ 33.67 $ 218.84 $ 72.95
$ 249.62 $ 103.05 $ 540.84 $ 223.28
$ 119.52 $ 15.15
$ 294.70 $ 57.97 55.

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