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Preferred Plus of Kansas

Federal Employees Health Benefits Program
2003 Plan Brochure
Accessible Version

Document Outline

Introduction
Plain Language
Stop Health Care Fraud! are retired.
Section 1. Facts about this HMO plan
Section 2. How we change for 2003
- Program-wide changes
  - Changes to this Plan
Section 3. How you get care get covered care
Section 4. Your costs for covered services
Section 5. Benefits
- Overview
Section 6. General exclusions -- things we don't cover
Section 7. Filing a claim for covered services
Section 8. The disputed claims process
Section 9. Coordinating benefits with other coverage
- When you have other health coverage
Section 10. Definitions of terms we use in this brochure
Section 11. FEHB facts
When you lose benefits
Long Term Care Insurance Is Still Available!
Index
Summary of benefits
2003 Rate

Pages 1--56

Page 1


Dear Federal Employees Health Benefits Program Participant: I am pleased to present this Federal Employees Health Benefits (FEHB) Program plan brochure for 2003. The brochure explains all the benefits this health plan offers to its enrollees. Since benefits can vary from year to year, you should review your plan's brochure every Open Season. Fundamentally, I believe that FEHB participants are wise enough to determine the care options best suited for themselves and their families. In keeping with the President's health care agenda, we remain committed to providing FEHB members with affordable, quality health care choices. Our strategy to maintain quality and cost this year rested on four initiatives. First, I met with FEHB carriers and challenged them to contain costs, maintain quality, and keep the FEHB Program a model of consumer choice and on the cutting edge of employer-provided health benefits. I asked the plans for their best ideas to help hold down premiums and promote quality. And, I encouraged them to explore all reasonable options to constrain premium increases while maintaining a benefits program that is highly valued by our employees and retirees, as well as attractive to prospective Federal employees. Second, I met with our own FEHB negotiating team here at OPM and I challenged them to conduct tough negotiations on your behalf. Third, OPM initiated a comprehensive outside audit to review the potential costs of federal and state mandates over the past decade, so that this agency is better prepared to tell you, the Congress and others the true cost of mandated services. Fourth, we have maintained a respectful and full engagement with the OPM Inspector General (IG) and have supported all of his efforts to investigate fraud and waste within the FEHB and other programs. Positive relations with the IG are essential and I am proud of our strong relationship. The FEHB Program is market-driven. The health care marketplace has experienced significant increases in health care cost trends in recent years. Despite its size, the FEHB Program is not immune to such market forces. We have worked with this plan and all the other plans in the Program to provide health plan choices that maintain competitive benefit packages and yet keep health care affordable. Now, it is your turn. We believe if you review this health plan brochure and the FEHB Guide you will have what you need to make an informed decision on health care for you and your family. We suggest you also visit our web site at www.opm.gov/insure.
		Sincerely, Kay Coles James Director

2
For changes in benefits, see
page 7.

-Preferred Plus of Kansas http:// www. phsystems. com 2003
A Health Maintenance Organization

Serving: Marion, Harvey, Kingman, Sedgwick, Butler, Sumner, Cowley, and Chautauqua Counties, in Kansas
Enrollment in this Plan is limited; see page 6 for requirements.

This plan has 3 years accreditation from JCAHO
Enrollment codes for this Plan:
VA1 Self Only VA2 Self and Family

RI 73-604 1.
1 Page 2 3
2.
2 Page 3 4
Notice of the Office of Personnel Management's
Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT
CAREFULLY.
By law, the Office of Personnel Management (OPM), which administers the Federal Employees Health Benefits (FEHB) Program, is required to protect the privacy of your personal medical information. OPM is also required to give you this notice to tell you how
OPM may use and give out (" disclose") your personal medical information held by OPM.
OPM will use and give out your personal medical information:
. To you or someone who has the legal right to act for you (your personal representative), .
To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is protected, . To law enforcement officials when investigating and/ or prosecuting alleged or civil or criminal actions, and

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

. For OPM and the General Accounting Office when conducting audits.
OPM may use or give out your personal medical information for the following purposes under limited circumstances:
. For Government healthcare oversight activities (such as fraud and abuse investigations), .
For research studies that meet all privacy law requirements (such as for medical research or education), and . To avoid a serious and imminent threat to health or safety.

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

information. . Get a listing of those getting your personal medical information from OPM in the past 6 years. The listing will not cover
your personal medical information that was given to you or your personal representative, any 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. 3.
3 Page 4 5
. Get a separate paper copy of this notice.
For more information on exercising your rights set out in this notice, look at www. opm. gov/ insure on the web. You may also call 202-606-0191 and ask for OPM's FEHB Program privacy official for this purpose.

If you believe OPM has violated your privacy rights set out in this notice, you may file a complaint with OPM at the following address:
Privacy Complaints Office of Personnel Management
P. O. Box 707 Washington, DC 20004-0707

Filing a complaint will not affect your benefits under the FEHB Program. You also may file a complaint with the Secretary of the Department of Health and Human Services.
By law, OPM is required to follow the terms in this privacy notice. OPM has the right to change the way your personal medical information is used and given out. If OPM makes any changes, you will get a new notice by mail within 60 days of the change. The
privacy practices listed in this notice will be effective April 14, 2003. 4.
4 Page 5 6
2003 Preferred Plus of Kansas Table of Contents 2
Table of Contents
Introduction................................................. 4
Plain Language............................................................... 4
Stop Health Care Fraud........... 5
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............................................................................................................... 9
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................................................................................................................ 32
(g) Dental benefits................................................................................................................................. 35
Section 6. General exclusions --things we don't cover.............................................................................................. 36 5.
5 Page 6 7
2003 Preferred Plus of Kansas Table of Contents 3
Section 7. Filing a claim for covered services ............................................................................................................ 37
Section 8. The disputed claims process 38
Section 9. Coordinating benefits with other coverage.. 40
When you have other health coverage. 40
. What is Medicare .. 40
. Medicare managed care plan.. 43
. TRICARE and CHAMPVA .................. 43
. Workers' Compensation 43
. Medicaid 43
Other Government agencies. 44
When others are responsible for injuries.. 44
Section 10. Definitions of terms we use in this brochure. 45
Section 11. FEHB facts 46
Coverage information.. . 46
. No pre-existing condition limitation ................................................................................................ 46
. Where you get information about enrolling in the FEHB Program.................................................. 46
. Types of coverage available for you and your family ...................................................................... 46
. Children's Equity Act ...................................................................................................................... 47
. When benefits and premiums start ................................................................................................... 47
. When you retire............................................................................................................................... 47
When you lose benefits ............................................................................................................................ 47
. When FEHB coverage ends ............................................................................................................. 47
. Spouse equity coverage................................................................................................................... 47
. Temporary Continuation of Coverage (TCC) ................................................................................. 48
. Converting to individual coverage .................................................................................................. 48
. Getting a Certificate of Group Health Plan Coverage..................................................................... 48
Long Term Care Insurance ........................................................................................................................ 50
Index ................................................................................................................................................................ 51
Summary of benefits .................................................................................................................................................... 52
Rates....... Back cover 6.
6 Page 7 8
2003 Preferred Plus of Kansas 4 Introduction/ Plain Language
Introduction
This brochure describes the benefits of Preferred Plus of Kansas, under our contract (CS 2667) with the Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. The address for Preferred Plus of Kansas'
administrative offices is:
Preferred Plus of Kansas 8535 E. 21 st North
Wichita, KS 67206
This brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations, and exclusions of this brochure. It is your responsibility to be informed about your health benefits.

If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled for Self and Family coverage, each eligible family member is also entitled to these benefits. You do not have a right to benefits that were available before
January 1, 2003, unless those benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2003, and are summarized on page 6. 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
Preferred Plus of Kansas.

. 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. 7.
7 Page 8 9
2003 Preferred Plus of Kansas 5 Health Care Fraud
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 employees 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.

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 your provider has charged you for services you did not receive, billed you twice for the same service, or
misrepresented any information, do the following:

Call the provider and ask for an explanation. There may be an error.
If the provider does not resolve the matter, call us at (316) 609-2390 or 1-800-660-8114 and explain the situation.
If we do not resolve the issue:

CALL THE HEALTH CARE FRAUD HOTLINE
202-418-3300

OR WRITE TO:
The United States Office of Personnel Management
Office of Inspector General Fraud Hotline
1900 E Street, NW, Room 6400
Washington, DC 20415

Do not maintain as a family member on your policy:
Your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise); or
Your child over age 22 (unless he/ she is disabled and incapable of self support).
If you have any questions about 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. 8.
8 Page 9 10
2003 Preferred Plus of Kansas 6 Section 1
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and other providers that contract with us. These Plan providers coordinate your health care services. The Plan is solely responsible for the selection of these
providers in your area. Contact the Plan for a copy of their most recent provider directory.
HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in addition to treatment for illness and injury. Our providers follow generally accepted medical practice when prescribing any course of treatment.

When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You only pay the copayments, 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?
Preferred Plus of Kansas is an individual practice prepayment (IPP) model HMO. As a member of Preferred Plus of Kansas, you will select a primary care doctor for yourself and each member of your family. Each member may designate his or her own primary care
doctor. You will be able to choose from a list of doctors located throughout the service area. Preferred Plus of Kansas has more than 300 primary care doctors in its Kansas service area and more than 1,100 referral specialists.

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.
. Preferred Plus of Kansas is licensed under the laws of Kansas, as a Health Maintenance Organization. .
Preferred Plus of Kansas was incorporated in 1991. . Preferred Plus of Kansas is a for-profit company.

If you want more information about us, call (316) 609-2390 or (800) 990-0345, or write to Preferred Health Systems, 8535 E. 21 st North, Wichita, KS 67206. You may also contact us by fax at (316) 609-2483, or visit our website at www. phsystems. com.
Service Area
To enroll in this plan, you must live or work in our Service Area. This is where our providers practice. Our service area is the following counties in Kansas: Marion, Harvey, Kingman, Sedgwick, Butler, Sumner, Cowley and Chautauqua.

You may also enroll with us if you live or work in the following places: The Kansas counties of Saline, Dickenson, Morris, McPherson, Chase, Reno, Harper, Greenwood and Elk.
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. We will not pay for any other health care services out of our service area unless the services have prior plan
approval.
If you or a covered family member moves outside of our service area, you 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 moves, you do not have to wait until Open Season to change plans. Contact your employing or retirement office. 9.
9 Page 10 11
2003 Preferred Plus of Kansas 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 decrease by {-8. 2%} for Self Only or {-3. 1%} for Self and Family.

. We changed outpatient speech therapy benefits by adding a $1500 per calendar year limit and by removing the 60 visit maximum and limiting it to $1, 500 per calendar year. (Section 5( a) ) See page 20

. We changed outpatient rehabilitation services by adding a $5000 per calendar year limit and by removing the 60 visit maximum and limiting it to $5, 000 per calendar year. (Section 5( a) ) See page 19
. We deleted the separate developmental therapy benefit for children under the age of 6.
. We added coverage for enteral nutrition (tube feeding). (Section 5( a) ) See page 22
. We removed the requirement for a written referral for an annual diabetic retinal eye examination. See page 20 10.
10 Page 11 12
2003 Preferred Plus of Kansas 8 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services from a Plan
provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits
enrollment confirmation (for annuitants), or your Employee Express confirmation letter.
If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at (316) 609-2390 or write to us at
Preferred Health Systems, 8535 E. 21 st Street, Wichita, Kansas 67206.

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

. Plan providers Plan providers are physicians and other health care professionals in our service area that
we contract with to provide covered services to our members. We credential Plan providers according to national standards.

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

It depends on the type of care you need. First, you and each family member must choose a primary care physician. This decision is important since your primary care physician
provides or arranges for most of your health care. A list of primary care providers can be reviewed in our provider directory for Preferred Plus of Kansas. You must complete a
physician selection form or you may call our Customer Services Department at (316) 609-2390, or (800) 660-8114.

. 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 physicians or if your primary care physician leaves the Plan, call us. We will help you select a new one.

. Specialty care Your primary care physician will refer you to a specialist for needed care. When you
receive a referral from your primary care physician, you must return to the primary care physician after the consultation, unless your primary care physician authorized a certain

number of visits without additional referrals. The primary care physician must provide or authorize all follow-up care. Do not go to the specialist for return visits unless your
primary care physician gives you a referral. However, you may see a contracting OB/ Gyn for an annual well-woman exam once a year or a contracting eye care provider
for an annual diabetic retinal eye examination without a referral, however, any follow-up care as a result of this visit does require primary care physician authorization.

Here are other things you should know about specialty care:
. If you need to see a specialist frequently because of a chronic, complex, or serious
medical condition, your primary care physician will develop a treatment plan that allows you to see your specialist for a certain number of visits without additional

referrals. Your primary care physician will use our criteria when creating your treatment plan (the physician may have to get an authorization or approval
beforehand).

What you must do to get covered care 11.
11 Page 12 13
2003 Preferred Plus of Kansas 9 Section 3
. 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 (316) 609-2390 or (800) 660-8114. If you are new to
the FEHB Program, we will arrange for you to receive care.
If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:

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

Circumstances beyond our control Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In that case, we will make all
reasonable efforts to provide you with the necessary care. 12.
12 Page 13 14
2003 Preferred Plus of Kansas 10 Section 3
Services requiring our prior approval Your primary care physician has authority to refer you for most services. For certain
services, however, your physician must obtain approval from us. Before giving approval, we consider if the service is covered, medically necessary, and follows generally
accepted medical practice.
we call this review and approval process, pre-certification. Your physician must obtain pre-certification for the following services:
. cardiac catheterization; .
durable medical equipment; . home IV services;

. hospice; .
inpatient hospitalizations; . matrix therapy;

. OB care; .
outpatient IV services; . out of the service area referrals;

. outpatient surgical procedures; .
pain management programs; . prosthetics;

. request for use of non-contracting provider; .
Weight loss program

It is the responsibility of the provider to receive precertification from us for the primary care physician authorized services. If the provider fails to pre-certify the services, he/ she
will be held responsible for the services. If you choose to seek any services without coordinating them with your primary care physician, you will be responsible for the costs
of the services. 13.
13 Page 14 15
2003 Preferred Plus of Kansas 11 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
. Copayments A copayment is a fixed amount of money you pay to the provider, facility pharmacy, etc..
when you receive services.

Example: When you see your primary care physician you pay a copayment of $10 per office visit and when you go in the hospital you pay $50 per day.

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

Your catastrophic protection out-of-pocket maximum We do not have an out of pocket maximum 14.
14 Page 15 16
2003 Preferred Plus of Kansas 12 Section 5
Section 5. Benefits OVERVIEW
(See page 7 for how our benefits changed this year and page 52 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 (316) 609-2390 or (800) 660-8114 or at our website at www. phsystems. 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
. Temporal Mandibular Joint (TMJ) Syndrome .
Organ/ tissue transplants . Anesthesia

(c) 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 ................................................................................................... 30-31
(f) Prescription drug benefits ............................................................................................................................... 32-34
(g) Dental benefits ...................................................................................................................................................... 35
Summary of benefits .................................................................................................................................................... 52 15.
15 Page 16 17
2003 Preferred Plus of Kansas 13 Section 5( a)
Section 5 (a) Medical services and supplies provided by physicians and other health care professionals
I M
P O
R T
A N
T

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

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

I M
P O
R T
A N
T

Benefit Description You pay

Diagnostic and treatment services
Professional services of physicians
. In physician's office

$10 per office 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

$10 per office visit

At home Nothing
Lab, X-ray and other diagnostic tests
Tests, such as:
. Blood tests
. Urinalysis
. Non-routine pap tests
. Pathology
. X-rays
. Non-routine Mammograms
. Cat Scans/ MRI
. Ultrasound
. Electrocardiogram and EEG

Nothing if you receive these services during your office visit;
otherwise, $10 per visit. 16.
16 Page 17 18
2003 Preferred Plus of Kansas 14 Section 5( a)
Preventive care, adult You Pay
Routine screenings, such as:
. Total Blood Cholesterol once every three years
. Colorectal Cancer Screening, including
. Fecal occult blood test
. Sigmoidoscopy, screening every five years starting at age 50

$10 per office visit

Prostate Specific Antigen (PSA test) one annually for men age 40 and older $10 per office visit
Routine pap test
Note: The office visit is covered if pap test is received on the same day; see Diagnosis and Treatment, above.
$10 per office visit

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

$10 per office visit

Dietitian services for up to 4 visits per member, per calendar year when authorized by your primary care doctor $10 per office visit
Routine immunizations, limited to:
. Tetanus-diphtheria (Td) booster once every 10 years, ages 19 and
over (except as provided for under Childhood immunizations)

. Influenza vaccines, annually
. Pneumococcal vaccine, age 65 and over

$10 per office visit

Not covered: Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, or travel. All charges
Preventive care, children
. Childhood immunizations recommended by the American Academy
of Pediatrics $10 per office visit

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

. Examinations, such as:
. Eye exams through age 17 to determine the need for vision
correction.

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

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

$10 per office visit 17.
17 Page 18 19
2003 Preferred Plus of Kansas 15 Section 5( a)
Maternity care You Pay
Complete maternity (obstetrical) care, such as:
. Prenatal care
. Delivery
. Postnatal care
. Prospective parents may receive authorization to select a primary
care physician for their unborn child and we will cover one visit to that physician prior to the birth of the child

Note: Here are some things to keep in mind:
. You do not need to precertify your normal delivery:
. 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. (Surgical benefits not maternity benefits apply to circumcision if this is the
case).
. We pay hospitalization and surgeon services (delivery) the same as
for illness and injury. See Hospital benefits (Section 5c) and Surgery benefits (Section 5b).

Nothing

. We cover childbirth classes from a participating hospital or
OB/ GYN up to a maximum benefit of $30. 50% of the charges up to a maximum Plan benefit of $30. You must submit proof of payment and

class completion to our Member Services Department.

Not covered: Routine sonograms to determine fetal age, size or sex All charges

Family planning
A broad range of voluntary family planning services, limited to:
. Voluntary sterilization (See Surgical procedures Section 5 (b)
. Surgically implanted contraceptives,
. Injectable contraceptive drugs, (such as Depo Provera)
. Intrauterine devices (IUDs)
. Diaphragms
NOTE: We cover oral contraceptives under the prescription drug benefit

$10 per office visit

Not covered: reversal of voluntary surgical sterilization, genetic counseling, or elective abortions All charges. 18.
18 Page 19 20
2003 Preferred Plus of Kansas 16 Section 5( a)
Infertility services You pay
Diagnosis and treatment of infertility, such as:
. Artificial insemination:
. intravaginal insemination (IVI)
. intracervical insemination (ICI)
. intrauterine insemination (IUI)
. Diagnostic services to establish the cause or reason for infertility,
including:

Medical evaluation limited to sperm counts
Hysterosalpingography
Endometrial biopsy
Counseling
Surgical correction of physiological abnormalities causing infertility

$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
. Fertility drugs and surrogate parenting

All charges.

Allergy care
Testing and treatment

. Allergy injection
Nothing

. Allergy serum Nothing
Not covered: provocative food testing and sublingual allergy desensitization All charges 19.
19 Page 20 21
2003 Preferred Plus of Kansas 17 Section 5( a)
Treatment therapies You pay
. Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed under

Organ/ Tissue Transplants on pages 19-20.
. Respiratory and inhalation therapy
. Dialysis hemodialysis and peritoneal dialysis
. Intravenous (IV)/ Infusion Therapy Home IV and antibiotic therapy
. Growth hormone therapy (GHT)
Note: We will only cover GHT when we preauthorize the treatment. Call 1-( 800)-424-0345 or (316) 609-2359 for preauthorization. We will

ask you to submit information that establishes if the GHT is medically necessary. Ask us to authorize GHT before you begin treatment;
otherwise, we will only cover GHT services from the date you submit the information. If you do not ask or if we determine GHT is not medically
necessary, we will not cover the GHT or related services and supplies. See Services requiring our prior approval in Section 3.

$10 per office visit

Physical and occupational therapies
. Outpatient services are limited to $5,000 per member, per calendar
year even if PCP renders such services:

. physical therapy
. occupational therapy
. spinal treatment and physical medicine modalities
. neuropsychological testing
. cardiac rehabilitation
. pulmonary rehabilitation
Note: We only cover therapy to restore bodily function when there has been total or partial loss of bodily function due to illness or injury.

$10 per office visit

Not covered:
. long-term rehabilitative therapy
. exercise programs

All charges 20.
20 Page 21 22
2003 Preferred Plus of Kansas 18 Section 5( a)
Speech therapy
. Coverage for speech therapy will be provided up to a maximum of
$1, 500 per member, per calendar year. $10 per visit

Hearing services (testing, treatment, and supplies)
. First hearing aid and testing only when necessitated by accidental
injury

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

$10 per office visit

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

Vision services (testing, treatment, and supplies)
. Lenses and Frames immediately following cataract surgery or cornea transplant surgery will be paid up to a maximum benefit of $150. All charges above our allowance

. Eye exam to determine the need for vision correction for children
through age 17 (see preventive care)

. Members may self-refer to a Contracting Provider for an annual
diabetic retinal eye examination.

$10 per office visit
$10 per office visit

Not covered:
. Eyeglasses or contact lenses. Eye examinations for persons over age
17

. 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 21.
21 Page 22 23
2003 Preferred Plus of Kansas 19 Section 5( a)
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.

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

. Internal prosthetic devices, such as artificial joints, pacemakers,
cochlear implants, and surgically implanted breast implant following mastectomy. Note: We pay internal prosthetic devices as

hospital benefits; see Section 5 (c) for payment information. See 5( b) for coverage of the surgery to insert the device.

. Orthopedic braces
. Shoes which are a part of a brace and custom fabricated shoe inserts
. One pair of orthopedic shoes per diabetic member, per calendar
year, for members who have documented peripheral vascular disease and/ or a peripheral neuropathy

Note: We will cover one standard appliance device per lifetime, unless repair/ replacement is medically necessary as a result of normal usage or
changes in condition.

Nothing

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

All charges.

Medical supplies
Two pair compression stockings per member, per calendar year Nothing

Not covered:
. over-the-counter bandages, gauze, and skin preparations All charges 22.
22 Page 23 24
2003 Preferred Plus of Kansas 20 Section 5( a)
Durable medical equipment (DME) You pay
Rental or purchase, at our option, including repair and adjustment, of durable medical equipment prescribed by your Plan physician, such as

oxygen and dialysis equipment. Under this benefit, we also cover:
. hospital beds;
. wheelchairs;
. crutches;
. walkers;
. blood pressure monitors;
. blood glucose monitors; and
. insulin pumps
. enteral nutrition (tube feeding) under the following conditions
. The medical record indicates the Member's medical condition has
existed longer than three months; and

. The Member has severe pathology of digestive tract, which does
not allow sufficient absorption of nutrients to maintain weight and strength

All charges over the $1, 000 yearly benefit maximum.

Not covered: . Motorized wheel chairs All charges.
Disposable Medical Supplies You pay Members may be reimbursed up to $500 per person per calendar year
with proof of purchase for specific disposable supplies when prescribed by the primary care physician. Covered disposable supplies are limited
to supplies relating to the care of:
. An ostomy (appliance pouches, skin care agents, support belts .
An open wound (gauze pads, wound packing strips, ABD pads); . A venous access catheter (alcohol pads, benzoin, OP site);

. Supplies used in conjunction with covered Durable Medical
Equipment; . Urinary supplies limited to catheters, bags and related supplies; and

. Tracheostomy supplies.

All charges above $500 per person per calendar year

Home health services You pay
. Home health care ordered by a Plan physician and provided by a
registered nurse (R. N.), licensed practical nurse (L. P. N.), licensed vocational nurse (L. V. N.), or home health aide.

. Services include oxygen therapy, intravenous therapy and
medications.

$10 per visit 23.
23 Page 24 25
2003 Preferred Plus of Kansas 21 Section 5( a)
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 You pay
. Manipulation of the spine and extremities
. Adjunctive procedures such as ultrasound, electrical muscle
stimulation, vibratory therapy, and cold pack application

Note: These services require primary care physician authorization.

$10 per office visit

Alternative treatments
Not covered: any alternative treatment not shown as covered, including, but not limited to:

. Naturopathic services . Hypnotherapy
. Biofeedback .
music therapy
. guided imagery . therapeutic touch

. aroma therapy . acupressure
. reflexology . cranio-sacred therapy
. acupuncture

All Charges

Educational classes and programs
Coverage is limited to:

. Smoking cessation when prescribed as part of a mental health treatment plan

. Diabetes self-management
Outpatient self management training, and education for diabetics is covered if treated in an approved program, and such treatment is rendered by a
person certified by the National Certification Board of Diabetic Educators.

Nothing 24.
24 Page 25 26
2003 Preferred Plus of Kansas 22 Section 5( b)
5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
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Here are some important things to keep in mind about these benefits:
. Please remember that all benefits are subject to the definitions, limitations, and exclusions in this
brochure and are payable only when we determine they are medically necessary.

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

. The amounts listed below are for the charges billed by a physician or other health care
professional for your surgical care. Look in Section 5( c) for charges associated with the facility (i. e. hospital, surgical center, etc.).

. YOUR PHYSICIAN MUST GET PRECERTIFICATION OF SOME SURGICAL
PROCEDURES. Please refer to the pre-certification information shown in Section 3 to be sure which services require pre-certification and identify which surgeries require pre-certification.

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Benefit Description You pay
Surgical procedures
A comprehensive range of services, such as:
. Operative procedures
. Treatment of fractures, including casting .
Normal pre-and post-operative care by the surgeon . Correction of amblyopia and strabismus

. Endoscopy procedures .
Biopsy procedures . Removal of tumors and cysts

. Correction of congenital anomalies (see reconstructive surgery) .
Surgical treatment of morbid obesity --a condition in which an individual weighs 100 pounds or 100% over his or her normal

weight according to current underwriting standards; eligible members must be age 18 or over
. Insertion of internal prosthetic devices. See 5( a) Orthopedic and
prosthetic devices for device coverage information.

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

pacemaker and Surgery benefits for insertion of the pacemaker.

$10 per office visit; nothing for hospital visits.

. 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

Surgical procedures-Continued on next page. 25.
25 Page 26 27
2003 Preferred Plus of Kansas 23 Section 5( b)
Surgical procedures (Continued) You pay
Not covered: . Reversal of voluntary sterilization

. Routine treatment of conditions of the foot; see Foot care.
All charges.

Reconstructive surgery . Surgery to correct a functional defect
. Surgery to correct a condition caused by injury or illness if:
. the condition produced a major effect on the member's
appearance and

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

. Surgery to correct a condition that existed at or from birth and is a
significant deviation from the common form or norm. Examples of congenital anomalies are: protruding ear deformities; cleft lip; cleft

palate; 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

Oral and maxillofacial surgery
Oral surgical procedures, limited to: . Reduction of fractures of the jaws or facial bones;

. Surgical correction of cleft lip, cleft palate or severe functional
malocclusion; . Removal of stones from salivary ducts;

. Excision of leukoplakia or malignancies; .
Excision of cysts and incision of abscesses when done as independent procedures; and

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

$10 per visit

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

. Services performed by a dentist unless specified in section 5g 26.
26 Page 27 28
2003 Preferred Plus of Kansas 24 Section 5( b)
Temporal Mandibular Joint Syndrome (TMJ) You Pay
Coverage for TMJ is provided for examinations, diagnostic x-rays and testing to diagnose the condition. If the diagnosis is organic in

nature (fracture, tumor, arthritis) then treatment of the condition will be covered including appliances; as the condition is non-dental in
origin.

$10.00 per office visit

Not covered:
Non-organic conditions
All Charges

Organ/ tissue transplants
Limited to:
. Cornea
. Heart
. Heart/ lung
. Kidney
. Kidney/ Pancreas
. Liver
. Lung: Single Double
. Pancreas
. Allogenic (donor) bone marrow transplants

. Autologous bone marrow transplants (autologous stem cell and
peripheral stem cell support) for the following conditions: acute lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's

lymphoma; advanced non-Hodgkin's lymphoma; advanced neuroblastoma; breast cancer; multiple myeloma; epithelial ovarian
cancer; and testicular, mediastinal, retroperitoneal and ovarian germ cell tumors

. Intestinal transplants (small intestine) and the small intestine with
the liver or small intestine with multiple organs such as the liver, stomach, and pancreas.

. National Transplant Program (NTP) -United Resource Network
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. We also cover transportation costs for the
member and a companion when the member resides more than 50 miles from the transplant site and if the transplant is performed outside our
service area. We define transportation costs as commercial transportation for the member receiving the transplant, and a
companion, to and from the site of the transplant. We also cover reasonable and necessary lodging and meal costs of the member and
companion beginning 24 hours prior to the hospitalization and 48 hours after discharge. We cover transportation, lodging and meals up to $125
per day up to a maximum benefit of $2, 000.

$10 per office visit

Organ/ tissue transplants continued on next page 27.
27 Page 28 29
2003 Preferred Plus of Kansas 25 Section 5( b)
Organ/ tissue transplant (Continued) 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 center
. Office

$10 per visit 28.
28 Page 29 30
2003 Preferred Plus of Kansas 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

Section 5( a) or (b).
. YOUR PHYSICIAN MUST GET PRECERTIFICATION OF HOSPITAL STAYS. Please refer to Section 3 to be sure which services require pre-certification.

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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.

$50 per day up to a $500 maximum per person per
calendar year and a $1,000 maximum per family per
calendar year

Other hospital services and supplies, such as: . Operating, recovery, maternity, and other treatment rooms
. Prescribed drugs and medicines .
Diagnostic laboratory tests and X-rays . Administration of blood and blood products

. Blood or blood plasma, if not donated or replaced .
Dressings, splints, casts, and sterile tray services . Medical supplies and equipment, including oxygen

. Anesthetics, including nurse anesthetist services .
Take-home items . Medical supplies, appliances, medical equipment, and any covered

items billed by a hospital for use at home

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 Preferred Plus of Kansas 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

Not covered: blood and blood derivatives not replaced by the member All charges
Extended care benefits/ skilled nursing care facility benefits We cover all necessary services with no dollar or day limit, including:

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

Nothing

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

Nothing

Not covered: Independent nursing, and homemaker services All charges
Ambulance
. Ambulance service when medically appropriate Nothing 30.
30 Page 31 32
2003 Preferred Plus of Kansas 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 subject to the definitions, limitations, and exclusions
in this brochure.

. We have no deductible.
. Be sure to read Section 4, Your costs for covered services for valuable information about
how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

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

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

What to do in case of emergency:
Emergencies within our service area: If you are in an emergency situation, please call your primary care doctor. In extreme emergencies, if you are unable to contact your doctor, contact the local emergency system (e. g., the 911
telephone system) or go to the nearest hospital emergency room. Be sure to tell the emergency room personnel that you are a Plan member so they can notify us. You or a family member should notify us within 48 hours. It is your
responsibility to ensure that we have been timely notified. We can be reached by phone at (316) 609-2390, or (800) 660-8114.

If you need to be hospitalized, we must be notified within 48 hours or on the first working day following your admission, unless it was not reasonably possible to notify us within that time. If you are hospitalized in non-Plan
facilities and Plan doctors believe care can be better provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges covered in full.

Benefits are available for care from non-Plan providers in a medical emergency only if delay in reaching a Plan provider would result in death, disability or significant jeopardy to your condition. To be covered by this Plan, any follow-up
care recommended by non-Plan providers must be approved by the Plan or provided by Plan providers.
Emergencies outside the 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, we must be notified within
48 hours or on the first working day following your admission, unless it was not reasonably possible to notify us 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. 31.
31 Page 32 33
2003 Preferred Plus of Kansas 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
$10 per visit

. Emergency care as an outpatient or inpatient at a hospital,
including doctors' services $50 per visit (copay is waived if admitted)

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
$10 per visit

. Emergency care as an outpatient or inpatient at a hospital, including
doctors' services $50 per visit (copay is waived if admitted)

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
Ambulance service when medically appropriate including, air ambulance

See 5( c) for non-emergency service.
Nothing 32.
32 Page 33 34
2003 Preferred Plus of Kansas 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.

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Benefit Description You pay
Mental health and substance abuse benefits
All diagnostic and treatment services recommended by a Plan provider and contained in a treatment plan that we approve. The treatment plan

may include services, drugs, and supplies described elsewhere in this brochure.

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

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

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

. Medication management
. Smoking cessation is covered when part of a behavioral modification
program

. Cognitive Therapy when prescribed as part of a mental health program

(including, but not limited to):

. behavioral training

. educational testing and training
. dyslexia testing
. learning disabilities and/ or
. mental retardation
. Diagnostic tests

$10 per office visit

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

$50 per day up to $500 per person per calendar year and
$1, 000 per family per calendar year 33.
33 Page 34 35
2003 Preferred Plus of Kansas 31 Section 5( e)
Mental health and substance abuse benefits -Continued
Mental health and substance abuse benefits (Continued) You pay

Not covered: Services not approved in advance by Preferred Health Systems

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.

Pre-authorization
To be eligible to receive these benefits you must obtain a treatment plan and follow all of the following authorization processes:

All services for mental conditions/ substance abuse benefits must be coordinated by Preferred Health Systems prior to receiving services. Please contact Preferred Health Systems at 316/ 609-2541 in Wichita or 1/ 866/ 338-4281 outside of
Wichita.

Limitation
We may limit your benefits if you do not obtain a treatment plan. 34.
34 Page 35 36
2003 Preferred Plus of Kansas 32 Section 5( f)
Section 5 (f). Prescription drug benefits
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Here are some important things to keep in mind about these benefits:
. We cover prescribed drugs and medications, as described in the chart beginning on the
next page.

. All benefits are subject to the definitions, limitations and exclusions in this brochure and
are payable only when we determine they are medically necessary.

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

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There are important features you should be aware of. These include:
. Who can write your prescription. A licensed physician must write the prescription
. Where you can obtain them. You must fill the prescription at a plan pharmacy, or by mail for a
maintenance medication.

. These are the dispensing limitations. A generic equivalent will be dispensed if it is available,
unless your physician specifically requires a brand name. If you receive a brand name drug when a Federally-approved generic drug is available, and your physician has not specified Dispense as

Written for the brand name drug, you have to pay the difference in cost between the brand name drug and the generic as well as the copayment.

. Participating Retail Pharmacy: Covered prescriptions are limited to a 34 day supply as specified
by the quantity sufficient for a standard course of therapeutic treatment as defined by FDA guideline, or 100 unit dose of tablets or capsules whichever is less. Covered prescriptions for

erectile dysfunction are limited to an eight (8) unit dose per 34 day supply. Oral Contraceptives may be dispensed in a three month supply, however, a co-payment is required for each months
supply. If we authorize an exception to the dispensing limitation, each supply given will be subject to a co-payment.

Participating Mail Order or Internet Pharmacy (Express Scripts): Covered prescriptions are limited to a 90 day supply, as specified by the quantity sufficient for a standard course of therapeutic
treatment as defined by FDA guideline, except as follows:
. Covered narcotic prescriptions, except Ritalin, are limited to a 34 day supply or a 100 dose of
tablets or capsules, whichever is less.

. Covered prescriptions for erectile dysfunction are limited to a twenty-four (24) unit dose per 90
day supply.

. Why use generic drugs? Generic drugs are lower-priced drugs that are the therapeutic equivalent to
more expensive brand-name drugs. They must contain the same active ingredients and must be equivalent in strength and dosage to the original brand-name product. Generics cost less than the

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

money.
. When you have to file a claim. The pharmacy will file the claim for you. If you have a situation
where the pharmacy is unable to file the claim for your prescription, contact our Member Service Department at (316) 609-2390 or (800) 660-8114, and ask them to send you a prescription

reimbursement form. 35.
35 Page 36 37
2003 Preferred Plus of Kansas 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, with a copay charge applied to each vial .
Disposable needles and syringes for the administration of covered medications

. Contraceptive drugs and devices .
Oral contraceptive drugs -up to a three-cycle supply may be obtained at one time with a copay charge applied to each cycle.

. Contraceptive devices, such as diaphragms and IUD's
Diabetic supplies, including syringes, diagnostic strips, alcohol swabs and lancets. Diagnostic strips will be subject to the name brand

copayment. All other diabetic supplies will be subject to the generic copayment.
. Intravenous fluids and medication for home use, implantable drugs,
such as Norplant and some injectable drugs, such as Depo Provera are covered under Medical and Surgical Benefits.

. Drugs to treat sexual dysfunction are limited to an 8 unit dose per 34-day
supply and a 24 unit dose per 90-day supply

$5 copay per generic prescription retail.
$15 copay per brand name prescription retail
$12 copay per generic mail-order prescription and $40 copay per
brand name mail order prescription

When generic substitution is permissible (i. e., a generic drug is
available and the prescribing doctor does not require the use of
a brand name drug), but you request the brand name drug, you
pay the difference between the generic and brand name drug as
well as the $15 copay
Note: If there is no generic equivalent available, you will still

have to pay the brand name copay.

Here are some things to keep in mind about our prescription drug program:
. Medications requiring pre-authorization include: Adderal, Dexedrine and
Desoxyn; Oral Anabolic Steroids; Medications to treat acne for persons over the age of 30 including, but not limited to, Retin-A, Accutane, and Differin;

Hormone suppositories and powders; Anti-fungal medication including, but not limited to, Lamisil or Sporanox; and Wellbutrin SR/ 150 mg. 36.
36 Page 37 38
2003 Preferred Plus of Kansas 34 Section 5( f)
Not covered:
. Drugs and supplies for cosmetic purposes
. Vitamins, nutrients and food supplements even if a physician
prescribes or administers them

. Drugs available without a prescription or for which there is a
nonprescription equivalent available.

. Drugs obtained at a non-Plan pharmacy except for out-of-area
emergencies.

. Medical supplies such as dressings and antiseptic.
. Drugs to enhance athletic performance.
. Drugs to aid in smoking cessation, including nicotine patches.
. Fertility drugs.
. Appetite suppressants, except for treatment of morbid obesity.

All Charges 37.
37 Page 38 39
2003 Preferred Plus of Kansas 35 Section 5( g)
Section 5 (g). Dental benefits
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 dentists must provide or arrange your care.
. We cover hospitalization for dental procedures only when a nondental physical impairment
exists which makes hospitalization necessary to safeguard the health of the patient; See Section 5 (c) for inpatient hospital benefits. We do not cover the dental procedure unless it is

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

I M
P O
R T
A N
T

Accidental injury benefit You pay
We cover restorative services and supplies necessary to promptly repair sound natural teeth. The need for these services must result from an

accidental injury. A treatment plan must be submitted to and approved by the Health Plan within 30 days of the date of injury. If a member is
in the process of receiving such treatment on the effective date of coverage, the Health Plan will continue to cover services if the
treatment plan is submitted and approved by the Health Plan within 30 days of the member's effective date.

$10 copay per office visit

Dental benefits
We cover the administration of general anesthetic and hospital inpatient charges (not the dental procedure) when we determine it to be medically

necessary for dental care for the following persons:
. Dependent children five years of age or under; or
. A member who is severely disabled; or
. A member who has a medical or behavioral condition which
requires hospitalization or general anesthesia when dental care is provided.

Subject to applicable Physician Office Visit Copayment and/ or
Inpatient Copayments

We have no other dental benefits. 38.
38 Page 39 40
2003 Preferred Plus of Kansas Section 6 36
Section 6. General exclusions --things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not cover it unless your Plan doctor determines it is medically necessary to prevent, diagnose, or treat your illness, disease, injury,
or condition.
We do not cover the following:
. Care by non-Plan providers except for authorized referrals or emergencies (see Emergency Benefits);
. Services, drugs, or supplies you receive while you are not enrolled in this Plan;
. Services, drugs, or supplies that are not medically necessary;
. Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice;
. Experimental or investigational procedures, treatments, drugs or devices;
. Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus
were carried to term or when the pregnancy is the result of an act of rape or incest;

. Services, drugs, or supplies related to sex transformations
. Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program; or

. Services, drugs, or supplies you receive without charge while in active military service. 39.
39 Page 40 41
2003 Preferred Plus of Kansas 37 Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at Plan pharmacies, you will not have to file claims. Just present your identification card and pay your copayment.

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

Medical, hospital, drug benefits In most cases, providers and facilities file claims for you. Physicians must file on the form HCFA-1500, Health Insurance Claim Form. Facilities will file on the UB-92 form.
For claims questions and assistance, call us at 1-( 800)-660-8114 or 316-( 609)-2390.
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: Preferred Health Systems, 8535 E. 21 st North, Wichita, Kansas 67206

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. 40.
40 Page 41 42
2003 Preferred Plus of Kansas 38 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: 8535 E. 21 st Street North, Wichita, Kansas 67206; and
(c) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure; and

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

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

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

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

Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Contracts Division 3, 1900 E Street, NW, Washington, DC 20415-3630. 41.
41 Page 42 43
2003 Preferred Plus of Kansas 39 Section 8
The Disputed Claims Process (Continued)
Send OPM the following information:
. A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;
. Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and
explanation of benefits (EOB) forms;

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

Note: If you want OPM to review more than one claim, you must clearly identify which documents apply to which claim.

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

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)-424-0345 or (316)-609-2359; 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 Benefits Contracts Division 3 at 202/ 606-0737 between 8 a. m. and 5 p. m. eastern time. 42.
42 Page 43 44
2003 Preferred Plus of Kansas 40 Section 9
Section 9. Coordinating benefits with other coverage
When you have other health coverage You must tell us if you or a covered or a family member have coverage under another group health plan or have automobile insurance that pays health care expenses without
regard to fault. This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in full as the primary payer and the other plan pays a reduced benefit as the secondary payer. We, like
other insurers, determine which coverage is primary according to the National Association of Insurance Commissioners' guidelines.

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

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

Medicare has two parts:
. Part A (Hospital Insurance). Most people do not have to pay for Part A. .If you or your spouse
worked for at least 10 years in Medicare-covered employment, you should be able to qualify for premium-free Part A insurance. (Someone who was a Federal employee

on January 1, 1983 or since automatically qualifies.) Otherwise, if you are age 65 or older, you may be able to buy it. Contact 1-800-MEDICARE for more information.

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

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

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

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 primary care physician, or precertified as required.

(Part A or Part B) 43.
43 Page 44 45
2003 Preferred Plus of Kansas 41 Section 9
Claims process when you have the Original Medicare Plan --You probably will never have to file a claim form when you have both our Plan and the Original Medicare Plan.
. When we are the primary payer, we process the claim first.
. When Original Medicare is the primary payer, Medicare processes your claim first.
In most cases, your claims will be coordinated automatically and we will 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 (316) 609-2390 or 1-(800)-660-8114 or locate us at www. phsystems. com.

We do not waive any costs if the Original Medicare is your primary payer.
(Primary payer chart begins on next page.) 44.
44 Page 45 46
2003 Preferred Plus of Kansas 42 Section 9
The following chart illustrates whether the Original Medicare Plan or this Plan should be the primary payer for you according to your employment status and other factors determined by Medicare. It is critical that you tell us if you or a covered family member
has Medicare coverage so we can administer these requirements correctly.
Primary Payer Chart
Then the primary payer is A. When either you --or your covered spouse --are age 65 or over and

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

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

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

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

your covered spouse is this type of judge),
5) Are enrolled in Part B only, regardless of your employment status, (for Part B
services)

(for other services)

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

(except for claims related to Workers'

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

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

c) Are a former spouse of an annuitant, or
d) Are a former spouse of an active employee 45.
45 Page 46 47
2003 Preferred Plus of Kansas 43 Section 9
. Medicare managed care plan If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare managed care plan. These are health care choices (like HMOs)
in some areas of the country. In most Medicare managed care plans, you can only go to doctors, specialists, or hospitals that are part of the plan. Medicare managed care plans
provide all the benefits that Original Medicare covers. Some cover extras, like prescription drugs. To learn more about enrolling in a Medicare managed care plan,
contact Medicare at 1-800-MEDICARE (1-800-633-4227) or at www. medicare. gov.

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

Suspended FEHB coverage to enroll in a Medicare managed care plan: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in a Medicare
managed care plan, eliminating your FEHB premium (OPM does not contribute to your Medicare managed care plan premium). For information on suspending your FEHB
enrollment, contact your retirement office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next open season unless you involuntarily
lose coverage or move out of the Medicare managed care plan's service area.
If you do not have one or both Parts of Medicare, you can still be covered under the FEHB Program. We will not require you to enroll in Medicare Part B and, if you can't
get premium-free Part A, we will not ask you to enroll in it.

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

Workers' Compensation We do not cover services that:
. 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.

. If you do not enroll in
Medicare Part A or Part B 46.
46 Page 47 48
2003 Preferred Plus of Kansas 43 Section 9
Suspended FEHB coverage to enroll in Medicaid or a similar State-sponsored program of medical assistance: If you are an annuitant or former spouse, you can
suspend your FEHB coverage to enroll in a one of these State programs, eliminating your FEHB premium. For information on suspending your FEHB enrollment, contact your
retirement office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage under the State
program.

When other Government agencies We do not cover services and supplies when a local, State, are responsible for your care or Federal Government agency directly or indirectly pays for them.
When others are responsible for injuries When you receive money to compensate you for medical or hospital care for injuries or
illness caused by another person, you must reimburse us for any expenses we paid. However, we will cover the cost of treatment that exceeds the amount you received in the
settlement.
If you do not seek damages you must agree to let us try. This is called subrogation. If you need more information, contact us for our subrogation procedures. 47.
47 Page 48 49
2003 Preferred Plus of Kansas 44 Section10
Section 10. Definitions of terms we use in this brochure
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on December 31 of the same
year.

Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 9

Covered services Care we provide benefits for, as described in this brochure.
Experimental or If a service has not been approved by the Federal Drug Administration investigational services (FDA) or is labeled experimental or investigational on the protocol, the Plan considers
the service experimental or investigational.

Medical necessity Means a service or item (intervention) that is delivered or undertaken primarily to prevent, diagnose, treat or palliate a disease, illness or injury, genetic or congenital
defect, pregnancy, or psychological condition that lies outside the range of normal, age appropriate human variation.
Interventions must be: . Effective for the patient's medical condition and indications, which is determined by
scientific evidence consisting primarily of controlled clinical trails that demonstrate the effect of the intervention on health outcomes. If clinical trails have not been
conducted, effectiveness is evaluated on the basis of professional standards of care or expert opinion.
. Expected to produce the intended results and have expected outcomes that outweigh
potential harmful effects. . Measurable by positive changes in the patient's health status as determined by length

or quality of life. . Appropriate for the patient's medical condition and indications. The expected
outcome relative to cost must represent an economically efficient use of resources. . Performed in the proper setting, at the proper time, in the proper amounts, and by the
proper provider of care relative to the patient's condition. . Recommended by the PCP and treating physician and determined by the Health Plan
medical director to meet the above criteria.

Us/ We Us and we refer to Preferred Plus of Kansas
You You refers to the enrollee and each covered family member. 48.
48 Page 49 50
2003 Preferred Plus of Kansas 46 Section 11
Section 11. FEHB facts
No pre-existing condition We will not refuse to cover the treatment of a condition that you had limitation before you enrolled in this Plan solely because you had the condition before you
enrolled.
Where you can get information See www. opm. gov/ insure. Also, your employing or retirement office about enrolling in the can answer your questions, and give you a Guide to Federal Employees

FEHB Program Health Benefits Plans, brochures for other plans, and other materials you need to make an informed decision about your FEHB coverage. These materials tell
you:
. When you may change your enrollment;
. How you can cover your family members;
. What happens when you transfer to another Federal agency, go on leave without pay, enter military service, or retire;

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

retirement office.

Types of coverage available Self Only coverage is for you alone. Self and Family coverage is for for you and your family you, your spouse, and your unmarried dependent children under age 22,
including any foster children or stepchildren your employing or retirement office authorizes coverage for. Under certain circumstances, you may also continue
coverage for a disabled child 22 years of age or older who is incapable of self-support.

If you have a Self Only enrollment, you may change to a Self and Family enrollment if you marry, give birth, or add a child to your family. You may
change your enrollment 31 days before to 60 days after that event. The Self and Family enrollment begins on the first day of the pay period in which the child is
born or becomes an eligible family member. When you change to Self and Family because you marry, the change is effective on the first day of the pay
period that begins after your employing office receives your enrollment form; 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. 49.
49 Page 50 51
2003 Preferred Plus of Kansas 47 Section 11
Children's Equity Act OPM has implemented the Federal Employees Health Benefits Children's Equity Act of 2000. This law mandates that you be enrolled for self and family
coverage in the Federal Employees Health Benefits (FEHB) Program, iif you are an employee subject to a court or administrative order requiring you to provide
health benefits for your child( ren).

If this law applies to you, you must enroll for self and family coverage in a health plan that provides full benefits in the area where your children live or
provide documentation to your employing office that you have obtained other health benefits coverage for your children. If you do not do so, your employing
office will enroll you involuntarily as follows:
If you have no FEHB coverage, your employing office will enroll you for
self and family coverage in the option of the Blue Cross and Blue Shield Benefit Plan that provides the lower level of coverage;

If you have self only enrollment in a fee-for-service plan or in an HMO that
serves the area where your children live, your employing offic will change your enrollment to self and family in the same option of 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 your employing office for further information.

When benefits and The benefits in this brochure are effective on January 1. If you joined this Plan during premiums start 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 the
coverage.

When you retire When you retire, you can usually stay in the FEHB Program. Generally, you must have been enrolled in the FEHB Program for the last five years of your Federal service. If you
do not meet this requirement, you may be eligible for other forms of coverage, such as temporary continuation of coverage (TCC).

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

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

. Spouse equity If you are divorced from a Federal employee or annuitant, you may not coverage continue to get benefits under your former spouse's enrollment. This is the case
even when the court has ordered your former spouse to supply health coverage to you. But, you may be eligible for your own FEHB coverage under the spouse
equity law or Temporary Continuation of Coverage (TCC). If you are recently divorced or are anticipating a divorce, contact your ex-spouse's employing or 50.
50 Page 51 52
2003 Preferred Plus of Kansas 48 Section 11
retirement office to get RI 70-5, the Guide to Federal Employees Health Benefits Plans for Temporary Continuation of Coverage and Former Spouse
Enrollees, or other information about your coverage choices. You can also download the guide from OPM's website, www. opm. gov/ insure.

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

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

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

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

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

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

For more information get OPM pamphlet RI 79-27, Temporary Continuation of Coverage (TCC) under the FEHB Program. See also the FEHB web site
(www. opm. gov/ insure/ health); refer to the "TCC and HIPAA" frequently asked questions. These highlight HIPAA rules, such as the requirement that Federal
employees must exhaust any TCC eligibility as one condition for guaranteed 51.
51 Page 52 53
2003 Preferred Plus of Kansas 49 Section 11
access to individual health coverage under HIPAA, and has information about Federal and State agencies you can contact for more information. 52.
52 Page 53 54
2003 Preferred Plus of Kansas 50 Long Term Care
Long Term Care Insurance Is Still Available!
Open Season The Federal Long Term Care Insurance Program's open season for enrollment ends on December 31, 2002. If you're a Federal employee, this is the chance for you and your
spouse to apply by answering only a few questions about your health.

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

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

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

Find Out More Call 1-800-LTC-FEDS (1-800-582-3337) or visit www. ltcfeds. com to get more information and to 53.
53 Page 54 55
2003 Preferred Plus of Kansas 51 Index
Index Do not rely on this page; it is for your convenience and may not show all pages where the terms appear.
Accidental injury 35 Allergy tests 16
Allogenetic (donor) bone marrow transplant 24
Alternative treatment 21 Ambulance 27

Anesthesia 25 Autologous bone marrow transplant
24 Biopsy 22
Blood and blood plasma 26 Casts 26
Changes for 2003 7 Chemotherapy 17
Childbirth 15 Chiropractic 21
Cholesterol tests 14 Claims 37
Cognitive Therapy 30
Colorectal cancer screening 14 Compression Stockings 19

Congenital anomalies 22 Contraceptive devices and drugs 15,33
Coordination of benefits 40 Covered providers 8
Crutches 20 Definitions 44
Dental care 35 Diagnostic services 13
Disposable medical supplies 20
Disputed claims review 38 Donor expenses (transplants 25

Dressings 27 Durable medical equipment (DME)
20 Educational classes and programs 21
Effective date of enrollment 46 Emergency 28

Experimental or investigational 36
Eyeglasses 18 Family planning 15
Fecal occult blood test 14 Fraud 5

General Exclusions 36
Hearing services 18 Home health services 20

Hospice care 27 Home nursing care 21
Hospital 26 Immunizations 14
Infertility 16 In-hospital physician care 26
Inpatient Hospital Benefits 26 Insulin 33
Laboratory and pathological services 13
Machine diagnostic tests 13 Magnetic Resonance Imagings (MRIs)
13 Mail Order Prescription Drugs 32
Mammograms 14 Maternity Benefits 15
Medicaid 43 Medicare 40
Mental Conditions/ Substance Abuse Benefits 30
Newborn care 15 Obstetrical care 15
Occupational therapy 17 Office visits 13
Oral and maxillofacial surgery 23 Orthopedic devices 19
Ostomy and catheter supplies 20
Out-of-pocket expenses 11 Outpatient facility care 27

Oxygen 20 Pap test 14
Physical examination 14 Physical therapy 17
Precertification 10 Preventive care, adult 14
Preventive care, children 14 Prescription drugs 32
Preventive services 14 Prior approval 10
Prostate cancer screening 14 Prosthetic devices 19
Radiation therapy 17 Renal dialysis 17
Room and board 26 Second surgical opinion 13
Skilled nursing facility care 27 Smoking cessation 30, 34
Speech therapy 18 Sterilization procedures 15
Substance abuse 30 Surgery 22
. Anesthesia 25 . Oral 23
. Outpatient 27 . Reconstructive 23
Syringes 33 Temporary continuation of coverage
47 Transplants 24
Treatment therapies 17
Vision services 18
Well child care 14 Wheelchairs 20

Workers' compensation 43 X-rays 13 54.
54 Page 55 56
2003 Preferred Plus of Kansas 52 Summary
Summary of benefits for the Preferred Plus of Kansas -2002
. 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 .........................................................................................

$50 copay per day up to $500 maximum per person per calendar
year/$ 1, 000 maximum per family

Nothing

26
27
Emergency benefits:
. In-area..............................................................................................

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

$50 per visit

28
29
Mental health and substance abuse treatment ....................................... Regular cost sharing 30
Prescription drugs ................................................................................. $5 generic copay; $15 name brand copay; $12 generic mail-order
copay; $40 name brand mail order copay
32

Dental Care ....................................................................................... Accidental injury benefit; $10 copay per visit 35
Vision Care ....................................................................................... No benefit. 18 55.
55 Page 56
2003 Preferred Plus of Kansas
2003 Rate Information for Preferred Plus of Kansas
Non-Postal rates apply to most non-Postal enrollees. If you are in a special enrollment category, refer to the FEHB Guide for that category or contact the agency that maintains your health benefits enrollment.
Postal rates apply to career Postal Service employees. Most employees should refer to the FEHB Guide for United States Postal Service Employees, RI 70-2. Different postal rates apply and special FEHB 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.

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

Location Information: Marion, Harvey, Kingman, Sedgwick, Butler, Sumner, Cowley and Chautauqua counties in Kansas

Self Only VA1 $109. 30 $36.86 $236. 82 $79.86 $129. 03 $17.13
Self and Family VA2 $249. 62 $139. 17 $540. 84 $301.. 54 $294. 70 $94.09 56.

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