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Foundation Health

Federal Employees Health Benefits Program
2003 Plan Brochure
Accessible Version

Document Outline

Introduction
Plain Language
Stop Health Care Fraud!
Section 1. Facts about this HMO plan
Section 2. How we change for 2003
- Program-wide changes
- Program-wide changes
Section 3. How you get 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
Long Term Care Insurance Is Still Available!
Index
Summary of benefits for the Foundation Health 2003
2003 Rate Information for Foundation Health

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

Foundation Health http:// www. fhfl. com
2003

Serving: South Florida (Miami-Dade, Broward, and Palm Beach Counties)
Enrollment in this Plan is limited. You must live or work in our Geographic service area to enroll. See page 6 for requirements.

Enrollment codes for this Plan:
5E1 Self Only 5E2 Self and Family

For changes in benefits
see page 7.

A Health Maintenance Organization

RI 73-683 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). 3.
3 Page 4 5

Ask OPM to limit how your personal medical information is used or given out. However, OPM may not be able to agree to your request if the information is used to conduct operations in the manner described above.
Get a separate paper copy of this notice.
For more information on exercising your rights set out in this notice, look at www. opm. gov/ insure on the web. You may also call 202-606-0191 and ask for OPM's FEHB Program privacy official for this purpose.

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

Filing a complaint will not affect your benefits under the FEHB Program. You also may file a complaint with the Secretary of the Department of Health and Human Services.
By law, OPM is required to follow the terms in this privacy notice. OPM has the right to change the way your personal medical information is used and given out. If OPM makes any changes, you will get a new notice by mail within 60 days of the change. The
privacy practices listed in this notice will be effective April 14, 2003. 4.
4 Page 5 6

Hospital care.................................................................................................................................................................. 9 Circumstances beyond our control ..................................................................................................................................... 10

2003 Foundation Health -Florida 3 Table of Contents
Flexible benefits option End stage renal disease (ESRD)
Diabetes Congestive heart failure (CHF)
Asthma (h) Dental benefits ............................................................................................................................................................ 35

2003 Foundation Health -Florida 4 Introduction/ Plain Language
Introduction
This brochure describes the benefits of Foundation Health under our contract (CS 2715) with the Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. The address for Foundation Health's
administrative offices is:
Foundation Health 1340 Concord Terrace
Sunrise Florida
This brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations, and exclusions of this brochure. It is your responsibility to be informed about your health benefits.

If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in Self and Family coverage, each eligible family member is also entitled to these benefits. You do not have a right to benefits that were available
before January 1, 2003, unless those benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2003, and changes are summarized on page 7. Rates are shown at the end of this brochure.

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

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

We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the Office of
Personnel Management. If we use others, we tell you what they mean first.

Our brochure and other FEHB plans' brochures have the same format and similar descriptions to help you compare plans.
If you have comments or suggestions about how to improve the structure of this brochure, let OPM know. Visit OPM's "Rate Us" feedback area at www. opm. gov/ insure or e-mail OPM at fehbwebcomments@ opm. gov. You may also write to OPM at the Office
of Personnel Management, Office of Insurance Planning and Evaluation Division, 1900 E Street, NW Washington, DC 20415-3650. 7.
7 Page 8 9
2003 Foundation Health -Florida 5 Stop 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 employs you or from which you retired.

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

Carefully review explanations of benefits (EOBs) that you receive from us.
Do not ask your doctor to make false entries on certificates, bills or records in order to get us to pay for an item or service.
If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or misrepresented any information, do the following:

Call the provider and ask for an explanation. There may be an error.
If the provider does not resolve the matter, call us at 1-800-441-5501 and explain the situation.
If we do not resolve the issue:

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

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

CALL --THE HEALTH CARE FRAUD HOTLINE 202-418-3300
OR WRITE TO: The United States Office of Personnel Management
Office of the Inspector General Fraud Hotline 1900 E Street, NW, Room 6400
Washington, DC 20415 8.
8 Page 9 10

2003 Foundation Health -Florida 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.

Who provides my health care
Foundation Health is an individual practice prepayment (IPP) plan that contracts with doctors to provide services for you out of their own offices.

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.
Foundation Health is a for-profit entity and has been operational since 1984. Foundation Health is NCQA accredited and is licensed by the Department of Insurance and the Agency for Health Care Administration to conduct business in the State of Florida.

If you want more information about us, call 1-800-441-5501, or write to Attn: Customer Service at Foundation Health 1340 Concord Terrace , Sunrise, Florida 33323. You may also contact us by fax at 954/ 846-8873 or visit our website at www. fhfl. com.
Service Area
To enroll in this Plan, you must live in or work in our Service Area. This is where our providers practice. Our service area is: South Florida Broward, Miami-Dade and Palm Beach counties. (Code 5E)

Ordinarily, you must get your care from providers who contract with us. If you receive care outside our service area, we will pay only for emergency care benefits. We will not pay for any other health care services out of our service area unless the services have prior
plan approval.
If you or a covered family member 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. Reciprocity arrangements do not exist in any other Foundation Health Plan networks. 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 Foundation Health -Florida 7 Section 2
Section 2. How we change for 2003
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5 Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here is a clarification that does not change
benefits.

Program-wide changes
A Notice of the Office of Personnel Management's Privacy Practices is included.
A section on the Children's Equity Act describes when an employee is required to maintain Self and Family coverage.
Program information on TRICARE and CHAMPVA explains how annuitants or former spouses may suspend their FEHB Program enrollment.

Program information on Medicare is revised.
By law, the DoD/ FEHB Demonstration project ends on December 31, 2002.

Changes to this Plan
Your share of the non-Postal premium will increase by 13. 7% for Self Only or 13. 8% for Self and Family. See Back Cover.
We changed the specialist office visit copay from $10 to $15. See Page 13.
We changed the hospital inpatient admission copay from $200 per calendar year to $100 per admission. See Page 26.
We changed the dispensing limit on prescriptions from a 34-day supply to a 30-day supply. See Page 32.
We changed the 60-visit limit on physical, occupational and speech therapies from per condition to per calendar year. See Page 17. 10.
10 Page 11 12

2003 Foundation Health -Florida 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 1-800-441-5501 or write to us at
1340 Concord Terrace, Sunrise, Florida 33323. You may also request replacement cards through our website at www. fhfl. com.

Where you get covered care You get care from "Plan providers" and "Plan facilities." You will only pay copayments, deductibles, and/ or coinsurance, and you will not have to file claims.
Plan providers Plan providers are physicians and other health care professionals in our service area 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. Using our provider directory to select your Primary Care Physician (PCP) you then complete and submit the HMO Provider
Choice card provided in your enrollment packet.
Primary care Your primary care physician can be a family practitioner, internist, general practitioner or a 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 the following
specialists without a referral: Chiropractor 12 times per calendar year; Dermatologist 5 times per calendar year; Podiatrist 12 times per calendar year; OBGYN once each
calendar year for a well woman exam and Optometrists for routine vision care and unlimited visits for medical conditions of the eye.
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

What you must do to get covered care 11.
11 Page 12 13
2003 Foundation Health -Florida 9 Section 3
treatment plan (the physician may have to get an authorization or approval beforehand).
If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician. Your primary care physician will decide what treatment you need. If he or
she decides to refer you to a specialist, ask if you can see your current specialist. If your current specialist does not participate with us, you must receive treatment from a
specialist who does. Generally, we will not pay for you to see a specialist who does not participate with our Plan.

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

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

reduce our service area and you enroll in another FEHB Plan,
you may be able to continue seeing your specialist for up to 90 days after you receive notice of the change. Contact us or, if we drop out of the Program, contact your new
plan.
If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can continue to see your specialist until
the end of your postpartum care, even if it is beyond the 90 days.
Hospital care Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled nursing or other type of
facility.
If you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at 1-800-441-5501. 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. 12.
12 Page 13 14
2003 Foundation Health -Florida 10 Section 3
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.
Your primary care physician has the authority to refer you for most services. However your PCP must contact Foundation Health for authorizations at 1-800-242-7174 for
certain medical services (see above list) for approval before the service is performed. Requests will be denied if the services are deemed not medically necessary, experimental
and/ or not covered. All preceritifcations are conditioned upon the member being actively enrolled at the time the services are requested and/ or performed. Medical services
receiving precertification are subject to the Plan's copayments.
If a member receives services that require precertification without approval, those services could be denied. If the services are denied based on medical necessity or
rendered without approval, the member may file a grievance.
We call this review and approval process precertification. Your physician must obtain precertification for the following services:

This is not an exhaustive list
Ambulance Transport (Non-Emergent) Non-Participating Provider Air Ambulance Oral Surgery
Ambulatory Surgery Out of Service Area (Non Emergent) Cosmetic Surgery PET Scan
DME Prosthetics/ Braces/ Orthotics Enhanced External Counter Pulsation Rehabilitation Facility Admission
Hospice Care Rehabilitation Therapies (Physical, Occupational and Speech)
Home Infusion and Injectibles Skilled Nursing Facility Admission Hospital Admission Sclerotherapy for Varicose Veins
Hospital Outpatient Services Transplants Home Health Care Wound Care
Hyperbaric Treatments Infertility Assessment and Treatment
Lab Work (Outpatient) not done through Quest Diagnostic Laboratories

Services requiring our prior approval 13.
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2003 Foundation Health -Florida 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 $100 per admission.
Deductible A deductible is a fixed expense you must incur for certain covered services and supplies before we start paying benefits for them. Copayments do not count toward any
deductible. We do not have a deductible.
Coinsurance Coinsurance is the percentage of our negotiated fee that you must pay for your care.
Example: In our Plan, you pay 50% of our allowance for infertility services.
After your copayments total $1,500 per person or $3,000 per family enrollment in any calendar year, you do not have to pay any more for covered services. However,
copayments/ coinsurance for the following services do not count toward your catastrophic protection out-of-pocket maximum, and you must continue to pay
copayments/ coinsurance for these services:
Routine vision care
Prescription drugs
Infertility treatment

Be sure to keep accurate records of your copayments since you are responsible for informing us when you reach the maximum.

Your catastrophic protection out-of-pocket maximum for
deductibles, coinsurance, and copayments 14.
14 Page 15 16

2003 Foundation Health -Florida 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
claim forms, claims filing advice, or more information about our benefits, contact us at 1-800-441-5501 or at our website at www. fhfl. com.

(a) Medical services and supplies provided by physicians and other health care professionals ....................................................... 13-21
Diagnostic and treatment services Lab, X-ray, and other diagnostic tests
Preventive care, adult Preventive care, children
Maternity care Family planning
Infertility services Allergy care
Treatment therapies Physical and occupational therapies

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

(b) Surgical and anesthesia services provided by physicians and other health care professionals................................................. 22-25
Surgical procedures Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue transplants
Anesthesia
(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......................................................................................................................................................... 32-33
(g) Special features ............................................................................................................................................................................. 34

Flexible benefits option
Services for deaf and hearing impaired
High risk pregnancies
Centers of excellence
Congestive heart failure (CHF)

(h) Dental benefits .............................................................................................................................................................................. 35
(i) Non-FEHB benefits available to Plan members............................................................................................................................ 36
Summary of benefits ............................................................................................................................................................................ 52 15.
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2003 Foundation Health -Florida 13 Section 5( a)
Section 5 (a). Medical services and supplies provided by physicians and other health care professionals
I M
P O
R T
A N
T

Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
Plan physicians must provide or arrange your care.
Be sure to read Section 4, Your costs for covered services, or 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 visit to your primary care physician
$15 per visit to a specialist

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

Nothing

Second surgical opinion Nothing if performed by a Plan physician or 40% of usual and customary charges if
performed by a non-Plan physician.

At home $10 per visit

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
primary care physician and $15 per specialist 16.
16 Page 17 18
2003 Foundation Health -Florida 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

Routine Prostate Specific Antigen (PSA) test one annually for men age 40 and older $10 per office visit
Routine pap test
Routine chlamydial screening
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 49, one every two years
At age 50 and older, one every year

Nothing

Not covered: Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, or travel. All charges.
Routine immunizations, limited to:
Tetanus-diphtheria (Td) booster once every 10 years, ages19 and over (except as provided for under Childhood immunizations)

Influenza vaccine, annually
Pneumococcal vaccine, age 65 and over

Nothing

Preventive care, children
Childhood immunizations recommended by the American Academy of Pediatrics Nothing

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

Ear exams through age 17 to determine the need for hearing correction
Examinations done on the day of immunizations (through age 22)

$10 per office visit 17.
17 Page 18 19
2003 Foundation Health -Florida 15 Section 5( a)
Maternity care You pay
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Note: Here are some things to keep in mind:

You do not need to precertify your normal delivery; see page 10 for other circumstances, such as extended stays for you or your baby.

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

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

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

$15 per office visit

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.

$200 copayment
$15 per office visit

Not covered: reversal of voluntary surgical sterilization, genetic counseling, All charges. 18.
18 Page 19 20
2003 Foundation Health -Florida 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)

50% of covered charges

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

Zygote transfer Services and supplies related to excluded ART procedures

Cost of donor sperm
Cost of donor egg

All charges.

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

Allergy serum Nothing
Not covered: provocative food testing and sublingual allergy desensitization All charges. 19.
19 Page 20 21
2003 Foundation Health -Florida 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 page 25.
Respiratory and inhalation therapy
Dialysis hemodialysis and peritoneal dialysis
Intravenous (IV)/ Infusion Therapy Home IV and antibiotic therapy

Growth hormone therapy (GHT)
Note: Growth hormone is covered under the prescription drug benefit.
Note: We will only cover GHT when we preauthorize the treatment. Call your primary care physician to coordinate your care. We will ask

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

$15 per office visit

Not covered: All charges.
Physical and occupational therapies
60 visits per condition per year for the services of each of the following:
qualified physical therapists and occupational therapists.

Note: We only cover therapy to restore bodily function when there has been a total or partial loss of bodily function due to illness or injury.
Cardiac rehabilitation following a heart transplant, bypass surgery or
a myocardial infarction, is provided for up to 100 sessions

$15 per office visit
$15 per outpatient visit
Nothing per visit during covered inpatient admission

Not covered:
long-term rehabilitative therapy
exercise programs
pulmonary rehabilitation

All charges.

Speech therapy
60 visits per condition per calendar year $15 per office visit

Nothing during covered inpatient hospital admission 20.
20 Page 21 22
2003 Foundation Health -Florida 18 Section 5( a)
Hearing services (testing, treatment, and supplies) You pay
First hearing aid and testing only when necessitated by accidental injury

Hearing testing for children through age 17 (see Preventive care, children)
$15 per office visit

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

Vision services (testing, treatment, and supplies)
Annual eye refractions, including written lens prescription Note: See Preventive care, children for eye exam to determine the need

for vision correction through age 18.

$19 per office visit

Eyeglasses
Standard frames (preselected collection)
Single vision lenses
Bifocal lenses
Trifocal lenses
One pair of eyeglasses or contact lenses to correct an impairment directly caused by accidental ocular injury or intraocular surgery

(such as for cataracts)

Nothing
$20

$25
$30
$10 per office visit

Medically necessary contact lenses (evaluation and fitting) Nothing
Daily wear contact lenses (Bausch & Lomb, Biomedics) $10

Extended wear contact lenses (Bausch & Lomb) $15
Disposable lens (2 boxes of all clear spherical lens) $48
All eyewear (including contact lenses) outside of the Select Plan 25% discount
Eye exam to determine the need for vision correction for children through age 18 (see Preventive care, children) $10 per office visit

Not covered: Eye exercises and orthoptics
Radial keratotomy and other refractive surgery
All charges. 21.
21 Page 22 23
2003 Foundation Health -Florida 19 Section 5( a)
Foot care You pay
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.
$15 per office visit

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

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

treatment is by open cutting surgery)

All charges.

Orthopedic and prosthetic devices
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: See 5( b) for coverage of the surgery to insert the device.

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

Nothing

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

prosthetic replacements provided less than3 years after the last one we covered

All charges. 22.
22 Page 23 24
2003 Foundation Health -Florida 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 glucose monitors; and
insulin pumps.
Note: Call us at 1-800-441-5501 as soon as your Plan physician prescribes this equipment.

Nothing

Not covered: Motorized wheel chairs unless medically necessary to meet the
minimum functional requirements of the member.
All charges.

Home health services You pay
Home health care ordered and performed by a Plan physician
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.

$15 per office visit
Nothing

Nothing
Not covered: nursing care requested by, or for the convenience of, the patient or
the patient's family; home care primarily for personal assistance that does not include a
medical component and is not diagnostic, therapeutic, or rehabilitative.

All charges.

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

12 visits without a referral per calendar year, additional visits require a referral from PCP.

$15 per office visit

Not covered: All services not deemed medically necessary. All charges. 23.
23 Page 24 25
2003 Foundation Health -Florida 21 Section 5( a)
Alternative treatments You pay
Biofeedback for migraine headaches $15 per office visit

Not covered: naturopathic services
hypnotherapy acupuncture
All charges.

Educational classes and programs
Coverage is limited to:
Smoking Cessation Up to $100 for one smoking cessation program per member per lifetime.
$15 per office visit

Diabetes self-management Nothing 24.
24 Page 25 26
2003 Foundation Health -Florida 22 Section 5( b)
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
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Plan physicians must provide or arrange your care.
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 precertification information shown in Section 3 to be sure which services require precertification and
identify which surgeries require precertification.

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

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

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

$15 per office visit
$100 per admission for inpatient hospital admissions

$50 per outpatient surgery

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.

$200 copayment
$15 per office visit

Not covered:
Reversal of voluntary sterilization Routine treatment of conditions of the foot; see Foot care.
All charges. 25.
25 Page 26 27
2003 Foundation Health -Florida 23 Section 5( b)
Reconstructive surgery You pay
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.

$15 per office visit
$100 per admission for inpatient hospital admissions

$50 per outpatient surgery

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.

$15 per office visit
$100 per admission for inpatient hospital admissions

$50 per outpatient surgery

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

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

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

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

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

$15 per office 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)
All charges. 27.
27 Page 28 29
2003 Foundation Health -Florida 25 Section 5( b)
Organ/ tissue transplants You pay
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single Double
Pancreas
Allogeneic (donor) bone marrow transplants Autologous bone marrow transplants (autologous stem cell and

peripheral stem cell support) for the following conditions: acute lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's
lymphoma; advanced non-Hodgkin's lymphoma; advanced neuroblastoma; breast cancer; multiple myeloma; epithelial ovarian
cancer; and testicular, mediastinal, retroperitoneal and ovarian germ cell tumors

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

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.

$100 per inpatient hospital admission

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 or outpatient)
Nothing

Professional services provided in
Skilled nursing facility
Ambulatory surgical center
Office

$15 per office visit 28.
28 Page 29 30
2003 Foundation Health -Florida 26 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
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Here are some important things to remember about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

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

including with Medicare.
The amounts listed below are for the charges billed by the facility (i. e., hospital or surgical center) or ambulance service for your surgery or care. Any costs associated with the professional charge

(i. e., physicians, etc.) are covered in Sections 5( a) or (b).
YOUR PHYSICIAN MUST GET PRECERTIFICATION OF HOSPITAL STAYS. Please refer to Section 3 to be sure which services require precertification.

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Benefit Description You pay
Inpatient hospital
Room and board, such as
ward, semiprivate, or intensive care accommodations;
general nursing care; and
meals and special diets.
NOTE: If you want a private room when it is not medically necessary, you pay the additional charge above the semiprivate room rate.

$100 per admission

Other hospital services and supplies, such as:
Operating, recovery, maternity, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays
Administration of blood and blood products
Blood or blood plasma, 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; included in the inpatient hospital admission copay

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 Foundation Health -Florida 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.

$50 per outpatient surgery

Not covered: blood and blood derivatives not replaced by the member All charges.
Extended care benefits/ skilled nursing care facility benefits
The Plan provides a comprehensive range of benefits for up to 100 days per calendar year when you are hospitalized under the care of a Plan

physician. All medically necessary services are covered.
Bed, board and general nursing care
Drugs, biological, supplies and equipment ordinarily provided or arranged by the skilled nursing facility when prescribed by a Plan

physician.

Nothing

Not covered: custodial care All charges.
Hospice care
The Plan covers supportive and palliative care for a terminally ill member. Coverage is provided in the home or a hospice facility.

Services include inpatient, outpatient care and family counseling; these services are provided under the direction of a Plan physician who
certifies that the patient is in terminal stages of illness, with a life expectancy of approximately six months or less.

Nothing

Not covered: Independent nursing, homemaker services All charges.
Ambulance
Local professional ambulance service when medically appropriate Nothing 30.
30 Page 31 32
2003 Foundation Health -Florida 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 and are payable only when we determine they are medically necessary.

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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:
If you are in an emergency situation, please call your primary doctor. In extreme emergencies, if you are unable to contact your doctor, contact the local emergency system (e. g., the 911 telephone system) or go to the nearest hospital emergency
room. Be sure to tell the emergency room personnel that you are a Plan member so they can notify the Plan. You or a family member should notify the Plan within 48 hours unless it is not reasonably possible to do so. It is your responsibility
to ensure that the Plan has been notified timely.
If you need to be hospitalized, the Plan must be notified within 48 hours or the first working day following your admission, unless it is not reasonably possible to notify the Plan in 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 ambulance charges covered in full.

Emergencies within our service area: Benefits are available for care from non-Plan provider in a medical emergency only if delay in reaching a Plan provider would result in death, disability or significant jeopardy to your
condition.

To be covered by this Plan, any follow-up care recommended by non-Plan providers must be approved by the Plan or provided by Plan providers.

Emergencies outside our service area: Benefits are available for any medically necessary service that is immediately required because of injury or unforeseen illness.
If you need to be hospitalized, the Plan must be notified within 48 hours or on the first working day following your admission, unless it was not reasonably possible to notify the Plan in 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. 31.
31 Page 32 33
2003 Foundation Health -Florida 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
Emergency care as an outpatient or inpatient at a hospital, including doctors' services

$10 per visit PCP / $15 Specialist
$25 per visit
$50 per visit (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 or
Emergency care at an urgent care center

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

$25 per visit
$50 per visit (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
Professional ambulance service when medically appropriate.
See 5( c) for non-emergency service.
Nothing

Not covered: air ambulance (unless pre-approved by the Plan) All charges. 32.
32 Page 33 34
2003 Foundation Health -Florida 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:
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.

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

$15 per visit

Mental health and substance abuse benefits -continued on next page 33.
33 Page 34 35
2003 Foundation Health -Florida 31 Section 5( e)
Mental health and substance abuse benefits (continued) You pay
Diagnostic tests Nothing if you receive these during your
office visit, otherwise $15 per visit

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

$100 per inpatient hospital admission

Not covered: Services we have not approved.
Note: OPM will base its review of disputes about treatment plans on the treatment plan's clinical appropriateness. OPM will generally not

order us to pay or provide one clinically appropriate treatment plan in favor of another.

All charges.

Preauthorization To be eligible to receive these benefits you must obtain a treatment plan and follow all of the following authorization processes:
Foundation Health requires you to call Psych/ Care directly at 1-800-221-5487. An assessment of your condition( s) will determine the type of service( s) you will need.

Limitation We may limit your benefits if you do not obtain a treatment plan. 34.
34 Page 35 36
2003 Foundation Health -Florida 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.

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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 or A plan physician or licensed dentist must write the prescription

Where you can obtain them. You may fill the prescription at a participating pharmacy, please see the complete listing of participating pharmacies in our provider directory.
We have an open formulary. If your physician believes a name brand product is necessary or there is no generic available, your physician may prescribe a name brand drug from a formulary list. If no generic is available the cost will be
a copayment amount of $14. This list of name brand drugs is a preferred list of drugs that we selected to meet patient needs at a lower cost. To order a prescription drug brochure, call 1-800-441-5501. We cover non-formulary drugs
prescribed by a Plan doctor.
We use a formulary. A formulary is a mandatory listing of covered prescription medications which are preferred for use by this Plan and will be dispensed through participating pharmacies to covered persons. All medications are listed by

generic name with brand names listed for reference. We cover non-formulary drugs prescribed by a Plan doctor. If a physician prescribes a drug that is not on the formulary, you will be responsible for a higher copayment of $34. If a
physician would like to make a recommendation for a formulary revision they may contact the Plan directly
We have an open formulary. If your physician believes a name brand product is necessary or there is no generic available, your physician may prescribe a name brand drug from a formulary list. If no generic is available the cost will be

a copayment amount of $14. This list of name brand drugs is a preferred list of drugs that we selected to meet patient needs at a lower cost. To order a prescription drug brochure, call 1-800-441-5501. We cover non-formulary drugs
prescribed by a Plan doctor.
These are the dispensing limitations. Retail drugs are dispensed in increments of 30-day supply or Foundation Health's Drug Utilization System is set to alert the dispensing pharmacy whenever a maintenance medication is presented for refill

very early after last dispensing, or if the patient has waited beyond specified days supply of their previous fill. If a physician prescribes a medication that does not have a generic equivalent the member is responsible to pay the brand
copay. Drugs to treat sexual dysfunction are limited to 4 pills or dosage units per month. Prior approval is required.
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 is available, you have to pay the brand name copay + the

difference in cost between the brand name and the generic.
Why use generic drugs? Generic drugs offer a safe and economic way to meet your prescription drug needs. The generic name of a drug is its chemical name; the name brand is the name under which the manufacturer advertises and sells a
drug. Under federal law, generic and name brand drugs must meet the same standards for safety, purity, strength, and effectiveness. A generic prescription costs you --and us --less than a name brand prescription.

When you have to file a claim. See Filing a Claim for Covered Services (section (7) 35.
35 Page 36 37
2003 Foundation Health -Florida 33 Section 5( f)
Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan physician and obtained from a Plan pharmacy or through our mail order

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

Disposable needles and syringes for the administration of covered medications

Contraceptive drugs and devices

$7 per generic
$14 per formulary brand when a generic is not available;

$34 per non-formulary drug
Note: If there is no generic equivalent available, you will still have to pay the

brand name copay.
$14 per generic / $28 per formulary brand (when a generic is not available) for up to a

90-day supply of maintenance medication by mail-order. (formulary only

Drugs for sexual dysfunction (Viagra, limited to 4 pills per month, prior authorization required) $34 per prescription
Drugs for smoking cessation (combined with all smoking cessation related services) $100 per person per lifetime
Insulin
Diabetic Supplies (lancets, syringes, strips, etc.)
$14 per 30-day supply
$7 per 30-day supply

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

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

All charges. 36.
36 Page 37 38
2003 Foundation Health -Florida 34 Section 5( g)
Section 5 (g). Special features
Feature Description

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

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

The decision to offer an alternative benefit is solely ours, and we may withdraw it at any time and resume regular contract benefits.
Our decision to offer or withdraw alternative benefits in not subject to OPM review under the disputed claims process.
Our
Services for deaf and hearing impaired If you are hearing or speech impaired and use a telephone device for the deaf, you may call 1-800-977-6747 Monday through Friday from 8a. m. to 6 p. m.

High risk pregnancies Foundation Health offers a dedicated OB Case Management unit, coordinating and monitoring all phases of care through the member's pregnancy.
Centers of excellence for transplants/ heart
surgery/ etc

Foundation Health utilizes the United Resource Network (URN) for transplants. URN centers are utilized on a case by case basis. URN has centers of excellence
nationwide for various transplants.

Congestive Heart Failure (CHF) Foundation Health offers members with congestive heart failure dedicated Case management services. We also provide educational materials to the member to
assist in the improvement of their condition. 37.
37 Page 38 39
2003 Foundation Health -Florida 35 Section 5( h)
Section 5 (h). Dental benefits
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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.

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

result from an accidental injury.
$15 per office visit

Dental benefits
We have no other dental benefits. 38.
38 Page 39 40
2003 Foundation Health -Florida 36 Section 5( i)
Section 5 (i). Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed claim about them. Fees you pay for these services do not count toward FEHB deductibles or
catastrophic protection out-of-pocket maximums.
Disease management programs for asthma, diabetes, congestive heart failure patients
Expanded Vision care Discounts on vision services are available to Foundation Health members. Services include eye exams, contact lenses, eyeglasses, designer eyeglasses, sunglasses etc. Non-medically necessary
contact lens evaluation and fitting services are provided by participating providers, there is a maximum charge of $45 for Foundation Health members.

For details on specific services and discounts, please call our Member Services department at 1-800-441-5501.
Lasik surgery services at preferred rates
Fitness Club Discounts 39.
39 Page 40 41
2003 Foundation Health -Florida 37 Section 6
Section 6. General exclusions --things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not cover it unless your Plan doctor determines it is medically necessary to prevent, diagnose, or treat your illness, disease, injury,
or condition.
We do not cover the following:
Care by non-Plan providers except for authorized referrals or emergencies (see Emergency Benefits);
Services, drugs, or supplies you receive while you are not enrolled in this Plan;
Services, drugs, or supplies that are not medically necessary;
Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice;
Experimental or investigational procedures, treatments, drugs or devices;
Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest

Services, drugs, or supplies related to sex transformations
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program; or
Services, drugs, or supplies you receive without charge while in active military service. 40.
40 Page 41 42
2003 Foundation Health -Florida 38 Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at Plan pharmacies, you will not have to file claims. Just present your identification card and pay your copayment.

You will only need to file a claim when you receive emergency services from non-plan providers. Sometimes these providers bill us directly. Check with the provider. If you need to file the claim, here is the process:
Medical, hospital and In most cases, providers and facilities file claims for you. Physicians must file on the prescription drug benefits form HCFA-1500, Health Insurance Claim Form. Facilities will file on the UB-92 form.
For claims questions and assistance, call us at 1-800-441-5501.
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);

Receipts, if you paid for your services; and
For services received outside of the U. S., please provide translation of services.

Submit your claims to:
Foundation Health Attn: FEHB Claims Department
1340 Concord Terrace Sunrise, Florida 33323

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. 41.
41 Page 42 43
2003 Foundation Health -Florida 39 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: Foundation Health Attn: FEHB Claims Department 1340 Concord Terrace Sunrise, Florida 33323; 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, Health Benefits Contracts Division 3, 1900 E Street, NW, Washington, DC 20415-3630. 42.
42 Page 43 44
2003 Foundation Health -Florida 40 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 1-800-441-5501and we will expedite our review; or
(b) We denied your initial request for care or preauthorization/ prior approval, then:
If we expedite our review and maintain our denial, we will inform OPM so that they can give your claim expedited treatment too, or

You may call OPM's Health Benefits Contracts Division 3 at 202/ 606-0755 between 8 a. m. and 5 p. m. eastern time. 43.
43 Page 44 45
2003 Foundation Health -Florida 41 Section 9
Section 9. Coordinating benefits with other coverage
When you have other health coverage You must tell us if you or a covered family member has 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 (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 Plan PCP, or precertified as required. We will not waive any of our copayments or coinsurance.

The Original Medicare Plan (Part A or Part B) 44.
44 Page 45 46

2003 Foundation Health -Florida 42 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 claim will be coordinated automatically and we will then provide secondary benefits for covered charges. You will not need to do anything. To find out if you need to do

something to file your claim, call us at 1-800-441-5501 or www. fhfl. com

We do not waive any costs if the Original Medicare Plan is your primary payer. 45.
45 Page 46 47
2003 Foundation Health -Florida 43 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) Areanactiveemployee withthe Federalgovernment(includingwhen youora familymemberare eligibleforMedicaresolely becauseofadisability), .

2) Are an annuitant, .
.
3) Are a reemployed annuitant with the Federal government when

a) The position is excluded from FEHB, or

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

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

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

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

.
(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 . 46.
46 Page 47 48

2003 Foundation Health -Florida 44 Section 9
Medicare managed care plan If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare managed care plan. These are health care choices (like HMOs)
in some areas of the country. In most Medicare managed care plans, you can only go to doctors, specialists, or hospitals that are part of the plan. Medicare managed care plans
provide all the benefits that Original Medicare covers. Some cover extras, like prescription drugs. To learn more about enrolling in a Medicare managed care plan,
contact Medicare at 1-800-MEDICARE (1-800-633-4227) or at www. medicare. gov.
If you enroll in a Medicare managed care plan, the following options are available to you:
This Plan and our Medicare managed care plan: You may enroll in our Medicare managed care plan and also remain enrolled in our FEHB plan. In this case, we do not
waive cost-sharing for your FEHB coverage
This Plan and another plan's Medicare managed care plan: You may enroll in another plan's Medicare managed care plan and also remain enrolled in our FEHB plan.
We will still provide benefits when your Medicare managed care plan is primary, even out of the managed care plan's network and/ or service area (if you use our Plan
providers), but we will not waive any of our copayments, coinsurance, or deductibles. If you enroll in a Medicare managed care plan, tell us. We will need to know whether you
are in the Original Medicare Plan or in a Medicare managed care plan so we can correctly coordinate benefits with Medicare.

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

If you do not enroll in Medicare Part A or Part B 47.
47 Page 48 49
2003 Foundation Health -Florida 45 Section 9
Workers' Compensation We do not cover services that:
you need because of a workplace-related illness or injury that the Office of Workers' Compensation Programs (OWCP) or a similar Federal or State agency determines

they must provide; or
OWCP or a similar agency pays for through a third-party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws.

Once OWCP or similar agency pays its maximum benefits for your treatment, we will cover your care. You must use our providers.

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

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

When others are responsible When you receive money to compensate you for for injuries medical or hospital care for injuries or illness caused by another person, you must
reimburse us for any expenses we paid. However, we will cover the cost of treatment that exceeds the amount you received in the settlement.

If you do not seek damages you must agree to let us try. This is called subrogation. If you need more information, contact us for our subrogation procedures. 48.
48 Page 49 50
2003 Foundation Health -Florida 46 Section 10
Section 10. Definitions of terms we use in this brochure
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on December 31 of the same
year.

Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. See page 11.

Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 11.
Covered services Care we provide benefits for, as described in this brochure.
Custodial care Services to support and generally maintain the patient's condition, provide for the patient's comfort or ensure the manageability of the patient. Custodial care that lasts 90
days or more is sometimes known as Long term care.
Services, supplies, drugs and procedures which have not demonstrated to be safe, effective, medically appropriate for use in the treatment of illness or injury. Also include
service, supplies, drugs and procedures that are determined to be the subject of clinical trial.

Group health coverage Healthcare insurance that covers a group of people (e. g. FEHB) under one master contract.
Medical necessity Services which are necessary and appropriate for the treatment of an illness or injury according to professionally recognized standards of practice and are consistent with
Foundation's medical policies.

Plan allowance Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. Plans determine their allowances in different ways. We determine our
allowance as follows: Covered benefits that require coinsurance are based on our Plan's allowance.

Us/ We Us and we refer to Foundation Health
You You refers to the enrollee and each covered family member.

Experimental or investigational services 49.
49 Page 50 51

2003 Foundation Health -Florida 47 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 about enrolling in the retirement office 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.

Children's Equity Act OPM has implemented the Federal Employees Health Benefits Children's Equity Act of 2000. This law mandates that you be enrolled for self and family coverage in the Federal
Employees Health Benefits (FEHB) Program, if you are an employee subject to a court or administrative order requiring you to provide health benefits for your child( ren).

If this law applies to you, you must enroll for self and family coverage in a health plan that provides full benefits in the area where your child( ren) live or provide documentation
to your employing office that you have obtained other health benefits coverage for your child( ren). If you do not do so, your employing office will enroll you involuntarily as
follows: 50.
50 Page 51 52

2003 Foundation Health -Florida 48 Section 11
If you have no FEHB coverage, your employing office will enroll you for Self and Family coverage in the Blue Cross and Blue Shield Service Benefit Plan's Basic
Option, if you have a self only enrollment in a fee-for-service plan or in an HMO that serves
the area where your children live, your employing office will change your enrollment to self and family in the same option of the same plan; or
if you are enrolled in an HMO that does not serve the area where the children live, your employing office will change your enrollment to Self and Family in the Blue
Cross and Blue Shield Service Benefit Plan's Basic Option.
As long as the court/ administrative order is in effect, and you have at least one child identified in the order who is still eligible under the FEHB Program, you cannot cancel
your enrollment, change to self only, or change to a plan that doesn't serve the area in which your child( ren) live, unless you provide documentation that you have other
coverage for the children. If the court/ administrative order is still in effect when you retire, and you have at least one child still eligible for FEHB coverage, you must continue
your FEHB coverage into retirement (if eligible) and cannot make any changes after retirement. Contact you employing office for further information.

When benefits and The benefits in this brochure are effective on January 1. If you joined this Plan premiums start during Open Season, your coverage begins on the first day of your first pay period that
starts on or after January 1. Annuitants' coverage and premiums begin on January 1. If you joined at any other time during the year, your employing office will tell you the
effective date of coverage.

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

When you lose benefits
When FEHB coverage ends You will receive an additional 31 days of coverage, for no additional premium, when:
Your enrollment ends, unless you cancel your enrollment, or
You are a family member no longer eligible for coverage.
You may be eligible for spouse equity coverage or Temporary Continuation of Coverage.

Spouse equity If you are divorced from a Federal employee or annuitant, you may not continue to get coverage benefits under your former spouse's enrollment. This is the case even when the court has
ordered your former spouse to supply health coverage to you. But, you may be eligible for your own FEHB coverage under the spouse equity law or Temporary Continuation of

Coverage (TCC). If you are recently divorced or are anticipating a divorce, contact your ex-spouse's employing or retirement office to get RI 70-5, the Guide to Federal
Employees Health Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees, or other information about your coverage choices. You can also
download the guide from OPM's website, www. opm. gov/ insure.
Temporary continuation If you leave Federal service, or if you lose coverage because you no longer qualify as a of coverage (TCC) 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. 51.
51 Page 52 53

2003 Foundation Health -Florida 49 Section 11
You may not elect TCC if you are fired from your Federal job due to gross misconduct.
Enrolling in TCC. Get the RI 79-27, which describes TCC, and the RI 70-5, the Guide to Federal Employees Health Benefits Plans for Temporary Continuation of Coverage
and Former Spouse Enrollees, from your employing or retirement office or from www. opm. gov/ insure. It explains what you have to do to enroll.

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

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

However, if you are a family member who is losing coverage, the employing or retirement office will not notify you. You must apply in writing to us within 31 days
after you are no longer eligible for coverage.
Your benefits and rates will differ from those under the FEHB Program; however, you will not have to answer questions about your health, and we will not impose a waiting
period or limit your coverage due to pre-existing conditions.
Getting a Certificate of The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a Federal Group Health Plan Coveragelaw that offers limited Federal protections for health coverage availability and continuity
to people who lose employer group coverage. If you leave the FEHB Program, we will give you a Certificate of Group Health Plan Coverage that indicates how long you have
been enrolled with us. You can use this certificate when getting health insurance or other health care coverage. Your new plan must reduce or eliminate waiting periods,
limitations, or exclusions for health related conditions based on the information in the certificate, as long as you enroll within 63 days of losing coverage under this Plan. If you
have been enrolled with us for less than 12 months, but were previously enrolled in other FEHB plans, you may also request a certificate from those plans.

For more information, get OPM pamphlet RI 79-27, Temporary Continuation of Coverage (TCC) under the FEHB Program. See also the FEHB web site
(www. opm. gov/ insure/ health); refer to the "TCC and HIPAA" frequently asked questions. These highlight HIPAA rules, such as the requirement that Federal employees
must exhaust any TCC eligibility as one condition for guaranteed access to individual health coverage under HIPAA, and have information about Federal and State agencies
you can contact for more information. 52.
52 Page 53 54

2003 Foundation Health -Florida 50 Long Term Care Insurance
Long Term Care Insurance Is Still Available!
Open Season for Long Term Care Insurance
You can protect yourself against the high cost of long term care by applying for insurance in the Federal Long Term Care Insurance Program.
Open Season to apply for long term care insurance through LTC Partners ends on December 31, 2002. If you're a Federal employee, you and your spouse need only answer a few questions about your health during Open Season.
If you apply during the Open Season, your premiums are based on your age as of July 1, 2002. After Open Season, your premiums are based on your age at the time LTC Partners receives your application.

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

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

Find Out More Contact LTC Partners by calling 1-800-LTC-FEDS (1-800-582-3337) (TDD for the hearing impaired: 1-800-843-3557) or visiting www. ltcfeds. com to get more information and to request an application. 53.
53 Page 54 55
2003 Foundation Health -Florida 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
Alternative treatment 21 Allogenetic (donor) bone marrow
transplant 25 Ambulance 29
Anesthesia 25 Autologous bone marrow transplant 25
Biopsies 22 Blood and blood plasma 26
Breast cancer screening 14 Casts 22
Catastrophic protection out-of-pocket maximum 11
Changes for 2003 7 Chemotherapy 17
Childbirth 15 Chiropractic 20
Cholesterol tests 14 Claims 38
Coinsurance 11 Colorectal cancer screening 14
Congenital anomalies 23 Contraceptive devices and drugs 33
Coordination of benefits 41 Covered providers 8
Crutches 20 Definitions 46
Dental care 35 Diagnostic services 13
Disputed claims review 39 Donor expenses (transplants) 25
Dressings 26 Durable medical equipment (DME) 20
Educational classes and programs 21 Effective date of enrollment 48
Emergency 28 Experimental or investigational 46
Eyeglasses 18 Family planning 15

Fecal occult blood test 14 Fraud 5
General Exclusions 37 Hearing services 18
Home health services 20 Hospice care 27
Home nursing care 20 Hospital 26
Immunizations 14 Infertility 16
Inhospital 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 33 Mammograms 14
Maternity Benefits 15 Medicaid 45
Medically necessary 46 Medicare 41
Mental Conditions/ Substance Abuse Benefits 30
Newborn care 15 Non-FEHB Benefits 36
Nurse Licensed Practical Nurse 20
Nurse Anesthetist 26 Registered Nurse 20
Nursery charges 15 Obstetrical care 15
Occupational therapy 17 Ocular injury 18
Office visits 14 Oral and maxillofacial surgery 24
Orthopedic devices 19 Ostomy and catheter supplies 26
Out-of-pocket expenses 11 Outpatient facility care 27

Oxygen 26 Pap test 14
Physical examination 14 Physical therapy 17
Physician 13 Pre-admission testing 26
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
Psychologist 30 Psychotherapy 30
Radiation therapy 17 Renal dialysis 17
Room and board 26 Second surgical opinion 13
Skilled nursing facility care 27 Smoking cessation 21
Speech therapy 17 Splints 22
Sterilization procedures 15 Subrogation 45
Substance abuse 30 Surgery 22
Anesthesia 25 Oral 24
Outpatient 27 Reconstructive 23
Syringes 33 Temporary continuation of coverage 48
Transplants 25 Treatment therapies 17
Vision services 18 Well child care 14
Wheelchairs 20 Workers' compensation 45
X-rays 13 54.
54 Page 55 56
2003 Foundation Health -Florida 52 Summary
Summary of benefits for the Foundation Health 2003
Do not rely on this chart alone. All benefits are provided in full unless indicated and are subject to the definitions, limitations,
and exclusions in this brochure. On this page we summarize specific expenses we cover; for more detail, look inside.

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

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

Benefits You Pay Page
Medical services provided by physicians:
Diagnostic and treatment services provided in the office................
Office visit copay: $10 primary care;
$15 specialist
13

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

$100 per admission copay 26
27
Emergency benefits:
In-area ...........................................................................................
Out-of-area ....................................................................................
$50 per. visit waived if admitted
$50 per visit waived if admitted

Mental health and substance abuse treatment....................................... Regular cost sharing. 30
Prescription drugs................................................................................. Generic formulary $7
Brand name formulary $14 (if no generic is available

Non-formulary $34
90-day supply mail order $14 generic / $28 brand name (formulary only)

Dental Care........................................................................................ No benefit. 35
Vision Care........................................................................................ $19 copay per visit for annual eye refraction.
Various copays/ discounts on frames and lenses.
18

Special features: Flexible benefits option, Services for deaf and hearing impaired, High risk pregnancies, Centers of excellence and Congestive Heart Failure 34
Protection against catastrophic costs (your catastrophic protection out-of-pocket maximum).................... Nothing after -$1,500/ Self Only or $3,000/ Family enrollment per year
Some costs do not count toward this protection
11 55.
55 Page 56
2003 Rate Information for Foundation Health
Non-Postal rates apply to most non-Postal enrollees. If you are in a special enrollment category, refer to the FEHB Guide for that category or contact the agency that maintains your
health benefits enrollment.
Postal rates apply to career Postal Service employees. Most employees should refer to the FEHB Guide for United States Postal Service Employees, RI 70-2. Different postal rates apply
and a special FEHB guide is published for Postal Service Inspectors and Office of Inspector General (OIG) employees (see RI 70-2IN).

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

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: South Florida (Miami-Dade, Broward, and Palm Beach Counties)
High Option
Self Only 5E1 $68.30 $22.76 $147.98 $49.32 $80.82 $10.24

High Option
Self and Family 5E2 $187.82 $62.61 $406.95 $135.65 $222. 26 $28.17 56.

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