Document Outline

• HealthSpring
• Letter to Participants
• Notice of the OPM's Privacy Practices
• Table of Contents
• Introduction
• Plain Language
• Stop Health Care Fraud!
  • THE HEALTH CARE FRAUD HOTLINE
• Section 1. Facts about this HMO plan
  • How we pay providers
  • Your Rights
  • Service Area
• Section 2. How we change for 2003
  • Program-wide changes
  • Changes to this Plan
• Section 3. How you get care
  • Identification cards
  • Where you get covered care
    • Plan providers
    • Plan facilities
  • What you must do to get covered care
    • Primary care
    • Specialty care
    • Hospital care
  • Circumstances beyond our control
  • Services requiring our prior approval
• Section 4. Your costs for covered services
  • Copayments
  • Deductible
  • Coinsurance
  • Your catastrophic protection out-of-pocket
• Section 5. Benefits OVERVIEW
  • (a) Medical services and supplies provided by physicians and other health care professionals
  • (b) Surgical and anesthesia services provided by physicians and other health care professionals
  • (c) Services provided by a hospital or other facility, and ambulance services
  • (d) Emergency services/accidents
  • (e) Mental health and substance abuse benefits
  • (f) Prescription drug benefits
  • (g) Special features
    • HealthSpring Disease Management Program
    • Quarterly Newsletters
    • Centers of Excellence
    • Hospitalist Program
  • (h) Dental Benefits
  • Summary of benefits
• Section 5 (a). Medical services and supplies provided by physicians and other health care professionals
  • 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
  • Vision services
  • Foot care
  • Orthopedic and prosthetic devices
  • Durable medical equipment (DME)
  • Home health services
  • Chiropractic
  • Alternative treatments
  • Educational classes and programs
• Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
  • Surgical procedures
  • Reconstructive surgery
  • Oral and maxillofacial surgery
  • Organ/tissue transplants
  • Anesthesia
• Section 5 (c). Services provided by a hospital or other facility, and ambulance services
  • Inpatient hospital
  • Outpatient hospital or ambulatory surgical center
  • Extended care benefits/skilled nursing care facility benefits
  • Hospice care
  • Ambulance
• Section 5 (d). Emergency services/accidents
  • What is a medical emergency?
  • What to do in case of emergency:
  • Emergency within our service area
  • Emergency outside our service area
  • Ambulance
• Section 5 (e). Mental health and substance abuse benefits
  • Mental health and substance abuse benefits
  • Preauthorization
  • Limitation
• Section 5 (f). Prescription drug benefits
  • Who can write your prescription
  • Where you can obtain them
  • We use a formulary
  • These are the dispensing limitations
  • Mail Order
  • Limitations
  • Why use generic drugs
  • When you have to file a claim
  • Covered medications and supplies
• Section 5 (g). Special features
  • HealthSpring Disease Management Program
  • Quarterly Newsletters
  • Centers of Excellence
  • Hospitalist Program
• Section 5 (h). Dental benefits
  • Accidental injury benefit
  • Covered Dental Services
    • Preventive and Diagnostic Dental Services
    • Basic Dental Services
    • Major Dental Services
    • Orthodontic Services
• 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
    • What is Medicare?
      • The Original Medicare Plan
  • Primary Payer Chart
    • A. When either you -- or your covered spouse -- are age 65 or over and
    • B. When you or a covered family member have Medicare based on end stage renal disease (ESRD) and
    • C. When you or a covered family member have FEHB and
      • Medicare managed care plan
      • If you do not enroll in Medicare Part A or Part
  • TRICARE and CHAMPVA
  • Workers Compensation
  • Medicaid
  • When other Government agencies are responsible for your care
  • When others are responsible for your injuries
• Section 10. Definitions of terms we use in this brochure
  • Calendar year
  • Coinsurance
  • Copayment
  • Covered services
  • Custodial care
  • Deductible
  • Experimental or investigational services
  • Medical necessity
  • Us/We
  • You
• Section 11. FEHB facts
  • No pre-existing condition limitation
  • Where you can get information about enrolling in the FEHB Program
  • Types of coverage available for you and your family
  • Childrens Equity Act
  • When benefits and premiums start
  • When you retire
  • When you lose benefits
    • When FEHB coverage ends
    • Spouse equity coverage
    • Temporary continuation of coverage (TCC)
    • Converting to individual coverage
    • Getting a Certificate of Group Health Plan Coverage
• Long Term Care Insurance Is Still Available!
  • Open Season for Long Term Care Insurance
  • FEHB Doesnt Cover It
  • You Can Also Apply Later, But
  • You Must Act To Receive an Application
• Index
• Summary of benefits for HealthSpring - 2003
• 2003 Rate Information for HealthSpring
  • Non-Postal rates
  • Postal rates

Pages 1--66

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

HealthSpring www. myhealthspring. com/ feds
2003 A Health Maintenance Organization

Serving: Metropolitan Nashville and 27 counties of Middle Tennessee.
Enrollment in this Plan is limited: You must live or work in our Geographic service area to enroll. See page 7 for requirements.

Enrollment codes for this Plan: HIGH OPTION STANDARD OPTION
6K1 Self Only 6K4 Self Only 6K2 Self and Family 6K5 Self and Family

RI 73-812

This Plan has URAC accreditation from the American Accreditation Healthcare Commission/ URAC.
See the 2003 Guide for more information on accreditation.

For changes in benefits
see page 8. 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. 3
3 Page 4 5

Ask OPM to communicate with you in a different manner or at a different place (for example, by sending materials to a P. O. Box instead of your home address).
Ask OPM to limit how your personal medical information is used or given out. However, OPM may not be able to agree to your request if the information is used to conduct operations in the manner described above.
Get a separate paper copy of this notice.
For more information on exercising your rights set out in this notice, look at http://www.opm.gov/insurethe web. You may also call 202-606-0191 and ask for OPM's FEHB Program privacy official for this purpose.

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

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

2003 HealthSpring 2 Table of Contents
Table of Contents
Introduction.................................................................................................................................................................................... 4
Plain Language................................................................................................................................................................................... 4
Stop Health Care Fraud!..................................................................................................................................................................... 5
Section 1. Facts about this HMO plan ........................................................................................................................................... 6
How we pay providers .................................................................................................................................................. 6
Your Rights................................................................................................................................................................... 6
Service area................................................................................................................................................................... 7
Section 2. How we change for 2003 .............................................................................................................................................. 8
Program-wide changes.................................................................................................................................................. 8
Changes to this Plan...................................................................................................................................................... 8
Section 3. How you get care ........................................................................................................................................................ 10
Identification cards...................................................................................................................................................... 10
Where you get covered care........................................................................................................................................ 10
Plan providers ...................................................................................................................................................... 10
Plan facilities........................................................................................................................................................ 10
What you must do to get covered care........................................................................................................................ 10
Primary care......................................................................................................................................................... 10
Specialty care....................................................................................................................................................... 11
Hospital care ........................................................................................................................................................ 11
Circumstances beyond our control.............................................................................................................................. 12
Services requiring our prior approval.......................................................................................................................... 12
Section 4. Your costs for covered services .................................................................................................................................. 14
Copayments ......................................................................................................................................................... 14
Deductible........................................................................................................................................................ 14
Coinsurance ......................................................................................................................................................... 14
Your catastrophic protection out-of-pocket maximum ............................................................................................... 14
Section 5. Benefits ....................................................................................................................................................................... 15
Overview..................................................................................................................................................................... 15
(a) Medical services and supplies provided by physicians and other health care professionals................................ 16
(b) Surgical and anesthesia services provided by physicians and other health care professionals ............................ 28
(c) Services provided by a hospital or other facility, and ambulance services .......................................................... 33
(d) Emergency services/ accidents.............................................................................................................................. 36
(e) Mental health and substance abuse benefits......................................................................................................... 38
(f) Prescription drug benefits .................................................................................................................................... 40
(g) Special features ................................................................................................................................................... 43 5
5 Page 6 7

2003 HealthSpring 3 Table of Contents
HealthSpring Disease Management Program .......................................................................................................... 43
Quarterly Newsletters .............................................................................................................................................. 43
Centers of Excellence ............................................................................................................................................. 43
Hospitalist Program ................................................................................................................................................. 43
(h) Dental Benefits ........................................................................................................................................................ 44
Section 6. General exclusions --things we don't cover ................................................................................................................... 46
Section 7. Filing a claim for covered services ................................................................................................................................. 47
Section 8. The disputed claims process ........................................................................................................................................... 48
Section 9. Coordinating benefits with other coverage .................................................................................................................... 50
When you have other health coverage ............................................................................................................................ 50
What is Medicare....................................................................................................................................... 50
Medicare managed care plan .................................................................................................................... 53
TRICARE and CHAMPVA ..................................................................................................................... 53
Workers' Compensation............................................................................................................................ 54
Medicaid........................................................................................................................................ 54
Other Government agencies ...................................................................................................................... 54
When others are responsible for injuries ................................................................................................... 54
Section 10. Definitions of terms we use in this brochure .................................................................................................................. 55
Section 11. FEHB facts ..................................................................................................................................................................... 56
Coverage information
No pre-existing condition limitation.......................................................................................................... 56
Where you can get information about enrolling in the FEHB Program .................................................... 56
Types of coverage available for you and your family ............................................................................... 56
Children's Equity Act ................................................................................................................................ 56
When benefits and premiums start ............................................................................................................ 57
When you retire......................................................................................................................................... 57
When you lose benefits................................................................................................................................................... 57
When FEHB coverage ends....................................................................................................................... 57
Spouse equity coverage ............................................................................................................................. 57
Temporary Continuation of Coverage (TCC)............................................................................................ 58
Converting to individual coverage ............................................................................................................ 58
Getting a Certificate of Group Health Plan Coverage ............................................................................... 58
Long term care insurance is still available ........................................................................................................................................... 60
Index .................................................................................................................................................................................................... 61
Summary of benefits ........................................................................................................................................................................ 62
Rates........................................................................................................................................................................... Back cover 6
6 Page 7 8

2003 HealthSpring 4 Introduction/ Plain Language
Introduction
This brochure describes the benefits of HealthSpring under our contract (CS 2865) with the Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. The address for HealthSpring's administrative offices is:
HealthSpring, Inc. 44 Vantage Way, Suite 300
Nashville, TN 37228
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 8. 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 HealthSpring.
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 http://www.opm.gov/insuree-mail OPM at mailto:fehbwebcomments@opm.govYou 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 HealthSpring 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 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 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 any 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 (615) 291-5030 and explain the situation.
If we do not resolve the issue:

CALL --THE HEALTH CARE FRAUD HOTLINE 202-418-3300

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

Do not maintain as a family member on your policy:
your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise); or
your child over age 22 (unless he/ she is disabled and incapable of self support).
If you have any questions about 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. 8
8 Page 9 10

2003 HealthSpring 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 deductible 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, deductibles or coinsurance.

Your Rights
OPM requires that all FEHB Plans to 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.
As a member of HealthSpring, you have rights:
Confidentiality Your medical information is confidential. HealthSpring is subject to applicable state and federal laws governing the release of your medical information.

Consent Your consent is required for treatment, unless you have an emergency, your life and health are in serious danger or you are unable to provide affirmative verbal or written consent. If your written consent is required for
special procedures such as surgery, be sure you understand the procedure and why it is advised. Should you decide you do not want a particular treatment, discuss your concerns with your Primary Care Physician.

Medical Records You have the right to access your personal medical records maintained at your physician's office as provided by state and federal laws.
Advance Directives Legal provisions allow your wishes to be carried out when you are incapable of making health care decisions. Your health care professional or legal advisor can assist you with making a living will, a durable power
of attorney for health care, or a mental health advance declaration a part of your medical records.
Voice Grievances You have the right to voice grievances about HealthSpring or the medical care you receive.
Information You have the right to be provided with information about HealthSpring, their participating providers, and your rights and responsibilities.

Years in existence We have been in business since 1984.
Profit status HealthSpring is a for profit company.
Compliance and Licensing requirements HealthSpring is licensed in the State of Tennessee as a Health Maintenance Organization. Licensing requires specified cash reserve levels, compliance with all state regulations governing the

license, mandated benefits and compliance with federal statues. 9
9 Page 10 11

2003 HealthSpring 7 Section 1
If you want more information about us, call (615) 291-5030 in Nashville or 1-800-917-3888 from outside Nashville, or write us at P. O. Box 20000, Nashville, TN 37202-9613. You may also contact us by visiting our website at www. myhealthspring. com/ feds.
Service Area
To enroll in this Plan, you must live in or work in our Service Area. This is where our providers practice. Our service area is the following Middle Tennessee counties:

MIDDLE TENNESSEE:
Bedford Humphreys Rutherford Cannon Lawrence Smith

Cheatham Lewis Stewart Coffee Macon Sumner
Davidson Marshall Trousdale
DeKalb Maury Warren Dickson Montgomery Wayne

Franklin Moore Williamson Hickman Robertson Wilson

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. If you or a family member moves, you do not have to wait until Open Season to change plans. Contact your employing or retirement office. 10
10 Page 11 12

2003 HealthSpring-8 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
HIGH OPTION -Your share of the non-postal premium will increase by 34% for Self Only coverage and 62. 2% for Self and Family coverage.

STANDARD OPTION 2003 is the first year we will have a Standard Option. Therefore, premium increase information does not apply to this option.
We now have a High and Standard Option discussed below. Our 2002 option became the High Option with the changes shown below.
HIGH OPTION
A primary care physician's office visit copayment is now $15 per visit; previously you paid $10 per visit. A specialist's office visit copayment is now $25 per visit; previously you paid $10 per visit. The copayment changes apply to all office

visits for all covered services except for the following:
Maternity care -the initial office visit copayment is now $25 per visit. You pay nothing for additional visits.
Physical and Occupational therapies -the office visit copayment is now $25 per visit.
Speech therapy -the office visit copayment is now $25 per visit.
Vision services -the office visit copayment is now $15 per visit.
Chiropractic services -the copayment is now $25 per visit.
The home health care visit copayment is now $15 for primary care doctors, nurses or home health aides' visits and $25 for a specialist. Previously, you paid $10 per visit.

The inpatient hospital admission copayment is now $250 per admission. Previously, you paid nothing.
The outpatient hospital or ambulatory surgical center copayment is now $250 per procedure. Previously, you paid nothing.
The hospital emergency room copayment is now $100 per visit. Previously, you paid $50 per visit.
The urgent care center copayment is now $50 per visit. Previously, you paid $25 per visit.
Mail Order maintenance drugs now require 3 copayments for a 90-day supply. Previously, you paid 2 copayments for a 90-day supply.

The out-of-pocket maximums are $2,000 for Self Only and $4,000 for Self and Family.
High Option Clarification:
We show coverage for cataract supplies (hardware and supplies). 11
11 Page 12 13

2003 HealthSpring-9 Section 2
STANDARD OPTION
A $500 calendar year deductible applies to most benefits. The deductible does not apply to routine immunizations, reconstructive surgery, organ/ tissue transplants benefits.

Coinsurance at 20% applies to most covered benefits. Coinsurance does not apply to routine immunizations, organ/ tissue transplants, inpatient hospital benefits and extended care/ skilled nursing facility benefits.
The out-of-pocket maximums are $3,000 for Self Only and $6,000 for Self and Family.
The primary care physician and specialist office visit copay of $20 per visit is not subject to the calendar year deductible or the 20% coinsurance.

The calendar year deductible and the 20% coinsurance apply to the following covered services:
Lab, x-ray and other tests Family planning

Infertility services Allergy care
Treatment therapies Physical and occupational therapies
Speech therapy Hearing services
Orthopedic and prosthetic devices -$1,500 maximum Plan benefit. Member must satisfy calendar year deductible and pay 20% of covered charges.
Durable medical equipment -$1,500 maximum Plan benefit. Member must satisfy calendar year deductible and pay 20% of covered charges.
Home health services Reconstructive surgery
Surgical procedures Oral and maxillofacial surgery
Anesthesia Outpatient hospital and ambulatory surgery
Accidental dental
The following covered services are not subject to calendar year deductible or 20% coinsurance. You pay only the amount shown for the service which we cover up to benefit allowance shown below:

Cataract Supplies (Hardware and lenses) -$100 Maximum Plan Allowance Hospice Care -No member copayment
Hospital Emergency Room Visit -$100 copayment per admission Emergency Doctor's Office Visit -$20 copayment per visit
Urgent Care Center Visit -$50 copayment per visit Ambulance -No member copayment
Prescription Drugs Copayment $10 Generic, $20 Preferred Brand Name, 50% coinsurance non-preferred brand name
Mail Order Prescription Drugs -90 day supply for 3 copays Inpatient hospital copayment -$250 per admission
Outpatient hospital or ambulatory surgical center copay -$250 per procedure

High Option and Standard Option Benefit Change
We now cover a more comprehensive list of dental benefits. See Section 5( h) for details.

High Option and Standard Option Clarification
We show coverage for smoking cessation. 12
12 Page 13 14

2003 HealthSpring 10 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 (615) 291-5030 in Nashville or
from outside Nashville at 1-800-917-3888. You may also request replacement cards through our website at www. myhealthspring. com/ feds.

Where you get covered care You get care from "Plan Providers" and "Plan Facilities." You pay only copayments, deductibles and coinsurance. 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. Our staff of medical professionals continually credentials and monitors participating doctors and hospitals to assure the network meets
strict industry standards of care.
Some Primary Care Physicians belong to independent physician associations (IPAs). IPAs are groups of physicians who contract with managed care organizations to provide
health care services. IPA networks may include general physicians or specialists like cardiologists and orthopedists. Note: Physicians in an IPA may refer only to other
physicians and hospitals affiliated with the same IPA. Members should look in their HealthSpring Provider Directory or call HealthSpring's Customer Service line,
(615) 291-5030 to find if a PCP has an IPA relationship.
We list Plan providers in the Provider Directory, which we update periodically. The provider list is also on our website. The directory lists IPA primary care and specialty
providers and independently contracted primary care providers and specialists. The provider list includes physician office addresses and phone numbers.

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 (PCP). This decision is important since your Primary
Care Physician provides or arranges most of your health care. Selection must be made from the HealthSpring network of Primary Care Physicians. Some Primary Care
Physicians belong to IPAs that refer patients only to other Providers in the same IPA. Members should look to their HealthSpring Provider Directory or call
HealthSpring's Customer Service line, (615) 291-5030 to find if a PCP has an IPA relationship. Once a PCP has been selected, you should schedule an initial appointment
with him/ her to establish a physician/ patient relationship.
Primary care Your Primary Care Physician can be a family practitioner, general practitioner, internist, or pediatrician. Your Primary Care Physician cannot be an OB/ GYN. Your Primary
Care Physician will provide most of your health care, or give you a referral to see a specialist.

What you must do To get covered care 13
13 Page 14 15
2003 HealthSpring 11 Section 3
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 consultation, unless your Primary Care Physician authorized a certain number of visits without additional referrals. The Primary Care Physician must provide
or authorize all follow-up care. Do not go to the specialist for return visits unless your Primary Care Physician gives you a referral. However, you may see a network
gynecologist for a routine examination once each calendar year.
Remember: Some physician groups in the directory refer to a limited number of OB/ GYNs. If your Primary Care Physician belongs to an IPA, you must choose an
obstetrician/ gynecologist who belongs to the same IPA.
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 work with the specialists and the
Plan to develop a treatment plan that allows you to see your specialist for a certain number of visits without additional referrals. Your Primary Care Physician will use
our criteria when creating your treatment plan (the physician may have to get an authorization or approval beforehand).

If you are seeing a specialist when you enroll in our Plan, talk to your Primary Care Physician before seeing your specialist. 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. 14
14 Page 15 16
2003 HealthSpring 12 Section 3
If you are in the hospital when your enrollment in our Plan begins, call our Customer Service Department immediately at (615) 291-5030 in Nashville or 1-800-917-3888. If
you are new to the FEHB Program, we will arrange for you to receive care.
If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:

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

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

We call this review and approval process precertification. There are two review processes associated with review and approval of services. Precertification involves
review of elective services 5-7 days before the service occurs. Authorization involves urgent/ emergent services and usually occurs within one business day of the service. This
review may be before or after the service occurs. Your Plan physician is responsible for obtaining approval for services. Below are some of the services requiring prior approval.

All inpatient hospital care Extended care/ skilled nursing facilities
Mental Health or substance abuse services (through Magellan) Inpatient rehab services
Cardiac and Pulmonary Rehab Organ and tissue transplants
Infertility procedures Specialty referrals
Home Health Care Durable Medical Equipment
Orthopedic and prosthetic devices Growth Hormone Therapy
Certain outpatient oral or injectable drugs Hospice
Outpatient surgery Surgical treatment of morbid obesity
Any request for non-par provider
Your Primary Care Physician must obtain a referral for specialty care physician services. If you receive services without obtaining a referral you may be obligated
to pay for unauthorized services.
Your Primary Care Physician or Specialty Care Physician is responsible for calling the Health Services Department to obtain precertification or authorization. Failure to obtain

Services requiring our prior approval 15
15 Page 16 17
2003 HealthSpring 13 Section 3
authorization or precertification may result in payment denial. You, or a provider on your behalf, may appeal any decision as outlined in the appeal and grievance process.
If your coverage is terminated prior to the date of service, the service will not be covered, regardless of a precertification or authorization given by us or your Primary or Specialty
Care Physician. 16
16 Page 17 18
2003 HealthSpring 14 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: Under the High Option Plan, you pay a $15 copayment for a Primary Care Physician office visit and a $25 copayment for a Specialist office visit. Under both
options, when you are admitted to the hospital, you pay a $250 copayment 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.
High Option Plan: We do not have any deductibles in the High Option Plan.
Standard Option Plan: The calendar year deductible is $500 per person or $1,000 per family enrollment.

Note: If you change plans during open season, you do not have to start a new deductible under your old plan between January 1 and the effective date of your new plan. If you
change plans at another time during the year, you must begin a new deductible under your new plan.

And, if you change options in this Plan during the year, we will credit the amount of covered expenses already applied toward the deductible of your old option to the
deductible of your new option.

Coinsurance Coinsurance is the percentage of our negotiated fee that you must pay for your care. Coinsurance does not begin until you meet your deductible.
Example: In our Standard Option Plan, you pay 20% of our allowable charges for the treatment of infertility after you satisfy the calendar year deductible.
High Option -The out-of-pocket maximum is $2,000 per person or $4,000 per family. You pay no more copayments once the out-of-pocket maximum is met.
Standard Option -The out-of-pocket maximum is $3,000 per person or $6,000 per family. Office visit copayments and calendar deductible do not count toward your
catastrophic protection out-of-pocket maximum, and you must continue to pay copayments for these services. Coinsurance amounts do apply to the out-of-pocket
maximum.
Be sure to keep accurate records of your copayments, deductible and coinsurance amounts since you are responsible for informing us when you reach the maximum.

Your catastrophic protection out-of-pocket maximum for deductibles,
coinsurance and copayments 17
17 Page 18 19

2003 HealthSpring 15 Section 5
Section 5. Benefits OVERVIEW
(See 62 for a benefits summary.)

NOTE: This benefits section is divided into subsections. Please read the important things 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, claim filing
advice, or more information about your benefits, contact us at (615) 291-5030 in Nashville or 1-800-917-3888 from outside Nashville or at our website at www. myhealthspring. com/ feds.

(a) Medical services and supplies provided by physicians and other health care professionals .......... 16
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........... 28
Surgical procedures Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services............. 33
Inpatient hospital Outpatient hospital or ambulatory surgical center Extended care benefits/ skilled nursing care facility benefits
Hospice care Ambulance

(d) Emergency services/ accidents............. 36
Medical emergency Ambulance
(e) Mental health and substance abuse benefits ........... 38
(f) Prescription drug benefits ........... 40
(g) Special features ............... 43

HealthSpring Disease Management Program Quarterly Newsletters
Centers of Excellence Hospitalist Program

(h) Dental benefits........................................................................................................................................................................... 44
Summary of benefits. .62 18
18 Page 19 20

2003 HealthSpring 16 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.
Calendar year deductible:
High Option -We have no calendar year deductible.
Standard Option -The calendar year deductible is $500 per person or $1,000 per family and applies to most benefits in this section. We added "( No deductible)" to show when the calendar

year deductible does not apply.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including

with Medicare.

I M
P O
R T
A N
T

Benefit Description You Pay -High Option You Pay -Standard Option
NOTE: The calendar year
deductible applies to most benefits in this
section for Standard Option. We show
"( No deductible)" when it does not
apply. Diagnostic and treatment services

Professional services of physicians
In a physician's office

During a hospital stay
In a skilled nursing facility
Office medical consultations
Second surgical opinion

$15 per primary care physician visit; $25 per
specialist visit
Nothing

Nothing
Nothing
$15 per primary care physician visit; $25 per
specialist visit

$20 per primary care physician visit or specialist
visit (No deductible)
Nothing

Nothing
Nothing
$20 per primary care physician visit or specialist
visit (No deductible)
Diagnostic and treatment services -continued on next page 19
19 Page 20 21
2003 HealthSpring 17 Section 5( a)
Diagnostic and treatment services (continued) You pay -High Option You pay -Standard Option
At home $15 per primary care physician visit; $25 per
specialist visit
20% of charges after satisfying calendar year
deductible

Not covered:
Services, drugs, or supplies you receive while you are not enrolled in this Plan

Services or supplies related to self-treatment; or services or supplies provided by any person
related to you by blood or marriage or any person who resides in your immediate household

All charges All charges

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 20% of charges after satisfying calendar year
deductible

Preventive care, adult
Routine screening, 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

Routine Prostate Specific Antigen (PSA) test one annually for men age 40 and older

$15 per primary care physician visit; $25 per
specialist visit
$20 per primary care physician visit or specialist
visit (No deductible)

Preventive Care, adult -continued on next page 20
20 Page 21 22

2003 HealthSpring 18 Section 5( a)
Preventive care, adult (continued) You pay -High Option You pay -Standard Option
Routine pap test
Note: The office visit is covered if pap test is received on the same day; see Diagnostic and

Treatment, above.

$15 per primary care physician visit; $25 per
specialist visit
$20 per primary care physician visit or specialist
visit (No deductible)

Routine mammogram covered for women age 35 and older, as follows:
From age 35 through 39, one during this five year period
Over age 40, one every calendar year

$15 per primary care physician visit; $25 per
specialist visit
$20 per primary care physician visit or specialist
visit (No deductible)

Not covered: Physical exams and immunizations required for obtaining or continuing employment or
insurance, attending schools or camp, or travel.
All charges All charges

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

under childhood immunizations)
Influenza vaccine annually
Pneumococcal vaccine, age 65 and over

$15 per primary care physician visit; $25 per
specialist visit
$20 per primary care physician visit or specialist
visit No deductible)

Preventive care, children
Childhood immunizations recommended by the American Academy of Pediatrics $15 per primary care physician visit; $25 per
specialist visit
$20 per primary care physician visit or specialist
visit (No deductible)

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)

$15 per primary care physician visit; $25 per
specialist visit
$20 per primary care physician visit or specialist
visit (No deductible) 21
21 Page 22 23

2003 HealthSpring 19 Section 5( a)
Maternity care You pay -High Option You pay -Standard Option
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 pre- certify your normal delivery. See page 12 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. Circumcision is covered under the
maternity benefit.
We pay hospitalization and surgeon services (delivery) the same as for illness and injury. See

Hospital benefits (Section 5c) and Surgery benefits (Section 5b).

$25 for the initial office visit to confirm pregnancy; no copay
for all prenatal and postnatal visits thereafter
$20 for the initial office visit to confirm pregnancy;
no copay for all prenatal and postnatal visits
thereafter (No deductible)

Not covered: Routine sonograms to determine fetal age, size or sex All charges All charges
Family planning
A range of voluntary family planning services, limited to:

Voluntary sterilization (e. g. Tubal ligation, Vasectomy)
Surgically implanted contraceptives (such as Norplant)
Injectable contraceptive drugs (such as Depo-Provera)
Intrauterine devices (IUDs)
Diaphragms
Note: We cover oral contraceptives under the Prescription Drug benefit.

$15 per primary care physician
visit; $25 per specialist visit

20% coinsurance

$35 copay
$35 copay
$20 copay

20% of charges after satisfying calendar year
deductible

Family planning -continued on next page 22
22 Page 23 24
2003 HealthSpring 20 Section 5( a)
Family planning (continued) You pay -High Option You pay -Standard Option
Not covered: Reversal of voluntary surgical sterilization; genetic counseling All charges All charges

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

Intravaginal insemination (IVI) Intracervical insemination (ICI)

Intrauterine insemination (IUI)

$15 per primary care physician visit; $25 per
specialist visit
20% coinsurance for treatment

20% of charges after satisfying calendar year
deductible

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

in vitro fertilization embryo transfer, gamete GIFT and zygote ZIFT

Zygote transfer
Services and supplies related to excluded ART procedure

Cost of donor sperm
Cost of donor egg
Fertility drugs

All charges All charges

Allergy care
Testing and treatment
Allergy injections
$15 per primary care physician visit; $25 per

specialist visit
20% of charges after satisfying calendar year
deductible

Allergy serum Nothing Nothing

Not covered: provocative food testing and sublingual allergy desensitization. All charges All charges 23
23 Page 24 25

2003 HealthSpring 21 Section 5( a)
Treatment therapies You pay -High Option You pay -Standard Option
Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone marrow transplants are

limited to those transplants listed under Organ/ Tissue Transplants on 31.

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. Your physician will be
given a prior authorization form and asked to submit information that establishes that GHT is
medically necessary. This process must occur before you begin treatment or this treatment may
not be covered. If you do not obtain precertification or if we determine that GHT is not
medically necessary, we will not cover the GHT. See Services requiring our prior approval in
Section 3.

$15 per primary care physician visit; $25 per
specialist visit
20% of charges after satisfying calendar year
deductible

Not covered: Non-medical ancillary services, testing and treatment which include, but are not
limited to, such services as: vocational rehabilitation, cognitive behavioral
training/ therapy, sleep therapy, recreational therapy, employment counseling, educational
testing or therapy for learning disabilities or mental retardation, hypnotherapy, assertiveness
training, stress management, biofeedback and marital sex or family therapy.

All charges All charges 24
24 Page 25 26

2003 HealthSpring 22 Section 5( a)
Physical and occupational therapies You pay -High Option You pay -Standard Option
60 visits per calendar year for the services of each of the following combined therapies:

qualified physical therapists; and
occupational therapists. Note: We cover therapy only 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 six (6) weeks of treatment, if begun within ninety (90) days following discharge
from the initial hospital.

$25 per outpatient visit; Nothing per inpatient visit
$25 per outpatient visit
20% of charges after satisfying calendar year
deductible

20% of charges after satisfying calendar year
deductible

Not covered:
Long-term rehabilitative therapy
Exercise programs

All charges All charges

Speech therapy
30 visits per calendar year $25 per visit 20% of charges after satisfying calendar year
deductible
Hearing services (testing, treatment, and supplies)

Hearing Screening
Hearing testing for children through age 17 (see Preventive care, children)
$15 per primary care physician visit; $25 per

specialist visit
20% of charges after satisfying calendar year
deductible

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

Hearing devices, including cochlear implants

All charges All charges 25
25 Page 26 27

2003 HealthSpring 23 Section 5( a)
Vision services (testing, treatment, and supplies) You pay -High Option You pay -Standard Option
Eye exam, including refraction, by a participating provider, once every 12 months $15 per office visit $20 per office visit
We limit coverage to $100 per member per calendar year.
One pair of eyeglasses or contact lenses to correct an impairment directly caused by accidental ocular injury
or intraocular surgery (such as cataracts)
Note: See Preventive care, children for eye exams for children.

Nothing up to our $100 benefit allowance per
calendar year and all charges that exceed our
maximum allowance

Nothing up to our $100 benefit allowance per
calendar year and all charges that exceed our
maximum allowance (No deductible)

Not covered:
Eyeglasses (lenses and frames, contact lenses);
Eye exercises and orthoptics
Radial keratotomy and other refractive surgery

All charges All charges

Foot care
Routine foot care when you are under active treatment for a metabolic or peripheral vascular
disease, such as diabetes.
See orthopedic and prosthetic devices for information on podiatric shoe inserts.

$15 per primary care physician visit; $25 per
specialist visit
$20 per primary care physician visit or specialist
visit (No deductible)

Not covered:
Routine foot care or the treatment of flat feet, corns, calluses, toe nails, fallen arches, weak feet,

chronic foot strain, or symptomatic complaints relating to the feet, unless determined by our
Medical Director to be medically necessary in the preventive treatment of Diabetics;

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 surgery).

All charges All charges 26
26 Page 27 28

2003 HealthSpring 24 Section 5( a)
Orthopedic and prosthetic devices You pay -High Option You pay -Standard Option
Our maximum allowance for external orthopedic and prosthetic devices and DME is limited to a combined
benefit of $1,500.
Artificial limbs and eyes;
Externally worn breast prostheses and surgical bras, including necessary replacements, following

a mastectomy;
Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain

dysfunction syndrome;
Internal prosthetic devices, such as artificial joints, pacemakers, surgically implanted breast implants

following mastectomy. Note: See 5 (b) for coverage of the surgery to insert the device.

Note: We pay for 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.

Nothing up to our maximum allowance and
all charges that exceed our maximum allowance
20% of charges after satisfying calendar year
deductible up to our maximum allowance and
all charges that exceed our maximum allowance

Not covered:
Orthopedic and corrective shoes;
Lumbosacral supports;
Corsets, trusses, elastic stockings, support hose, and other supportive devices;

Penile prostheses or erection devices whether implantable or external;
Replacement of external prosthetics or orthotics due to wear and tear, loss, theft, destruction or
improved available technology of the device. Repair of external prosthetics or orthotics or
payment of warranties related to the prosthetic or orthotic device. Replacement of prosthetics and
orthotics is covered only when due to the member's physical development or growth; or

Supportive devices, including repairs (example: arch supports), orthotics for the feet or orthopedic
shoes, except when necessary as a component of an authorized brace.

All charges All charges 27
27 Page 28 29
2003 HealthSpring 25 Section 5( a)
Durable medical equipment (DME) You pay -High Option You pay -Standard Option
Our maximum allowance for external orthopedic and prosthetic devices and DME is limited to a combined
benefit of $1,500.
We cover, at our option, rental or purchase, 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:

oxygen delivery systems;
nebulizers;
hospital beds;
wheelchairs;
crutches;
walkers;
blood glucose monitors; and
insulin pumps (with approval of Medical Director)

Nothing up to our maximum allowance and
all charges that exceed our maximum allowance
20% of charges after satisfying calendar year
deductible up to our maximum allowance and
all charges that exceed our maximum allowance

Not covered:
Rentals of equipment that extend beyond the original prescription and authorization if recertification has

not been obtained;
Braces and splints that are used primarily to assist a member during athletic activities;

Repairs of DME except for repairs necessary due to reasonable wear and tear. Replacement of DME
equipment is covered only if due to the member's physical development or growth;

Air conditioners, air filters, heaters, humidifiers, and other equipment that adjusts or regulates the interior
environment, even if ordered by a participating provider;

Physical fitness equipment, saunas, whirlpools, water purifiers, swimming pools, tanning beds or
recreational equipment even if ordered by a participating provider; or

Self-help or hygienic products including, but not limited to, bathtub and shower chairs, safety-grab
bars, stair gliders or elevators, over-the-bed tables, or motorized vehicles.

All charges All charges 28
28 Page 29 30

2003 HealthSpring 26 Section 5( a)
Home health services You pay -High Option You pay -Standard Option
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.
Note: Oxygen covered as a DME benefit (see Durable Medical Equipment).

$15 per visit 20% of charges after satisfying calendar year
deductible

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; or
Rest, custodial, domiciliary, convalescent care; personal comfort or convenience items, sitter services,

private duty nursing, homemaker services, (including home-delivered means) or transportation services.

All charges All charges

Chiropractic
Limited to members 18 years of age and older. Maximum of 20 visits per calendar year per member.

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

application
Note: All diagnostic and lab procedures must be coordinated by your Primary Care Physician. We will

not cover these services if not arranged by your PCP.
Note: We cover benefits only when we determine care is clinically appropriate to treat your condition and is

arranged by us.

$25 per office visit $20 per primary care physician visit or
specialist visit (No deductible)

Not covered: Services or supplies related to the use of acupuncture or acupressure. All charges All charges
Alternative treatments
No benefit All charges All charges 29
29 Page 30 31
2003 HealthSpring 27 Section 5( a)
Educational classes and programs You pay -High Option You pay -Standard Option
Coverage is limited to:
Diabetes self-management

Smoking cessation -Our maximum lifetime benefit is $100

$15 per primary care physician visit; $25 per
specialist visit
Nothing up to our maximum lifetime benefit
and all charges that exceed our maximum allowance.

$20 per primary care physician visit or specialist
visit (No deductible)
Nothing up to our maximum lifetime benefit
and all charges that exceed our maximum allowance.
(No deductible) 30
30 Page 31 32

2003 HealthSpring 28 Section 5( b)
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
I M
P O
R T
A N
T

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

Plan physicians must provide or arrange your care.
Calendar year deductible:
High Option -We have no calendar year deductible.
Standard Option -The calendar year deductible is $500 per person or $1,000 per family and applies to most benefits in this section. We added "( No deductible)" to show when the calendar

year deductible does not apply.
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.

I M
P O
R T
A N
T

Benefit Description You pay -High Option You pay -Standard Option
NOTE: The calendar year deductible applies
to almost all benefits in this section for the
Standard Option. We show "( No deductible)"
when it does not apply.
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

$15 per primary care physician visit; $25 per
specialist visit
20% of charges after satisfying calendar year
deductible

Surgical Procedures -continued on next page 31
31 Page 32 33

2003 HealthSpring 29 Section 5( b)
Surgical procedures (continued) You pay -High Option You pay -Standard Option
Correction of congenital anomalies (see Reconstructive surgery)
Surgical treatment of morbid obesity is covered when the following criteria are met:
-Eligible members must be 18 years or older, AND
-Documented history of repeated failure of
physicians supervised medical dietary therapies, AND

A body mass index (BMI) exceeding 40 or greater than 35 in conjunction with severe co-morbidity such
as cardiopulmonary complications or severe diabetes.

$15 per primary care physician visit; $25 per
specialist visit
20% of charges after satisfying calendar year
deductible

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.

$15 per primary care physician visit; $25 per
specialist visit
20% of charges after satisfying calendar year
deductible

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

All charges All charges

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

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

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

Surgery to correct a condition that existed at or from birth and is a significant deviation from the common

form or norm. Examples of congenital anomalies are: protruding ear deformities; cleft lip; cleft palate;
birth marks; webbed fingers; and webbed toes.

$15 per primary care physician visit; $25 per
specialist visit
20% of charges (No deductible)

Reconstructive surgery -continued on next page 32
32 Page 33 34

2003 HealthSpring 30 Section 5( b)
Reconstructive surgery (continued) You pay -High Option You pay -Standard Option
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 primary care physician visit; $25 per
specialist visit
20% of charges after satisfying calendar year
deductible

Oral and maxillofacial surgery
Oral surgical procedures, limited to:
Reduction of fractures of the jaws or facial bones;
Surgical correction of cleft lip, cleft palate or severe functional malocclusion;

Removal of stones from salivary ducts;
Excision of leukoplakia or malignancies;
Treatment for TMJ;
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 primary care physician visit; $25 per
specialist visit
20% of charges after satisfying calendar year
deductible

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 All charges 33
33 Page 34 35
2003 HealthSpring 31 Section 5( b)
Organ/ tissue transplants You pay -High Option You pay -Standard Option
Limited to:
Cornea
Heart
Heart/ Lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single Double
Pancreas
Small Bowel
Small Bowel/ Liver
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

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. Covered
services are limited to those services and supplies directly related to the transplant procedure itself.

Nothing 20% of charges after satisfying calendar year
deductible

Transportation services, lodging and meals for the member, and one companion.
Our maximum Plan allowance for this benefit is $5,000 per person, with prior approval and coordination by
HealthSpring Case Management Department.

Nothing up to our maximum allowance of
$5,000 per person.
Nothing up to our maximum allowance of
$5,000 per person.

Organ/ tissue transplants -continued on next page 34
34 Page 35 36
2003 HealthSpring 32 Section 5( b)
Organ/ tissue transplants (continued) You pay -High Option You pay -Standard Option
Not covered:
Donor screening tests and donor search expenses, except those performed for the actual donor

Artificial, mechanical or animal heart, or any other artificial organ or associated expenses
Furnishing an organ or tissue
Transplants not listed as covered

All charges All charges

Anesthesia
Professional services provided in
Hospital (inpatient)
Nothing 20% of charges after satisfying calendar year

deductible
Professional services provided in
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center
Office

Nothing 20% of charges after satisfying calendar year
deductible 35
35 Page 36 37

2003 HealthSpring 33 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
I M
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T

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

Plan physicians must provide or arrange your care and you must be hospitalized in a Plan facility.
Calendar year deductible:
High Option -We have no calendar year deductible.
Standard Option -The calendar year deductible is $500 per person or $1,000 per family and applies to most benefits in this section. We added "( No deductible)" to show when the calendar

year deductible does not apply.
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 5( a) or (b).
YOUR PHYSICIAN MUST GET PRECERTIFICATION OF HOSPITAL STAYS. Please refer to Section 3 to be sure which services require precertification.

I M
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T

Benefit Description You pay -High Option You pay -Standard Option
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.
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 donated or replaced

$250 per admission copay
Nothing
$250 per admission copay
Nothing

Inpatient hospital -continued on next page 36
36 Page 37 38
2003 HealthSpring 34 Section 5( c)
Inpatient hospital (continued) You pay -High Option You pay -Standard Option
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 covered in $250 per admission copay Nothing covered in $250 per admission copay

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

Private nursing care
Storage of autologous blood

All charges All charges

Outpatient hospital or ambulatory surgical center
Operating, recovery, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology services

Administration of blood, blood plasma, and other biologicals
Blood and blood plasma, if 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 non-dental

procedures by a non-dental physical impairment. We do not cover the dental procedure.

$250 per procedure $250 per procedure (No deductible)

Not covered: blood and blood derivatives not replaced by the member All charges All charges 37
37 Page 38 39
2003 HealthSpring 35 Section 5( c)
Extended care benefits/ skilled nursing care facility benefits You pay -High Option You pay -Standard Option
Skilled nursing facility (SNF): Limited to 100 days per calendar year when full-time skilled nursing care is
necessary and confinement in a skilled nursing facility is medically appropriate as determined by a Plan doctor
and approved by the Plan.

Nothing Nothing

Not covered: custodial care All charges All charges
Hospice care
Hospice Services
We cover a maximum plan benefit of $10,000 per calendar year Nothing up to our maximum Plan benefit and all charges

that exceed our maximum
Nothing up to our maximum Plan benefit and all charges
that exceed our maximum

Not covered: Independent nursing, homemaker services All charges All charges

Ambulance
Non-emergency local professional ambulance service when medically appropriate Nothing Nothing 38
38 Page 39 40

2003 HealthSpring 36 Section 5( d)
Section 5 (d). Emergency services/ accidents
I M
P O
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A N
T

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

Calendar year deductible:
High Option -We have no calendar year deductible.
Standard Option -The calendar year deductible is $500 per person or $1,000 per family and applies to most benefits in this section. We added "( No deductible)" to show when the calendar year

deductible does not apply.
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 Medicare.

I M
P O
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T

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

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

What to do in case of emergency:
Emergencies within our service area: In an emergency, go to the nearest medical facility for treatment. Notify your Primary Care Physician and HealthSpring within 24 hours of receiving emergency services unless it is not reasonably possible to

do so. Your Primary Care Physician must coordinate all follow-up care including suture removal. Emergency treatment does not require a written referral. You will have coverage for emergency room charges only when the presenting symptoms to the
emergency room meet the definition of an emergency. Emergency service copayment will be waived if admitted to the hospital from the emergency room.

Emergencies outside our service area: If an emergency occurs outside the service area, and you could not reasonably return to the service area, you should contact your Primary Care Physician the next business day after receiving treatment to
coordinate follow-up care or arrange for a transfer back into the service area. Emergency Service copayment will be waived if admitted as an inpatient from the emergency room. 39
39 Page 40 41

2003 HealthSpring 37 Section 5( d)
Benefit Description You pay -High Option You pay -Standard Option
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

Note: Hospital emergency room copayment is waived if member is admitted to the hospital.

$15 per primary care physician visit; $25 per
specialist visit
$50 per visit
$100 per visit

$20 per primary care physician visit or specialist
visit
$50 per visit
$100 per visit

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

Note: Hospital emergency room copayment is waived if member is admitted to hospital.

$15 per primary care physician visit; $25 per
specialist visit
$50 per visit
$100 per visit

$20 per primary care physician visit or specialist
visit
$50 per visit
$100 per visit

Not covered:
Elective care or non-emergency care

Emergency care provided outside the service area if the need for care could have been foreseen before
leaving the service area
Medical and hospital costs resulting from a normal full-term delivery of a baby outside the service area

All charges All charges

Ambulance
Professional ambulance service when medically appropriate.

See 5( c) for non-emergency service.
Air ambulance service when medically appropriate and pre-approved by Plan.

Nothing Nothing 40
40 Page 41 42

2003 HealthSpring 38 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
I M
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A N
T

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

Calendar year deductible: High Option -We have no calendar year deductible.

Standard Option -The calendar year deductible is $500 per person or $1,000 per family and applies to most benefits in this section. We added "( No deductible)" to show when the calendar
year deductible does not apply.
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 FOR THESE SERVICES. See the instructions after the benefits description below.

I M
P O
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A N
T

Benefit Description You pay -High Option You pay -Standard Option
Mental health and substance abuse benefits
All diagnostic and treatment services must be recommended by a Plan provider and contained in a
treatment plan 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.
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

$25 per visit $20 per visit (No deductible)

Diagnostic tests Nothing 20% of charges after satisfying calendar year
deductible

Mental health and substance abuse -continued on next page 41
41 Page 42 43
2003 HealthSpring 39 Section 5( e)
Mental health and substance abuse benefits (continued) You pay -High Option You pay -Standard Option
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

$250 per admission copay $250 per admission copay

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 All charges

Preauthorization To be eligible to receive these benefits you must obtain a treatment plan and follow all of the following authorization processes:
To obtain Mental Health or Substance Abuse benefits, call 1-800-500-4638 to receive a referral for any inpatient or outpatient behavioral health services.
All mental health and substance abuse care must be coordinated by a Participating Provider and prior authorization received from the Mental Health Organization contracted by HealthSpring.
Your Participating provider is responsible for obtaining prior approval for services. Before giving approval, we consider benefit design, medical necessity, and generally accepted
practices. Member must call 1-800-500-4638 to receive a referral for any inpatient or outpatient behavioral health services.

Limitation We may limit your benefits if you do not obtain a treatment plan. 42
42 Page 43 44

2003 HealthSpring 40 Section 5( f)
Section 5 (f). Prescription drug benefits
I M
P O
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A N
T

Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart beginning on the next page.
All benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.

We have no calendar year deductible for the prescription drug benefit under either our High Option or Standard Option.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

I M
P O
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A N
T

There are important features you should be aware of. These include:
Who can write your prescription? A plan physician or referral physician must write the prescription.
Where you can obtain them. You may fill the prescription at a participating pharmacy or by mail for maintenance medications. You must use a network pharmacy. Walgreen's is not a participating pharmacy. For a complete list of

participating pharmacies, please check our web page at www. myhealthspring. com/ feds.
We use a formulary. The formulary is a list of prescription drugs that physicians use in prescribing medications. A Pharmacy and Therapeutics Committee evaluates prescription drugs for safety, effectiveness, quality, and overall value and schedules the
medications as preferred or non preferred brand after they have been on the market for at least 6 months. The formulary is subject to change. For a current list of covered medications included in the formulary, as well as their classifications as
generic, preferred brand, or non preferred brand, please check our web page at www. myhealthspring. com/ feds or you may request a list of covered products by calling Customer Service at (615) 291-5030 in Nashville or 1-800-917-3888. All
therapeutic classes are covered. Your physician may request a non-formulary drug by submitting to us medical record information regarding treatment failure with formulary alternatives, but such requests may require up to 5 working days for
approval. All injectable medication with a cost of $500 per course of treatment requires prior approval. Your physician must send a request, with medical records, to our Medical Management/ Pharmacy authorization desk at:

HealthSpring
Medical Management / Pharmacy Authorization
Phone: 615-291-7024
Fax: 615-291-7025
and such drugs are listed on the web site www. myhealthspring. com/ feds.

These are the dispensing limitations. When the prescription is filled at participating pharmacy, the pharmacy may dispense up to a 90-day supply for each oral drug or refill. One vial of insulin per one copayment, or one commercially prepared unit
(one inhaler, one bottle of ophthalmic medication, one tube of topical ointment, etc.) A prescription may not be refilled before 75% of it has been used.

Mail Order. Maintenance medication prescribed by participating doctors for long term use may be obtained through our mail order program for up to a 90-day supply for three copays. Certain classes of drugs are not available for mail order. For the
list, please check the web site. Mail order forms are available from Customer Service at (615) 291-5030 in Nashville or 1-800-917-3888. 43
43 Page 44 45

2003 HealthSpring 41 Section 5( f)
Certain limitations apply:
-Covered drugs are limited to the formulary;
-In no event will the copayment exceed the cost of the drug;
-Certain injectables require prior authorization (when course of treatment exceeds $500);
-Viagra, or similar drugs for sexual dysfunction, is limited to 8 tablets per month;
-Some medications have quantity dispensing limits per month, in accordance with FDA guidelines and to promote patient
safety. (See our web site, www. myhealthspring. com/ feds, for monthly quantity limits).

Why use generic drugs? Generic drugs are lower-priced drugs that are the therapeutic equivalent to more expensive brand-name drugs. They must contain the same active ingredients and must be equivalent in strength and dosage to the original
brand-name product. Generics cost less than the equivalent brand-name product. The U. S. Food and Drug Administration sets quality standards for generic drugs to ensure that these drugs meet the same standards of quality and strength as brand-name
drugs.
You can save money by using generic drugs, which have the lowest copayment. However, you and your physician have the option to request a name-brand drug. When a FDA approved generic is available and you or your physician requests the

brand name drug, you must pay the difference in cost between the generic and the brand name drug, plus the brand copayment. Certain drugs are exempt from the mandatory generic program and such drugs are listed on the web site
www. myhealthspring. com/ feds.

When you have to file a claim. In most cases, you do not have to file a claim when purchasing drugs at a participating pharmacy. However you must pay for the drug when dispensed, and file a claim for reimbursement when the following
occurs:
Your plan ID is not available, eligibility cannot be determined, or when the prescription is filled for a medical emergency outside the service area.

For assistance in filing a claim for direct member reimbursement, call Customer Service at (615) 291-5030 in Nashville or 1-800-917-3888.

Benefit Description You pay -High Option You pay -Standard Option
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 as listed as Not covered.
Insulin
Drugs for sexual dysfunction (see limitations above)
Oral contraceptive drugs
Diabetic supplies and meters (preferred product only)

Retail Pharmacy up to a 30 day supply
$10 per generic
$20 per brand name preferred

$35 per brand name non-preferred

Retail Pharmacy up to a 30 day supply
$10 per generic
$20 per brand name preferred

50% of covered charges for brand name non-preferred

Covered medications and supplies -continued on next page 44
44 Page 45 46

2003 HealthSpring 42 Section 5( f)
Covered medications and supplies (continued) You Pay -High Option You pay -Standard Option
Disposable needles and syringes for to inject the administration of covered medications
Drugs for sexual dysfunction (see limitations on page 41)
Self administered injectables, subject to prior approval
Intravenous and provider administered medications are covered under medical, surgical, or home health
benefits see section 5( a).
Growth hormone

Mail Order (Maintenance medications only) up to a
90 day supply
$30 per generic
$60 per brand name preferred
$105 per brand name non preferred

Mail Order (Maintenance medications only) up to a
90 day supply
$30 per generic
$60 per brand name referred

50% of covered charges for brand name non preferred

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

Drugs used for purpose of weight reduction or appetite suppression (unless approved as part of a
treatment plan for morbid obesity);
Medical supplies such as dressings and antiseptic
Drugs for orthodontic care, dental implants, and periodontal disease

Replacement of drugs due to loss, theft, or destruction
Vitamins, nutrients and food supplements even if a physician prescribes or administers them
Nonprescription medicines or over the counter medications

All charges All charges 45
45 Page 46 47
2003 HealthSpring 43 Section 5( g)
Section 5 (g). Special features
Feature Description

HealthSpring Disease Management Program Disease Management Programs are designed to assist you and your family in managing chronic disease states. This management is done through educational assistance, dedicated telephonic nurse
coordinator, integrated member care and case management.

Quarterly Newsletters You receive Healthful News, a quarterly newsletter. The newsletter provides updates, changes and/ or important news about your Health Plan and promotes health and wellness.

Centers of Excellence Patients requiring transplant services have access to nationally recognized transplant centers. HealthSpring has dedicated Case Managers who follow the transplant candidate from initial referral,
facility selection, initial evaluation, pre-transplant services, transplant and post-transplant care.

Hospitalist Program Hospitalists are highly skilled hospital-based physicians who work with your Primary Care Physician in coordinating and managing your overall medical care during inpatient admissions. The hospitalists are
readily available to monitor your daily progress and improve the physician/ patient communication. 46
46 Page 47 48

2003 HealthSpring 44 Section 5h
Section 5 (h). Dental benefits
I M
P O
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A N
T

Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable onlywhen we determine theyare medicallynecessary.

Plan dentists must provide or arrange your care. Dental Benefits are the same for both the High Option and the Standard Option Benefit Plans.

The calendar year deductible is: $25 per person and $75 per family. The calendar year deductible applies to all Preventive and Diagnostic Services.
We cover hospitalization for dental procedures onlywhen physical impairment exists which makes hospitalization necessaryto 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 costsforcoveredservices, for valuable information about howcost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

HOW TO ACCESS OUR DENTAL BENEFITS: The plan offers access to a
network of dentists who have agreed to provide services at a discounted rate. To locate a network dentist in your area, visit our website www. myhealthspring. com\ feds. For

questions about the benefits, call dental Customer Service at 1-800-511-6940. After taking your deductible, a network dentist will submit your claim for preventive
services to the dental claim processor for payment. If you receive preventive services from an out-of-network provider, you or the provider must submit your claim to the
address on your dental ID card for payment. When receiving covered services you must submit payment to the in-network provider based on the contracted, discounted fee.

I M
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T

Dental Benefits High and Standard Options In Network Out-of-Network
Accidental injury benefit You pay You pay
We cover treatment of accidental injury to sound natural teeth to relieve pain and stop bleeding when
service occurs within 24-hours of the injury. The need for these services must result from an accidental injury.
$15 primary care physician; $25 per
specialist visit
20% of charges after satisfying calendar year
deductible

Covered Dental Services -High and Standard Options In-Network You pay Out-of-Network You pay
Annual Maximum Benefit (combined for both In-Network and Out-of-Network services) $500 per person per calendar year $500 per person per calendar year
Individual Deductible $25 per calendar year $25 per calendar year
Family Deductible $75 per calendar year $75 per calendar year
Annual deductible applies to preventive and diagnostic services Yes Yes

For new enrollees, a 12-month waiting period applies to major services & orthodontics No No
Dental benefits --continued on next page 47
47 Page 48 49
2003 HealthSpring 45 Section 5h
Dental Benefits High and Standard Options (continued) In Network Out-of-Network
Preventive and Diagnostic Dental Services
High and Standard Options You Pay You Pay

Periodic Oral Examinations Up to 2 per year
Bitewing X-Rays one series of films per year
Complete Series or Panorex X-rays one time per 36 months

Dental Prophylaxis (Cleanings) Up to 2 per year
Fluoride Treatments for covered persons under the age of 16 years, up to 2 per year

Sealants For covered persons under the age of 14 years, once per first or second permanent molar every 5
years

After deductible nothing After deductible 20%

Basic Dental Services In-Network You pay Out-of-Network You pay
Amalgam restorations (Fillings)
Resin one surface, Posterior permanent (Fillings)
Space maintainers
Root canal, Molar, Excl. final restoration
Single tooth extraction
Periodontal surgery
Removal of impacted tooth-soft tissue
Palliative treatment
General anesthesia, 1st 30 minutes
Frenectomy

Discount applies All Charges

Major Dental Services In-Network You pay Out-of-Network You pay
Onlay-procelain/ Ceramic, 3 surface
Crown, porcelain fused to Hi Noble
Complete denture upper
Lower partial denture metal base
Adjustment of complete dentures upper
Pontic-procelain fused to HI Noble metal

Discount applies All Charges

Orthodontic Services In-Network You pay Out-of-Network You pay
Diagnose or correct misalignment of the teeth or bite including Phase I & II, child only to age 19 Preauthorization required then discount applies All Charges 48
48 Page 49 50

2003 HealthSpring 46 Section 6
Section 6. General exclusions --things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not cover it unless your Plan doctor determines it is Medically Necessary to prevent, diagnose, or treat your illness, disease,
injury, or condition, and we agree, as discussed under What Services Require Our Prior Approval on page 12.
We do not cover the following:
Care by non-Plan providers except for authorized referrals or emergencies (See Emergency Benefits);
Services, drugs, or supplies you receive while you are not enrolled in this Plan;
Services, drugs, or supplies that are not medically necessary;
Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice;
Experimental or investigational procedures, treatments, drugs or devices;
Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest;

Services, drugs, or supplies related to sex transformations;
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program;
Services, drugs, or supplies you receive without charge while in active military service. 49
49 Page 50 51
2003 HealthSpring 47 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 participating pharmacies, you will not have to file claims. Present your identification card and pay your copayment or coinsurance.

You will only 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.
In most cases, providers and facilities file claims for you. Physicians must file on the form HCFA-1500, Health Insurance Claim Form. Facilities will file on the UB-92 form. For claims
questions and assistance, call us at (615) 291-5030 in Nashville or 1-800-917-3888 from outside Nashville.

When you must file a claim --such as for services you receive outside of the Plan's service area --submit it on the HCFA-1500 or a claim form that includes the information shown below.
Bills and receipts should be itemized and show:

Covered member's name and ID number;
Name and address of the physician or facility that provided the service or supply;
Dates you received the services or supplies;
Diagnosis;
Type of each service or supply;
The charge for each service or supply;
A copy of the explanation of benefits, payments, or denial from any primary payer --such as the Medicare Summary Notice (MSN); and

Receipts, if you paid for your services.
Submit your claims to: HealthSpring P. O. Box 20000
Nashville, TN 37202-9613

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.

Medical, hospital and drug benefits 50
50 Page 51 52
2003 HealthSpring 48 Section 8
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your claim or request for services, drugs, or supplies including a request for preauthorization:

Step Description
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: HealthSpring, P. O. Box 20000, Nashville, TN 37202-9613; and
(c) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure; and

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

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

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

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

Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Contracts Division 3, 1900 E Street, NW, Washington, DC 20415-3630. 51
51 Page 52 53
2003 HealthSpring 49 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 (615) 291-5030 and we will expedite our review; or
(b) We denied your initial request for care or preauthorization/ prior approval, then:
If we expedite our review and maintain our denial, we will inform OPM so that they can give your claim expedited treatment too, or

You may call OPM's Health Benefits Contracts Division 3 at 202/ 606-0737 between 8 a. m. and 5 p. m. eastern time. 52
52 Page 53 54
2003 HealthSpring 50 Section 9
Section 9. Coordinating benefits with other coverage
You must tell us if you or a covered family member have coverage under another group health plan or have automobile insurance that pays health care
expenses without regard to fault. This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in full as the primary payer and the other plan pays a reduced benefit as the secondary
payer. We, like other insurers, determine which coverage is primary according to the National Association of Insurance Commissioners'
guidelines.
When we are the primary payer, we will pay the benefits described in this brochure. When we are the secondary payer, we will determine our allowance.
After the primary plan pays, we will pay what is left of our allowance, up to our regular benefit. We will not pay more than our allowance.

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

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

employment, you should be able to qualify for premium-free Part A insurance. (Someone who was a Federal employee on January 1, 1983 or
since automatically qualifies.) Otherwise, if you are age 65 or older, you may be able to buy it. Contact 1-800-MEDICARE for more information.

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

If you are eligible for Medicare, you may have choices in how you get your health care. Medicare + Choice is the term used to describe the various health
plan choices available to Medicare beneficiaries. The information in the next few pages shows how we coordinate benefits with Medicare, depending on the
type of Medicare managed care plan you have.
The Original Medicare Plan (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 be coordinated by your Primary Care Physician (PCP) and provided by participating plan providers unless approved in advance by the Plan, except in

The Original Medicare Plan (Part A or Part B)

When you have other health coverage 53
53 Page 54 55

2003 HealthSpring 51 Section 9
an emergency. We will not waive any of our copayment or coinsurance.
Please note: If your Plan physician does not participate in Medicare, you will have to file a claim with Medicare.

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 (615) 291-5030 or contact us through our web site at www. myhealthspring. com/ feds.

We do not waive any out-of-pocket costs when you have the Original Medicare Plan.
(Primary payer chart begins on next page.) 54
54 Page 55 56
2003 HealthSpring 52 Section 9
The following chart illustrates whether the Original Medicare Plan or this Plan should be the primary payer for you according to your employment status and other factors determined by Medicare. It is critical that you tell us if you or a
covered family member has Medicare coverage so we can administer these requirements correctly.
Primary Payer Chart
Then the primary payer is A. When either you --or your covered spouse --are age 65 or over and

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

disability),
!

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

a) The position is excluded from FEHB, or
b) The position is not excluded from FEHB

(Ask your employing office which of these applies to you.) !
4) Are a Federal judge who retired under title 28, U. S. C., or a Tax Court judge who retired under Section 7447 of title 26, U. S. C. (or if your

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

!
(except for claims related to Workers'

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

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

b) Are an active employee, or !
c) Are a former spouse of an annuitant, or !
d) Are a former spouse of an active employee ! 55
55 Page 56 57

2003 HealthSpring 53 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
choices (like HMOs) in some areas of the country. In most Medicare managed care plans, you can only go to doctors, specialists, or hospitals that are part of
the plan. Medicare managed care plans provide all the benefits that Original Medicare covers. Some cover extras, like prescription drugs. To learn more
about enrolling in a Medicare managed care plan, contact Medicare at 1-800-MEDICARE (1-800-633-4227) or at www. medicare. gov.

If you enroll in a Medicare managed care plan, the following options are available to you:
This Plan and our Medicare managed care plan: You may enroll in our Medicare managed care plan and also remain enrolled in our FEHB plan. In
this case, we do not waive any of our copayments or coinsurance 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 or coinsurance. 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 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 56
56 Page 57 58
2003 HealthSpring 54 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 preceding 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 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.

We do not cover services and supplies when a local, State, or Federal Government agency directly or indirectly pays for them.

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.

When other Government agencies are responsible for your care
When others are responsible for your injuries 57
57 Page 58 59

2003 HealthSpring 55 Section 10
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 14.

Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 14.
Covered services Care we provide benefits for, as described in this brochure.
Custodial care Care that is provided primarily for maintenance of your condition. Custodial care is designed to assist in activities of daily living (walking, bathing, dressing,
feeding, housekeeping) and includes self-administration of medications not requiring constant attention of medical personnel. Custodial care that lasts 90
days or more is sometimes known as Long term care.

Deductible A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for those services.
See page 14.

Service not already in general use or not recognized by the United States Pharmacopeail Convention, the American Medial Association, or the American
society of Pharmacists Compendia.

Medical necessity Treatment that is non-experimental or investigational, consistent with the symptoms or diagnosis of the condition, appropriate in regards to standards of
good medical practice, not primarily for the convenience of the patient, physician, hospital or other provider, and the most appropriate supply or level of
service which can safely be provided.

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

Section 10. Definitions of terms we use in this brochure
Experimental or investigational services 58
58 Page 59 60

2003 HealthSpring 56 Section 11
We will not refuse to cover the treatment of a condition that you had before you enrolled in this Plan solely because you had the condition before you
enrolled.
See http://www.opm.gov/insureAlso, your employing or retirement office can answer your questions, and give you a Guide to Federal Employees Health
Benefits Plans, brochures for other plans, and other materials you need to take 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.

Self Only coverage is for you alone. Self and Family coverage is for 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 employment 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,

Section 11. FEHB facts
No pre-existing condition limitation

Where you can get information about enrolling
in the FEHB Program

Types of coverage available for you and your family 59
59 Page 60 61
2003 HealthSpring 57 Section 11
if you are an employee subject to a court or administrative order requiring you to provide health benefits for your child( ren).
If this law applies to you, you must enroll for Self and Family coverage in a health plan that provides full benefits in the area where your children live or
provide documentation to your employing office that you have obtained other health benefits coverage for your children. If you do not do so, your
employing office will enroll you involuntarily as follows:
If you have no FEHB coverage, your employing office will enroll you for Self and Family coverage in the option of the Blue Cross and Blue Shield
Service Benefit Plan'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 lower option of the Blue Cross and Blue Shield Service Benefit Plan's Basic Option.

As long as the court/ administrative order is in effect, and you have at least one child identified in the order who is still eligible under the FEHB
Program, you cannot cancel your enrollment, change to Self only, or change to a plan that doesn't serve the area in which your children live, unless you
provide documentation that you have other coverage for the children. If the court/ administrative order is still in effect when you retire, and you have at
least one child still eligible for FEHB coverage, you must continue your FEHB coverage into retirement (if eligible) and cannot make any changes
after retirement. Contact your employing office for further information.
The benefits in this brochure are effective on January 1. If you joined this Plan during Open Season, your coverage begins on the first day of your first
pay period that starts on or after January 1. Annuitants' coverage and premiums begin on January 1. If you joined at any other time during the
year, your employing office will tell you the effective date of coverage.

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

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

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

Spouse equity coverage If you are divorced from a Federal employee or annuitant, you may not continue to get benefits under your former spouse's enrollment. This is the
case even when the court has ordered your former spouse to supply health

When benefits and premiums start 60
60 Page 61 62

2003 HealthSpring 58 Section 11
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 of coverage (TCC) longer qualify as a family member, you may be eligible for Temporary
Continuation of Coverage (TCC). For example, you can receive TCC if you are not able to continue your FEHB enrollment after you retire, if you lose
your job, if you are a covered dependent child and you turn 22 or marry, etc.
You may not elect TCC if you are fired from your Federal job due to gross misconduct.

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 http://www.opm.gov/insureIt 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.

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

Getting a Certificate of Group Health Plan Coverage 61
61 Page 62 63

2003 HealthSpring 59 Section 11
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. 62
62 Page 63 64

2003 HealthSpring 60 Long Term Care
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 call "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 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 annuitant 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 though 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.

Long Term Care Insurance Is Still Available! 63
63 Page 64 65

2003 HealthSpring 61 Index
Index
Do not rely on this page; it is for your convenience and may not show all pages where the terms appear.

Accidental dental injury ........................ 44 Allergy tests ......................................... 20
Ambulance ..................................... 35, 37 Anesthesia ........................................... 32
Blood and blood plasma ............... 33, 34 Chemotherapy ..................................... 21
Chiropractic ......................................... 26 Contraceptive devices and drugs ... 19, 41
Diagnostic services .............................. 16 Durable medical equipment (DME) .. 25
Emergency ........................................... 36 Family planning ................................... 19
General Exclusions .............................. 46 Home health services ........................... 26
Hospice care ......................................... 35 Hospital ............................................... 33
Immunizations ..................................... 18 Infertility .............................................. 20
Inpatient Hospital Benefits .................. 33

Laboratory and pathological service...... 17 Mail Order Prescription Drugs............... 40
Mammograms ....................................... 18 Maternity Benefits ................................. 19
Medicare .............................................. 50 Mental Conditions/ Substance Abuse
Benefits........................................... 38 Occupational therapy............................ 22
Orthopedic devices................................. 23 Oxygen................................................... 25
Pap test ................................................. 18 Physical therapy .................................... 22
Precertification ............................... 12 Preventive care, adult ...................... 17
Preventive care, children.................. 18 Prescription drugs ................................. 40
Prior approval ........................................ 40 Prosthetic devices .................................. 24

Skilled nursing facility care............ 35 Speech therapy................................ 22
Surgery ........................................... 28 Transplants .................................... 31
Vision services................................ 23 64
64 Page 65 66

2003 HealthSpring 62 Summary of Benefits
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 -High Option You Pay Standard Option Page
Medical services provided by physicians:
Diagnostic and treatment services provided in the office. Office visit copay: $15 primary care; $25 specialist Office visit copay: $20 primary care; $20 specialist 16

Services provided by a hospital:
Inpatient.

Outpatient..
$250 per admission

$250 copayment
$250 per admission
$250 copayment
33
34

Emergency benefits:
In-area.. .

Out-of-area.
$50 per urgent care center visit; $100 per emergency care visit $50 per urgent care center visit; $100 per emergency care visit 36

Mental health and substance abuse treatment ............................................ Regular cost sharing. Regular cost sharing. 38
Prescription drugs .............................. Retail Pharmacy: $10 generic; $20 brand preferred; $35 brand non-
preferred
Mail Order Maintenance Drugs: $30 generic; $60 brand preferred;
$105 brand non-preferred

Retail Pharmacy: $10 generic; $20 brand preferred; 50% brand non-
preferred
Mail Order Maintenance Drugs: $30 generic; $60 brand preferred;
50% brand non-preferred

40

Comprehensive Dental Benefit... See section 5( h) for details See section 5( h) for details 44
Vision Care (Eye exam, including annual refraction)........................................... $15 office visit copay $20 office visit copay 23

Special features: HealthSpring Disease Management Program; Quarterly Newsletters, Centers of Excellence, Hospitalist Program 43
Protection against catastrophic costs (your catastrophic protection out-of-
pocket maximum) ..............................

$2,000 per individual/$ 4,000 per family $3,000 per individual/$ 6,000 per family
14

Summary of benefits for HealthSpring -2003 65 <B