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Kaiser Foundation Health Plan, Inc.
Southern California

Federal Employees Health Benefits Program
2003 Plan Brochure
Accessible Version

Document Outline

Introduction
Plain Language
Stop Health Care Fraud!
Section 1. Facts about this HMO plan
Section 2. How we change for 2003
- Program-wide changes
- Changes to this Plan
Section 3. How you get care
Section 4. Your costs for covered services
Section 5. Benefits
Section 6. General exclusions things we dont cover
Section 7. Filing a claim for covered services
Section 8. The disputed claims process
Section 9. Coordinating benefits with other coverage
Section 10. Definitions of terms we use in this brochure
Section 11. FEHB facts
Long Term Care Insurance Is Still Available!
Index
Summary of benefits
Rate

Pages 1--70

Page 1


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

Kaiser Foundation Health Plan, Inc.
Southern California Region http:// www. kaiserpermanente. org
2003 A Health Maintenance Organization

Serving: Southern California service area
Enrollment in this Plan is limited. You must live or work in our geographic service area to enroll. See page 8 for requirements.

Enrollment codes for this Plan:
621 Self Only 622 Self and Family

RI 73-822

This Plan has excellent accreditation from the NCQA. See the 2003 Guide for more information on accreditation.
For changes in
benefits see page 9 1.
1 Page 2 3
Dear Federal Employees Health Benefits Program Participant:
I am pleased to present this Federal Employees Health Benefits (FEHB) Program plan brochure for 2003. The brochure explains all the benefits this health plan offers to its enrollees. Since
benefits can vary from year to year, you should review your plan's brochure every Open Season. Fundamentally, I believe that FEHB participants are wise enough to determine the care
options best suited for themselves and their families.
In keeping with the President's health care agenda, we remain committed to providing FEHB members with affordable, quality health care choices. Our strategy to maintain quality and cost
this year rested on four initiatives. First, I met with FEHB carriers and challenged them to contain costs, maintain quality, and keep the FEHB Program a model of consumer choice and
on the cutting edge of employer-provided health benefits. I asked the plans for their best ideas to help hold down premiums and promote quality. And, I encouraged them to explore all
reasonable options to constrain premium increases while maintaining a benefits program that is highly valued by our employees and retirees, as well as attractive to prospective Federal
employees. Second, I met with our own FEHB negotiating team here at OPM and I challenged them to conduct tough negotiations on your behalf. Third, OPM initiated a comprehensive
outside audit to review the potential costs of federal and state mandates over the past decade, so that this agency is better prepared to tell you, the Congress and others the true cost of mandated
services. Fourth, we have maintained a respectful and full engagement with the OPM Inspector General (IG) and have supported all of his efforts to investigate fraud and waste within the
FEHB and other programs. Positive relations with the IG are essential and I am proud of our strong relationship.

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

Sincerely,

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

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

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

To communicate with your FEHB health plan when you or someone you have authorized to act on your behalf asks for our assistance regarding a benefit or customer service issue.
To review, make a decision, or litigate your disputed claim. For OPM and the General Accounting Office when conducting audits.

OPM may use or give out your personal medical information for the following purposes under limited circumstances:
For Government healthcare oversight activities (such as fraud and abuse investigations), For research studies that meet all privacy law requirements (such as for medical research or education), and
To avoid a serious and imminent threat to health or safety.
By law, OPM must have your written permission (an "authorization") to use or give out your personal medical information for any purpose that is not set out in this notice. You may take back (" 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 www. opm. gov/ insure on the web. You may also call 1-202-606-0191 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 Kaiser Foundation Health Plan, Inc. 5 Introduction/ Plain Language/ Advisory Southern California Region
Introduction
This brochure describes the benefits of Kaiser Foundation Health Plan, Inc. Southern California Region, under our contract (CS1044-B) with the Office of Personnel Management (OPM), as authorized by the Federal Employees
Health Benefits law. The Southern California Region's administrative office is:
Kaiser Foundation Health Plan, Inc. 393 East Walnut Street
Pasadena, CA 91188
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 9. 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" or "Plan" means Kaiser Foundation Health Plan, Inc.
We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the Office of Personnel Management. If we use others, we tell you what they mean first.
Our brochure and other FEHB plans' brochures have the same format and similar descriptions to help you compare plans.
If you have comments or suggestions about how to improve this brochure, let us know. Visit OPM's "Rate Us" feedback area at www. opm. gov/ insure or e-mail us at fehbwebcomments@ opm. gov. You may also write to OPM at
the Office of Personnel Management, Office of Insurance Planning and Evaluation, 1900 E Street NW, Washington, DC 20415.

Stop Health Care Fraud!
Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits (FEHB) Program premium.
OPM's Office of the Inspector General investigates all allegations of fraud, waste and abuse in the FEHB Program regardless of the agency that employs you or from which you retired. 8.
8 Page 9 10
2003 Kaiser Foundation Health Plan, Inc. 6 Introduction/ Plain Language/ Advisory Southern California Region
Protect Yourself From Fraud Here are some things you can do to prevent fraud:
Be wary of giving your plan identification (ID) number over the telephone or to people you do not know, except to your doctor, other provider, or authorized plan or OPM representative.

Let only the appropriate medical professionals review your medical record or recommend services.
Avoid using health care providers who say that an item or service is not usually covered, but they know how to bill us to get it paid.

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

If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or misrepresented any information, do the following:
Call the provider and ask for an explanation. There may be an error.
If the provider does not resolve the matter, call our Member Service Call Center at 1-800-464-4000 and explain the situation.

If we do not resolve the issue:

CALL THE HEALTH CARE FRAUD HOTLINE
1-202-418-3300
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. 9.
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2003 Kaiser Foundation Health Plan, Inc. 7 Section 1 Southern California Region
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 our most recent provider directory. HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and
immunizations, in addition to treatment for illness and injury. Our providers follow generally accepted medical practice when prescribing any course of treatment.

When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You only pay the copayments and coinsurance described in this brochure. When you receive emergency services or services
covered under the travel benefit, from non-Plan providers, you may have to submit claim forms.
You should join an HMO because you prefer the plan's benefits, not because a particular provider is available. You cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician,
hospital, or other provider will be available and/ or remain under contract with us.

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

Your Rights
OPM requires that all FEHB plans provide certain information to their FEHB members. You may get information about us, our networks, providers, and facilities. OPM's FEHB website (www. opm. gov/ insure) lists the specific types
of information that we must make available to you. Some of the required information is listed below.
We are a federally qualified health maintenance organization, and we have provided health care services to Californians for nearly 60 years. Kaiser Foundation Health Plan, Inc., is a California not-for-profit organization. This
Plan is part of the Kaiser Permanente Medical Care Program, a group of not-for-profit organizations and contracting medical groups that serve over 8 million members nationwide. Our Southern California Permanente Medical Group,
operates Plan medical offices throughout Southern California.
If you want more information about us, call 1-800-464-4000, or write to 393 East Walnut Street, Pasadena, California 91188. You may visit our website at www. kaiserpermanente. org, which lists the specific types of information that we
must make available to you. 10.
10 Page 11 12
2003 Kaiser Foundation Health Plan, Inc. 8 Section 1 Southern California Region
Service Area
To enroll in this Plan, you must live or work in our service area. This is where our providers practice. Our service area counties are:

Orange and Los Angeles (except zip code 90704).
Portions of the following counties, as indicated by the zip codes below, are also within the service area:
Imperial: 92275
Kern: 93203, 93205-06, 93215-16, 93220, 93222, 93224-26, 93238, 93240-41, 93243, 93250-52, 93263, 93268, 93276, 93280, 93285, 93287, 93301-09,
93311-13, 93380-90, 93501-02, 93504-05, 93518-19, 93531, 93560-61, 93581

Riverside: 91752, 92201-03, 92210-11, 92220, 92223, 92230, 92234-36, 92240-41, 92253-55, 92258, 92260-64, 92270, 92274, 92276, 92282, 92292, 92320,
92501-09, 92513-19, 92521-22, 92530-32, 92543-46, 92548, 92551-57, 92562-64, 92567, 92570-72, 92581-87, 92595-96, 92599, 92860, 92877-
83
San Bernardino: 91701, 91708-10, 91729-30, 91737, 91739, 91743, 91758, 91761-64, 91784-86, 91798, 92252, 92256, 92268, 92277, 92278, 92284-86, 92305,
92307-08, 92313-18, 92321-22, 92324-26, 92329, 92333-37, 92339-41, 92345-46, 92350, 92352, 92354, 92357-59, 92369, 92371-78, 92382,
92385-86, 92391-94, 92397, 92399, 92401-08, 92410-15, 92418, 92420, 92423-24, 92427

San Diego: 91901-03, 91908-17, 91921, 91931-33, 91935, 91941-47, 91950-51, 91962-63, 91976-80, 91990, 92007-09, 92014, 92018-27, 92029-30,
92033, 92037-40, 92046, 92049, 92051-52, 92054-58, 92064-65, 92067-69, 92071-72, 92074-75, 92078-79, 92082-85, 92090-93, 92096, 92101-
24, 92126-40, 92142-43, 92145, 92147, 92149-50, 92152-55, 92158-79, 92182, 92184, 92186-87, 92190-99

Tulare: 93261
Ventura: 91319-20, 91358-63, 91377, 93001-07, 93009, 93010-12, 93015-16, 93020-21, 93022, 93030-35, 93040, 93041-44, 93060-61, 93062-66,
93093, 93099

Ordinarily, you must receive your care from physicians, hospitals, and other providers who contract with us. However, we are part of the Kaiser Permanente Medical Care Program, and if you are visiting another Kaiser
Permanente service area, you can receive virtually all of the benefits of this Plan at any other Kaiser Permanente facility, including our mail order prescription program. You must pay the charges or copayments imposed by the
Kaiser Permanente Plan you are visiting, with the exception of mail order prescriptions which are administered by your home Plan. See Section 5( g), Special Features, for more details. We also pay for certain follow-up services or
continuing care services while you are traveling outside the service area, as described on page 42; and for emergency care obtained from any non-Plan provider, as described on page 32. We will not pay for any other health care
services.
If you or a covered family member move outside of our service area, you can enroll in another plan. If your dependents live out of the area (for example, if your child goes to college in another state), you should consider
enrolling in a fee-for-service plan or an HMO that has agreements with affiliates in other areas. If you or a family member move, you do not have to wait until Open Season to change plans. Contact your employing or retirement
office. 11.
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2003 Kaiser Foundation Health Plan, Inc. 9 Section 2 Southern California Region
Section 2. How we change for 2003
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5 Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here is a
clarification that does not change benefits.
Program-wide changes
A Notice of the Office of Personnel Management's Privacy Practices is included. A section on the Children's Equity Act describes when an employee is required to maintain Self and Family

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

Changes to this Plan
Your share of the non-Postal premium will increase by 15. 5% for Self Only or 15. 5% for Self and Family.

This Plan is now two separate Regions in California, with different benefits and brochures. You must live or work in our Southern California service area to receive the benefits described in this brochure. (See Section 1)

We increased the fee charged when you fail to make your copayment at the time you receive services from $10 to $13.50.
We increased the copayment for allergy testing from $3 to $10.
We moved coverage for ostomy and urological supplies to the orthopedic and prosthetic devices benefit and increased the copayment to 20% of our allowance.

We increased the copayment for external sexual dysfunction devices covered under the durable medical equipment benefit from 20% of our allowance to 50% of our allowance.
We cover a wide range of health education classes for all members, including smoking cessation.
We extended the eligibility for hospice to members who have a terminal illness, with a life expectancy of 6 months or less to 12 months or less.

We limit recovery services for chemical dependency in a non-medical residential facility to no more than 60 days of covered care per calendar year and no more than 120 days in any five-consecutive year period.
We dispense less than a 100-day supply of prescription drugs that are in limited supply in the market.
We increased the copayment for brand-name drugs from $20 to a $25 copayment.
We cover smoking cessation drugs for as many courses of treatment per calendar year as medically necessary.
We will charge the brand-name drug copayment for compounded products listed on our drug formulary, or that include ingredients requiring a prescription by law.

We exclude drugs that shorten the duration of the common cold.
We exclude drugs for the promotion, prevention, or other treatment of hair loss or hair growth.
We exclude compounded products unless the product is listed on our drug formulary, or one of the ingredients requires a prescription by law.

We exclude any requested packaging of drugs (such as dose packaging) other than the dispensing pharmacy's standard packaging.
We will charge 50% of our allowance for excluded drugs that we have been covering and providing to you for FDA approved uses, if a Plan physician continues to prescribe the drug for the same reason.
We changed some of your Kaiser Permanente Senior Advantage-FEHBP enhanced benefits. (See Section 9). 12.
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2003 Kaiser Foundation Health Plan, Inc. 10 Section 3 Southern California Region
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 our
Member Service Call Center at 1-800-464-4000, or write to us at: Kaiser Permanente California Service Center Federal Account Team, 3840
Murphy Canyon Road, San Diego, CA 92123.

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

Plan providers Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our
members. Health Plan contracts with Southern California Permanente Medical Group and independent multispecialty groups of physicians to
provide or arrange all necessary physician care for Plan members. Medical care is provided through physicians, nurse practitioners, and
other skilled medical personnel working as medical teams at Kaiser Permanente facilities. We credential Plan providers according to national
standards. Specialists in most major specialties are available as part of the medical teams for consultation and treatment. Other necessary
medical care, such as physical therapy and laboratory and X-ray services, is also available. Plan physicians also arrange any necessary specialty
care.
We list Plan providers in the provider directory, which we update periodically. The list is also on our website.

Plan facilities Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members. Kaiser
Permanente offers comprehensive, affordable health care at 10 major Medical Centers and more than 90 medical offices conveniently located
throughout the Southern California area.
The Plan's facility directory lists the Plan's facilities and services, with the locations and phone numbers. Directories are updated on a regular
basis and are available at the time of enrollment or upon request by calling our Member Service Call Center at 1-800-464-4000. You should
use this directory to:
Receive more information about facility locations and services Receive information about how to get established with a Plan
physician

You must receive your health services at Plan facilities, except if you have an emergency. If you are visiting another Kaiser Permanente
service area, you may receive health care services at those Kaiser 13.
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2003 Kaiser Foundation Health Plan, Inc. 11 Section 3 Southern California Region
Permanente facilities. Under the circumstances specified in this brochure, you may receive follow-up or continuing care while you travel
anywhere.

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

Primary care Your primary care physician can be either a family practitioner, pediatrician, gynecologist, or internist. Your primary care physician will
provide most of your health care, or give you a referral to see a specialist. Please notify the Plan of the primary care physician you choose. If you
need help choosing a primary care physician, call the Plan. You may change your primary care physician at any time. You are free to see
other Plan physicians if your primary care physician is not available, and to receive care at other Kaiser Permanente facilities.

If you want to change primary care physicians or if your primary care physician leaves the Plan, call us. We will help you select a new one.
Specialty care Your primary care physician will refer you to a specialist for needed care. When you receive a referral from your primary care physician, you must
return to the primary care physician after the consultation, unless your primary care physician authorized a certain number of visits without
additional referrals. The primary care physician must provide or authorize all follow-up care. Do not go to the specialist for return visits
unless your primary care physician gives you a referral. However, you may see a gynecologist, an optometrist, or our mental health and
substance abuse Plan providers without a referral.
Here are other things you should know about specialty care:
If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician
will develop a treatment plan that allows you to see your specialist for a certain number of visits without additional referrals. Your primary
care physician will use our criteria when creating your treatment plan (the physician may have to get an authorization or approval
beforehand).
If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician. Your primary care physician will decide
what treatment you need. If he or she decides to refer you to a specialist, ask if you can see your current specialist. If your current
specialist does not participate with us, you must receive treatment from a specialist who does. Generally, we will not pay for you to see
a specialist who does not participate with our Plan.
If you are seeing a specialist and your specialist leaves the Plan, call your primary care physician, who will arrange for you to see another
specialist. You may receive services from your current specialist until we can make arrangements for you to see someone else.

If you have a chronic or disabling condition and lose access to your specialist because we:
terminate our contract with your specialist for other than cause; or 14.
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2003 Kaiser Foundation Health Plan, Inc. 12 Section 3 Southern California Region
drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB plan; or
reduce our service area and you enroll in another FEHB plan,
you may be able to continue seeing your specialist for up to 90 days after you receive notice of the change. Contact us or, if we drop out
of the Program, contact your new plan.
If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can
continue to see your specialist until the end of your postpartum care, even if it is beyond the 90 days.

Hospital care Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission
to a skilled nursing or other type of facility.
If you are in the hospital when your enrollment in our Plan begins, call our Member Service Call Center immediately at 1-800-464-4000. If you
are new to the FEHB Program, we will arrange for you to receive care.
If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:

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

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

Services requiring our Your primary care physician has authority to refer you for most services. prior approval In certain cases your primary care physician can arrange for specialty
services through a process we call a referral. Your physician must write a referral for services such as neurology, orthopedics, rheumatology,
endocrinology, and any service that will not be provided by Plan physicians.

If a Plan physician determines that a referral for medical care is necessary, those arrangements will be prepared in writing and in advance
of such medical care. If you receive care outside the Plan without a referral, you will be responsible for those expenses. We encourage you
to participate in your medical care and discuss any questions about our referral process with your primary care physician. If your request for
referral is denied, please contact our Member Service Call Center at 1-800-464-4000 or refer to Section 8 of this brochure. 15.
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2003 Kaiser Foundation Health Plan, Inc. 13 Section 4 Southern California Region
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive services. Example: When you see your
primary care physician, you pay a copayment of $10 per office visit.
Deductible We do not have a deductible.

Coinsurance Coinsurance is the percentage of our allowance that you must pay for certain services you receive. Example: In our Plan, you pay 50% of our
allowance for infertility services.
Fees when you fail to If you do not pay your copayment at the time you receive services, we make your copayment will bill you. You will be required to pay a $13.50 charge for each bill sent
for unpaid services.

Your catastrophic protection After your copayments and coinsurance total $1,500 per person or out-of-pocket maximum for $3,000 per family enrollment in any calendar year, you do not have to pay

copayments and coinsurance any more for covered services. However, copayments or coinsurance for the following services do not count toward your catastrophic protection
out-of-pocket maximum. You must continue to pay copayments or coinsurance for these services:

Prescription drugs Durable medical equipment
Orthopedic and prosthetic devices Dental services
Contraceptive devices Chiropractic services
The $25 charge paid for follow-up or continuing care outside the service area

Be sure to keep accurate records of your copayments and coinsurance, since you are responsible for informing us when you reach the maximum. 16.
16 Page 17 18

2003 Kaiser Foundation Health Plan, Inc. 14 Section 5 Southern California Region
Section 5. Benefits OVERVIEW
(See page 9 for how our benefits changed this year and page 65 for a benefits summary.)

NOTE: This benefits section is divided into subsections. Please read the important things you should keep in mind at the beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the
following subsections. To obtain claim forms, claims filing advice, or more information about our benefits, contact us at 1-800-464-4000 or our website at www. kaiserpermanente. org.

(a) Medical services and supplies provided by physicians and other health care professionals........................... 15-24
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 and alternative treatments Educational classes and programs

(b) Surgical and anesthesia services provided by physicians and other health care professionals ....................... 25-28
Surgical procedures Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services..................................................... 29-31
Inpatient hospital Outpatient hospital or ambulatory surgical
center
Extended care benefits/ skilled nursing care facility benefits
Hospice care Ambulance

(d) Emergency services/ accidents......................................................................................................................... 32-34
Emergency within our service area Emergency outside our service area Ambulance

(e) Mental health and substance abuse benefits.................................................................................................... 35-37
(f) Prescription drug benefits ............................................................................................................................... 38-40
(g) Special features ............................................................................................................................................... 41-43

Flexible benefits option Services from other Kaiser Permanente Plans
Travel benefit
24 hour nurse line Services for deaf and hearing impaired
Centers of excellence
(h) Dental benefits ..................................................................................................................................................... 44
(i) Non-FEHB benefits available to Plan members .................................................................................................. 45

Summary of benefits ................................................................................................................................................... 65 17.
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2003 Kaiser Foundation Health Plan, Inc. 15 Section 5( a) Southern California Region
Section 5 (a). Medical services and supplies provided by physicians and other health care professionals
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Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and we cover them only when we determine they are medically necessary.

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

coverage, including with Medicare.
Note: Instead of a $10 charge, you pay only $5 if you enroll in our Medicare+ Choice Plan and assign your Medicare benefits to the Plan.

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Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians and other health care professionals
In a physician's office
In an urgent care center
Second opinion within Plan
Consultations with specialists

$10 per office visit

During a hospital stay
In a skilled nursing facility
Initial examination of a newborn child covered under a family enrollment

Nothing

At home Nothing 18.
18 Page 19 20
2003 Kaiser Foundation Health Plan, Inc. 16 Section 5( a) Southern California Region
Lab, X-ray, and other diagnostic tests You pay
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine mammograms
CAT scans/ MRI
Ultrasound
Electrocardiogram and EEG

Nothing

Preventive care, adult
Routine screenings, such as:
Total blood cholesterol
Colorectal cancer screening, including
Fecal occult blood test
Sigmoidoscopy -every five years starting at age 50
Routine Prostate Specific Antigen (PSA) test -one annually for men age 40 and older

Routine pap test
Note: You should consult with your physician to determine what is appropriate for you.

Nothing

Routine mammogram covered for women age 35 and older, as follows:
Age 35 through 39, one during this five-year period
Age 40 through 64, one every calendar year
At age 65 and older, once every two consecutive calendar years
Note: In addition to routine screening, we cover mammograms when medically necessary to diagnose or treat your illness.

Nothing

Routine immunizations, including but not limited to:
Tetanus-diphtheria (Td) booster once every 10 years, ages 19 and over (except as provided for under childhood immunizations)

Influenza/ Pneumococcal vaccines
Hepatitis vaccinations

Nothing

(Preventive care, adult continues on next page) 19.
19 Page 20 21
2003 Kaiser Foundation Health Plan, Inc. 17 Section 5( a) Southern California Region
Preventive care, adult (continued) You pay
Not covered:
Physical exams required for:
Obtaining or continuing employment
Insurance
Travel

All charges

Preventive care, children
Well-child preventive care visits (23 months and younger)
Childhood immunizations recommended by the American Academy of Pediatrics
Nothing

Well-child care charges for routine examinations age 24 months and older, such as:
Eye exams to determine the need for vision correction
Ear exams to determine the need for hearing correction

$10 per office visit

Not covered:
Physical exams required for:
Obtaining or continuing employment
Insurance

All charges

Maternity care
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
First scheduled postnatal care visit
Note: Here are some things to keep in mind:
You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will extend your

inpatient stay if medically necessary.
We cover routine nursery care of the newborn child during the covered portion of the mother's maternity stay. We will cover other

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

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

Nothing

Not covered:
Routine sonograms to determine fetal age, size, or sex
All charges 20.
20 Page 21 22
2003 Kaiser Foundation Health Plan, Inc. 18 Section 5( a) Southern California Region
Family planning You pay
Voluntary sterilization (See Surgical procedures Section 5 (b))
Genetic counseling
Insertion of surgically implanted time-release contraceptive drugs or injectable contraceptive drugs

Note: The following devices or contraceptives are provided at no charge: intrauterine devices (IUDs); implanted time-release
contraceptive drugs and injectable contraceptive drugs. We cover oral contraceptives, cervical caps, and diaphragms under the prescription
drug benefit.

$10 per office visit

Not covered:
Reversal of voluntary surgical sterilization
All charges

Infertility services
Diagnosis and treatment of infertility, such as:
Artificial insemination:
Intravaginal insemination (IVI)
Intracervical insemination (ICI)
Intrauterine insemination (IUI)
Note: We cover fertility drugs under the prescription drug benefit.

50% of our allowance

Not covered:
These exclusions apply to fertile as well as infertile individuals or couples:

Assisted reproductive technology (ART) procedures, such as:
In vitro fertilization
Embryo transfer and GIFT
Services and supplies related to excluded ART procedures
Cost of donor sperm and donor eggs and services related to their procurement and storage

All charges

Allergy care
Allergy testing $10 per office visit

Allergy treatment and injections $3 per office visit
Allergy serum Nothing
Not covered:
Provocative food testing
Sublingual allergy desensitization

All charges 21.
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2003 Kaiser Foundation Health Plan, Inc. 19 Section 5( a) Southern California Region
Treatment therapies You pay
Chemotherapy and radiation therapy
Note: We limit high-dose chemotherapy in association with autologous bone marrow transplants to those transplants listed under Organ/ Tissue

Transplants on page 28.
Intravenous (IV)/ Infusion therapy Home IV and antibiotic therapy

Nothing for services provided by a non-physician provider
$10 for services provided by a physician

Respiratory and inhalation therapy
Growth hormone therapy (GHT)
Note: We cover human growth hormone under the prescription drug benefit.

Dialysis hemodialysis and peritoneal dialysis

$10 per office visit

Not covered:
Chemotherapy supported by a bone marrow transplant or with stem cell support, for any diagnosis not listed as covered
All charges

Physical and occupational therapies
We cover initial courses of therapy for up to two months per condition for:

Physical therapy by qualified physical therapists to restore bodily function when you have a total or partial loss of bodily function due
to illness or injury
Occupational therapy by occupational therapists to assist you in achieving and maintaining self-care and improved functioning in

other activities of daily life
Note: We provide subsequent courses of therapy for up to two months if you show significant improvement in your condition.

Cardiac rehabilitation following a heart transplant, bypass surgery, or a myocardial infarction.

Multidisciplinary outpatient rehabilitation is provided for up to two months per condition. This includes diagnostic and restorative
services comprising a program of physical, speech, occupational, and respiratory therapy, as well as certain other items and services
that are medically necessary for rehabilitation. The two-month limit applies to all inpatient and outpatient multidisciplinary
rehabilitative services you may receive for the same condition.

$10 per outpatient visit
Nothing for inpatient

Not covered:
Long-term rehabilitative therapy
Exercise programs

All charges 22.
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2003 Kaiser Foundation Health Plan, Inc. 20 Section 5( a) Southern California Region
Speech therapy You pay
We cover initial and subsequent courses of therapy for up to two months per condition for:

Speech therapy by speech therapists when medically necessary
$10 per outpatient visit
Nothing for inpatient

Hearing services (testing, treatment, and supplies)
Hearing testing $10 per office visit

Not covered:
Hearing aids
Hearing tests to determine the most appropriate hearing aid

All charges

Vision services (testing, treatment, and supplies)
Diagnosis and treatment of diseases of the eye
Eye refractions to determine the need for vision correction and provide a prescription for eyeglasses
$10 per office visit

Therapeutic contact lenses for the condition of aniridia for up to two lenses per eye in a 12-month period Nothing
Not covered:
Eyeglasses or contact lenses (except for the condition of aniridia)
Eye exercises and orthoptics
Radial keratotomy and other refractive surgery

All charges

Foot care
Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes $10 per office visit

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

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

treatment is by open cutting surgery)

All charges 23.
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2003 Kaiser Foundation Health Plan, Inc. 21 Section 5( a) Southern California Region
Orthopedic and prosthetic devices You pay
We cover internally implanted FDA-approved devices, including but not limited to:

Artificial joints
Pacemakers
Cochlear implants
Intraocular implants following cataract removal
Surgically implanted breast implants following a mastectomy
Note: See Section 5( b) for coverage of the surgery to insert the device.

Nothing

We cover FDA-approved devices that are in general use and are required because of a defect in form or function of a permanently
inoperative or malfunctioning body part, including but not limited to:
Artificial limbs and eyes and stump hose
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
Podiatric devices (including footwear) to prevent or treat diabetes-related complications when prescribed by a Plan podiatrist,
physiatrist, or orthopedist
Enteral formula for members who require tube feeding per Medicare guidelines

Ostomy and urological supplies in accord with the Plan's formulary guidelines

20% of our allowance

Not covered:
Comfort, convenience, or luxury equipment or features
Heel pads and heel cups
Lumbosacral supports
Corsets, trusses, elastic stockings, support hose, and other supportive devices

Shoes or arch supports, even if custom-made, except to treat diabetes-related complications when prescribed by a Plan
podiatrist, physiatrist, or orthopedist

All charges

Durable medical equipment (DME)
During a covered stay in a Plan hospital or skilled nursing facility
We limit coverage to the standard item that meets your medical needs consistent with our Plan DME formulary guidelines.
Nothing

(Durable medical equipment (DME) continues on next page) 24.
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2003 Kaiser Foundation Health Plan, Inc. 22 Section 5( a) Southern California Region
Durable medical equipment (DME) (continued) You pay
For use in the home when intended to be used repeatedly. Includes but is not limited to:

Oxygen and oxygen dispensing equipment
Hospital beds
Wheelchairs including motorized when medically necessary
Crutches
Walkers
Blood glucose testing monitors and related supplies
Insulin pumps
Infant apnea monitors
Repairs and replacements resulting from normal use
We limit coverage to the standard item that meets your medical needs consistent with our Plan DME formulary guidelines. We decide

whether to rent or purchase the item, and choose the vendor.
Note: We only provide DME in the Plan's service area.

20% of our allowance

External devices used for the treatment of sexual dysfunction
We limit coverage to the standard item that meets your medical needs consistent with our Plan DME formulary guidelines. We decide

whether to rent or purchase the item, and choose the vendor.
Note: We only provide DME in the Plan's service area.

50% of our allowance

Not covered:
Comfort, convenience, or luxury equipment or features
Devices not medical in nature, such as sauna baths, exercise and hygiene equipment

Electronic monitors of the function of the heart or lungs, except for infant apnea monitors
Devices to perform medical tests on blood or other bodily substances or excretions, except diabetic testing equipment and supplies
Dental appliances
Experimental or research equipment
Modifications to the home or auto

Items which are no longer medically necessary must be paid for or returned

All charges 25.
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2003 Kaiser Foundation Health Plan, Inc. 23 Section 5( a) Southern California Region
Home health services You pay
Home health care ordered by a Plan physician and provided by a registered nurse (RN), licensed practical nurse (LPN), licensed

vocational nurse (LVN), or home health aide
Services include oxygen therapy, intravenous therapy, and medications

Note: We only provide these services in the Plan's service area.

Nothing

Not covered:
Nursing care requested by, or for the convenience of, the patient or
the patient's family

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

Services outside of our service area

All charges

Chiropractic and alternative treatments
Chiropractic services covering the diagnosis or treatment of neuromusculoskeletal disorders limited to 20 visits per year. You can

access services in the following ways:
Chiropractic services are provided through American Specialty Health Plans (ASH Plans). You will have direct access to a participating
ASHP chiropractor without the need to obtain a Plan physician referral. You can obtain a list of ASH Plans Participating Providers by calling 1-800-
678-9133.
Specific details of this chiropractic benefit are listed in the ASH Plans' evidence of coverage/ disclosure form. You phone the ASH Plans
chiropractor you have selected for an initial examination. After the initial examination and except for chiropractic emergency services, your
ASH Plans chiropractor is responsible to obtain authorization from ASH Plans for any additional chiropractic services on your behalf. ASH
Plans will not cover any chiropractic services if you were referred through your Plan physician.

NOTE: When necessary and prescribed by an ASH Plans chiropractor, you may receive up to $50 of chiropractic appliances per calendar year.

$15 per office visit

(Chiropractic and alternative treatments continue on next page) 26.
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2003 Kaiser Foundation Health Plan, Inc. 24 Section 5( a) Southern California Region
Chiropractic and alternative treatments (continued) You pay
Not covered:
Naturopathic services
Hypnotherapy

All charges

Educational classes and programs
We cover a wide range of health education programs to help protect and improve your health. Examples of covered health education topics

include: smoking cessation, pregnancy, depression and living with chronic conditions.

Selected health education programs and materials including information on how to use our services
Individual health education visits
Other health education programs, materials and services
Note: Call the Member Service Call Center at 1-800-464-4000 for information on classes near you.

Nothing
Nothing
Nominal charges 27.
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2003 Kaiser Foundation Health Plan, Inc. 25 Section 5( b) Southern California Region
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
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medically necessary.
Plan physicians must provide or arrange your care.
We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with

other coverage, including with Medicare.
The amounts listed below are for the charges billed by a physician or other health care professional for your surgical care. Look in Section 5( c) for charges associated with the

facility (i. e., hospital, surgical center, etc.).
YOUR PHYSICIAN MUST GET A REFERRAL FOR SOME SURGICAL PROCEDURES. Please refer to the referral information shown in Section 3 to be sure

which services require a referral and identify which surgeries require a referral.

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Benefit Description You pay
Surgical procedures
A comprehensive range of services, such as:
Operative procedures
Treatment of fractures, including casting
Treatment of burns
Normal pre-and postoperative care by the surgeon
Pre-surgical testing
Correction of amblyopia and strabismus
Endoscopy procedures
Biopsy procedures
Removal of tumors and cysts
Correction of congenital anomalies (see Reconstructive surgery)
Surgical treatment of morbid obesity
Voluntary sterilization (e. g., tubal ligation, vasectomy)
Insertion of internally implanted, time-release contraceptive drugs and intrauterine devices (IUDs)

Insertion of other implantable time-release drugs
Injection of contraceptive drugs

$10 per office visit when provided on an outpatient basis
Nothing when provided on an inpatient basis

(Surgical procedures continue on next page) 28.
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2003 Kaiser Foundation Health Plan, Inc. 26 Section 5( b) Southern California Region
Surgical procedures (continued) You pay
Note: The following devices or contraceptives are provided at no charge: intrauterine devices (IUDs), implanted time-release

contraceptive drugs and injectable contraceptive drugs. We cover oral contraceptives, cervical caps, and diaphragms under the prescription
drug benefit.
Treatment for sexual dysfunction or inadequacy

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

$10 per office visit when provided on an outpatient basis
Nothing when provided on an inpatient basis

Not covered:
Reversal of voluntary surgical sterilization
Routine treatment of conditions of the foot

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

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; and

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.

$10 per office visit when provided on an outpatient basis
Nothing when provided on an inpatient basis

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

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

All charges 29.
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2003 Kaiser Foundation Health Plan, Inc. 27 Section 5( b) Southern California Region
Oral and maxillofacial surgery You pay
Oral surgical procedures, limited to:
Reduction of fractures or dislocations of the jaw or facial bones
Surgical correction of cleft lip, cleft palate, or severe functional malocclusion

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

Medical and surgical treatment of TMJ
Other surgical procedures that do not involve the teeth or their supporting structures

$10 per office visit when provided on an outpatient basis
Nothing when provided on an inpatient basis

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

All charges 30.
30 Page 31 32
2003 Kaiser Foundation Health Plan, Inc. 28 Section 5( b) Southern California Region
Organ/ tissue transplants You pay
Limited to:
Cornea
Heart
Heart/ Lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single Double
Pancreas
Allogeneic (donor) bone marrow transplants
Autologous bone marrow transplants (autologous stem cell and peripheral stem cell support) for the following conditions: acute

lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's lymphoma; advanced non-Hodgkin's lymphoma; advanced
neuroblastoma; breast cancer; multiple myeloma; epithelial ovarian cancer; and testicular, mediastinal, retroperitoneal, and ovarian germ
cell tumors
Intestinal transplants (small intestine) and the small intestine with the liver or small intestine with multiple organs such as the liver,

stomach, and pancreas
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 your transplant.

$10 per office visit when provided on an outpatient basis
Nothing when provided on an inpatient basis

Not covered:
Donor screening tests and donor search expenses, except those performed for the actual donor

Implants of non-human artificial organs
Transplants not listed as covered

All charges

Anesthesia
Professional services provided during a surgical procedure
Hospital (inpatient)
Ambulatory surgery center (outpatient)

Nothing 31.
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2003 Kaiser Foundation Health Plan, Inc. 29 Section 5( c) Southern California Region
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
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medically necessary.
Plan physicians must provide or arrange your care and you must be hospitalized in a Plan facility.

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

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

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

I M
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Benefit Description You pay
Inpatient hospital
Room and board, such as
Ward, semiprivate, or intensive care accommodations
General nursing care
Meals and special diets
NOTE: Your physician may prescribe accommodation or private duty nursing care if it is medically necessary. If you want a private room

when it is not medically necessary, you pay the additional charge above the semiprivate room rate.

Nothing

(Inpatient hospital continues on next page) 32.
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2003 Kaiser Foundation Health Plan, Inc. 30 Section 5( c) Southern California Region
Inpatient hospital (continued) You pay
Other hospital services and supplies, such as:
Operating, recovery, maternity, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays
Administration of blood and blood products
Blood or blood plasma
Dressings, splints, casts, and sterile tray services
Medical supplies and equipment, including oxygen
Anesthetics, including nurse anesthetist services
Plan physicians' and surgeons' services and supplies, including consultation and treatment by specialists

Take-home items
Note: You may receive covered hospital services for certain dental procedures if a Plan physician determines you need to be hospitalized

for reasons unrelated to the dental procedure. The conditions for which we will provide hospitalization include hemophilia and heart disease.
The need for anesthesia, by itself, is not such a condition.

Nothing

Not covered:
Custodial care and care in an intermediate care facility
Personal comfort items, such as barber services, guest meals, and beds

Private nursing care unless medically necessary
Inpatient dental procedures

All charges

Outpatient hospital or ambulatory surgical center
Operating, recovery, and other treatment rooms
Prescribed drugs and medicines
Dressings, casts, and sterile trays
Diagnostic laboratory tests, X-rays, and pathology services
Administration of blood, blood plasma, and other biologicals
Blood and blood plasma
Pre-surgical testing
Dressings, casts, and sterile tray services
Medical supplies, including oxygen
Anesthetics and anesthesia service

Nothing 33.
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2003 Kaiser Foundation Health Plan, Inc. 31 Section 5( c) Southern California Region
Extended care benefits/ skilled nursing care facility benefits You pay
Up to 100 days per benefit period when you need full-time skilled nursing care. Your benefit period begins when you enter a hospital or
skilled nursing facility and ends when you have not been a patient in either a hospital or skilled nursing facility for 60 consecutive days.

All necessary services are covered, including;
Bed, board, and general nursing care
Prescribed drugs and their administration, biologicals, supplies, and equipment ordinarily provided or arranged by the skilled

nursing facility

Nothing

Not covered:
Custodial care
Care in an intermediate care facility

All charges

Hospice care
Supportive and palliative care for a terminally ill member:
You must reside in the service area
Services are provided in the home
Services are provided in a Plan-approved hospice facility
Services include inpatient care, outpatient care, and family counseling. A Plan physician must certify that you have a terminal illness, with a

life expectancy of approximately twelve months or less.
Note: Hospice is a program for caring for the terminally ill that emphasizes supportive services, such as home care and pain control,

rather than curative care of the terminal illness. A person who is terminally ill may elect to receive hospice benefits. These palliative
and supportive services include nursing care, medical social services, physician services, and short-term inpatient care for pain control and
acute and chronic symptom management. We also provide counseling and bereavement services for the individual and family members, and
therapy for purposes of symptom control to enable the person to continue life with as little disruption as possible. If you make a hospice
election, you are not entitled to receive other health care services that are related to the terminal illness. If you have made a hospice election,
you may revoke that election at any time, and your standard health benefits will be covered.

Nothing

Ambulance
Professional ambulance service, including air ambulance, when medically appropriate Nothing

Not covered:
Transports that we determine are not medically necessary
All charges 34.
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2003 Kaiser Foundation Health Plan, Inc. 32 Section 5( d) Southern California Region
Section 5 (d). Emergency services/ accidents
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coverage, including with Medicare.

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

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

What to do in case of emergency:
You are covered for medical emergencies anywhere in the world. In a medical emergency, call 911 or go to the nearest hospital. If you call 911, when the operator answers, stay on the phone and answer all questions.

Emergencies within our service area:
If you think you have a medical emergency, call 911 or go to the nearest hospital. To better coordinate your emergency care, we recommend that you go to a Plan Hospital if it is reasonable to do so considering your condition or symptoms.
Please refer to the Guidebook for the location of Plan Hospitals that provide emergency care. If an ambulance comes, you (or your representative) should tell the paramedics that you are a Kaiser Permanente member.

When you are sick or injured, you may have an urgent care need. An urgent care need is one that requires prompt medical attention, but is not a medical emergency. If you think you may need urgent care, call the appropriate
appointment or advice nurse number at a Plan Facility. Please refer to the Guidebook for advice nurse and Plan Facility telephone numbers.

Emergencies outside our service area:
If you think you have a medical emergency, call 911 or go to the nearest hospital. If an ambulance comes, you (or your representative) should tell the paramedics that you are a Kaiser Permanente member.

Post-stabilization care is the services and supplies you receive after your treating physician determines that you are clinically stable following a medical emergency. We cover post-stabilization care if a Plan Provider provides it or if
you obtain authorization from us to receive the care from a non Plan Provider.
When you are sick or injured, you may have an urgent care need. An urgent care need is one that requires prompt medical attention, but is not a medical emergency. If you think you may need urgent care, call the appropriate
appointment or advice nurse number at a Plan Facility. Please refer to the Guidebook for advice nurse and Plan Facility telephone numbers. If you are temporarily outside the Service Area and have an urgent care need due to an unforeseen 35.
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2003 Kaiser Foundation Health Plan, Inc. 33 Section 5( d) Southern California Region
illness or injury, we cover the medically necessary services and supplies you receive from a non Plan Provider if we find that the services and supplies were necessary to prevent serious deterioration of your health and they could not be
delayed until you returned to the Service Area.
You may obtain emergency and urgent care services from Kaiser Permanente medical facilities and providers when you are in the service area of another Kaiser Permanente plan. The facilities will be listed in the local telephone book under
Kaiser Permanente. These numbers are available 24 hours a day, seven days a week. You may also obtain information about the location of facilities by calling 1-800-227-2415.

How to Obtain Authorization
You must call us at 1-800-225-8883 (the telephone number is also on your ID card) to: Request authorization for post-stabilization care before you obtain the care from a non Plan Provider if it is
reasonably possible to do so (otherwise, call us as soon as reasonably possible) Notify us that you have been admitted to a non Plan Hospital. You must notify us within 24 hours of any
admission or as soon as reasonably possible. We will decide whether to make arrangements for necessary continued care where you are, or to transfer you to a facility we designate. If you don't notify us, as soon as
reasonably possible, we will not cover any services and supplies you receive after transfer would have been possible.

We know that extraordinary circumstances can delay your ability to call us, for example if you are unconscious or a young child without a parent or guardian. In these cases, you must call us as soon as it is reasonably possible. Please
keep in mind that anyone can call us. If you don't call us when it becomes possible for you to call, you will be financially responsible for the cost of the unauthorized services and supplies received after you became clinically
stable. 36.
36 Page 37 38
2003 Kaiser Foundation Health Plan, Inc. 34 Section 5( d) Southern California Region
Benefit Description You pay
Emergency within our service area
Emergency room visit for emergency services
Note: We waive the $50 if you are admitted to the hospital.
$50 per visit

Not covered:
Elective care or non-emergency care (unless you receive prior authorization)

Urgent care at a non-Plan urgent care center

All charges

Emergency outside our service area
Emergency care as an outpatient or inpatient at a hospital, including physicians' services

Emergency room visit for emergency services
Emergency care at an urgent care center
Emergency care in a Kaiser Foundation hospital in another Kaiser Foundation Health Plan service area

Note: See the "Travel Benefit" for coverage of continuing or follow-up care.

$50 per visit
The amount you would be charged if you were a member
in that service area

Not covered:
Elective care or non-emergency care at non-Plan facilities (unless you receive prior authorization)
All charges

Ambulance
Professional ambulance service, including air ambulance, when medically appropriate $50 per trip

Not covered:
Transports we determine are not medically necessary
All charges 37.
37 Page 38 39
2003 Kaiser Foundation Health Plan, Inc. 35 Section 5( e) Southern California Region
Section 5 (e). Mental health and substance abuse benefits
I M
P O
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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 that all benefits are subject to the definitions, limitations, and exclusions in this brochure and we cover them only when we determine they are clinically appropriate

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

coverage, including with Medicare.

I M
P O
R T
A N
T

Benefit Description You pay
Mental health and substance abuse benefits
We cover all diagnostic and treatment services recommended by a Plan provider and contained in a treatment plan. The treatment plan may

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

Note: We cover the services only when we determine that the care is clinically appropriate to treat your condition, and only when you receive
the care as part of a treatment plan developed by a Plan provider.
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 in favor of another.

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

(Mental health and substance abuse benefits continue on next page) 38.
38 Page 39 40
2003 Kaiser Foundation Health Plan, Inc. 36 Section 5( e) Southern California Region
Mental health and substance abuse benefits (continued) You pay
Diagnosis and treatment of psychiatric conditions, mental illness, and mental disorders. Services include:

Diagnostic evaluation
Treatment (including individual, family, and group therapy visits)
Crisis intervention and stabilization for acute episodes
Psychological testing that is medically necessary to determine the appropriate psychiatric treatment

Medication management and evaluation
Diagnosis and treatment of alcoholism and drug abuse. Services include:
Treatment and counseling (including individual, family, and group therapy visits)

Outpatient detoxification (medical management of withdrawal from the substance)
Note: You may see a Plan mental health or substance abuse provider for outpatient treatment without a referral from your primary care
physician.
Note: Your Plan provider will develop a treatment plan to assist you in improving or maintaining your condition and functional level, or to

prevent relapse and will determine which diagnostic and treatment services are appropriate for you.

$10 per office visit

Inpatient psychiatric care
Hospital alternative services, such as partial hospitalization and intensive outpatient psychiatric treatment programs

Inpatient substance abuse care and rehabilitation
Inpatient detoxification
Methadone treatment for a pregnant woman throughout the pregnancy and for two months after delivery

Note: All inpatient admissions and hospital alternative services treatment programs require approval by a Plan physician.

Nothing

Recovery services for alcoholism and drug abuse in a non-medical residential care facility
Note: All inpatient and alternative services treatment programs require approval by a Plan physician. We cover up to 60 days per calendar year
and no more than 120 days in any five consecutive year period of non-medical residential recovery care.

$100 per stay

(Mental health and substance abuse benefits continue on next page) 39.
39 Page 40 41
2003 Kaiser Foundation Health Plan, Inc. 37 Section 5( e) Southern California Region
Mental health and substance abuse benefits (continued) You pay
Not covered:
Care that is not clinically appropriate for the treatment of your condition

Services we have not approved
Intelligence, IQ, aptitude ability, learning disorders, or interest testing not necessary to determine the appropriate treatment of a psychiatric

condition
Evaluation or therapy on court order or as a condition of parole or probation, or otherwise required by the criminal justice system, unless

determined by a Plan physician to be medically necessary and appropriate

Services that are custodial in nature
Services rendered or billed by a school or a member of its staff
Services provided under a federal, state, or local government program
Psychoanalysis or psychotherapy credited toward earning a degree or furtherance of education or training regardless of diagnosis or

symptoms

All charges

Limitation We may limit your benefits if you do not obtain a treatment plan. 40.
40 Page 41 42
2003 Kaiser Foundation Health Plan, Inc. 38 Section 5( f) Southern California Region
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.

Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and we cover them only when we determine they are
medically necessary.
We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about

coordinating benefits with other coverage, including with Medicare.

I M
P O
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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 any dentist must write the prescription. Drugs prescribed by dentists are not covered if a Plan physician determines that they are not

medically necessary.
Where you can obtain them. You must fill the prescription at a Plan pharmacy or another pharmacy that we designate, or through our mail order program.

We use a formulary. A formulary is a listing of preferred pharmaceutical substances and formulas. A team of Kaiser Permanente physicians and pharmacists independently and objectively
evaluates the scientific literature to identify the FDA-approved drugs best suited to treat specific medical conditions. The Plan uses this formulary to determine which prescribed drugs will be
provided to members.
Our formulary includes a list of prescription drugs that have been approved by our Pharmacy and Therapeutics Committee. This committee, which is comprised of Plan physicians and other Plan

providers, selects prescription drugs for the formulary based on a number of factors, including safety and effectiveness as determined from a review of medical literature and research. The
committee meets quarterly to consider adding and removing prescription drugs on the formulary. If you would like information about whether a particular drug is included on our formulary, please
call the Member Service Call Center at 1-800-464-4000.
If the physician specifically prescribes a non-formulary drug because it is medically necessary, the non-formulary drug will be covered. If you request the non-formulary drug when your physician

has prescribed a substitution, the non-formulary drug is not covered. However, you may purchase the non-formulary drug from a Plan pharmacy at prices charged to members for non-covered drugs.

These are the dispensing limitations. We provide up to a 100-day supply for most drugs, except certain drugs that have a significant potential for waste will be provided for up to a 30-day supply
in any 30-day period. In addition, we may limit the provision of drugs that are in limited supply in the market. Please contact our Member Service Call Center at 1-800-464-4000 for the current list
of these drugs. Maintenance medications may be obtained for up to a 100-day supply when ordered through our mail-order program.

When you have to file a claim. When you receive drugs from a Plan pharmacy, you do not have to file a claim. For a covered out-of-area emergency, you will need to file a claim when you
receive drugs from a non-Plan pharmacy.

Prescription drug benefits begin on the next page. 41.
41 Page 42 43
2003 Kaiser Foundation Health Plan, Inc. 39 Section 5( f) Southern California Region
Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan physician and obtained from a Plan pharmacy or through our mail order

program:
Certain self-administered IV drugs and fluids requiring specific types of parenteral infusion, and the supplies required for their

administration
Amino acid-modified products used to treat congenital errors of amino acid metabolism

Diabetes urine-testing supplies
Vaccines and immunizations approved for use by the Food and Drug
Administration

Elemental dietary enteral formula when used as a primary therapy
for regional enteritis

Nothing

Drugs and medicines that by Federal law of the United States require a physician's prescription for their purchase, except as excluded
below. We also cover certain drugs that do not require a prescription by law if they are listed on our drug formulary.

Insulin
Certain insulin administration devices
Disposable needles and syringes for the administration of covered medications

Smoking cessation drugs are covered only if you participate in a Plan approved behavioral intervention program

Note: The brand-name drug copayment will apply to compounded products listed on our drug formulary, or that include ingredients
requiring a prescription by law.

$10 per prescription for generic drugs
$25 per prescription for brand-name drugs
All charges if you request a brand-name drug in place of a generic
drug

Oral contraceptives

Cervical caps and diaphragms

$10 per prescription for generic drugs and $25 per prescription for brand-name
drugs (up to a 3-cycle supply); all charges if you request a brand-name
drug in place of a generic drug

$25 per device
(Covered medications and supplies continue on next page) 42.
42 Page 43 44
2003 Kaiser Foundation Health Plan, Inc. 40 Section 5( f) Southern California Region
Covered medications and supplies (continued) You pay
Fertility drugs
Sexual dysfunction drugs
Episodic drugs will be provided up to a maximum of 27 doses in any 100-day period. Additional prescribed doses during the same

100 days will be dispensed at our allowance.
Maintenance drugs that require doses at regulated intervals

50% of our allowance

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

Nonprescription drugs, unless they are included in our drug formulary
Medical supplies, such as dressings and antiseptics
Drugs to enhance athletic performance
Drugs that shorten the duration of the common cold
Drugs for the promotion, prevention, or other treatment of hair loss or growth

Compounded products unless the product is listed on our drug formulary, or one of the ingredients requires a prescription by law
Any requested packaging of drugs (such as dose packaging) other than the dispensing pharmacy's standard packaging
Note: If a drug for which a prescription is required by law is excluded and we had been covering and providing it to you for a use approved by
the FDA, we will continue to provide the drug upon payment of 50% of our allowance if a Plan physician continues to prescribe the drug for
the same condition.

All charges 43.
43 Page 44 45
2003 Kaiser Foundation Health Plan, Inc. 41 Section 5( g) Southern California Region
Section 5 (g). Special features
Feature Description

Flexible benefits option Under the flexible benefits option, we determine the most effective way to provide services.
We may identify medically appropriate alternatives to traditional care and coordinate other benefits as a less costly alternative
benefit.
Alternative benefits are subject to our ongoing review.
By approving an alternative benefit, we cannot guarantee you will get it in the future.

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

Services from other Kaiser Permanente
Plans

When you visit the service area of another Kaiser Permanente plan, you are entitled to receive virtually all the benefits described in this brochure
(including our mail order prescription program) at any Kaiser Permanente medical office or medical center. You must pay the charges or
copayments imposed by the Kaiser Permanente Plan you are visiting, with the exception of mail order prescriptions which are administered by your
home Plan. You will have to pay the charges imposed by the Plan you are visiting. If the Plan you are visiting has a benefit that is different from the
benefits of this Plan, you are not entitled to receive that benefit.
Some services covered by this Plan, such as artificial reproductive services and the services of specialized rehabilitation facilities, will not be
available in other Kaiser Permanente service areas. If a benefit is limited to a specific number of visits or days, you are entitled to receive only the
number of visits or days covered by the Plan in which you are enrolled.
If you are seeking routine, non-emergent, or non-urgent services, you should call the Kaiser Permanente Member Services Department in that
service area and request an appointment. You may obtain routine follow-up or continuing care from these Plans, even when you have obtained the
original services in the service area of this Plan. If you require emergency services as the result of unexpected or unforeseen illness that requires
immediate attention, you should go directly to the nearest Kaiser Permanente facility to receive care.

At the time you register for services, you will be asked to pay the charges required by the local Plan.
If you plan to travel to an area with another Kaiser Permanente plan and wish to obtain more information about the benefits available to you from
the Kaiser Permanente Plan, please call our Member Service Call Center at 1-800-464-4000. 44.
44 Page 45 46
2003 Kaiser Foundation Health Plan, Inc. 42 Section 5( g) Southern California Region
Travel benefit Kaiser Permanente's travel benefits for Federal employees provide you with outpatient follow-up and/ or continuing medical care when you are temporarily outside your home service area by more than 100 miles or
outside of any other Kaiser Permanente service area. These benefits are in addition to your emergency and urgent care benefits and include:

Outpatient follow-up care necessary to complete a course of treatment after a covered emergency. Services include removal of
stitches, a catheter, or a cast.
Outpatient continuing care for conditions diagnosed and treated within the previous 90 days by a Kaiser Permanente health care

provider or affiliated Plan provider. Services include dialysis and prescription drug monitoring.

You pay $25 for each follow-up and/ or continuing care office visit. This amount will be deducted from the payment we make to
you.
Your benefit is limited to $1,200 each calendar year.
For more information about this benefit call 1-800-464-4000.
File claims as shown on page 47.
The following are not included in your travel benefits coverage:
Non-emergency hospitalization
Infertility treatments
Medical and hospital costs resulting from a normal full-term delivery of a baby outside the service area

Transplants
DME
Prescription drugs

Home health services

24 hour nurse line For any of your health concerns, 24 hours a day, 7 days a week, you may talk with a registered nurse who will discuss treatment options and answer your health questions. You can obtain an advice nurse
phone number for the nearest Kaiser Permanente facility in the white pages of your phone book under "Kaiser Permanente".

Services for deaf and hearing impaired We provide a TTY/ text telephone number 1-800-777-1370. Sign language services are also available. 45.
45 Page 46 47
2003 Kaiser Foundation Health Plan, Inc. 43 Section 5( g) Southern California Region
Centers of excellence Kaiser Permanente's National Transplant Network (NTN) was created to offer members greater choice of and access into Centers of Excellence (COE) that exceed minimum quality standards for
experience (based on volume of cases and transplant team composition), outcomes, and service (waiting time and access to the
Center). The goal is to ensure that members are treated at Centers where optimal outcomes can be expected, measured, and managed.
Currently, the NTN contains 20 Centers that include 70 transplant programs. Transplant services provided through the NTN are heart,
lung, heart/ lung, liver, simultaneous kidney/ pancreas, pancreas, small bowel, and bone marrow/ stem cell (autologous and allogeneic). 46.
46 Page 47 48
2003 Kaiser Foundation Health Plan, Inc. 44 Section 5( h) Southern California Region
Section 5 (h). Dental benefits
I M
P O
R T
A N
T

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

necessary.
We cover hospitalization for dental procedures at a Plan hospital we designate only when a non-dental physical impairment exists which makes hospitalization necessary to

safeguard the health of the patient. See Section 5( c) for inpatient hospital benefits. We do not cover the dental procedure except as described below.

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

I M
P O
R T
A N
T

Dental benefits
We have no dental benefits. 47.
47 Page 48 49
2003 Kaiser Foundation Health Plan, Inc. 45 Section 5( i) Southern California Region
Section 5 (i). Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed claim about them. Fees you pay for these services do not count toward FEHB deductibles or catastrophic protection
out-of-pocket maximums.
Eyewear discount
As a Kaiser Permanente FEHB Program Member, you and your eligible dependents will be able to purchase eyewear at significant savings. When you visit any of the Southern California Health Plan Optical Departments, you will

receive 25 percent off our allowance for frames and lenses and options such as no-line bifocals and prescription and non-prescription sunglasses. You will also be able to receive 25 percent off our allowance for cosmetic contact lenses
and the required lens fitting.
Limitations & exclusions: This discount will apply only to purchased eyewear under the FEHBP basic coverage. The vision discount may not be coordinated with any other Kaiser Permanente Health Plan vision benefit. This discount

will also not apply to any sale, promotional, or packaged eyewear program or for any contact lens Extended Purchase Agreement (which includes products purchased in this Agreement) or to low-vision aids or devices.

Expanded dental benefits
Kaiser Permanente is pleased to offer Federal employees, retirees, and dependents a choice of dental coverages to supplement your medical plan.

Option I/ Delta Care DeltaCare offers dental health maintenance organization (HMO) benefits that are administered by PMI, an affiliate of
Delta Dental Plan of California. You select a dentist from the network of contracting DeltaCare dental offices that is most convenient for you and your family. With DeltaCare, there are no claim forms to worry about. DeltaCare also
provides a full range of services that includes preventive, restorative, endodontics, periodontics, prosthetics, oral surgery, and orthodontics. Under this program, the subscriber pays a specific copayment for most covered services.

Option II/ KPIC's Dental Plan KPIC's Dental Plan, a table of allowances program, allows you to select any licensed dentist. After you satisfy a
deductible, KPIC's Dental Plan will pay a predetermined amount that is specified in a table toward each covered service, and you pay the remainder of the fee. You do not need to satisfy a deductible toward covered preventive
services you receive. KPIC's Dental Plan offers a full range of services; diagnostic, preventive, restorative, endodontics, periodontics, oral surgery, and both fixed and removable prosthodontics. Orthodontics is not available
under the KPIC's Dental Plan.
Monthly Premium* Option I/ DeltaCare Option II/ KPIC's Dental Plan
Monthly Premium Quarterly Premium Monthly Premium Self Only $ 9.55 $ 28.64 $ 24. 37
Self & One Party $ 15.97 $ 47.92 $ 43. 35 Self & Two or More $ 24.22 $ 72.66 $ 65. 16

KPIC's Dental Plan and DeltaCare are available only if you enroll or are currently enrolled in the Kaiser Permanente Plan for FEHB Members. You do not need to enroll in either dental plan if you choose not to. All subscribers who
enroll in either dental program, when eligible, must continue enrollment in the selected dental program until the next open enrollment period. This does not apply if employment is terminated.

How to enroll Please use the enclosed postage-paid card to send in your application. If you would like more information on KPIC's
Dental Plan, please call 1-800-933-9312. A Delta Dental representative will be able to assist you Monday through Friday, 6 a. m. to 6 p. m.

Payments for the KPIC's Dental Plan or DeltaCare programs will be made by automatic withdrawal from your checking, savings, or credit union account.

* These rates are effective January 1, 2003 through December 31, 2003. 48.
48 Page 49 50
2003 Kaiser Foundation Health Plan, Inc. 46 Section 6 Southern California Region
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 physician determines it is medically necessary to prevent, diagnose, or
treat your illness, disease, injury, or condition.
We do not cover the following:
Care by non-Plan providers except for authorized referrals or emergencies (see Section 5( d)), services under the Travel Benefit (see Section 5( g)), and services received from other Kaiser Permanente plans

(see Section 5( g));
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 you receive without charge while in active military service;
Services, drugs, or supplies related to sex transformations; or
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program 49.
49 Page 50 51
2003 Kaiser Foundation Health Plan, Inc. 47 Section 7 Southern California Region
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or fill your prescription drugs at Plan pharmacies, you will not have to file claims. Just present your identification card and pay your copayment or
coinsurance.

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

Medical, hospital, and drug benefits In most cases, providers and facilities file claims for you. Physicians must file on the form HCFA-1500, Health Insurance
Claim Form. Facilities will file on the UB-92 form. For claims questions and assistance, call our Member Service Call Center
at 1-800-464-4000.
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; Follow up services rendered out-of-area
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:
Kaiser Foundation Health Plan, Inc. Claims Department
P. O. Box 7102 Pasadena, CA 91109-9880

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. 50.
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2003 Kaiser Foundation Health Plan, Inc. 48 Section 7 Southern California Region
If you have a malpractice claim If you have a malpractice claim because of services you did receive, or did not receive, from a Plan provider, you must
submit the claim to binding arbitration. The Plan has the information that describes the arbitration process. Contact our
Member Services Call Center at 1-800-464-4000 for copies of our requirements. These will explain how you can begin the
binding arbitration process. 51.
51 Page 52 53
2003 Kaiser Foundation Health Plan, Inc. 49 Section 8 Southern California Region
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 a referral:

Step Description
1 Ask us in writing to reconsider our initial decision. You must: (a) Write to us within six months from the date of our decision; and
(b) Send your request to us at: Kaiser Permanente, Member Relations, 393 E. Walnut Street, Pasadena, CA 91188; 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. 52.
52 Page 53 54
2003 Kaiser Foundation Health Plan, Inc. 50 Section 8 Southern California Region
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 referral, then call us at 1-888-987-7247 and we will expedite our review; or
(b) We denied your initial request for care or a referral, 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 1-202-606-0755 between 8 a. m. and 5 p. m. eastern time. 53.
53 Page 54 55
2003 Kaiser Foundation Health Plan, Inc. 51 Section 9 Southern California Region
Section 9. Coordinating benefits with other coverage
When you have other health 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. If we are the secondary payer, and
you received your services from Plan providers, we may bill the primary carrier.

What is Medicare? Medicare is a Health Insurance Program for:
People 65 years of age and older. Some people with disabilities, under 65 years of age.

People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant).

Medicare has two parts:
Part A (Hospital Insurance). Most people do not have to pay for Part A. If you or your spouse worked for at least 10
years in Medicare-covered employment, you should be able to qualify for premium-free Part A insurance. (Someone
who was a Federal employee on January 1, 1983 or since automatically qualifies.) Otherwise, if you are age 65 or
older, you may be able to buy it. Contact 1-800-MEDICARE for more information.

Part B (Medical Insurance). Most people pay monthly for Part B. Generally, Part B premiums are withheld from your
monthly Social Security check or your retirement check.
If you are eligible for Medicare, you may have choices in how you get your health care. Medicare+ Choice is the term used to
describe the various health plan choices available to Medicare beneficiaries. The information in the next few pages shows how
we coordinate benefits with Medicare, depending on the type of Medicare managed care plan you have.

The Original Medicare Plan The Original Medicare Plan (Original Medicare) is available (Part A or Part B) 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 54.
54 Page 55 56
2003 Kaiser Foundation Health Plan, Inc. 52 Section 9 Southern California Region
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. We will not waive any of our copayments.
Claims process when you have the Original Medicare Plan You probably will never have to file a claim form when you
have both our Plan and the Original Medicare Plan.
When we are the primary payer, we process the claim first.
When Original Medicare is the primary payer, Medicare processes your claim first. In most cases, your claim will be
coordinated automatically and we will then provide secondary benefits for covered charges. You will not need
to do anything. To find out if you need to do something to file your claim, call us at 1-800-443-0815.

(Primary payer chart begins on next page.) 55.
55 Page 56 57
2003 Kaiser Foundation Health Plan, Inc. 53 Section 9 Southern California Region
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 . 56.
56 Page 57 58

2003 Kaiser Foundation Health Plan, Inc. 54 Section 9 Southern California Region
Medicare managed care plan If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare managed care plan. These are health
care choices (like HMOs) in some areas of the country. In most Medicare managed care plans, you can only go to doctors, specialists, or
hospitals that are part of the plan. Medicare managed care plans provide all the benefits that Original Medicare covers. Some cover extras, like
prescription drugs. To learn more about enrolling in a Medicare managed care plan, contact Medicare at 1-800- MEDICARE
(1-800-633-4227) or at www. medicare. gov.

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

This Plan and our Medicare managed care plan: You may enroll in our Medicare managed care plan, known as Medicare+ Choice or Kaiser
Permanente Senior Advantage, and also remain enrolled in our FEHB Plan. There is no additional premium to enroll in Senior Advantage. In
this case, we have lowered or waived some of our copayments and coinsurance for your FEHB and Medicare coverage. If you would like
information about our Medicare+ Choice plan, please call 1-800-443-0815. Your Kaiser Permanente Senior Advantage-FEHBP
benefits that we lowered or waived are:
Prescriptions: $20 for each brand name drug for up to a 100-day supply. The same price applies to mail-order drugs.

Physician office visits: $5 for physician/ specialist office visits
Preventive services: $5
Routine physical and hearing exams: $5 for routine physical and hearing exam

Urgently needed care: $5 for each visit to a Plan facility; $50 for each visit to a non-Plan facility in or out of the Plan's service area;
Worldwide coverage
Vision services:

$5 for routine eye exam
A flat allowance of $150 every 24 months will be applied to lenses, frames and contact lenses. A separate allowance of $150

per eye per lifetime will apply to post cataract eyewear covered by Medicare.

Dental services:
$0 for oral exams or X-rays
$15 for cleanings, up to two office visits each year
No referral necessary for network providers You will also enjoy:

Health/ Wellness Education: No copayments for covered health education classes
No deductibles and virtually no paperwork
On-line access to health information and resources at our award-winning members only website

Quarterly member communication in our "Senior Outlook" magazine
You must use Kaiser Permanente Plan and affiliated providers and continue to pay Medicare premiums.

This Plan and another plan's Medicare managed care plan: You may enroll in another plan's Medicare managed care plan and also remain 57.
57 Page 58 59
2003 Kaiser Foundation Health Plan, Inc. 55 Section 9 Southern California Region
enrolled in our FEHB plan. We will still provide benefits when your Medicare managed care plan is primary if you use our Plan providers, but
we will not waive or lower 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 service area.
If you enroll in Medicare If you enroll in Medicare Part B, we require you to assign your Medicare Part B Part B benefits to the Plan for its services.

If you do not enroll in If you do not have one or both Parts of Medicare, you can still be Medicare Part A or Part B covered under the FEHB Program. We will not require you to enroll in
Medicare Part B, and if you cannot 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.

Workers' Compensation We do not cover services that:
you need because of a workplace-related illness or injury that the Office of Workers' Compensation Programs (OWCP) or a similar
Federal or State agency determines they must provide; or
OWCP or a similar agency pays for through a third-party injury settlement or other similar proceeding that is based on a claim you
filed under OWCP or similar laws.
Once OWCP or similar agency pays its maximum benefits for your treatment, we will cover your care. You must use our providers. 58.
58 Page 59 60
2003 Kaiser Foundation Health Plan, Inc. 56 Section 9 Southern California Region
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.

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

When others are responsible When you receive money to compensate you for medical or hospital care for injuries 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. 59.
59 Page 60 61
2003 Kaiser Foundation Health Plan, Inc. 57 Section 10 Southern California Region
Section 10. Definitions of terms we use in this brochure
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on
December 31 of the same year.

Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. See page 13.

Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 13.
Covered services Care we provide benefits for, as described in this brochure.
Custodial care (1) Assistance with activities of daily living, for example, walking, getting in and out of bed, dressing, feeding, toileting, and taking
medicine. (2) Care that can be performed safely and effectively by people who, in order to provide the care, do not require medical licenses
or certificates or the presence of a supervising licensed nurse. 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 13.

Durable medical equipment Durable medical equipment (DME) is equipment that is intended for repeated use, medically necessary, primarily and customarily used to
serve a medical purpose, generally not useful to a person who is not ill or injured, designed for prolonged use, appropriate for use in the home, and
serves a specific therapeutic purpose in the treatment of an illness or injury.

Experimental or We carefully evaluate whether a particular therapy is safe and effective or offers a reasonable degree of promise with respect to improving health
outcomes. The primary source of evidence about health outcomes of any intervention is peer-reviewed medical or dental literature. When the
service or supply, including a drug: (1) has not been approved by the FDA; or (2) is the subject of a new drug or new device application on file
with the FDA; or (3) is part of a Phase I or Phase II clinical trial, as the experimental or research arm of a Phase III clinical trial; or is intended to
evaluate the safety, toxicity, or efficacy of the service; or (4) is available as the result of a written protocol that evaluates the service's safety,
toxicity, or efficacy; or (5) is subject to the approval or review of an Institutional Review Board; or (6) requires an informed consent that
describes the service as experimental or investigational; then this Plan considers that service, supply, or drug to be experimental, and not
covered by the Plan.

investigational services 60.
60 Page 61 62
2003 Kaiser Foundation Health Plan, Inc. 58 Section 10 Southern California Region
Group health coverage Health care benefits that are available as a result of your employment, or the employment of your spouse, and that are offered by an employer or
through membership in an employee organization. Health care coverage may be insured or indemnity coverage, self-insured or self-funded
coverage, or coverage through health maintenance organizations or other managed care plans. Health care coverage purchased through
membership in an organization is also "group health coverage."

Medically necessary All benefits need to be medically necessary in order for them to be covered benefits. Generally, if your Plan physician provides the service
in accord with the terms of this brochure, it will be considered medically necessary. However, some services are reviewed in advance of your
receiving them to determine if they are medically necessary. When we review a service to determine if it is medically necessary, a Plan
physician will evaluate what would happen to you if you do not receive the service. If not receiving the service would adversely affect your
health, it will be considered medically necessary. The services must be a medically appropriate course of treatment for your condition. If they are
not medically necessary, we will not cover the services. In case of emergency services, the services that you received will be evaluated to
determine if they were medically necessary.

Our allowance The amount we use to determine your coinsurance. When you receive services or supplies from Plan providers, it is the amount that we set for
the services or supplies if we were to charge for them. When you receive services from non-Plan providers, we determine the amount that we
believe is usual and customary for the service or supply, and compare it to the charges. Our allowance is based upon the reasonableness of the
charges. If the charges exceed what we believe is reasonable, you may be responsible for the excess over our allowance in addition to your
coinsurance.

Us/ We Us and we refer to Kaiser Foundation Health Plan, Inc., Southern California Region.

You You refers to the enrollee and each covered family member. 61.
61 Page 62 63
2003 Kaiser Foundation Health Plan, Inc. 59 Section 11 Southern California Region
Section 11. FEHB facts
No pre-existing condition We will not refuse to cover the treatment of a condition that you had limitation before you enrolled in this Plan solely because you had the condition
before you enrolled.
Where you can get information See www. opm. gov/ insure. Also, your employing or retirement office about enrolling in the can answer your questions, and give you a Guide to Federal Employees

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

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

employing or retirement office.

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

If you have a Self Only enrollment, you may change to a Self and Family enrollment if you marry, give birth, or add a child to your family. You
may change your enrollment 31 days before to 60 days after that event. The Self and Family enrollment begins on the first day of the pay period
in which the child is born or becomes an eligible family member. When you change to Self and Family because you marry, the change is effective
on the first day of the pay period that begins after your employing office receives your enrollment form; benefits will not be available to your
spouse until you marry.
Your employing or retirement office will not notify you when a family member is no longer eligible to receive health benefits, nor will we.
Please tell us immediately when you add or remove family members from your coverage for any reason, including divorce, or when your child
under age 22 marries or turns 22.
If you or one of your family members is enrolled in one FEHB plan, that person may not be enrolled in or covered as a family member by another
FEHB plan.

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) 62.
62 Page 63 64
2003 Kaiser Foundation Health Plan, Inc. 60 Section 11 Southern California Region
Program, if you are an employee subject to a court or administrative order requiring you to provide health benefits for your child( ren).
If this law applies to you, you must enroll for Self and Family coverage in a health plan that provides full benefits in the area where your children
live or provide documentation to your employing office that you have obtained other health benefits coverage for your children. If you do not
do so, your employing office will enroll you involuntarily as follows:
If you have no FEHB coverage, your employing office will enroll you for Self and Family coverage in the Blue Cross and Blue Shield
Service Benefit Plan's Basic Option, If you have a Self Only enrollment in a fee-for-service plan or in an
HMO that serves the area where your children live, your employing office will change your enrollment to Self and Family in the same
option of the same plan; or If you are enrolled in an HMO that does not serve the area where the
children live, your employing office will change your enrollment to Self and Family in the Blue Cross and Blue Shield Service Benefit
Plan's Basic Option.
As long as the court/ administrative order is in effect, and you have at least one child identified in the order who is still eligible under the FEHB
Program, you cannot cancel your enrollment, change to Self Only, or change to a plan that doesn't serve the area in which your children live,
unless you provide documentation that you have other coverage for the children. If the court/ administrative order is still in effect when you
retire, and you have at least one child still eligible for FEHB coverage, you must continue your FEHB coverage into retirement (if eligible) and
cannot make any changes after retirement. Contact you employing office for further information.

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

When you retire When you retire, you can usually stay in the FEHB Program. Generally, you must have been enrolled in the FEHB Program for the last five years
of your Federal service. If you do not meet this requirement, you may be eligible for other forms of coverage, such as temporary continuation of
coverage (TCC).
When you lose benefits
When FEHB coverage ends You will receive an additional 31 days of coverage, for no additional premium, when:

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

Spouse equity 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 coverage to you. But, you may be eligible for your own FEHB 63.
63 Page 64 65
2003 Kaiser Foundation Health Plan, Inc. 61 Section 11 Southern California Region
coverage under the spouse equity law or Temporary Continuation of Coverage (TCC). If you are recently divorced or are anticipating a
divorce, contact your ex-spouse's employing or retirement office to get RI 70-5, the Guide to Federal Employees Health Benefits Plans for
Temporary Continuation of Coverage and Former Spouse Enrollees, or other information about your coverage choices. You can also download
the guide from OPM's website, www. opm. gov/ insure.
Temporary continuation of If you leave Federal service, or if you lose coverage because you no 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 www. opm. gov/ insure.
It explains what you have to do to enroll.
Converting to You may convert to a non-FEHB individual policy if: individual coverage

Your coverage under TCC or the spouse equity law ends (if you canceled your coverage or did not pay your premium, you cannot
convert);
You decided not to receive coverage under TCC or the spouse equity law; or

You are not eligible for coverage under TCC or the spouse equity law.
If you leave Federal service, your employing office will notify you of your right to convert. You must apply in writing to us within 31 days
after you receive this notice. However, if you are a family member who is losing coverage, the employing or retirement office will not notify
you. You must apply in writing to us within 31 days after you are no longer eligible for coverage.

Your benefits and rates will differ from those under the FEHB Program; however, you will not have to answer questions about your health, and
we will not impose a waiting period or limit your coverage due to pre-existing conditions.

Getting a Certificate of The Health Insurance Portability and Accountability Act of 1996 Group Health Plan Coverage (HIPAA) is a Federal law that offers limited Federal protections for health
coverage availability and continuity to people who lose employer group coverage. If you leave the FEHB Program, we will give you a Certificate
of Group Health Plan Coverage that indicates how long you have been enrolled with us. You can use this certificate when getting health
insurance or other health care coverage. Your new plan must reduce or eliminate waiting periods, limitations, or exclusions for health related
conditions based on the information in the certificate, as long as you enroll within 63 days of losing coverage under this Plan. If you have
been enrolled with us for less than 12 months, but were previously 64.
64 Page 65 66
2003 Kaiser Foundation Health Plan, Inc. 62 Section 11 Southern California Region
enrolled in other FEHB plans, you may also request a certificate from those plans. For more information, get OPM pamphlet RI 79-27,
Temporary Continuation of Coverage (TCC) under the FEHB Program. See also the FEHB web site (www. opm. gov/ insure/ health); refer to the
"TCC and HIPAA" frequently asked questions. These highlight HIPAA rules, such as the requirement that Federal employees must exhaust any
TCC eligibility as one condition for guaranteed access to individual health coverage under HIPAA, and have information about Federal and
State agencies you can contact for more information. 65.
65 Page 66 67

2003 Kaiser Foundation Health Plan, Inc. 63 Long Term Care Insurance Southern California Region
Long Term Care Insurance Is Still Available!
Open Season for Long Term Care Insurance
You can protect yourself against the high cost of long term care by applying for insurance in the Federal Long Term Care Insurance Program.
Open Season to apply for long term care insurance through LTC Partners ends on December 31, 2002. If you're a Federal employee, you and your spouse need only answer a few questions about your health
during Open Season. If you apply during the Open Season, your premiums are based on your age as of July 1, 2002. After Open
Season, your premiums are based on your age at the time LTC Partners receives your application.
FEHB Doesn't Cover It
Neither FEHB plans nor Medicare cover the cost of long term care. Also called "custodial care", long term care helps you perform the activities of daily living such as bathing or dressing yourself. It can also provide
help you may need due to a severe cognitive impairment such as Alzheimer's disease.
You Can Also Apply Later, But
Employees and their spouses can still apply for coverage after the Federal Long Term Care Insurance Program Open Season ends, but they will have to answer more health-related questions.
For annuitants and other qualified relatives, the number of health-related questions that you need to answer is the same during and after the Open Season.

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

Find Out More Contact LTC Partners by calling 1-800- LTC-FEDS (1-800-582-3337) (TDD for the hearing impaired: 1-800-843-3557) or visiting www. ltcfeds. com to get more information and to request an application. 66.
66 Page 67 68
2003 Kaiser Foundation Health Plan, Inc. 64 Index Southern California Region
Index
Do not rely on this page; it is for your convenience and may not show all pages where the terms appear.
Accidental injury 26 Allergy tests 9, 18
Alternative treatment 14, 23-24 Ambulance 29, 31-32, 34
Anesthesia 28 Autologous bone marrow
transplant 19, 28 Biopsies 25
Blood and blood plasma 30 Breast cancer screening 16

Casts 30 Centers of excellence 43
Changes for 2003 9 Chemotherapy 19
Chiropractic 23 Cholesterol tests 16
Coinsurance 13 Colorectal cancer screening 16
Congenital anomalies 26 Contraceptive devices and drugs 13, 18
Coordination of benefits 51 Covered providers 10
Crutches 22 Deaf and hearing impaired
service 42 Deductible 13, 57
Dental care 44 Diagnostic services 15
Disputed claims review 49 Donor expenses (transplants) 28
Dressings 30 Durable medical equipment
(DME) 21, 57 Educational classes and programs 24
Effective date of enrollment 60 Emergency 32
Experimental or investigational 46, 58
Eyeglasses 20, 45 Family planning 18
Fecal occult blood test 16 Flexible benefits options 41
General Exclusions 46 Hearing services 20
Home health services 23 Hospice care 31
Hospital 7, 12, 29, 30 Immunizations 17
Infertility 18 Inpatient Hospital Benefits 29
Insulin 39

Laboratory and pathological services 16
Magnetic Resonance Imagings (MRIs) 16
Mail Order Prescription Drugs 38 Mammograms 16
Maternity Benefits 17 Medicaid 55
Medically necessary 16, 17, 19, 20, 22, 29, 30, 33, 58
Medicare 51 Mental Conditions/ Substance
Abuse Benefits 35 Newborn care 17
Non-FEHB Benefits 45 Nurse
Licensed Practical Nurse 23 Nurse Anesthetist 30
Nurse Practitioner 10 Registered Nurse 23, 42
Nursery charges 17 Obstetrical care 17
Occupational therapy 19 Ocular injury 20
Oral and maxillofacial surgery 27 Orthopedic devices 21
Ostomy and catheter supplies 21, 42 Out-of-pocket expenses 13
Oxygen 22, 30 Pap test 16
Physical examination 17 Physical therapy 19
Precertification 50 Preventive care, adult 16
Preventive care, children 17 Preventive services 54
Prior approval 11 Prostate cancer screening 16
Prosthetic devices 21 Psychotherapy 6
Radiation therapy 19 Renal dialysis 51, 53
Room and board 29, 31 Second surgical opinion 15
Services from other Kaiser Permanente Plans 42
Skilled nursing facility care 12, 15, 21, 31
Smoking cessation 24 Speech therapy 20
Splints 30 Sterilization procedures 18, 25,
26

Subrogation 56 Substance abuse 35, 65
Surgery 25 Anesthesia 28
Oral 27 Outpatient 30
Reconstructive 26 Syringes 39
Temporary continuation of coverage 60, 61
Transplants 19, 28, 42 Travel benefit 42
Treatment therapies 19 Vision services 20, 45, 54
Well child care 17 Wheelchairs 22
Workers' compensation 55 X-rays 16
24 hour nurse line 42 67.
67 Page 68 69
2003 Kaiser Foundation Health Plan, Inc. 65 Summary Southern California Region
Summary of benefits for Kaiser Foundation Health Plan, Inc., Southern California Region 2003
Do not rely on this chart alone. All benefits are provided in full unless indicated and are subject to the definitions, limitations, and exclusions in this brochure. On this page we summarize specific expenses we cover;
for more detail, look inside.
If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on your enrollment form.

We only cover services provided or arranged by Plan physicians, except in emergencies.
Benefits You Pay Page
Medical services provided by physicians:
Diagnostic and treatment services provided in the office................. $10 per office visit 15

Services provided by a hospital:
Inpatient ............................................................................................
Outpatient .........................................................................................
Nothing
Nothing
29
30

Emergency benefits:
In-area.............................................................................................
Out-of-area .....................................................................................
$50 per visit
$50 per visit
32
32

Mental health and substance abuse treatment: ................................. Regular cost sharing 35
Prescription drugs ................................................................................ $10 per prescription for generic drugs; $ 25 per prescription for
brand-name drugs; all charges if you request a brand-name drug in
place of a generic drug

Dental Care ....................................................................................... No benefit 44
Vision Care ....................................................................................... Refractions; $10 per office visit 45
Special features: Flexible benefits option; Services from other Kaiser Permanente Plans; Travel benefit; 24 hour nurse line; Services for deaf and hearing impaired; Centers of excellence 41

Protection against catastrophic costs (your catastrophic protection out-of-pocket maximum).................... Nothing after $1,500/ Self Only or $3,000/ Family enrollment per
year
Some costs do not count toward this protection

13 68.
68 Page 69 70
2003 Kaiser Foundation Health Plan, Inc. 66 Notes Southern California Region
Notes 69.
69 Page 70
2003 Rate Informat