**PacifiCare Southwest Region**

**Oklahoma/Texas**

PacifiCare http://www.pacificare.com 2004

# A Health Maintenance Organization

**Serving:** Oklahoma and Texas

**Enrollment in this Plan is limited. You must live or work in our**

**geographic service area to enroll. See pages 7-8 for requirements.**

Enrollment codes for this Plan: These plans have Excellent Accreditation
from the NCQA. See the 2004 Guide for more information on NCQA.

**Oklahoma**

**2N1 Self Only**

**2N2 Self and Family**

**Texas**

**GF1 Self Only**

**GF2 Self and Family**

RI 73-827

http://www.pacificare.com

For changes

in benefits,

see page 9

Dear Federal Employees Health Benefits Program Participant:

I am pleased to present this 2004 Federal Employees Health Benefits
(FEHB) Program plan brochure. The brochure describes the benefits this
plan offers you for 2004. Because benefits vary from year to year, you
should review your plan's brochure every Open Season -- especially
Section 2, which explains how the plan changed.

It takes a lot of information to help a consumer make wise healthcare
decisions. The information in this brochure, our FEHB Guide, and our
web-based resources, make it easier than ever to get information about
plans, to compare benefits and to read customer service satisfaction
ratings for the national and local plans that may be of interest. Just
click on [www.opm.gov/insure!](http://www.opm.gov/insure!)

The FEHB Program continues to be an enviable national model that offers
exceptional choice, and uses private-sector competition to keep costs
reasonable, ensure high-quality care, and spur innovation. The Program,
which began in 1960, is sound and has stood the test of time. It enjoys
one of the highest levels of customer satisfaction of any healthcare
program in the country.

I continue to take aggressive steps to keep the FEHB Program on the
cutting edge of employer-sponsored health benefits. We demand
cost-effective quality care from our FEHB carriers and we have
encouraged Federal agencies and departments to pay the full FEHB health
benefit premium for their employees called to active duty in the Reserve
and National Guard so they can continue FEHB coverage for themselves and
their families. Our carriers have also responded to my request to help
our members to be prepared by making additional supplies of medications
available for emergencies as well as call-up situations and you can help
by getting an Emergency Preparedness Guide at www.opm.gov. OPM's
*HealthierFeds* campaign is another way the carriers are working with us
to ensure Federal employees and retirees are informed on healthy living
and best-treatment strategies. You can help to contain healthcare costs
and keep premiums down by living a healthy life style.

Open Season is your opportunity to review your choices and to become an
educated consumer to meet your healthcare needs. Use this brochure, the
FEHB Guide, and the web resources to make your choice an informed one.
Finally, if you know someone interested in Federal employment, refer
them to [www.usajobs.opm.gov](http://www.usajobs.opm.gov/).

**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 United States Office of Personnel Management (OPM), which
administers the Federal Employees Health Benefits (FEHB) Program, is
required to protect the privacy of your personal medical information.
OPM is also required to give you this notice to tell you how OPM may use
and give out ("disclose") your personal medical information held by OPM.

OPM **will** use and give out your personal medical information:

• To you or someone who has the legal right to act for you (your
personal representative),

• To the Secretary of the Department of Health and Human Services, if
necessary, to make sure your privacy is protected,

**•** To law enforcement officials when investigating and/or prosecuting
alleged or civil or criminal actions, and

**•** Where required by law.

OPM **has the right to** use and give out your personal medical
information to administer the FEHB Program. For example:

**•** To communicate with your FEHB health plan when you or someone you
have authorized to act on your behalf asks for our assistance regarding
a benefit or customer service issue.

**•** To review, make a decision, or litigate your disputed claim

.

**•** For OPM and the General Accounting Office when conducting audits.

OPM **may** use or give out your personal medical information for the
following purposes under limited circumstances:

**•** For Government healthcare oversight activities (such as fraud and
abuse investigations),

**•** For research studies that meet all privacy law requirements (such
as for medical research or education), and

**•** To avoid a serious and imminent threat to health or safety.

By law, OPM must have your written permission (an "authorization") to
use or give out your personal medical information for any purpose that
is not set out in this notice. You may take back ("revoke") your written
permission at any time, except if OPM has already acted based on your
permission.

By law, you **have the right to**:

**•** See and get a copy of your personal medical information held by
OPM.

**•** Amend any of your personal medical information created by OPM if
you believe that it is wrong or if information is missing, and OPM
agrees. If OPM disagrees, you may have a statement of your disagreement
added to your personal medical

information.

**•** Get a listing of those getting your personal medical information
from OPM in the past 6 years. The listing will not cover your personal
medical information that was given to you or your personal
representative, any information that you authorized OPM to release, or
that was given out for law enforcement purposes or to pay for your
health care or a disputed claim.

**•** Ask OPM to communicate with you in a different manner or at a
different place (for example, by sending materials to a P.O. Box instead
of your home address).

**•** Ask OPM to limit how your personal medical information is used or
given out. However, OPM may not be able to agree to your request if the
information is used to conduct operations in the manner described above.

**•** Get a separate paper copy of this notice.

For more information on exercising your rights set out in this notice,
look at www.opm.gov/insure on the web. You may also call 202-606-0191
and ask for OPM's FEHB Program privacy official for this purpose.

If you believe OPM has violated your privacy rights set out in this
notice, you may file a complaint with OPM at the following address:

Privacy Complaints

United States 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 are effective April 14, 2003.

# Table of Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4

Plain Language . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Stop Health Care Fraud!. . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

Preventing Medical Mistakes . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

Section 1. Facts about this HMO plan . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . .7

How we pay providers . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7

Your Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7

Service Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Section 2. How we change for 2004 . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Program-wide changes. . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

Changes to this Plan. . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Section 3. How you get care . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Identification cards. . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Where you get covered care . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

. Plan providers . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

. Plan facilities. . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

What you must do to get covered care . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . 10

. Primary care . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

. Specialty care . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

. Hospital care . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Circumstances beyond our control . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Services requiring our prior approval . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Section 4. Your costs for covered services . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . 13

. Copayments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

. Deductible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

. Coinsurance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

Your catastrophic protection out-of-pocket maximum . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . 13

Section 5. Benefits . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

\(a\) Medical services and supplies provided by physicians and other
health care professionals. 15

\(b\) Surgical and anesthesia services provided by physicians and other
health care professionals . . . . . .22

\(c\) Services provided by a hospital or other facility, and ambulance
services . . . . . . . . . . . . . . 25

\(d\) Emergency services/accidents . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

\(e\) Mental health and substance abuse benefits . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . 29

\(f\) Prescription drug benefits . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 31 *2004 PacifiCare Southwest Region 2 Table of Contents*

\(g\) Special features . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

. Health Improvement Programs . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

. PacifiCare PerksSM Program. . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

. Eye Glasses and Hearing Aids. . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . .34

. Centers of Excellence . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

\(h\) Dental benefits . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

\(i\) Non-FEHB benefits available to Plan members . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . 38

Section 6. General exclusions -- things we don't cover . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . 39

Section 7. Filing a claim for covered services. . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . .40

Section 8. The disputed claims process. . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Section 9. Coordinating benefits with other coverage . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . 43

When you have other health coverage . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . 43

. What is Medicare?. . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

. Should I enroll in Medicare? . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

. Medicare+Choice . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

. TRICARE and CHAMPVA. . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . 46

. Workers' Compensation . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

. Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

. Other Government agencies. . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

. When others are responsible for injuries . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . 47

Section 10. Definitions of terms we use in this brochure . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . 48

Section 11. FEHB facts . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Coverage information . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

. No pre-existing condition limitation . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

. Where you get information about enrolling in the FEHB Program . . . .
. . . . . . . . . . . . . . . . . . 49

. Types of coverage available for you and your family. . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . 49

. Children's Equity Act . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

. When benefits and premiums start . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . 50

. When you retire. . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

When you lose benefits . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

. When FEHB coverage ends. . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . 50

. Spouse equity coverage . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

. Temporary Continuation of Coverage (TCC). . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . 51

. Converting to individual coverage . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

. Getting a Certificate of Group Health Plan Coverage. . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . 51

Two new Federal Programs complement FEHB benefits . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . 53

The Federal Flexible Spending Account Program -- *FSAFEDS*. . . . . . .
. . . . . . . . . . . . . . . . . . . 53

The Federal Long Term Care Insurance Program . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . 56

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 57

Summary of benefits . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Back cover

*2004 PacifiCare Southwest Region* 3 *Table of Contents*

## Introduction

This brochure describes the benefits of PacifiCare of Oklahoma, Inc and
PacifiCare of Texas, Inc under our contract (CS 2885) with the United
States Office of Personnel Management (OPM), as authorized by the
Federal Employees Health Benefits law. The address for administrative
offices is:

PacifiCare Southwest Region

P.O. Box 400046

San Antonio, TX 78229

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, 2004, unless those benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefit
changes are effective January 1, 2004, and 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" means
PacifiCare.

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

**•** Our brochure and other FEHB plans' brochures have the same format
and similar descriptions to help you compare plans.

If you have comments or suggestions about how to improve the structure
of this brochure, let OPM know. Visit OPM's "Rate Us" feedback area at
www.opm.gov/insure or e-mail OPM at fehbwebcomments@opm.gov. You may
also write to the OPM at the Office of Personnel Management, Insurance
Services Program, Program Planning and Evaluation Group, 1900 E Street
NW, Washington, DC 20415-3650.

# Stop Health Care Fraud!

Fraud increases the cost of health care for everyone and increases your
Federal Employees Health Benefits (FEHB) Program premium.

OPM's Office of the Inspector General investigates all allegations of
fraud, waste, and abuse in the FEHB Program regardless

of the agency that employs you or from which you retired.

**[Protect Yourself From Fraud]{.underline}** -- 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, authorized plan or OPM representative.

**•** Let only the appropriate medical professionals review your medical
record or recommend services.

*2004 PacifiCare Southwest Region* 4 *Introduction/Plain
Language/Advisory*

**•** Avoid using health care providers who say that an item or service
is not usually covered, but they know how to bill us to get it paid.

**•** Carefully review explanations of benefits (EOBs) that you receive
from us.

**•** Do not ask your doctor to make false entries on certificates,
bills or records in order to get us to pay for an item or service.

**•** If you suspect that a provider has charged you for services you
did not receive, billed you twice for the same service, or
misrepresented any information, do the following:

**•** Call the provider and ask for an explanation. There may be an
error.

**•** If the provider does not resolve the matter, call us at
1/800-531-3341 and explain the situation.

**•** If we do not resolve the issue:

**CALL --- THE HEALTH CARE FRAUD HOTLINE**

**202-418-3300**

**OR WRITE TO:**

**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.

**Preventing Medical Mistakes**

An influential report from the Institute of Medicine estimates that up
to 98,000 Americans die every year from medical mistakes in hospitals
alone. That's about 3,230 preventable deaths in the FEHB Program a year.
While death is the most tragic outcome, medical mistakes cause other
problems such as permanent disabilities, extended hospital stays, longer
recoveries, and even additional treatments. By asking questions,
learning more and understanding your risks, you can improve the safety
of your own health care, and that of your family members. Take these
simple steps:

1\. **Ask questions if you have doubts or concerns.**

**•** Ask questions and make sure you understand the answers.

**•** Choose a doctor with whom you feel comfortable talking.

**•** Take a relative or friend with you to help you ask questions and
understand answers.

2\. **Keep and bring a list of all the medicines you take.**

**•** Give your doctor and pharmacist a list of all the medicines that
you take, including non-prescription medicines.

**•** Tell them about any drug allergies you have.

**•** Ask about side effects and what to avoid while taking the
medicine.

**•** Read the label when you get your medicine, including all warnings.

**•** Make sure your medicine is what the doctor ordered and know how to
use it.

**•** Ask the pharmacist about your medicine if it looks different than
you expected.

### 2004 PacifiCare Southwest Region 5 Introduction/Plain Language/Advisory

3\. **Get the results of any test or procedure.**

**•** Ask when and how you will get the results of test or procedures.

**•** Don't assume the results are fine if you do not get them when
expected, be it in person, by phone, or by mail.

**•** Call your doctor and ask for your results.

**•** Ask what the results mean for your care.

4\. **Talk to your doctor about which hospital is best for your health
needs.**

**•** Ask your doctor about which hospital has the best care and results
for your condition if you have more than onehospital to choose from to
get the health care you need.

**•** Be sure you understand the instructions you get about follow-up
care when you leave the hospital.

5\. **Make sure you understand what will happen if you need surgery.**

**•** Make sure you, your doctor, and your surgeon all agree on exactly
what will be done during the operation.

**•** Ask your doctor, "Who will manage my care when I am in the
hospital?"

**•** Ask your surgeon:

Exactly what will you be doing?

About how long will it take?

What will happen after surgery?

How can I expect to feel during recovery?

**•** Tell the surgeon, anesthesiologist, and nurses about any
allergies, bad reaction to anesthesia, and any medications you are
taking.

Want more information on patient safety?

. www.ahrq.gov/consumer/pathqpack.htm. The Agency for Healthcare
Research and Quality makes available a wide-ranging list of topics not
only to inform consumers about patient safety but to help choose quality
healthcare providers and improve the quality of care you receive.

. www.npsf.org. The National Patient Safety Foundation has information
on how to ensure safer healthcare for you and your family.

. www.talkaboutrx.org/consumer.html. The National Council on Patient
Information and Education is dedicated to improving communication about
the safe, appropriate use of medicines.

. www.leapfroggroup.org. The Leapfrog Group is active in promoting safe
practices in hospital care.

. www.ahqa.org. The American Health Quality Association represents
organizations and healthcare professionals working to improve patient
safety.

. www.quic.gov/report. Find out what federal agencies are doing to
identify threats to patient safety and help prevent mistakes in the
nation's healthcare delivery system.

*2004 PacifiCare Southwest Region 6 Introduction/Plain
Language/Advisory*

# Section 1. Facts about this HMO plan

This Plan is a health maintenance organization (HMO). We require you to
see specific physicians, hospitals, and other providers that contract
with us. These Plan providers coordinate your health care services. The
Plan is solely responsible for the selection of these providers in your
area. Contact the Plan for a copy of their most recent provider
directory.

HMO's emphasize preventive care such as routine office visits, physical
exams, well-baby care, and immunizations, in addition to treatment for
illness and injury. Our providers follow generally accepted medical
practice when prescribing any course of treatment.

When you receive services from Plan providers, you will not have to
submit claim forms or pay bills. You only pay the copayments,
coinsurance, and deductibles described in this brochure. When you
receive emergency services from non-Plan providers, you may have to
submit claim forms.

**You should join an HMO because you prefer the plan's benefits, not
because a particular provider is available. You cannot change plans
because a provider leaves our Plan. We cannot guarantee that any one
physician, hospital, or other provider will be available and/or remain
under contract with us.**

**How we pay providers**

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

**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.

**•** PacifiCare Health Systems has been in existence since 1975. We
were founded by the Lutheran Hospital Society now called UniHealth
America. We began operating as a Federally qualified Health Maintenance
Organization (HMO) in 1978.

**•** PacifiCare is a for profit organization.

If you want more information about us, call 1 (800) 531-3341, or write
to P.O. Box 400046, San Antonio, TX 78229. You may also contact us by
fax at (210) 474-5331 or visit our website at
[www.pacificare.com](http://www.pacificare.com/).

2004 PacifiCare Southwest Region 7 Section 1

#### Service Area

To enroll in this Plan, you must live or work in our service area. This
is where our providers practice.

**Our service areas are:**

**OKLAHOMA**

Serving Central and Northeastern Oklahoma:

The counties of: Canadian, Cleveland, Creek, Logan, Oklahoma,
Pottawatomie, Rogers, Tulsa and Wagoner,and portions of the following
counties identified by zip code:

Muskogee: 74436

Osage: 74002, 74035, 74054, 74060

Washington: 74061, 74082

**TEXAS**

Serving San Antonio and Dallas/Ft. Worth:

Atascosa, Bandera, Bexar, Collin, Comal, Dallas, Denton, Ellis,
Guadalupe, Hood, Hunt, Johnson, Kaufmann, Kendall, Rockwall, Tarrant,
and Wise.

Ordinarily, you must get your care from providers who contract with us.
If you receive care outside our service area, we will pay only for
emergency care benefits. We will not pay for any other health care
services out of our service area unless the services have prior plan
approval.

If you or a covered family member move outside of our service area, you
can enroll in another plan. If your dependents live out of the area (for
example, if your child goes to college in another state), you should
consider enrolling in a fee-for-service plan or an HMO that has
agreements with affiliates in other areas. If you or a family member
move, you do not have to wait until Open Season to change plans. Contact
your employing or retirement office.

*2004 PacifiCare Southwest Region* 8 *Section 1*

# Section 2. How we change for 2004

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**

**•** We added information regarding two new Federal Programs that
complement FEHB benefits, the Federal Flexible Spending Account Program
-- *FSAFEDS* and the Federal Long Term Care Insurance Program. See page
50.

**•** We added information regarding Preventing medical mistakes. See
page 5.

**•** We added information regarding enrolling in Medicare. See page 42.

**•** We revised the Medicare Primary Payer Chart. See page 43.

**Changes to this Plan**

**•** If you are enrolled in **Code 2N,** your share of the non-Postal
premium will increase by 4.5% for Self Only coverage and decrease 9.1%
for Self and Family coverage.

**•** If you are enrolled in **Code GF,** your share of the non-Postal
premium will increase by 27.8% for Self Only coverage and decrease 10.9%
for Self and Family coverage.

**• Office visit copayments** -- You now pay a \$20 copayment for visits
to your primary care physician and a \$40 copayment for visits to
specialists, including behavioral health specialist.

**• Prescription drugs** -- You now pay \$20 for generic formulary
drugs, \$40 for brand-name formulary. You pay two copayments per 90-day
supply through the mail order program.

**• Prescription drugs** -- You may now purchase non-formulary drugs for
a \$50 copayment per 30-day supply.

**• Maternity care** -- You now pay a single \$40 copayment for the
entire pregnancy.

**• Inpatient hospital** -- You now pay \$400 copayment per day up to 5
days per admission.

**• Lab, X-ray and other diagnostic tests** -- You now pay a \$200
copayment for all specialized scanning exams, such as, MRI, CT Scans,
PET Scans and SPECT Scans.

**• Treatment therapy** -- You now pay a \$40 copayment per treatment
for chemotherapy and radiation therapy.

**• Skilled nursing facility** -- You now pay a \$200 copayment per day
up to 5 days per admission to a skilled nursing facility. All necessary
services will be covered up to 100 consecutive days per qualifying
condition per calendar year.

**• Outpatient hospital or ambulatory surgical center** -- You now pay a
\$200 copayment per outpatient surgery or procedure.

**• Emergency services** -- You now pay a \$20 copayment per visit to an
urgent care center and for emergency care provided after hours in your
PCP's office. You now pay a \$250 copayment per visit to an emergency
room. The Plan will no longer waive the copayment if you are admitted to
the hospital.

**• Physical, occupational and speech therapies** -- You now pay a \$40
copayment for physical, occupational and speech therapy.

**• Out-of-pocket maximum** -- Your catastrophic protection out of
pocket maximum has increased to \$5,000 per person or \$15,000 per
family enrollment.

**• Service area changes** -- PacifiCare of Oklahoma will now provide
service in Logan County.

**• Chiropractic services --** We will no longer provide chiropractic
care in PacifiCare of Oklahoma or PacifiCare of Texas

*2004 PacifiCare Southwest Region* 9 *Section 2*

# Section 3. How you get care

**Identification cards:** We will send you an identification (ID) card.
You should carry your ID card with you at all times. You must show it
whenever you receive services from a Plan provider, or fill a
prescription at a Plan pharmacy. Until you receive your ID card, use
your copy of the Health Benefits Election Form, SF-2809, your health
benefits enrollment confirmation (for annuitants), or your Employee
Express confirmation letter.

If you do not receive your ID card within 30 days after the effective
date of your enrollment, or if you need replacement cards, call us at 1
(800) 531-3341 or write to us at PacifiCare Southwest Region, P.O. Box
400046, San Antonio, TX 78229. You may also request replacement cards
through our website at [www.pacificare.com](http://www.pacificare.com/).

**Where you get covered care:** You get care from "Plan providers" and
"Plan facilities." You will only pay copayments and/or coinsurance, and
you will not have to file claims unless you receive out of area
emergency services.

**•Plan providers:** Plan providers are physicians and other health care
professionals in our service area that we contract with to provide
covered services to our members. We credential Plan providers according
to national standards. We list Plan providers in the provider directory,
which we update periodically. The list is also on our website, which you
can also access at [www.pacificare.com](http://www.pacificare.com/).

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

**What you must do to get covered care:** It depends on the type of care
you need. First, you and each family member must choose a primary care
physician. This decision is important since your primary care physician
provides or arranges for most of your health care. You may select a
primary care doctor by completing the Primary Care Doctor Selection form
inside your enrollment packet.

**•Primary care:** Your primary care physician can be a family
practitioner, internist, general practitioner or pediatrician for
children under 18 years of age. Your primary care physician will provide
most of your health care, or give you a referral to see a specialist. If
you want to change primary care physicians or if your primary care
physician leaves the Plan, call us. We will help you select a new one.

**•Specialty care:** Your primary care physician will refer you to a
specialist for needed care. When you receive a referral from your
primary care physician, you must return to the primary care physician
after the consultation, unless your primary care physician authorized a
certain number of visits without additional referrals. The primary care
physician must provide or authorize all follow-up care. Do not go to the
specialist for return visits unless your primary care physician gives
you a referral. However, women may see an OB/Gyn within their primary
medical group once every twelve months for the well-woman exam, without
a referral. If you are enrolled in PacifiCare of Texas (GF), you may
also see any Woman's Healthcare provider within the network for
maternity care, reproductive health services, gynecological care and
general examinations without a referral.

*2004 PacifiCare Southwest Region Section* 10 *Section 3*

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
coordinate with your specialist and PacifiCare to develop a treatment
plan that allows you to see your specialist for a certain number of
visits without additional referrals. Your primary care physician will
use our criteria when creating our treatment plan (the physician may
have to get an authorization or approval beforehand).

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

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

**•** If you have a chronic or disabling condition and lose access to
your specialist because we:

**•** terminate our contract with your specialist for other than cause;
or

> **•** drop out of the Federal Employees Health Benefits (FEHB) Program
> and you enroll in another FEHB Plan; or

**•** reduce our service area and you enroll in another FEHB Plan,

you may be able to continue seeing your specialist for up to 90 days
after

you receive notice of the change. Contact us or, if we drop out of the

Program, contact your new plan.

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

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

If you are in the hospital when your enrollment in our Plan begins, call
our customer service department immediately at 1 (800) 531-3341. If you
are new to the FEHB Program, we will arrange for you to receive care.

If you changed from another FEHB plan to us, your former plan will pay
for the hospital stay until:

**•** You are discharged, not merely moved to an alternative care
center; or

**•** The day your benefits from your former plan run out; or

**•** The 92nd day after you become a member of this Plan, whichever
happens first.

*2004 PacifiCare Southwest Region* 11 *Section 3*

These provisions apply only to the benefits of the hospitalized person.
If your plan terminates participation in the FEHB Program in whole or in
part, or if OPM orders an enrollment change, this continuation of
coverage provision does not apply. In such case, the hospitalized family
member's benefits under the new plan begin on the effective date of
enrollment.

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

**Services requiring our prior approval:** Your primary care physician
has authority to refer you for most services. For certain services,
however, your physician must obtain approval from us. Before giving
approval, we consider if the service is covered, medically

necessary, and follows generally accepted medical practice.

We call this the approval process precertification. Your physician must
obtain

approval for some services such as but not limited to:

• Cardiovascular bypass surgery

**•** Septoplasty

**•** Cholecystectomy

**•** Hysterectomy

**•** Arthroplasty

**•** MRIs and CTs

**•** Growth Hormone Treatment (GHT)

PacifiCare Health Plans may determine medical necessity by using
preauthorization programs and criteria. Our criteria are written
guidelines established by us to determine medical necessity and/or
coverage for certain procedure and treatments. Our criteria are based on
research of scientific literature, collaboration with physician
specialists and compliance with federal and national regulatory agency
guidelines. Criteria are approved by the PacifiCare Interpretation
Committee and Technology Assessment and Guideline and are reviewed and
revised on a regular basis. Criteria are available for review by the
member's participating physician, the member or the member's
representative. If you do not receive prior approval you may be
responsible for charges. Always return to your primary care physician
for prior approval.

*2004 PacifiCare Southwest Region* 12 *Section 3*

## 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 or pharmacy when you receive services.

Example: When you see your primary care physician you pay a copayment of
\$20 per office visit and when you go in the hospital, you pay \$400 per
day up to 5 days.

**•Deductible:** We do not have a deductible.

**•Coinsurance:** Coinsurance is the percentage that you must pay for
your care.

**Your Catastrophic Protection out-of-pocket maximum for copayments:**

After your copayments total \$5,000 per person or \$15,000 per family
enrollment in any calendar year, you do not have to pay any more for
covered services. However, copayments for the following services do not
count toward your catastrophic protection out-of-pocket maximum, and you
must continue to pay copayments for these services:

**•** Prescription Drugs

**•** Dental Services

**•** Vision services

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

*2004 PacifiCare Southwest Region* 13 *Section 4*

# Section 5. Benefits -- OVERVIEW

***(See page 9 for how our benefits changed this year and page 56 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. For more information about our benefits, contact us at 1
(800) 531-3341 or at our Web site at
[www.pacificare.com](http://www.pacificare.com/).

(a) Medical services and supplies provided by physicians and other
    health care professionals

15 -- 21

**•** Diagnostic and treatment services **•** Speech Therapy

**•** Lab, X-ray, and other diagnostic tests **•** Hearing services
(testing, treatment, and supplies)

**•** Preventive care, adult **•** Vision services (testing, treatment,
and supplies)

**•** Preventive care, children **•** Foot care

**•** Maternity care **•** Orthopedic and prosthetic devices

**•** Family planning **•** Durable medical equipment (DME)

**•** Infertility services **•** Home health services

**•** Allergy care **•** Treatment therapies

**•** Educational classes and programs **•** Physical and occupational
therapies

(b) Surgical and anesthesia services provided by physicians and other
    health care professionals 22 -- 24

**•** Surgical procedures **•** Oral and maxillofacial surgery

**•** Reconstructive surgery **•** Organ/tissue transplants

**•** Anesthesia

(c)Services provided by a hospital or other facility, and ambulance
services ...................25 -- 26

**•** Inpatient hospital **•** Extended care benefits/skilled nursing
care

**•** Outpatient hospital or ambulatory facility **•** Ambulance

benefits surgical center **•** Hospice care

\(d\) Emergency
services/accidents......................................................................\.....27
-- 28

**•** Accidental injury **•** Medical emergency

**•** Ambulance

\(e\) Mental health and substance abuse
\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....29
-- 30

\(f\) Prescription drug
benefits\...\.............................................................................\...31
-- 32

\(g\) Special
features\...\...\...\...\...\...\...\...\........................................................................\...\...\...33

**•** Health Improvement Programs **•** PacifiCare PerksSM Programs

-   Eyeglasses and Hearing Aids **•** Centers of Excellence

\(h\) Dental
benefits\...\...\...\...\...\...\...\...\...........................................................................34
-- 35

\(i\) Non-FEHB benefits available to Plan members
\...\...\...\...\...\...\...\...\...\.....................................36

Summary of
benefits\...\...\...\...\...\...\...\...\...\...\.........................................................................56

*2004 PacifiCare Southwest Region* 14 *Section 5*

**Section 5 (a) Medical services and supplies provided by physicians and
other health care professionals**

**[Here are some important things to keep in mind about these
benefits:]{.underline}**

**[• Please remember all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when
we determine they are medically necessary.]{.underline}**

**[• Plan physicians must provide or arrange your care.]{.underline}**

**[• We do not have a deductible.]{.underline}**

**[• 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.]{.underline}**

**[Diagnostic and treatment services]{.underline} [You
pay]{.underline}**

Professional services of physicians \$20 per primary care physician

**•** In a physician's office (PCP) office visit, Nothing for

**•** In an urgent care center inpatient services.\$40 per

**•** During a hospital stay specialist office visit

**•** In a skilled nursing facility

**•** Office medical consultations

**•** Second surgical opinion

**•** Electrocardiogram

**•** EEG

At home doctors house calls or visits by nurses and health aides: \$20
per visit

**[Lab, X-ray and other diagnostic tests]{.underline} [You
pay]{.underline}**

Tests, such as: Nothing if you receive the referral for these services
during

**•** Blood tests your office visit.

**•** Urinalysis

**•** Non-routine pap tests

**•** Pathology

**•** X-rays

**•** Non-routine Mammograms

**[Specialized Scanning diagnostic exams]{.underline} [You
pay]{.underline}**

**•** CT Scans \$200 copayment per exam

**•** PET Scans

**•** SPECT Scans

**•** MRI

*2004 PacifiCare Southwest Region* 15 *Section 5(a)*

**[Preventive care, adult]{.underline} [You pay]{.underline}**

Routine screenings, such as: Nothing if you receive these services
during your office

**•** Total Blood Cholesterol -- once every three years visit;
otherwise, \$20 per PCP

**•** Colorectal Cancer Screening, including office visit, \$40 per
specialist

-- Fecal occult blood test office visit

-   Sigmoidoscopy, screening -- every five years starting

at age 50.

**•** Ultrasound

Prostate Specific Antigen (PSA test) -- one annually for men \$20 per
PCP office visit,

age 40 and older \$40 per specialist office visit

Routine pap test \$20 per PCP office visit,

> \$40 per specialist office visit

Note: The office visit is covered if pap test is received on

the same day; see Diagnosis and Treatment, above.

Routine mammogram -- covered for women age 35 Nothing if you receive the
and older, as follows: referral

**•** From age 35 through 39, one during this five year period for these
services during your

**•** From age 40 through 64, one every calendar year office visit;
otherwise,

**•** At age 65 and older, one every two consecutive \$20 per PCP office
visit,

calendar years \$40 per specialist office visit

### Not covered: Physical exams required for obtaining All charges

*or continuing employment or insurance, attending*

*schools or camp, or travel.*

**•** *Immunizations for travel*

Routine immunizations limited to: Nothing if you receive these

**•** Tetanus-diphtheria (Td) booster -- once every 10 years, services
during your office visit;

ages 19 and over otherwise,

(except as provided for under Childhood immunizations). \$20 per PCP
office visit,

**•** Influenza vaccines, annually, Pneumococcal vaccine, \$40 per
specialist office visit

age 65 and over visit

**[Preventive care, children]{.underline} [You Pay]{.underline}**

**•** Childhood immunizations recommended by the Nothing if you receive

American Academy of Pediatrics and the ACIP these services during your

office visit; otherwise;

> \$20 per PCP office visit,
>
> \$40 per specialist office visit

**•** Examinations, such as: \$20 per PCP office visit,

-- Eye exams to determine the need for vision correction. \$40 per
specialist office visit

-- Ear exams to determine the need for hearing correction.

-- Examinations done on the day of immunizations

(up to age 22 years).

**•** Well-child care charges for routine examinations,

immunizations and care (up to age 22 years).

*2004 PacifiCare Southwest Region* 16 *Section 5(a)*

**[Maternity care]{.underline} [You pay]{.underline}**

Complete maternity (obstetrical) care, such as: A single \$40 copayment
for the

**•** Prenatal care entire pregnancy.

**•** Delivery

**•** Postnatal care

Note: Here are some things to keep in mind:

**•** You do not need to precertify your normal delivery; see page

25 for other circumstances, such as extended stays for you

or your baby.

**•** You may remain in the hospital up to 48 hours after a regular
delivery and

96 hours after a cesarean delivery. We will extend your inpatient stay
if

medically necessary.

**•** We cover routine nursery care of the newborn child during the
covered

portion of the mother's maternity stay. We will cover other care of an
infant

who requires non-routine treatment only if we cover the infant under a
Self

and Family enrollment. Note: Circumcisions for newborns are covered
under

surgical benefit not maternity benefits. See section 5 (b).

**•** We pay hospitalization and surgeon services (delivery) the same as
for

illness and injury. See Hospital benefits (Section 5c) and Surgery

benefits (Section 5b).

*Not covered: Routine sonograms and genetic testing to determine fetal
sex. You pay all charges.*

**[Family planning]{.underline} [You Pay]{.underline}**

A broad range of family services such as: \$20 per PCP office visit,

**•** Voluntary sterilization (See Surgical procedures Section 5(b) \$40
per specialist office visit.

**•** Surgically implanted contraceptives

**•** Injectable contraceptive drugs (such as Depo-Provera) \$200
copayment if done at

**•** Intrauterine devices (IUDs) an outpatient surgical center.

**•** Diaphragms

Note: we cover oral contraceptives under the

prescription drug benefit.

*Not covered: Reversal of voluntary surgical sterilization*

*Genetic counseling, unless part of authorized genetic testing.*

*You pay all charges.*

**[Infertility services]{.underline} [You Pay]{.underline}**

Diagnosis and treatment of infertility, such as: 50% of all covered
charges

**•** Artificial insemination: (Up to six cycles per pregnancy)

-- intravaginal insemination (IVI)

-- intracervical insemination (ICI)

-- intrauterine insemination (IUI)

**•** Injectable fertility drugs

Note: We cover oral fertility drugs under the

prescription drug benefit.

*Infertility Services continued on next page.*

*2004 PacifiCare Southwest Region* 17 *Section 5(a)*

[**Infertility services** *(continued)*]{.underline} **[You
Pay]{.underline}**

*Not covered: All charges.*

*• Assisted reproductive technology (ART) procedures,*

*such as:*

*-- in vitro fertilization*

*-- embryo transfer gamate GIFT and zygote ZIFT*

*-- Zygote transfer*

*• Services and supplies related to excluded ART*

*procedures*

*• Cost of donor sperm*

*• Cost of donor egg*

**[Allergy care]{.underline} [You Pay]{.underline}**

Testing and treatment \$20 per PCP office visit,

Allergy injection \$40 per specialist office visit

Allergy serum Nothing

*Not covered: provocative food testing and sublingual allergy
desensitization. You pay all charges.*

**[Treatment therapies]{.underline} [You Pay]{.underline}**

**•** Chemotherapy and radiation therapy \$40 per treatment

Note: High dose chemotherapy in association

with autologous bone marrow transplants are limited to those

transplants listed under Organ/Tissue Transplants on page 24.

**•** Respiratory and inhalation therapy

**•** Dialysis -- hemodialysis and peritoneal dialysis

**•** Intravenous (IV)/Infusion Therapy -- Home IV and antibiotic
therapy

**•** Growth hormone therapy (GHT)

Note: We will only cover GHT when we preauthorize the treatment. We will
ask you

to submit information that establishes that the GHT is medically
necessary. Ask us to

authorize GHT before you begin treatment; otherwise, we will only cover
GHT

services from the date you submit the information. If you do not ask or
if we

determine GHT is not medically necessary, we will not cover the GHT or
related

services and supplies. See Services requiring our prior approval in
Section 3.

*Not covered: Other treatment services not listed as covered. You pay
all charges.*

**[Physical and occupational therapies]{.underline} [You
Pay]{.underline}**

Physical therapy, occupational therapy \$40 per specialist visit

**•** Unlimited visits for the services of each of the following:

-- qualified physical therapists;

-- occupational therapists

Note: We only cover therapy to restore bodily function when there has
been

a total or partial loss of bodily function or due to illness or injury.

**•** Cardiac rehabilitation following a heart transplant, bypass
surgery or

a myocardial infarction is provided with no day limit.

**•** Pulmonary Rehabilitation

*Not covered:.*

*• long-term rehabilitative therapy*

*• exercise programs*

*2004 PacifiCare Southwest Region* 18 *Section 5(a)*

**[Speech Therapy]{.underline} [You Pay]{.underline}**

Unlimited visits for the services of: \$40 per visit

**•** Qualified speech therapists

Note: All therapies are subject to medical necessity

**[Hearing services (testing, treatment, and supplies)]{.underline} [You
Pay]{.underline}**

**•** First hearing aid and testing only when necessitated \$20 per PCP
office visit,

by accidental injury

**•** Hearing testing (see Preventive care) \$40 per specialist visit

*Not covered: All charges.*

*• all other hearing testing*

*• all other hearing aids*

**[Vision services (testing, treatment, and supplies)]{.underline} [You
Pay]{.underline}**

**•** One pair of eyeglasses or contact lenses to correct \$20 per PCP
office visit,

an impairment directly caused by accidental ocular injury \$40 per
specialist visit

or intraocular surgery (such as for cataracts)

**•** You may receive one annual eye refraction in \$20 per PCP office
visit,

a twelve month period. \$40 per specialist visit

Note: See preventive care children for eye exams for children

*Not covered: All charges.*

*• Eyeglasses or contact lenses*

*• Eye exercises and orthoptics*

*• Radial keratotomy and other refractive surgery*

**[Foot care]{.underline} [You Pay]{.underline}**

Routine foot care when you are under active \$20 per PCP office visit,

treatment for a metabolic or peripheral vascular \$40 per specialist
visit

disease, such as diabetes. See orthopedic and

prosthetic devices for information on podiatric shoe inserts.

*Not covered: All charges.*

*• 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).*

**[Orthopedic and prosthetic devices]{.underline} [You
Pay]{.underline}**

**•** Artificial limbs and eyes; stump hose. Nothing

**•** Foot Orthotics when medical criteria is met.

**•** Externally worn breast prostheses and surgical

bras, including necessary replacements, following a mastectomy.

**•** Internal prosthetic devices, such as artificial joints,
pacemakers,

cochlear implants, and surgically implanted breast implant

following mastectomy. Note: See 5(b) for coverage of the

surgery to insert the device.

*Orthopedic and prosthetic devices continued on next page*

2004 PacifiCare Southwest Region 19 Section 5(a)

[**Orthopedic and prosthetic devices***(continued)*]{.underline} **[You
Pay]{.underline}**

**•** Corrective orthopedic appliances for non-dental treatment Nothing

of temporomandibular joint (TMJ) pain dysfunction syndrome.

**•** Prosthetic Replacements when the device is beyond repair

or the patient requires a new device because of a physical change.

*Not covered: All charges.*

*• orthopedic and corrective shoes*

*• arch supports*

*• heel pads and heel cups*

*• lumbosacral supports*

*• corsets, trusses, elastic stockings, support hose, and other
supportive devices*

*• Prosthetic replacements provided less than three years after the last
one we covered*

**[Durable medical equipment (DME)]{.underline} [You Pay]{.underline}**

Rental or purchase, at our option, including repair Nothing

and adjustment of durable medical equipment, such

as oxygen and dialysis equipment.

Under this benefit, we also cover durable medical

equipment prescribed by your Plan physician such as,

but not limited to:

**•** orthopedic brace;

**•** hospital beds;

**•** wheelchairs;

**•** crutches;

**•** walkers;

**•** insulin pumps.

Note: Call us at 1 (800) 531-3341 as soon as your Plan

physician prescribes this equipment. We will advise you

of the appropriate provider to contact to arrange

rental or purchase of this equipment.

Not covered: All charges.

*• Specialized wheelchairs for comfort and convenience.*

##### [Home health services]{.underline} [You Pay]{.underline}

**•** Home health care ordered by a Plan physician Nothing

and provided by a registered nurse (R.N.), licensed

practical nurse (L.P.N.), licensed vocational nurse (

L.V.N.), or home health aide for members who are

homebound or confined to an institution that is not a

hospital. Homebound members are those who have

a physical condition such that there is a normal inability

to leave the home.

**•** Services include oxygen therapy, intravenous

therapy and medications such as injectables.

**•** Injectable medications for home use and

self-administration by patient when approved by the Plan or your Medical
Group.

*Home health services continued on next page.*

*2004 PacifiCare Southwest Region* 20 *Section 5(a)*

[**Home health services**(continued)]{.underline} **[You
Pay]{.underline}**

Not covered: All charges.

*• nursing care requested by, or for the convenience of, the patient or
the patient's*

*family;*

*• services primarily for hygiene, feeding, exercising, moving the
patient,*

*homemaking, companionship or giving oral medication.*

*• home care primarily for personal assistance that does not include a
medical*

*component and is not diagnostic, therapeutic or rehabilitative.*

###### Alternative treatments You pay

Note: See page 33 for the PacifiCare PerksSM

program for discounts on these services.

*Not covered: All charges.*

*• acupuncture*

*• naturopathic services*

*• hypnotherapy*

*• biofeedback*

*• massage therapy*

*• chiropractic care*

###### 

###### Educational classes and programs You Pay

Coverage is limited to: \*Note: There is a \$20

**•** Smoking cessation -- including all related prescription

expenses such as Nicotine Replacement\* drug copayment for smoking

**•** Taking Charge of Your Heart Health cessation products

**•** Diabetes self-management (Taking Charge of Diabetes®).

**•** Pregnancy to Pre-School

**•** Managing Depression

For Health Improvement programs offered in your area and for costs
associated with

those programs, call 1 (800) 531-3341.

*2004 PacifiCare Southwest Region* 21 *Section 5(a)*

**Section 5 (b). Surgical and anesthesia services provided**

**by physicians and other health care professionals**

**Here are some important things to keep in mind about these benefits:**

**• Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when
we determine they are medically necessary.**

**• Plan physicians must provide or arrange your care.**

**• We have no calendar year deductible**

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

**coverage, including with Medicare.**

**• The amounts listed below are for the charges billed by a physician
or other health care**

**professional for your surgical care. Look in section 5(c) for charges
associated with the**

**facility (i.e. hospital, surgical center, etc.)**

**• YOUR PHYSICIAN MUST GET PRECERTIFICATION FOR SOME SURGICAL**

**PROCEDURES. Please refer to the precertification information shown in
Section 3 to be sure which services require precertification and
identify which surgeries require precertification.**

**Benefit Description You pay**

**[Surgical procedures]{.underline} [You Pay]{.underline}**

A comprehensive range of services, such as: \$20 per PCP office visit,

**•** Operative procedures \$40 per specialist office

**•** Treatment of fractures, including casting \$400 per day up to 5
days

**•** Normal pre- and post-operative care by per admission

the surgeon

**•** Correction of amblyopia and strabismus \$200 copayment for
outpatient

**•** Endoscopy procedures surgical centers

**•** Biopsy procedures

**•** Circumcision

**•** Removal of tumors and cysts

**•** Correction of congenital anomalies

(see reconstructive surgery)

**•** Surgical treatment of morbid obesity

-- a condition in which an individual

weighs 100 pounds or 100% over his or her

normal weight according to current underwriting

standards; eligible members must be age 18 or over.

You must meet the National Institute of Health guidelines

**•** Insertion of internal prosthetic devices.

See 5(a) -- Orthopedic and prosthetic devices for device coverage
information.

**•** Voluntary sterilization(e.g., Tubal ligation, Vasectomy)

**•** Treatment of burns

Note: Generally, we pay for internal prostheses (devices) according

to where the procedure is done. For example, we pay Hospital benefits

for a pacemaker and Surgery benefits for insertion of the pacemaker.

*Not covered: All charges.*

*• Reversal of voluntary sterilization*

*• Routine treatment of conditions of the foot; see Foot care.*

*2004 PacifiCare Southwest Region* 22 *Section 5 (b)*

**[Reconstructive surgery]{.underline} [You pay]{.underline}**

**•** Surgery to correct a functional defect Nothing after your \$400
copayment

**•** Surgery to correct a condition caused by injury or illness if: per
day up to 5 days per

\- the condition produced a major effect on the member's admission or
\$200 copayment

appearance and per surgery for outpatient

\- the condition can reasonably be expected to be surgery.

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 See above.

a mastectomy, such as:

-- surgery to produce a symmetrical appearance on the other breast;

-- treatment of any physical complications, such as lymphedemas;

-   breast prostheses and surgical bras and replacements

(see Prosthetic devices)

Note: If you need a mastectomy, you may choose to

have the procedure performed on an inpatient basis

and remain in the hospital up to 48 hours after the procedure.

*Not covered: All charges.*

*• 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*

**[Oral and maxillofacial surgery]{.underline} [You Pay]{.underline}**

Oral surgical procedures, limited to: Nothing after your \$400

**•** Reduction of fractures of the jaws or facial bones; copayment per
day up to 5

**•** Surgical correction of cleft lip, cleft palate or severe days per
admission

functional malocclusion; or \$200 copayment per surgery

**•** Removal of stones from salivary ducts; for outpatient surgery.

**•** Excision of leukoplakia or malignancies;

**•** Excision of cysts and incision of abscesses when

done as independent procedures; and

**•** Other surgical procedures that do not involve

the teeth or their supporting structures.

**•** TMJ surgery and related non-dental treatment.

*Not covered: All charges.*

*• Oral implants and transplants*

*• Procedures associated with oral and dental implants,*

*such as skin or bone grafting.*

*• Procedures that involve the teeth or their supporting*

*structures (such as the periodontal membrane, gingiva,*

*and alveolar bone)*

*2004 PacifiCare Southwest Region* 23 *Section 5(b)*

**[Organ/tissue transplants]{.underline} [You pay]{.underline}**

Limited to: Nothing after your \$400

**•** Cornea copayment per day up to 5 days

**•** Heart per admission or \$200

**•** Heart/lung copayment per surgery for

**•** Kidney outpatient surgery.

**•** Kidney/Pancreas

**•** Liver

**•** Lung: Single --Double

**•** Pancreas

**•** Allogeneic (donor) bone marrow transplant

**•** 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 liver, stomach and pancreas

**•** PacifiCare preferred transplant network facility

**•** Limited Benefits -- Treatment for breast cancer, multiple

myeloma, and epithelial ovarian cancer may be provided

in an NCI- or NIH-approved clinical trial at a Plan-designated

center of excellence and if approved by the Plan's medical

director in accordance with the Plan's protocols.

Note: We cover related medical and hospital expenses of the donor when

we cover the recipient.

*Not covered: All charges.*

*• Donor screening tests and donor search expenses,*

*except those performed for the actual donor*

*• Implants of artificial organs*

*• Transplants not listed as covered*

###### Anesthesia You Pay

Professional services provided in: Nothing after your \$400

**•** Hospital (inpatient) per day up to 5 days per

admission.

Professional services provided in: Nothing after your \$400 **•**
Hospital outpatient department copayment per day up to 5 days

**•** Skilled nursing facility per admission or \$200

**•** Ambulatory surgical center copayment per surgery for

**•** Office outpatient surgery.

*2004 PacifiCare Southwest Region* 24 *Section 5(b)*

**Section 5 (c). Services provided by a hospital or other facility,**

**and ambulance services**

**Here are some important things to remember about these benefits:**

**• Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when
we determine they are medically necessary.**

**• Plan physicians must provide or arrange your care and you must be
hospitalized in a Plan facility.**

**• We do not have a 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
Section 5(a) or (b).**

**• *[YOUR PHYSICIAN MUST GET PRECERTIFICATION FOR
HOSPITAL]{.underline}***

***[STAYS]{.underline}*. Please refer to Section 3 to be sure which
services require precertification.**

**Benefit Description You pay**

**[Inpatient hospital]{.underline} [You Pay]{.underline}**

Room and board, such as: \$400 per day up to 5 days per

**•** ward, semiprivate, or intensive care accommodations; hospital
admission.

**•** general nursing care; and

**•** meals and special diets.

NOTE: If you want a private room when it is not medically

necessary, you pay the additional charge above the

semiprivate room rate.

Other hospital services and supplies, such as: Nothing

**•** Operating, recovery, maternity, and other treatment rooms

**•** 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

**•** Take-home items

**•** Medical supplies, appliances, medical equipment,

and any covered items billed by a hospital for use at home.

*Not covered: All charges.*

*• Custodial care*

*• Non-covered facilities, such as nursing homes and schools*

*• Personal comfort items, such as telephone, television,*

*barber services, guest meals and beds*

*• Private nursing care*

*2004 PacifiCare Southwest Region* 25 *Secton 5(c)*

**[Outpatient hospital or ambulatory surgical center]{.underline} [You
pay]{.underline}**

**•** Operating, recovery, and other treatment rooms \$200 copayment per
outpatient

**•** Diagnostic laboratory tests, X-rays, and pathology services
surgery or procedure.

**•** Administration of blood, blood plasma, and other biologicals

**•** Blood and blood plasma, if not donated or replaced

**•** Pre-surgical testing

**•** Dressings, casts, and sterile tray services

**•** Medical supplies, including oxygen

**•** Anesthetics and anesthesia service

NOTE: We cover hospital services and supplies related to

dental procedures when necessitated by a non-dental physical

impairment. We do not cover the dental procedures.

**[Extended care benefits/skilled nursing]{.underline} [You
Pay]{.underline}**

**[care facility benefits]{.underline}**

Extended care benefit: We provide a wide range of benefits \$200
copayment up to 5 days

for full-time nursing care and confinement in a skilled per admission.

nursing facility when your doctor determines

it to be medically necessary. The Plan

must also approve this service.

All necessary services are covered up to 100 days per

calendar year, including:

**•** Bed, board and general nursing care

**•** Drugs, biologicals, supplies, and equipment ordinarily

provided or arranged by the skilled nursing facility when

prescribed by a Plan doctor.

*Not covered: All charges.*

*• Custodial care*

*• Homemaker Services*

###### Hospice care You Pay

Supportive and palliative care for a terminally ill Nothing

member is covered in the home or hospice facility

when approved by our Medical Director.

Services include:

**•** Inpatient and outpatient care

**•** Family counseling

These services are provided under the direction of a Plan doctor who
certifies

that the patient is in the terminal stages of illness, with a life
expectancy of

approximately twelve months or less.

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

###### Ambulance You Pay

**•** Local professional ambulance service when medically appropriate.
Nothing

*2004 PacifiCare Southwest Region* 26 *Section 5(c)*

# Section 5 (d). Emergency services/accidents

**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 have no deductible.**

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

**coverage, including with Medicare.**

**What is a medical emergency?**

A medical emergency is the sudden and unexpected onset of a condition or
an injury that you believe endangers your life or could result in
serious injury or disability, and requires immediate medical or surgical
care. Some problems are emergencies because, if not treated promptly,
they might become more serious; examples include deep cuts and broken
bones. Others are emergencies because they are potentially
life-threatening, such as heart attacks, strokes, poisonings, gunshot
wounds, or sudden inability to breathe. There are many other acute
conditions that we may determine are medical emergencies -- what they
all have in common is the need for quick action.

**What to do in case of emergency:**

**Emergencies within our service area:**

If you have an emergency situation, please call your primary care
physician. In extreme emergencies, if you are unable to contact your
doctor, contact the local emergency system (e.g., the 911 telephone
system) or go to the nearest hospital emergency room. Be sure to tell
the emergency room personnel that you are a Plan member so they can
notify the Plan. You or a family member should notify the Plan within 48
hours (unless it is not reasonably possible to do so). It is your
responsibility to notify us in a timely manner. If you need to be
hospitalized, the Plan must be notified within 48 hours or on the first
working day following your admission, unless it was not reasonably
possible to notify the Plan within that time. If you are hospitalized in
non-Plan facilities and Plan doctors believe care can be better provided
in a Plan hospital, you will be transferred when medically feasible with
any ambulance charges covered in full. Benefits are available for care
from non- Plan providers in a medical emergency only if delay in
reaching a Plan provider would result in death, disability or
significant jeopardy to your condition. To be covered by us you must get
all follow up care from plan providers or follow up care must be
approved by us.

**Emergencies outside our service area:**

Benefits are available for any medically necessary health service that
is immediately required because of injury or unforeseen illness. If you
need to be hospitalized, the Plan must be notified within 48 hours or on
the first working day following your admission, unless it was not
reasonably possible to notify the Plan within that time. If a Plan
doctor believes care can be better provided in a Plan hospital, you will
be transferred when medically feasible with any ambulance charges
covered in full. To be covered by this Plan, you must get all follow up
care from plan providers or your follow up care must be approved by the
Plan.

**Benefit Description You pay**

*2004 PacifiCare Southwest Region* 27 *Section 5(d)*

**Emergency within our service area [You Pay]{.underline}**

**•** Emergency care at a doctor's office \$20 per PCP office visit,

\$40 per specialist visit

**•** After hours care in your doctor's office \$20 per PCP office
visit,

\$40 per specialist visit

**•** Emergency care at an urgent care center \$20 per visit

**•** Emergency care at a hospital, including doctors' services \$250
per emergency room visit

Note: We do not waive the \$250

copayment if you are admitted to

the hospital.

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

**[Emergency outside our service area]{.underline} [You
Pay]{.underline}**

**•** Emergency care at a doctor's office \$20 per PCP office visit,

\$40 per specialist visit

**•** Emergency care at an urgent care center \$20 per urgent care
center visit

**•** Emergency care at a hospital, including doctors' services \$250
copayment per emergency

room visit.

Note: We do not waive the \$250

copayment if you are admitted

*.* to the hospital.

*Not covered: All charges*

*• Elective care or non-emergency care*

*• Emergency care provided outside the service*

*area if the need for care could have been foreseen before*

*leaving the service area.*

*• Medical and hospital costs resulting from a full-term*

*delivery of a baby outside the service area.*

###### Ambulance You Pay

Professional ambulance service, including Nothing

air ambulance services when medically appropriate.

See 5(c) for non-emergency services.

*2004 PacifiCare Southwest Region* 28 *Section 5(d)*

# Section 5 (e). Mental health and substance abuse benefits

**When you get our approval for services and follow a treatment plan we
approve, costsharing 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 things to keep in mind about these
benefits:]{.underline}***

**• 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 do not have a 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.**

**• *[YOU MUST GET PREAUTHORIZATION FOR THESE SERVICES.]{.underline}*
(See the**

**instructions after the benefits description below.)**

**Benefit Description You pay**

**[Mental health and substance abuse benefits]{.underline} [You
Pay]{.underline}**

Diagnostic and treatment services recommended by Your cost sharing

a Plan provider and contained in a treatment plan responsibilities are

that we approve. The treatment plan may include services, no greater
than for other

drugs and supplies. Illness or conditions.

Note: Plan benefits are payable only when we determine

the care is clinically appropriate to treat your condition and

only when you receive the care as part of a treatment plan

that we approve.

**•** Professional services, including individual or group therapy \$40
per visit

by Behavioral Health providers such as psychiatrists,

psychologists, or clinical social workers

**•** Medication management

**•** Diagnostic tests such as routine lab work and X-rays Nothing

**Specialized scanning** \$200 copayment per diagnostic

**•** CT Scans test.

**•** PET Scans

**•** MRI's

**•** SPECT Scans

**•** Services provided by a hospital or other facility \$400 per day up
to 5 days per

**•** Services in approved alternative care settings admission.

such as partial hospitalization, half-way house,

residential treatment, full-day hospitalization,

facility-based intensive outpatient treatment

*Mental health and substance abuse benefits continued on next page.*

*2004 PacifiCare Southwest Region* 29 *Section 5(e)*

###### Mental health and substance abuse benefits You Pay

*[(continued]{.underline})*

*Not covered: Services we have not approved. All charges.*

*Note: OPM will base its review of disputes about*

*treatment plans on the treatment plan's clinical appropriateness.*

*OPM will generally not order us to pay or provide one clinically*

*appropriate treatment plan in favor of another.*

**[Preauthorization]{.underline}** To receive these benefits you must
obtain a treatment plan and follow the authorization processes. Please
call the following customer service department in your area to access
benefits or to obtain a list of providers:

PacifiCare Behavioral Health at 1 (800) 999-9585

(Web site www.pbhi.com)

*2004 PacifiCare Southwest Region* 30 *Section 5(e)*

# Section 5 (f). Prescription drug benefits

**[Here are some important things to keep in mind about these
benefits:]{.underline}**

**• We cover prescribed drugs and medications, as described in the chart
beginning on the next page.**

**• All benefits are subject to the definitions, limitations and
exclusions in this brochure and are payable**

**only when we determine they are medically necessary.**

**• We do not have a 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.**

**There are important features you should be aware of. These include:**

**• Who can write your prescription.** A plan physician must write the
prescription including medically necessary prescriptions authorized for
dental treatment.

**• Where you can obtain them.** You must fill the prescription at a
plan pharmacy, or by mail for a maintenance medication.

**• We use a formulary.** PacifiCare covers most FDA-approved generics
and a broad selection of brand name drugs. The PacifiCare Formulary is a
list of prescription drugs that Physicians use as a guide when
prescribing medications for patients. The Formulary helps us provide
safe, effective and affordable prescription drugs to PacifiCare members.
We work with physicians and pharmacists to make sure you are getting the
drug therapy you need. A Pharmacy and Therapeutics Committee evaluates
prescription drugs for safety, effectiveness, quality treatment and
overall value. The committee considers the safety and effectiveness of a
medication before they review the cost. Our physicians may get
preauthorization for non-formulary drugs. We cover non-Formulary drugs
prescribed by a Plan doctor.

**• These are the dispensing limitations.** Drugs are dispensed in
accordance with the Plan's drug formulary. Prescription drugs prescribed
by a Plan or referral doctor and obtained at a Plan pharmacy will be
dispensed for up to a 30-day supply. For medications that come in trade
size packages, you will be responsible for one applicable copayment per
prepackaged unit. Nonformulary drugs will be covered when prescribed by
a Plan doctor. Prior authorization is not needed because there are
different copayments for formulary and non-formulary medications.
Clinical edits (limitations) can be used for safety reasons, quantity
limitations, age limitations, and benefit plan exclusions. You can get
your prescription drugs at a participating pharmacy as long as it is
written by your primary care doctor or a **Plan** specialist. You will
get up to a 30-day supply, 2 vials of the same kind of insulin or one
commercially prepared unit (i.e., one inhaler, one vial of ophthalmic
medication, topical ointment or cream) for a \$20 copayment per
prescription unit or refill for generic formulary drugs or a \$40
copayment for name brand formulary drugs or a \$50 copayment for generic
or brand name non-formulary drugs. Some drugs may be dispensed in
quantities other than a 30-day supply they are;

**•** Medications with quantity limits that may be set at a smaller
amount to promote appropriate medication and patient safety.

**•** Pre-packaged medications such as inhalers , eye drops, creams or
other types of medications that are normally dispensed in pre-packaged
units of 30 days or less will be considered one prescription unit.

*2004 PacifiCare Southwest Region* 31 *Section 5(f)*

**•** Medications that are manufactured in prescription units to exceed
a 30-day supply may be subject to more than one copayment.

**•** If you are called to active military duty or in the event of a
National emergency and you are in need of prescription medications call
1 (800) 562-6223.

**•** The most convenient and affordable way to obtain your
prescriptions is to take advantage of our mail service program. It takes
approximately seven days to receive your 90-day supply from the mail
service program. In the event of a national emergency, please contact
your pharmacist about obtaining an override. Our Customer Service
Associates can also help you with your medication needs call 1 (800)
624-8822 or TDHI 1 (800) 442-8833. Prescription drugs can also be
obtained through the mail order program for up to a 90 day supply of
oral medication; 6 vials of insulin; or 3 commercially prepared units
(i.e., inhaler, vials ophthalmic medication or topical ointments or
creams). Call 1(800) 531-3341 for mail order customer service.

**You pay** a \$40 copayment per prescription unit or refill for generic
formulary drugs, a \$80 copayment for name brand formulary maintenance
medications or a \$100 copayment for generic or brand non-formulary
medications. Call 1-800-562-6223 (TDHI 1-800-498-5428) for mail order
customer service.

**•** When you have to file a claim. Please refer to Section 7 for
information on how to file a pharmacy claim, or contact our Customer
Service Department at 1 (800) 562-6223.

**•** Why use generic drugs? To reduce your out-of-pocket expenses! A
generic drug is the chemical equivalent of a corresponding brand name
drug. Generic drugs are less expensive than brand name drugs; therefore,
you may reduce your out-of-pocket costs by choosing to use a generic
drug.

**Benefit Description You pay**

**[Covered medications and supplies]{.underline} [You Pay]{.underline}**

We cover the following medications and supplies \$20 per generic
formulary

prescribed by a Plan physician and obtained from prescription unit or
refill.

a Plan pharmacy or through our mail order program:

**•** Drugs and medicines that by Federal law of the

United States require unit or refill

**•** A physician's prescription for their purchase, \$40 per brand
formulary

except those listed as not covered prescription unit or refill.

**•** Insulin

**•** Diabetic supplies such as lancets and blood

glucose test strips

**•** Disposable needles and syringes for the \$50 per non-formulary
brand

administration of covered medications or generic medication.

**•** Contraceptive drugs and devices

**•** Intravenous fluids and medications for home use

(covered under Section 5(a) Home Health Services 50% copayment

\- see page 15) up to the dosage limits

**•** Prenatal vitamins all charges above that.

**•** Oral medications prescribed to treat infertility,

or the underlying cause of and infertility including

Clomiphene Citrate, Bromocriptine Mesylate and Note: If there is no
generic 5(a)

Dexamethasone (Note: Injectable infertility drugs equivalent available,
you will still

are covered under Section Infertility Services) have to pay the
brand-name

> copayment.

*2004 PacifiCare Southwest Region* 32 *Section 5(f)*

[**Covered medications and supplies** (continued)]{.underline} **[You
Pay]{.underline}**

Limited benefits 50% of the cost of the

**•** Drugs to treat sexual dysfunction are covered medication

when Plan's medical criteria is met. Contact per prescription unit or
refill up

the plan for dose limits. to the dosage limit; you pay all

> charges above that.

*Not covered: All charges.*

*• Non-prescription medicines*

*• Drugs obtained at a non-Plan pharmacy except for*

*out of area emergencies.*

*• Vitamins, nutrients and food supplements even*

*if a physician prescribes or administers them*

*(except prenatal Vitamins)*

*• Medical supplies such as dressings and antiseptics*

*• Diet pills*

*• Drugs and/or supplies for cosmetic purposes*

*• Drugs to enhance athletic performance*

*• Smoking cessation drugs and medication,*

*including nicotine patches unless you are enrolled in our*

*Smoking Cessation program (see page 33).*

*• Diabetic supplies, except those shown above*

*• Injectable medications prescribed for the treatment of infertility*

*• Drugs prescribed by a dentist*

*2004 PacifiCare Southwest Region* 33 *Section 5 (g)*

# Section 5 (g). Special features

**PacifiCare PerksSM Program:** A PacifiCare members only program which
offers discounts for health clubs, alternative care, vitamins and much
more! Call 1 (800) 531-3341 for more information regarding PacifiCare
PerksSM benefits.

**Health Improvement Programs:** For Health Improvement programs offered
in your area and costs associated with these programs call 1
(800)531-3341. Managing your Heart Health, Managing Diabetes,\* Smoking
Cessation, Pregnancy to Pre-school and Managing Depression.

\*There is a \$20 Prescription Drug copayment for smoking cessation
products.

**Centers of excellence:** Services performed at Centers of Excellence
are covered when medically necessary and preapproved. You pay \$20 for
outpatient PCP visits, \$40 fors pecialist visits and \$400 per day up
to a \$2,000 maximum copayment per admission for inpatient
hospitalization.

**Travel benefit/services overseas:** Covered for emergencies only.

**Hearing Aids for Children:** The Oklahoma Plan (2N) covers hearing
aids for children up to the age of 18 years old.

**Scalp Prosthesis:** The Oklahoma Plan (2N) will pay up to \$150
annually for scalp prosthesis for members undergoing chemotherapy. 2004
PacifiCare Southwest Region Section 5(g)

*2004 PacifiCare Southwest Region* 34 *Section 5(g)*

# Section 5 (h). Dental benefits

**[Here are some important things to keep in mind about these
benefits:]{.underline}**

**• For more information call PacifiCare Dental at 1 (800) 591-5915.**

**• 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. For a full list of benefits,
exclusions and limitations please refer to the Plan information pamphlet
for the 2004 PacifiCare Dental Indemnity Plan for Federal Employees.**

**• We do not have a deductible.**

**• There is no waiting period for eligibility to access these dental
benefits; however, there are waiting periods to obtain bridges and
dentures.**

**• There is a \$1,000 calendar year maximum.**

**• Your PacifiCare medical plan covers hospitalization for dental
procedures only when a nondental physical impairment exists which makes
hospitalization necessary to safeguard the health of the patient; we do
not cover the dental procedure unless it is described below.**

**• For treatment or therapy of Temporal Mandibular Joint (TMJ)
disorders, see section 5 (a), Medical benefits.**

**• 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.**

**• For medically necessary prescriptions authorized for dental
treatment see Section 5 (f), *Prescription drug benefits.***

####### Service We Pay You pay

**[Accidental injury benefit]{.underline} [We Pay]{.underline} [You
Pay]{.underline}**

We cover emergency dental care only. N/A \$20 PCP office visit
copayment,

Immediate (within 48 hours) stabilization \$40 specialist visit
copayment

and emergency services for trauma/injury \$250 copayment if you receive

to sound natural teeth, jawbone, or surrounding these services in an
emergency

tissues. When you require emergency dental room.

services, we will cover these services under

your medical plan. Note: We do not waive the \$250

> copayment if you are admitted
>
> to the hospital.

**[Preventive and Diagnostic]{.underline} [We Pay]{.underline} [You
Pay]{.underline}**

**ADA code**

**00150** Comprehensive Oral exam 100% Usual, All charges in excess of
the

(one every six months) customary and

reasonable scheduled amounts.

(UCR).

**00210** Intraoral X-rays

(one bitewing series of four every For all

preventive listed to the left six months,

one full mouth per five years) and diagnostic

services.

**01110** Prophylaxis (one every six months)

*2004 PacifiCare Southwest Region* 35 *Section 5(h)*

[**Preventive and Diagnostic** *(continued)*]{.underline} **[We
pay]{.underline} [You pay]{.underline}**

**Basic and Major Services**

**01120** Amalgam fillings \$18 All charges in excess of

(one tooth surface, permanent teeth) the scheduled amount

listed to the left.

**02120** Amalgam fillings \$23

(two tooth surfaces, permanent teeth)

**02751** Porcelain with metal crown \$200

**02740** Porcelain Crown \$125

**03310** Single root canal \$90

**03320** Bi-root canal \$115

**04341** Periodontal root planing and scaling \$30

(per quadrant)

**05110** Full mouth dentures (upper) \$232.50

**05120** Full mouth dentures (lower) \$232.50

**05213** Partial dentures \$225

**06250** Bridges: Tru-pontic type \$82.50

**07110** Extractions \$15

Note: There is a waiting period for bridges and dentures. Initial
dentures or bridges are covered after a 36-month deferment period. If
you were covered under another dental plan immediately before enrolling
in this plan, that time will be applied to your deferment period.
Replacement dentures are covered only if we have written proof that your
existing bridge or denture cannot be made fit for use and it is at least
5 years old.

*2004 PacifiCare Southwest Region* 36 *Section 5(h)*

# 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.

**PacifiCare Has a Plan to Help Keep Your Smile Healthy ... and Your
Vision Sharp!**

**Dental**

A new PacifiCare Non-FEHB Dental Plan now available for Federal
Employees in your state. This dental network plan allows you to receive
care from any dentist -- but, you enjoy the greatest savings when you
use network dentists. No waiting periods on most services. On your
effective date, you are immediately covered at 100% for most Preventive
and Diagnostic Services and 80% for most Basic Services. If you are
currently a member of another dental plan, other waiting periods may be
waived. Available to **all** Federal Employees, you don't have to be a
member of the medical plan to join!

Non-FEHB dental benefits are not coordinated with the dental benefits
included in the PacifiCare medical plan.

**Vision**

Take advantage of significant savings with the new Non-FEHB vision plan
from PacifiCare Dental and Vision. This Eyewear Vision Plan offers the
following when you use network vision providers:

**•** Standard lenses at NO cost (single vision, bifocal, trifocal)

**•** Frames (up to \$100)

**•** Contact Lenses

**•** Independent doctors, Sears Optical, Target Optical, JCPenney
Optical and Pearle Vision

**•** Laser vision surgery discount available

With the Eyewear Vision Plan, you can have your vision exam and choose
your eyewear at the same location. The exam benefit your PacifiCare
medical plan offers can be received through the same network of eye care
providers as the Eyewear Vision Plan. You do not have to be a member of
the medical plan to enroll in the vision plan. **For more information,
please**

**call 1 (800) 229-1985 from 7 a.m. to 6 p.m., PST, Monday through
Friday.**

**Healthy Renewal Pass -- Introducing PacifiCare's Healthy Renewal
Pass**

You can now enroll in the Healthy Renewal Pass as a supplement to your
medical plan. Healthy Renewal Pass is a unique, voluntary buy-up card
that encourages members to take care of their mind, body and spirit. For
a single monthly premium, members can enjoy a portfolio of enriched
benefits including a fitness club membership, access to additional
chiropractic benefits ,acupuncture benefits, and massage therapy
benefits, as well as, discounts on prescriptions, over-the-counter
medications and a number of other health related products. For more
information visit www.pacificare.com or call 1 (800) 230-3034.

*2004 PacifiCare Southwest Region* 37 *Section 5(i)*

##### Medicare Managed Care and Medicare Supplement plans

If you are Medicare eligible and are interested in enrolling in a
Medicare HMO or a Medicare Supplement Plan sponsored by this Plan
without dropping your enrollment in this Plan's FEHB plan, call 1 (800)
637-9284 for information.

**Medicare+Choice HMO** -- With nearly a million members, Secure
Horizons is one of the largest Medicare+Choice contracting plans in the
nation. As a member of Secure Horizons, you benefit from low or no plan
copayments, low or no deductibles, and virtually no paperwork. Secure
Horizons offers peace of mind for Medicare beneficiaries residing in
parts of AZ, CA, CO, NV, OK, OR, TX, & WA by offering more services than
original Medicare for little additional cost. For more information, call
toll free 1 (800) 637-9284 (TDHI 1 (800) 647-6038) or visit our Web site
www.securehorizons.com.

**Medicare Supplement** -- Secure Horizons Medicare Supplement Plans
pick up where Medicare leaves off, so you don't have to worry about
overwhelming medical bills. As a Medicare beneficiary you can choose the
level of coverage you feel best suits your needs. Choices range from a
plan that covers some basic hospitalization and medical coinsurance
expenses, to a plan with a richer benefit package that includes foreign
travel emergency and at-home recovery. For more information, call toll
free 1 (800) 637-9284 (TDHI 1 (800) 647-6038) or visit our Web site
www.securehorizons.com.

*2004 PacifiCare Southwest* 38 *Region Section 5(i)*

**Section 6. General exclusions -- things we don't cover**

The exclusions in this section apply to all benefits. **Although we may
list a specific service as a benefit, we will not cover it unless your
Plan doctor determines it is medically necessary to prevent, diagnose,
or treat your illness, disease, injury, or condition.**

We do not cover the following:

**•** Care by non-Plan providers except for authorized referrals or
emergencies (see Emergency Benefits);

**•** Services, drugs, or supplies you receive while you are not
enrolled in this Plan;

**•** Services, drugs, or supplies that are not medically necessary;

**•** Services, drugs, or supplies not required according to accepted
standards of medical, dental, or psychiatric practice;

**•** Experimental or investigational procedures, treatments, drugs or
devices;

**•** Services, drugs, or supplies related to abortions, except when the
life of the mother would be endangered if the fetus were

carried to term or when the pregnancy is the result of an act of rape or
incest;

**•** Services, drugs, or supplies related to sex transformations; or

**•** Services, drugs, or supplies you receive from a provider or
facility barred from the FEHB Program.

**•** Services, drugs, or supplies you receive without charge while in
active military service.

*2004 PacifiCare Southwest Region* 39 *Section 6*

# Section 7. Filing a claim for covered services

When you see Plan physicians, receive services at Plan hospitals and
facilities, or obtain your prescription drugs at Plan pharmacies, you
will not have to file claims. Just present your identification card and
pay your copayment.

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

**Medical and hospital, prescription drugs, and Durable Medical
Equipment (DME) Benefits**

In most cases, providers and facilities file claims for you. Physicians
must file on the form HCFA-1500, Health Insurance Claim Form. Facilities
will file on the UB-92 form. For claims questions and assistance, call
us at 1 (800) 531-3341.

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

**•** Covered member's name and ID number;

**•** Name and address of the physician or facility that provided the
service or supply;

**•** Dates you received the services or supplies;

**•** Diagnosis;

**•** Type of each service or supply;

**•** The charge for each service or supply;

**•** A copy of the explanation of benefits, payments, or denial from
any primary payer --such as the Medicare Summary Notice (MSN); and

**•** Receipts, if you paid for your services.

**•** Be sure to keep a copy for your records.

**Submit your claims to:**

PacifiCare Southwest Region

P.O. Box 400046

San Antonio, TX 78229

**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.

*2004 PacifiCare Southwest* 40 *Region Section 7*

# Section 8. The disputed claims process

Follow this Federal Employees Health Benefits Program disputed claims
process if you disagree with our decision on your claim or request for
services, drugs, or supplies -- including a request for
preauthorization:

**Step Description**

1 Ask us in writing to reconsider our initial decision. You must:

\(a\) Write to us within 6 months from the date of our decision; and

\(b\) Send your request to us at: **P.O. Box 400046, San Antonio, TX
78229**; 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: United States Office of Personnel Management, Insurance
Services Programs, Health Insurance Group 3, 1900 E Street NW,
Washington, D.C. 20415-3630.

Send OPM the following information:

**•** A statement about why you believe our decision was wrong, based on
specific benefit provisions in this brochure;

**•** Copies of documents that support your claim, such as physicians'
letters, operative reports, bills, medical records,

and explanation of benefits (EOB) forms;

**•** Copies of all letters you sent to us about the claim;

**•** Copies of all letters we sent to you about the claim; and

**•** Your daytime phone number and the best time to call.

*2004 PacifiCare Southwest Region* 42 *Section 8*

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 the year in which
you were denied precertification or prior approval. This is the only
deadline that may not be extended.

OPM may disclose the information it collects during the review process
to support their disputed claim decision. This information will become
part of the court record.

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

**NOTE: If you have a serious or life-threatening condition** (one that
may cause permanent loss of bodily functions or death if not treated as
soon as possible), and

\(a\) We haven't responded yet to your initial request for care or
preauthorization/prior approval, then call us at 1 (800) 531-3341 and we
will expedite our review; or

\(b\) We denied your initial request for care or preauthorization/prior
approval, then:

**•** If we expedite our review and maintain our denial, we will inform
OPM so that they can give your claim expedited treatment too, or

**•** You may call OPM's Health Insurance Group 3 at (202) 606-0737
between 8 a.m. and 5 p.m. eastern time.

2004 PacifiCare Southwest Region 42 Section 8

# 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.

**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+Choice plan you have.

*2004 PacifiCare Southwest* *Region* 43 *Section 9*

**• Should I enroll in Medicare?** The decision to enroll in Medicare is
yours. We encourage you to apply for Medicare benefits 3 months before
you turn age 65. It's easy. Just call the Social Security Administration
toll-free number 1 (800) 772-1213 to set up an appointment to apply. If
you do not apply for one or both Parts of Medicare, you can still be
covered under the FEHB Program.

If you can get premium-free Part A coverage, we advise you to enroll in
it. Most Federal employees and annuitants are entitled to Medicare Part
A at age 65 **without cost**. When you don't have to pay premiums for
Medicare Part A, it makes good sense to obtain the coverage. It can
reduce your out-of-pocket expenses as well as costs to the FEHB, which
can help keep FEHB premiums down.

Everyone is charged a premium for Medicare Part B coverage. The Social
Security Administration can provide you with premium and benefit
information. Review the information and decide if it makes sense for you
to buy the Medicare Part B coverage.

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

When you are enrolled in Original Medicare along with this Plan, you
still need to follow the rules in this brochure for us to cover your
care. Your care must continue to be authorized by your Plan PCP, or
precertified as required. We will not waive any of our copayments.
(Primary Payer chart begins on next page.)

**Claims process when you have the Original Medicare Plan** -- You
probably will never have to file a claim form when you have both our
Plan and the Original Medicare Plan.

**•** When we are the primary payer, we process the claim first.

**•** When Original Medicare is the primary payer, Medicare processes
your claim first. In most cases, your claims will be coordinated
automatically and we will provide secondary benefits for covered
charges. You will not need to do anything. To find out if you need to do
something about filing your claims, call us at 1 (800) 531-3341, visit
us on our Web site at www.pacificare.com, or you can fax us at (925)
602-1626.

**We do not waive any costs if the Original Medicare Plan is your
primary payer.**

*2004 PacifiCare Southwest* 44 *Region Section 9*

Medicare always makes the final determination as to whether they are the
primary payer. The following chart illustrates whether Medicare 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

+-------------------------------------------------+---------+---------+
| **A. When you -- or your covered spouse -- are  | **The   |         |
| age 65 or over and have Medicare and you\...**  | primary |         |
|                                                 | payer   |         |
|                                                 | for the |         |
|                                                 | ind     |         |
|                                                 | ividual |         |
|                                                 | with    |         |
|                                                 | M       |         |
|                                                 | edicare |         |
|                                                 | i       |         |
|                                                 | s\...** |         |
+-------------------------------------------------+---------+---------+
|                                                 | **Med   | **This  |
|                                                 | icare** | Plan**  |
+-------------------------------------------------+---------+---------+
| 1\) Are an active employee with the Federal     |         | X       |
| government and                                  |         |         |
|                                                 |         |         |
| **•** You have FEHB coverage on your own or     |         |         |
| through your spouse who is also an active       |         |         |
| employee                                        |         |         |
+-------------------------------------------------+---------+---------+
| **•** You have FEHB coverage through your       | X       |         |
| spouse who is an annuitant                      |         |         |
+-------------------------------------------------+---------+---------+
| 2\) Are an annuitant and...                     | X       | X       |
|                                                 |         |         |
| **•** You have FEHB coverage on your own or     |         |         |
| through your spouse who is also                 |         |         |
|                                                 |         |         |
| an annuitant                                    |         |         |
|                                                 |         |         |
| **•** You have FEHB coverage through your       |         |         |
| spouse who is an active employee                |         |         |
+-------------------------------------------------+---------+---------+
| 3\) Are a reemployed annuitant with the Federal | X\*     |         |
| government and your position is excluded from   |         |         |
| the FEHB (your employing office will know if    |         |         |
| this is the case)                               |         |         |
+-------------------------------------------------+---------+---------+
| 4\) Are a reemployed annuitant with the Federal |         | X       |
| government and your position is not excluded    |         |         |
| from the FEHB (your employing office will know  |         |         |
| if this is the case) and                        |         |         |
|                                                 |         |         |
| **•** You have FEHB coverage on your own or     |         |         |
| through your spouse who is also                 |         |         |
|                                                 |         |         |
| an active employee                              |         |         |
+-------------------------------------------------+---------+---------+
| **•** You have FEHB coverage through your       | X       |         |
| spouse who is an annuitant                      |         |         |
+-------------------------------------------------+---------+---------+
| 5\) Are a Federal judge who retired under title | X       |         |
| 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)      |         |         |
+-------------------------------------------------+---------+---------+
| 6\) Are enrolled in Part B only, regardless of  | X for   | X for   |
| your employment status                          | Part B  | other   |
|                                                 | s       | s       |
|                                                 | ervices | ervices |
+-------------------------------------------------+---------+---------+
| 7\) Are a former Federal employee receiving     | X\*\*   |         |
| workers' compensation and the Office of         |         |         |
| workers' compensation programs has determined   |         |         |
| that you are unable to return to duty)          |         |         |
+-------------------------------------------------+---------+---------+
| **B. When you -- or a covered family            |         |         |
| member...**                                     |         |         |
+-------------------------------------------------+---------+---------+
| 1\) Have Medicare solely based on end stage     |         | X       |
| renal disease (ESRD) and                        |         |         |
|                                                 |         |         |
| **•** It is within the first 30 months of       |         |         |
| eligibility for or entitlement to Medicare due  |         |         |
| to ESRD (30-month coordination period)          |         |         |
+-------------------------------------------------+---------+---------+
| **•** It is beyond the 30-month coordination    | X       |         |
| period and you or a family member are still     |         |         |
| entitled to Medicare due to ESRD                |         |         |
+-------------------------------------------------+---------+---------+
| 2\) Become eligible for Medicare due to ESRD    |         | X for   |
| while already a Medicare beneficiary and...     |         | 3       |
|                                                 |         | 0-month |
| **•** This Plan was the primary payer before    |         | coord   |
| eligibility due to ESRD for 30-month            |         | ination |
| coordination period                             |         | period  |
+-------------------------------------------------+---------+---------+
| **•** Medicare was the primary payer before     | X       |         |
| eligibility due to ESRD                         |         |         |
+-------------------------------------------------+---------+---------+
| **C. When either you or your spouse are         |         |         |
| eligible for Medicare solely due to disability  |         |         |
| and you ...**                                   |         |         |
+-------------------------------------------------+---------+---------+
| 1\) Are an active employee with the Federal     |         | X       |
| government and...                               |         |         |
|                                                 |         |         |
| **•** You have FEHB coverage on your own or     |         |         |
| through your spouse who is also                 |         |         |
|                                                 |         |         |
| an active employee                              |         |         |
+-------------------------------------------------+---------+---------+
| **•** You have FEHB coverage through your       | X       |         |
| spouse who is an annuitant                      |         |         |
+-------------------------------------------------+---------+---------+
| 2\) Are an annuitant and...                     | X       |         |
|                                                 |         |         |
| **•** You have FEHB coverage on your own or     |         |         |
| through your spouse who is also an annuitant    |         |         |
+-------------------------------------------------+---------+---------+
| **•** You have FEHB coverage through your       |         | X       |
| spouse who is an active employee                |         |         |
+-------------------------------------------------+---------+---------+
| **D. Are covered under the FEHB Spouse Equity   | X       |         |
| provision as a former spouse**                  |         |         |
+-------------------------------------------------+---------+---------+

\* Unless you have FEHB coverage through your spouse who is an active
employee

\*\* Workers' Compensation is primary for claims related to your
condition under Workers' Compensation.

**• Medicare+Choice** If you are eligible for Medicare, you may choose
to enroll in and get your Medicare benefits from a Medicare+Choice plan.
These are health care choices (like HMOs) in some areas of the country.
In most Medicare+Choice plans, you can only go to doctors, specialists,
or hospitals that are part of the plan. Medicare+Choice plans provide
all the benefits that Original Medicare covers. Some cover extras, like
prescription drugs. To learn more about enrolling in a Medicare+Choice
plan, contact Medicare at 1 (800) MEDICARE (1 (800) 633-4227) or at
[www.medicare.gov](http://www.medicare.gov/).

If you enroll in a Medicare+Choice plan, the following options are
available to you:

**This Plan and our Medicare+Choice plan:** You may enroll in our
Medicare+ Choice plan and also remain enrolled in our FEHB plan. In this
case, we do not waive cost-sharing for your FEHB coverage.

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

**Suspended FEHB coverage to enroll in a Medicare+Choice plan:** If you
are an annuitant or former spouse, you can suspend your FEHB coverage to
enroll in a Medicare+Choice plan, eliminating your FEHB premium (OPM
does not contribute to your Medicare+ Choice plan premium). For
information on suspending your FEHB enrollment, contact your retirement
office. If you laterwant 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+Choice plan's service area.

**TRICARE and CHAMPVA:** TRICARE is the health care program for members,
eligible dependents of military persons and retirees of the military.
TRICARE includes the CHAMPUS program. CHAMPVA provides health coverage
to disabled Veterans and their eligible dependents. If TRICARE or
CHAMPVA and this Plan cover you, we pay first. See your TRICARE or
CHAMPVA Health Benefits Advisor if you have questions about these
programs.

**Suspended FEHB coverage to enroll in TRICARE or CHAMPVA:** If you are
an annuitant or former spouse, you can suspend your FEHB coverage to
enroll in a one of these programs, eliminating your FEHB premium. (OPM
does not contribute to any applicable Plan premiums.) For information on
suspending your FEHB enrollment, contact your retirement office. If you
later want to reenroll in the FEHB Program, generally you may do so only
at the next Open Season unless you involuntarily lose coverage under the
program. If both TRICARE and this Plan cover you, we pay first.

*2004 PacifiCare Southwest* 46 *Region Section 9*

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

**•** you need because of a workplace-related illness or injury that the
Office of Workers' Compensation Programs (OWCP) or a similar Federal or
State agency determines they must provide; or

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

**Medicaid:** When you have this Plan and Medicaid, we pay first.

**Suspended FEHB coverage to enroll in Medicaid or a similar State
sponsored program of medical assistance:** If you are an annuitant or
former spouse, you can suspend your FEHB coverage to enroll in a one of
these State programs, eliminating your FEHB premium. For information on
suspending your FEHB enrollment, contact your retirement office. If you
later want to reenroll 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 are responsible for your care:** We do
not cover services and supplies when a local, State, or Federal
Government agency directly or indirectly pays for them.

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

If you do not seek damages you must agree to let us try. This is called
subrogation. If you need more information, contact us for our
subrogation procedures.

*2004 PacifiCare Southwest* 47 *Region Section 9*

# 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:** We do not have Coinsurance.

**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:** Day to day care including assistance with daily
living activities that can be provided by a non-medical individual.

**Experimental or investigational services:** Our National and Regional
Medical Committees determine whether or not treatments, procedures and
drugs are no longer considered experimental or investigational. Our
determinations are based on the safety and efficacy of new medical
procedures, technologies, devices and drugs.

**Medical necessity:** Medical necessity refers to medical services or
hospital services that are

determined by us to be:

**•** Rendered for the treatment or diagnosis of an injury or illness;
and

**•** Appropriate for the symptoms, consistent with diagnosis, and
otherwise in accordance with sufficient scientific evidence and
professionally recognized standards; and

**•** Not furnished primarily for the convenience of the Member, the
attending

physician, or other provider of service; and

**•** Furnished in the most economically efficient manner which may be
provided safely and effectively to the Member.

**Plan allowance:** Plan allowance is the amount we use to determine our
payment and your coinsurance for covered services. Plans determine their
allowances in different ways. We determine our allowance by our
contracted rate with the participating provider.

**Us/We:** Us and we refer to PacifiCare Health Plans.

**You:** You refers to the enrollee and each covered family member.

*2004 PacifiCare Southwest* 48 *Region Section 10*

# Section 11. FEHB facts

**Coverage Information**

**No pre-existing condition limitation:** We will not refuse to cover
the treatment condition that you had before you enrolled in this Plan
solely because you had the condition before you enrolled.

**Where you can get information about enrolling in the FEHB Program:**
See www.opm.gov/insure. Also, your employing or retirement office can
answer your questions, and give you a Guide to Federal Employees Health
Benefits Plans, brochures for other plans, and other materials you need
to make an informed decision about your FEHB coverage. These materials
will 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 for you and your family:** Self Only
coverage is for you alone. Self and Family coverage is for you, your
spouse, and your unmarried dependent children under age 22, including
any foster children or stepchildren your employing or retirement office
authorizes coverage for. Under certain circumstances, you may also
continue coverage for a disabled child 22 years of age or older who is
incapable of self-support.

If you have a Self Only enrollment, you may change to a Self and Family
enrollment if you marry, give birth, or add a child to your family. You
may change your enrollment 31 days before to 60 days after that event.
The Self and Family enrollment begins on the first day of the pay period
in which the child is born or becomes an eligible family member. When
you change to Self and Family because you marry, the change is effective
on the first day of the pay period that begins after your employing
office receives your enrollment form; benefits will not be available to
your spouse until you marry.

Your 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.

*2004 PacifiCare Southwest* 49 *Region Section 11*

**Children's Equity Act:** OPM has implemented the Federal Employees
Health Benefits Children's Equity Act of 2000. This law mandates that
you be enrolled for Self and Family coverage in the Federal Employees
Health Benefits (FEHB) Program, 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 cancel your coverage, change to Self Only, or
change to a plan that doesn't serve the area in which your children live
as long as the court/administrative order is in effect. Contact your
employing office for further information.

**When benefits and premiums start:** The benefits in this brochure are
effective on January 1. If you joined this Plan during Open Season, your
coverage begins on the first day of your first pay period that starts on
or after January 1. If you changed plans or plan options during Open
Season and you receive care between January 1 and the effective date of
coverage under your new plan or option, your claims will be paid
according to the 2004 benefits of your old plan or option. However, if
your old plan left the FEHB Program at the end of the year, you are
covered under that plan's 2003 benefits until the effective date of your
coverage with your new plan. 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).

*2004 PacifiCare Southwest* 50 *Region Section 11*

**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 (TCC), or a conversion policy (a non-FEHB individual
policy).

**•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 for you. But, you may be
eligible for your own FEHB coverage under the spouse equity law or
Temporary Continuation of Coverage (TCC). If you are recently divorced
or are anticipating a divorce, contact your ex-spouse's employing or
retirement office to get RI 70-5, the *Guide to Federal Employees Health
Benefits Plans for Temporary Continuation of Coverage and Former Spouse
Enrollees*, or other information about your coverage choices. You can
also download the guide from OPM's Web site,
[www.opm.gov/insure](http://www.opm.gov/insure).

**•Temporary Continuation of Coverage (TCC):** If you leave Federal
service, or if you lose coverage because you no longer of Coverage (TCC)
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 individual coverage:** You may convert to a non-FEHB
individual policy if:

**•** 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.

*2004 PacifiCare Southwest* 51 *Region Section 11*

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

For more information get OPM pamphlet RI 79-27, Temporary Continuation
of

Coverage (TCC) under the FEHB Program. See also the FEHB Web site

(www.opm.gov/insure/health); refer to the "TCC and HIPAA" frequently
asked

question. These highlight HIPAA rules, such as the requirement that
Federal

employees must exhaust any TCC eligibility as one condition for
guaranteed

access to individual health coverage under HIPAA, and have information
about

Federal and State agencies you can contact for more information.

*2004 PacifiCare Southwest* 52 *Region Section 11*

# Two new Federal Programs complement FEHB benefits

**Important information** OPM wants to be sure you know about two new
Federal programs that complement the FEHB Program. First, the **Flexible
Spending Account (FSA) Program**, also known as **FSAFEDS**, lets you
set aside tax-free money to pay for health and dependent care expenses.
The result can be a discount of 20 to more than 40 percent on services
you routinely pay for out-of-pocket. Second, the **Federal Long Term
Care Insurance Program** (FLTCIP) covers long term care costs not
covered under the FEHB.

**The Federal Flexible Spending Account Program - *FSAFEDS***

**• What is an FSA?:** It is a tax-favored benefit that allows you to
set aside pre-tax money from your paychecks to pay for a variety of
eligible expenses. *By using an FSA, you can reduce your taxes while
paying for services you would have to pay for anyway, producing a
discount that can be over 40%!*

There are two types of FSA's offered by the FSAFEDS Program:

**Health Care Flexible Spending Account (HCFSA):**

**•** Covers eligible health care expenses not reimbursed by this Plan,
or any other medical, dental, or vision care plan you or your dependents
may have

**•** Eligible dependents for this account include anyone you claim on
your Federal income tax return as a qualified dependent under the U.S.
Internal Revenue Service (IRS) definition and/or with whom you jointly
file your Federal income tax return, even if you don't have self and
family health benefits coverage. ***Note:*** The IRS has a broader
definition than that of a "family member" than is used under the FEHB
Program to provide benefits by your FEHB Plan.

**•** The maximum amount that can be allotted for the HCFSA is \$3,000
annually. The minimum amount is \$250 annually.

**Dependent Care Flexible Spending Account (DCFSA):**

**•** Covers eligible dependent care expenses incurred so you can work,
or if you are married, so you and your spouse can work, or your spouse
can look for work or attend school full-time.

**•** Eligible dependents for this account include anyone you claim on
your Federal income tax return as a qualified IRS dependent and/or with
whom you jointly file your Federal income tax return.

**•** The maximum that can be allotted for the DCFSA is \$5,000
annually. The minimum amount is \$250 annually. ***Note:*** The IRS
limits contributions to a Dependent Care FSA. For single taxpayers and
taxpayers filing a joint return, the maximum is \$5,000 per year. For
taxpayers who file their taxes separately with a spouse, the maximum is
\$2,500 per year. The limit includes any child care subsidy you may
receive.

**Enroll during Open Season:** You **must make an election** to enroll
in an FSA during the FEHB Open Season. Even if you enrolled during the
initial Open Season for 2003, you must make a new election to continue
participating in 2004. Enrollment is easy!

**•** Enroll online anytime during Open Season (November 10 through
December 8, 2003) at www.fsafeds.com.

**•** Call the toll-free number 1-877-FSAFEDS (372-3337) Monday through
Friday, from 9 a.m. until 9 p.m. eastern time and a FSAFEDS Benefit
Counselor will help you enroll.

**• What is SHPS?** SHPS is a third-party administrator hired by OPM to
manage the FSAFEDS Program. SHPS is the largest FSA administrator in the
nation and will be responsible for enrollment, claims processing,
customer service, and day-to-day operations of FSAFEDS.

*2004 PacifiCare Southwest Region* 53 *Two new Federal Programs
complement FEHB benefits*

**Who is eligible to enroll?:** If you are a Federal employee eligible
for FEHB -- even if you're not enrolled in FEHB -- you can choose to
participate in either, or both, of the flexible spending accounts. If
you are not eligible for FEHB, you are not eligible to enroll for a
Health Care FSA. However, almost all Federal employees are eligible to
enroll for the Dependent Care FSA. The only exception is intermittent
(also called when actually employed \[WAE\]) employees expected to work
less than 180 days during the year.

*Note:* FSAFEDS is the FSA Program established for all Executive Branch
employees and Legislative Branch employees whose employers signed on.
Under IRS law, FSAs are not available to annuitants. In addition, the
U.S. Postal Service and the Judicial Branch, among others, are Federal
agencies that have their own plans with slightly different rules, but
the advantages of having an FSA are the same no matter what agency you
work for.

**• How much should I contribute to my FSA:** Plan carefully when
deciding how much to contribute to an FSA. Because of the tax benefits
of an FSA, the IRS places strict guidelines on them. You need to
estimate how much you want to allocate to an FSA because current IRS
regulations require you forfeit any funds remaining in your account(s)
at the end of the FSA plan year. This is referred to as the
"use-it-or-lose-it" rule. You will have until April 29, 2004 to submit
claims for your eligible expenses incurred during 2003 if you enrolled
in FSAFEDS when it was initially offered. You will have until April 30,
2005 to submit claims for your eligible expenses incurred from January 1
through December 31, 2004 if you elect FSAFEDS during this Open Season.

The **FSAFEDS Calculator** at www.fsafeds.com will help you plan your
FSA allocations and provide an estimate of your tax savings based on
your individual situation.

**• What can my HCFSA pay for:** Every FEHB health plan includes cost
sharing features, such as deductibles you must meet before the Plan
provides benefits, coinsurance or copayments that you pay when you and
the Plan share costs, and medical services and supplies that are not
covered by the Plan and for which you must pay. These out-of pocket
costs are summarized on page 13 and detailed throughout this brochure.
Your HCFSA will reimburse you for such costs when they are for tax
deductible medical care for you and your dependents that is NOT covered
by this FEHB Plan or any other coverage that you have.

Under this plan, typical out-of-pocket expenses include:

-   Infertility services

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-   Custodial home health care

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-   Experimental or investigational procedures and treatments not
    covered by this Plan

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-   Care received by non-plan providers

The IRS governs expenses reimbursable by a HCFSA. See Publication 502
for a comprehensive list of tax-deductible medical expenses. **Note:
While you will see insurance premiums listed in Publication 502, they
are NOT a reimbursable expense for FSA purposes.** Publication 502 can
be found on the IRS Web site at http://www.irs.gov/pub/irs-pdf/p502.pdf.
If you do not see your service or expense listed in Publication 502,
please call a FSAFEDS Benefit Counselor at 1-877-FSAFEDS (372-3337), who
will be able to answer your specific questions.

2004 PacifiCare Southwest Region 54 Two new Federal Programs complement
FEHB benefit

**• Tax savings with an FSA:** An FSA lets you allot money for eligible
expenses before your agency deducts taxes from your paycheck. This means
the amount of income that your taxes are based on will be lower, so your
tax liability will also be lower. Without an FSA, you would still pay
for these expenses, but you would do so using money remaining in your
paycheck after Federal (and often state and local) taxes are deducted.
The following chart illustrates a typical tax savings example:

+----------------------------------+------------------+----------------+
| #### Annual Tax Savings Example  | **With FSA**     | **Without      |
|                                  |                  | FSA**          |
+----------------------------------+------------------+----------------+
| If your taxable income is:       | \$50,000         | \$50,000       |
+----------------------------------+------------------+----------------+
| And you deposit this amount into | \$2,000          | \$0-           |
| a FSA:                           |                  |                |
+----------------------------------+------------------+----------------+
| Your taxable income is now:      | \$48,000         | \$50,000       |
+----------------------------------+------------------+----------------+
| Subtract Federal & Social        | \$13,807         | \$14,383       |
| Security Taxes:                  |                  |                |
+----------------------------------+------------------+----------------+
| If you spend after -- tax        | \$-0             | \$2,000        |
| dollars for expenses:            |                  |                |
+----------------------------------+------------------+----------------+
| Your real spendable income is:   | \$34,193         | \$33,617       |
+----------------------------------+------------------+----------------+
| Your tax savings                 | \$576            | \$-0           |
+----------------------------------+------------------+----------------+

**Note:** This example is intended to demonstrate a typical tax savings
based on 27% Federal and 7.65% FICA taxes. Actual savings will vary
based upon in which retirement system you are enrolled (CSRS or FERS),
as well as your individual tax situation. In this example, the
individual received \$2,000 in services for \$1,424, a discount of
almost 36%! You may also wish to consult a tax professional for more
information on the tax implications of an FSA.

**•Tax credits anddeductions:** You *cannot* claim expenses on your
Federal income tax return if you receive reimbursement for them from
your HCFSA or DCFSA. Below are some guidelines that may help you decide
whether to participate in FSAFEDS.

**Health care expenses:** The HCFSA is tax-free from the first dollar.
In addition, you may be reimbursed from the HCFSA at any time during the
year for expenses up to the annual amount you've elected to contribute.

Only health care expenses exceeding 7.5% of your adjusted gross income
are eligible to be deducted on your Federal income tax return. Using the
example listed in the above chart, only health care expenses exceeding
\$3,750 (7.5% of \$50,000) would be eligible to be deducted on your
Federal income tax return. In addition, money set aside through a HCFSA
is also exempt from FICA taxes. This exception is not available on your
Federal income tax return.

**Dependent care expenses:** The DCFSA generally allows many families to
save more than they would with the Federal tax credit for dependent care
expenses. Note that you may only be reimbursed from the DCFSA up to your
current account balance. If you file a claim for more than your current
balance, it will be held until additional payroll allotments have been
added to your account. Visit www.fsafeds.com and download the Dependent
Care Tax Credit

Worksheet from the Quick Links box to help you determine what is best
for

your situation. You may also wish to consult a tax professional for more
details.

*2004 PacifiCare Southwest Region* 55 *Two new Federal Programs
complement FEHB benefits*

**•Does it cost me anything participate in FSAFEDS?:** Probably not.
While there is an administrative fee of \$4.00 per month for an to HCFSA
and 1.5% of the annual election for a DCFSA, most agencies have elected
to pay these fees out of their share of employment tax savings. To be
sure, check the FSAFEDS.com Web site or call 1-877-FSAFEDS (372-3337).
Also, remember that participating in FSAFEDS can cost you money if you
don't spend your entire account balance by the end of the plan year and
wind up forfeiting your end of year account balance, per the IRS
"use-it-or-lose-it" rule.

**•Contact us:** To find out more or to enroll, please visit the
**FSAFEDS Web site** at **www.fsafeds.com**, or contact SHPS by email or
by phone. SHPS Benefit Counselors are available from 9:00 a.m. until
9:00 p.m. eastern time, Monday through Friday.

**•** E-mail: fsafeds@shps.net

**•** Telephone: 1-877-FSAFEDS (372-3337)

**•** TTY: 1-800-952-0450 (for hearing impaired individuals that would
like to utilize a text messaging service)

**The Federal Long Term Care Insurance Program**

**It's important protection:** Here's why you should consider enrolling
in the Federal Long Term Care Insurance Program:

**• FEHB plans do not cover the cost of long term care.** Also called
"custodial care," long term care is help you receive when you need
assistance performing activities of daily living -- such as bathing or
dressing yourself. This need can strike anyone at any age and the cost
of care can be substantial.

**• The Federal Long Term Care Insurance Program can help protect you
from the potentially high cost of long term care.** This coverage gives
you control over the type of care you receive and where you receive it.
It can also help you remain independent, so you won't have to worry
about being a burden to your loved ones.

**• It's to your advantage to apply sooner rather than later.** Long
term care insurance is something you must apply for, and pass a medical
screening (called underwriting) in order to be enrolled. Certain medical
conditions will prevent some people from being approved for coverage. By
applying while you're in good health, you could avoid the risk of having
a change in health disqualify you from obtaining coverage. Also, the
younger you are when you apply, the lower your premiums.

**• You don't have to wait for an open season to apply.** The Federal
Long Term Care Insurance Program accepts applications from eligible
persons at any time. You will have to complete a full underwriting
application, which asks a number of questions about your health.
However, if you are a new or newly eligible employee, you (and your
spouse, if applicable) have a limited opportunity to apply using the
abbreviated underwriting application, which asks fewer questions. If you
marry, your new spouse will also have a limited opportunity to apply
using abbreviated underwriting. Qualified relatives are also eligible to
apply with full underwriting.

**To find out more and to request an application:** Call 1-800-LTC-FEDS
(1-800-582-3337) (TTY 1-800-843-3557) or visit
[www.ltcfeds.com](http://www.ltcfeds.com/).

*2004 PacifiCare Southwest Region* 56 *Two new Federal Programs
complement FEHB benefits*

# Index

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

**A**ccidental injury 19, 23, 34

Allergy tests 18

Allogeneic Bone Marrow Transplant

24 Alternative treatment 21

Ambulance 25-28

Anesthesia 22, 24, 26

Autologous bone marrow transplant

18, 24

**B**lood and blood plasma 15, 16, 25, 26,

32

**C**asts 25, 26

Catastrophic protection

out-of-pocket expense 9, 19, 36

Changes for 2004 9

Chemotherapy 9, 14, 33

Childbirth 47

Chiropractic 9, 21, 36

Cholesterol tests 16

Circumcision 17, 22

Claims 10, 38, 38, 39, 40, 42, 51

Coinsurance 7, 10, 19, 36, 44, 46, 51

Colorectal cancer screening 16

Congenital anomalies 22, 29

Contraceptive devices and drugs 17, 32

Coordination of benefits 41

Covered charges 17, 42

Covered providers 7, 10, 27, 37, 38,

44

Crutches 20

**D**eductible 13

Definitions 46

Dental care 19, 26, 31, 34, 35, 36,

37, 50

Diagnostic services 9, 15, 20, 25, 26,

29, 34, 35, 36

Disputed claims review 26, 39-40

Donor expenses (transplants) 24

Dressings 25, 26, 32

Durable medical equipment (DME)

12, 18

**E**ducational classes and programs 21

Effective date of enrollment 10, 12, 36,

44, 48

Emergency 9, 10, 14, 2728, 31, 32,

34, 36, 37, 38

Experimental or investigational 27, 46,

52

Eyeglasses 19

**F**amily planning 17

Fecal occult blood test 16

Fraud 4

**G**eneral Exclusions 37

**H**earing services 19

Home health services 20, 32

Hospice care 26

Home nursing care 20

Hospital 11, 25-26

**I**mmunizations 16

Infertility 17-18, 32, 51

In-hospital physician care

Inpatient Hospital Benefits 9, 25

Insulin 20, 31, 32

**L**aboratory and pathological services 25-

26

**M**achine diagnostic tests 9, 15, 29

Magnetic Resonance Imaging (MRIs) 9,

12, 15, 29

Mail Order Prescription Drugs 31-32

Mammograms 15, 16

Maternity Benefits 17

Medicaid 45

Medically necessary 12, 15, 27, 37

Medicare 9, 36, 41-44

Members 36

Mental Conditions/Substance

Abuse Benefits 29-30

**N**ewborn care 17

Non-FEHB Benefits 36

Nurse 25

Licensed Practical Nurse 20

Nurse Anesthetist 25

Registered Nurse 20

Nursery charges 17

**O**bstetrical care 17

Occupational therapy 18

Ocular injury 19

Office visits 7

Oral and maxillofacial surgery 23

Orthopedic devices 19-20

Out-of-pocket expenses 32, 42, 51

Outpatient facility care 26

Oxygen 20, 25, 26

**P**ap test 15, 16

Physical examination 16

Physical therapy 18

Physician 7, 10, 13, 15-24

Precertification 12, 17, 22, 40

Preventive care, adult 16

Preventive care, children 16

Prescription drugs 9, 13, 31-32

Preventive services 16, 34, 35

Prior approval 12, 18, 40

Prostate cancer screening 16

Prosthetic devices 19-20, 22, 23

Psychologist 29

Psychotherapy 29

**R**adiation therapy 9, 18

Renal dialysis 41

Room and board 25

**S**econd surgical opinion 15

Skilled nursing facility care 9, 26

Smoking cessation 21, 32, 33

Speech therapy 9, 19

Splints 25

Sterilization procedures 17, 22

Subrogation 45

Substance abuse 29-30

Surgery 22

• Anesthesia 24

• Oral 23

• Outpatient 26

• Reconstructive 23

Syringes 32

**T**emporary continuation of

coverage 49

Transplants 24

Treatment Therapies 9, 18

**V**ision services 19

**W**ell child care 16

Wheelchairs 20

Workers' compensation 40

**X**-rays 15, 25, 26, 34

### 

### 2004 PacifiCare Southwest Region 57 Index

# Summary of benefits for the PacifiCare Southwest Region -- 2004

-   **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.

```{=html}
<!-- -->
```
-   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.

```{=html}
<!-- -->
```
-   We only cover services provided or arranged by Plan physicians,
    except in emergencies.

+------------------------------------+--------------------------+-----+
| **Benefits**                       | **You Pay**              | **  |
|                                    |                          | Pag |
|                                    |                          | e** |
+------------------------------------+--------------------------+-----+
| Medical services provided by       | Office visit copayment:  | 15  |
| physicians:                        |                          | -24 |
|                                    | \$20 primary care;       |     |
| **•** Diagnostic and treatment     |                          |     |
| services provided in the office    | \$40 specialist          |     |
+------------------------------------+--------------------------+-----+
| Services provided by a hospital:   | \$400 per day up to 5    | 25  |
|                                    | days per hospital        |     |
| **•** Inpatient.                   | admission                |     |
+------------------------------------+--------------------------+-----+
| **•** Outpatient                   | \$200 copayment per      | 26  |
|                                    | outpatient surgery or    |     |
|                                    | procedure                |     |
+------------------------------------+--------------------------+-----+
| Emergency benefits:                | \$250 per emergency room | 28  |
|                                    | visit                    |     |
| **•** In-area                      |                          |     |
+------------------------------------+--------------------------+-----+
| **•** Out-of-Area                  | \$250 per emergency room | 28  |
|                                    | visit                    |     |
+------------------------------------+--------------------------+-----+
| Note: Emergency room copayment is  | \$250 copayment to the   | 28  |
| not waived if you are admitted     | hospital                 |     |
+------------------------------------+--------------------------+-----+
| Mental health and substance abuse  | \$400 per day up to 5    | 29  |
| treatment                          | days per hospital        | -30 |
|                                    | admission.               |     |
+------------------------------------+--------------------------+-----+
| Prescription drugs                 | \$20 copayment for       | 31  |
|                                    | generic formulary        | -32 |
|                                    | prescriptions            |     |
|                                    |                          |     |
|                                    | \$40 for brand formulary |     |
|                                    |                          |     |
|                                    | \$50 non-formulary       |     |
|                                    | prescriptions            |     |
+------------------------------------+--------------------------+-----+
| Dental Care                        | Nothing for preventive   | 36  |
|                                    | services scheduled       |     |
|                                    | allowance for other      |     |
|                                    | services                 |     |
+------------------------------------+--------------------------+-----+
| Vision Care                        | Discounts for frames and | 33  |
|                                    | lenses through the       |     |
|                                    | PacifiCare PerksSM       |     |
|                                    | program.                 |     |
+------------------------------------+--------------------------+-----+
| Eye Exams                          | \$20 copayment per PCP   | 16  |
|                                    | office visit;            |     |
|                                    |                          |     |
|                                    | \$40 copayment per       |     |
|                                    | specialist office visit  |     |
+------------------------------------+--------------------------+-----+
| Protection against catastrophic    | Nothing after            | 13  |
| costs (your catastrophic           | \$5,000/Self Only or     |     |
| protection out-of-pocket maximum)  | \$15,000/Family          |     |
|                                    | enrollment per calendar  |     |
|                                    | year                     |     |
|                                    |                          |     |
|                                    | Some costs do not count  |     |
|                                    | toward                   |     |
|                                    |                          |     |
|                                    | this protection          |     |
+------------------------------------+--------------------------+-----+

*2004 PacifiCare Southwest Region* 58 *Summary of Benefits*

**2004 Rate Information for**

**PacifiCare Southwest Region**

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

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

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

+-------------------+-------+-------+------+-----+------+-------+-----+
| **Type of         | **C   | **    |      |     |      | **P   |     |
| Enrollment**      | ode** | Non-P |      |     |      | ostal |     |
|                   |       | ostal |      |     |      | Prem  |     |
|                   |       | Prem  |      |     |      | ium** |     |
|                   |       | ium** |      |     |      |       |     |
+-------------------+-------+-------+------+-----+------+-------+-----+
|                   |       | **    |      | ##  |      | **    |     |
|                   |       | Biwee |      | ### |      | Biwee |     |
|                   |       | kly** |      | ### |      | kly** |     |
|                   |       |       |      | # M |      |       |     |
|                   |       |       |      | ont |      |       |     |
|                   |       |       |      | hly |      |       |     |
+-------------------+-------+-------+------+-----+------+-------+-----+
|                   |       | **Go  | **Yo | **G | **Yo | **U   | **  |
|                   |       | v't** | ur** | ov' | ur** | SPS** | You |
|                   |       |       |      | t** |      |       | r** |
|                   |       | **Sh  | *    |     | *    | **Sh  |     |
|                   |       | are** | *Sha | **S | *Sha | are** | **S |
|                   |       |       | re** | har | re** |       | har |
|                   |       |       |      | e** |      |       | e** |
+-------------------+-------+-------+------+-----+------+-------+-----+

**Oklahoma:** Central and Northeastern Oklahoma

  --------------- --------- -------------- -------------- -------------- -------------- -------------- -------------
  **Self Only**   **2N1**   **\$121.40**   **\$40.74**    **\$263.03**   **\$88.27**    **\$143.32**   **\$18.82**

  **Self and      **2N2**   **\$277.09**   **\$113.70**   **\$600.36**   **\$246.35**   **\$327.12**   **\$63.67**
  Family**                                                                                             
  --------------- --------- -------------- -------------- -------------- -------------- -------------- -------------

**Texas:** San Antonio, Dallas/Ft. Worth

+--------------+----+-------+-------+-------+-------+-------+------+
| **Self       | ## | **    | *     | **    | *     | **    | **\  |
| Only**       | ## | \$121 | *\$45 | \$263 | *\$99 | \$143 | $23. |
|              |  G | .40** | .70** | .03** | .02** | .32** | 78** |
|              | F1 |       |       |       |       |       |      |
+--------------+----+-------+-------+-------+-------+-------+------+
| **Self and   | *  | **    | **    | **    | **    | **    | **\  |
| Family**     | *G | \$277 | \$108 | \$600 | \$235 | \$327 | $58. |
|              | F2 | .09** | .86** | .36** | .87** | .12** | 83** |
|              | ** |       |       |       |       |       |      |
+--------------+----+-------+-------+-------+-------+-------+------+

*2004 PacifiCare Southwest Region* *2004 Rate Information*