Document Body Page Navigation Panel Document Outline

Piedmont Community HealthCare

Federal Employees Health Benefits Program
2003 Plan Brochure
Accessible Version

Document Outline

Introduction
Plain Language
Stop Health Care Fraud!
Facts about this HMO plan
How we change for 2003
- Program-wide changes
- Changes to this Plan
How you get care
Your costs for covered services
Your out-of-pocket maximum
Benefits
General exclusions -- things we don't cover
Filing a claim for covered services
The disputed claims process
Coordinating benefits with other coverage
Definitions of terms we use in this brochure
FEHB facts
- Coverage Information
- When you lose benefits
Long Term Care Insurance Is Still Available
Index
Summary of benefits
Rate Information

Pages 1--60

Page 1


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

Piedmont Community HealthCare http:// www. pchp. net 2003
A Health Maintenance Organization with a point of service product

Serving: The Virginia cities of Bedford and Lynchburg; the Virginia counties of Albemarle, Amherst, Appomattox, Bedford, Buckingham,
Campbell, Charlotte, Cumberland, Halifax, Lunenburg, Nelson, Nottoway, Pittsylvania, and Prince Edward.

Enrollment in this Plan is limited. You must live or work in our Geographic service area to enroll. See page 7 for requirements.

Enrollment codes for this Plan:
2C1 Self Only 2C2 Self and Family

RI 73-799

For changes in benefits,
see page 8. 1.
1 Page 2 3
2.
2 Page 3 4
Notice of the Office of Personnel Management's
Privacy Practices

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

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

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

OPM may use or give out your personal medical information for the following purposes under limited circumstances:
For Government healthcare oversight activities (such as fraud and abuse investigations), For research studies that meet all privacy law requirements (such as for medical research or education), and
To avoid a serious and imminent threat to health or safety.
By law, OPM must have your written permission (an "authorization") to use or give out your personal medical information for any purpose that is not set out in this notice. You may take back (" revoke") your written permission
at any time, except if OPM has already acted based on your permission.
By law, you have the right to:
See and get a copy of your personal medical information held by OPM. Amend any of your personal medical information created by OPM if you believe that it is wrong or if
information is missing, and OPM agrees. If OPM disagrees, you may have a statement of your disagreement added to your personal medical information.
Get a listing of those getting your personal medical information from OPM in the past 6 years. The listing will not cover your personal medical information that was given to you or your personal representative, any
information that you authorized OPM to release, or that was given out for law enforcement purposes or to pay for your health care or a disputed claim.
Ask OPM to communicate with you in a different manner or at a different place (for example, by sending materials to a P. O. Box instead of your home address). 3.
3 Page 4 5

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

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

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

2003Piedmont Community HealthCare 4 Introduction/ Plain Language/ Advisory
Introduction
This brochure describes the benefits of Piedmont Community HealthCare under our contract (CS 2858) with the Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. The address
for Piedmont Community HealthCare administrative offices is:
Piedmont community HealthCare Benefit Plan 2255 Langhorne Road
Lynchburg, VA 24501
This brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations, and exclusions of this brochure. It is your responsibility to be informed about your health benefits.

If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in Self and Family coverage, each eligible family member is also entitled to these benefits. You do not have a right to
benefits that were available before January 1, 2003, unless those benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2003, and changes are summarized on page 56. 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 Piedmont Community HealthCare.

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

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

If you have comments or suggestions about how to improve the structure of this brochure, let OPM know. Visit OPM's "Rate Us" feedback area at www. opm. gov/ insure or e-mail OPM at fehbwebcomments@ opm. gov. You may
also write to OPM at the Office of Personnel Management, Office of Insurance Planning and Evaluation Division, 1900 E Street, NW Washington, DC 20415-3650. 7.
7 Page 8 9
2003Piedmont Community HealthCare 5 Introduction/ Plain Language/ Advisory
Stop Health Care Fraud!
Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits (FEHB) Program premium.
OPM's Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program regardless of the agency that employs you or from which you retired.

Protect Yourself From Fraud -Here are some things you can do to prevent fraud:
Be wary of giving your plan identification (ID) number over the telephone or to people you do not know, except to your doctor, other provider, or authorized plan or OPM representative.
Let only the appropriate medical professionals review your medical record or recommend services. Avoid using health care providers who say that an item or service is not usually covered, but they know how to
bill us to get it paid. Carefully review explanations of benefits (EOBs) that you receive from us.
Do not ask your doctor to make false entries on certificates, bills or records in order to get us to pay for an item or service.
If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or misrepresented any information, do the following:
Call the provider and ask for an explanation. There may be an error. If the provider does not resolve the matter, call us at (434) 947-4463 and explain the situation.
If we do not resolve the issue:

Do not maintain as a family member on your policy: your former spouse after a divorce decree or annulment is final (even if a court order stipulates
otherwise); or your child over age 22 (unless he/ she is disabled and incapable of self support).
If you have any questions about the eligibility of a dependent, check with your personnel office if you are employed or with OPM if you are retired.
You can be prosecuted for fraud and your agency may take action against you if you falsify a claim to obtain FEHB benefits or try to obtain services for someone who is not an eligible family member or who is no
longer enrolled in the Plan.

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

2003 Piedmont Community HealthCare 6 Section 1
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and other providers that contract with us. These Plan providers coordinate your health care services. The Plan is solely
responsible for the selection of these providers in your area. Contact the Plan for a copy of their most recent provider directory.

HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in addition to treatment for illness and injury. Our providers follow generally accepted medical practice when
prescribing any course of treatment.
When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You only pay the copayments, coinsurance, and deductibles described in this brochure. When you receive emergency services from
non-Plan providers, you may have to submit claim forms.
You should join an HMO because you prefer the plan's benefits, not because a particular provider is available. You cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician,
hospital, or other provider will be available and/ or remain under contract with us.
We also have Point-of-Service (POS) benefits:
Our HMO offers Point-of-Service (POS) benefits. This means you can receive covered services from a participating provider without a required referral, or from a non-participating provider. These out-of-network benefits have higher
out-of-pocket costs than our in-network benefits.
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 Piedmont Community HealthCare physician provides your health care. Your primary care physician will coordinate all of your health care needs. Please note that a referral from your primary care physician is not necessary
for emergency services or for up to two office visits each year for female members to a Plan OB/ GYN physician.
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.
Piedmont Community HealthCare, Inc. has been in existence four years, Piedmont Community HealthCare, Inc. is a for profit company,
Customer satisfaction surveys are conducted each year for Piedmont Community HealthCare in conjunction with the parent company, Piedmont Community Health Plan, Inc.,
The network providers include approximately 150 primary care physicians and 450 specialists, and Providers are compensated based on our fee schedule and have agreed to a 20 percent withhold from their
payments.
If you want more information about us, call 434/ 947-4463, or write to Piedmont Community HealthCare, P. O. Box 2455, Lynchburg, VA 24501. You may also contact us by fax at 434/ 947-4465 or visit our website at www. pchp. net. 9.
9 Page 10 11
2003 Piedmont Community HealthCare 7 Section 1
Service Area
To enroll in this Plan, you must live in or work in our Service Area. This is where our providers practice. Our service area is: the cities of Bedford and Lynchburg; the counties of Albemarle, Amherst, Appomattox, Bedford,
Buckingham, Campbell, Charlotte, Cumberland, Halifax, Lunenburg, Nelson, Nottoway, Pittsylvania, and Prince Edward.

Ordinarily, you should get your care from providers who contract with us. If you receive care outside our service area, we will pay only for emergency care or point-of-service benefits.
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. Children in college are covered for emergency and urgent care, however, routine care is not covered at the higher point-of-service level
while outside of our service area. 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. 10.
10 Page 11 12
2003 Piedmont Community HealthCare 8 Section 2
Section 2. How we change for 2003 Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5
Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here is a clarification that does not change benefits.
Program-wide changes
A Notice of the Office of Personnel Management's Privacy Practices is included. A section on the Children's Equity Act describes when an employee is required to maintain Self and Family

coverage. Program information on TRICARE and CHAMPVA explains how annuitants or former spouses may suspend
their FEHB Program enrollment. Program information on Medicare is revised.
By law, the DoD/ FEHB Demonstration project ends on December 31, 2002.
Changes to this Plan
Your share of the non-Postal premium increase by 40.4% for Self Only or 40.1% for Self and Family.

Your copay amount has increased from $10 to $20 for all office visits.
Your coinsurance amounts have increased from 10% to 20% for all applicable services.
Your point of service out-of-plan coinsurance has increased from 30% to 40% for all applicable services.
Your copay amount for a 30-day supply or 100 units of prescription drugs for the following tiers:
$5 to $10 for generic drugs (first tier)
$15 to $20 for brand name drugs (second tier)
Your copay amount for a 90 day supply or 300 uni9ts of generic prescriptions for the following tiers:
$10 to $20 for generic drugs (first tier)
$30 to $40 for brand name drugs (second tier)
Fitness Club discounts are no longer available from the YMCA of Lynchburg.
Target no longer has an optical center that provides discounts on eyewear and contacts.
For Mental health and substance abuse benefits, please contact Piedmont Community HealthCare for authorization at (434) 947-4463 or toll free at (800) 400-7247.

The following are ongoing Piedmont Community Health Plan patient safety initiatives:
Piedmont Community Health Plan does concurrent chart reviews of all patients hospitalized within its local hospitals to ensure satisfactory delivery of care.
Piedmont Community Health Plan does office chart reviews biannually to verify accurate, comprehensive medical record keeping by each primary care physician.
Piedmont Community Health Plan utilization review personnel identify, investigate and resolve any complaints by patient regarding quality of care issues. This activity is overseen directly by the Piedmont
Community Health Plan medical and psychiatric medical directors. Piedmont Community Health Plan maintains a formal grievance resolution process for all grievances whether they relate to issues of medial
necessity or other patient or provider concerns. Piedmont Community Health Plan maintains comprehensive credentialing standards for network physicians,
including biannual review of malpractice insurance coverage and history of professional liability claims. As a part of its Quality Assessment/ Quality Improvement Program, Piedmont Community Health Plan uses
targeted patient communications for patients with certain medical conditions to ensure patients receive recommended services under the direction of their physicians. 11.
11 Page 12 13
2003 Piedmont Community HealthCare 9 Section 3
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 888/ 674-
3368.

Where you get covered care You get care from "Plan providers" and "Plan facilities." You will only pay copayments, or coinsurance, and you will not have to file claims. If
you use our point-of-service program, you can also get care from non-Plan providers, or from participating providers without a required
referral, but it will cost you more. In those instances, you will have a deductible and higher coinsurance with no copayments.

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

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

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. Simply complete the primary care physician selection form and return it to us.

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

Specialty care Your primary care physician will refer you to a specialist for needed care. When you receive a referral from your primary care physician, you must
return to the primary care physician after the consultation, unless your primary care physician authorized a certain number of visits without
additional referrals. The primary care physician must provide or authorize all follow-up care. Do not go to the specialist for return visits
unless your primary care physician gives you a referral. However, you 12.
12 Page 13 14
2003 Piedmont Community HealthCare 10 Section 3
may see participating OB/ GYN physicians twice a year without a referral.
Here are other things you should know about specialty care:
If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician
will work with your specialist and us to develop a treatment plan that allows you to see your specialist for a certain number of visits without
additional referrals. Your primary care physician will use our criteria when creating your treatment plan (the physician may have to get an
authorization or approval beforehand).
If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician. 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, you will receive point-of-service
benefits when you 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 1-888-674-3368. 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: 13.
13 Page 14 15
2003 Piedmont Community HealthCare 11 Section 3
You are discharged, not merely moved to an alternative care center; or
The day your benefits from your former plan run out; or
The 92 nd day after you become a member of this Plan, whichever happens first.

These provisions apply only to the hospital benefits of the hospitalized person.

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

Services requiring our prior approval Your primary care physician has authority to refer you for most services.
For certain services, however, your physician must obtain approval from us. Before giving approval, we consider if the service is covered,
medically necessary, and follows generally accepted medical practice.
We call this review and approval process precertification. Except for services rendered under our Point of Service benefits, your physician
must obtain precertification for the following services such as: referrals for covered services to non-participating providers

transplants non-emergency ambulance or air ambulance transportation
physical therapy, occupational therapy, and speech therapy drugs to treat sexual disfunction

Your primary care physician will submit a referral to us for these services. We will establish that the appropriate criteria have been met
and provide an authorization to your primary care physician and to the provider to whom you have been referred. Without the proper
authorization, services may be paid at the out-of-network benefit level or not covered at all. 14.
14 Page 15 16
2003 Piedmont Community HealthCare 12 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive services.

Example: When you see your primary care physician you pay a copayment of $20 per office visit.
Deductible A deductible is a fixed expense you must incur for certain covered services and supplies before we start paying benefits for them.
Copayments do not count toward any deductible. We do not have a deductible for in-plan benefits. A $500 individual and $1,000 family
deductible applies to out-of-plan benefits.
Note: If you change plans during open season, you do not have to start a new deductible under your old plan between January 1 and the effective
date of your new plan. If you change plans at another time during the year, you must begin a new deductible under your new plan

And, if you change options in this Plan during the year, we will credit the amount of covered expenses already applied toward the deductible of
your old option to the deductible of your new option.
Coinsurance Coinsurance is the percentage of our negotiated fee that you must pay for your care. Coinsurance applies to all services except for office visits and
emergency/ urgent care services.
Example: In our Plan, you pay 20% of our allowance for all hospital related services including inpatient, outpatient and diagnostic testing,
infertility services and durable medical equipment.

Your out-of-pocket maximum After your copayments and coinsurance total $1,000 per person or $2,000 per family enrollment in any calendar year, you do not have to pay any
more for covered services received in-plan. However, copayments or coinsurance for the following services do not count toward your out-of-pocket
maximum, and you must continue to pay copayments or coinsurance for these services:

Prescription drug copayments Vision exam copayments
Be sure to keep accurate records of your copayments and coinsurance since you are responsible for informing us when you reach the maximum.
Please note that your out-of-pocket maximum for Point of Service benefits total to $2,000 per person and $4,000 per family. (See page 38) 15.
15 Page 16 17

2003 Piedmont Community HealthCare 13 Section 5
Section 5. Benefits --OVERVIEW (See page 8 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. Also read the General Exclusions in Section 6; they apply to the benefits in the
following subsections. To obtain claims forms, claims filing advice, or more information about our benefits, contact us at 888-674-3368 or at our website at www. pchp. net.

(a) Medical services and supplies provided by physicians and other health care professionals ........................... 13-22
Diagnostic and treatment services Lab, X-ray, and other diagnostic tests
Preventive care, adult Preventive care, children
Maternity care Family planning
Infertility services Allergy care
Treatment therapies Physical and occupational therapies
Speech therapy

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

(b) Surgical and anesthesia services provided by physicians and other health care professionals........................ 23-26
Surgical procedures Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services...................................................... 27-29
Inpatient hospital Outpatient hospital or ambulatory surgical
center
Extended care benefits/ skilled nursing care facility benefits
Hospice care Ambulance

(d) Emergency services/ accidents ......................................................................................................................... 30-31 Medical emergency Ambulance
(e) Mental health and substance abuse benefits .................................................................................................... 32-33
(f) Prescription drug benefits................................................................................................................................ 34-35
(g) Special features..................................................................................................................................................... 36 Flexible benefits option

Local service and assistance Fitness club discounts
Eyewear discounts (h) Dental benefits...................................................................................................................................................... 37

(i) Point of service benefits ................................................................................................................................. 38-39
Summary of benefits.................................................................................................................................................... 56 Rates ............................................................................................................................................................. Back Cover 16.
16 Page 17 18
2003 Piedmont Community HealthCare 14 Section 5( a)
Section 5 (a) Medical services and supplies provided by physicians and other health care professionals
I M
P O
R T
A N
T

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

Plan physicians must provide or arrange your care.
The calendar year deductible of $500 per individual and $1,000 per family only applies to out-of-plan point of service benefits.

I M
P O
R T
A N
T

Benefit Description You pay

Diagnostic and treatment services
Professional services of physicians
In physician's office $20per officevisit

Professional services of physicians
In an urgent care center
Office medical consultations $20 per office visit

Second surgical opinion
During a hospital stay
In a skilled nursing facility 20% of allowable charge

At home $20 per physician visit
20% of allowable charge for home health services

Lab, X-ray and other diagnostic tests
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG

Nothing if you receive these services during your office visit;
otherwise, $20 per visit
20% of allowable charge for services performed at a hospital 17.
17 Page 18 19
2003 Piedmont Community HealthCare 15 Section 5( a)
Preventive care, adult
$20 per office visit Routine screenings, such as: Total Blood Cholesterol once every three years

Colorectal Cancer Screening, including
Fecal occult blood test one annually at age 50 and older
Sigmoidoscopy, screening every three to five years starting at age 50
Routine Prostate Specific Antigen (PSA) test one annually for men age 40 and older $20 per office visit

Routine pap test
Note: The office visit is covered if pap test is received on the same day; see Diagnosis and Treatment, above.
$20 per office visit

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

$20 per office visit

Not covered: Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, or travel. All charges.
Routine immunizations, limited to:
Tetanus-diphtheria (Td) booster once every 10 years, ages 20 and over (except as provided for under Childhood immunizations)

Influenza vaccine, annually
Pneumococcal vaccine, age 65 and over

$20 per office visit

Preventive care, children You pay
Childhood immunizations recommended by the American Academy of Pediatrics $20 per office visit

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

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

$20 per office visit 18.
18 Page 19 20
2003 Piedmont Community HealthCare 16 Section 5( a)
Maternity care You pay
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Note: Here are some things to keep in mind:
You will need one referral from your primary care physician to your OB/ GYN for pregnancy, prenatal care, delivery and postnatal care.

Precertification for your normal delivery is included with your referral; see page 23, 27, and 39 for other circumstances, such as
extended stays for you or your baby.
You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will extend

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

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

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

$20 per visit (initial visit only, all other routine visits, routine testing
and delivery require no additional copayments)

Not covered: Non-diagnostic routine sonograms to determine fetal age, size or sex All charges
Family planning
A range of voluntary family planning services, limited to:
Voluntary sterilization (See Surgical procedures Section 5 (b))
Surgically implanted contraceptives (such as Norplant)
Injectable contraceptive drugs (such as Depo provera)
Intrauterine devices (IUDs)
Diaphragms
NOTE: We cover oral contraceptives under the prescription drug benefit.

$20 per office visit
20% of allowable charge (procedures performed at a

hospital-inpatient or outpatient)

Not covered: reversal of voluntary surgical sterilization, genetic counseling, All charges 19.
19 Page 20 21
2003 Piedmont Community HealthCare 17 Section 5( a)
Infertility services You pay
Diagnosis and treatment of infertility, such as:
Artificial insemination:
intravaginal insemination (IVI)
intracervical insemination (ICI)
intrauterine insemination (IUI)
Fertility drugs
Note: We cover injectable fertility drugs under medical benefits and oral fertility drugs under the prescription drug benefit.

$20 per visit (office visit)
20% of allowable charge (outpatient facility)

Not covered:
Assisted reproductive technology (ART) procedures, such as:
in vitro fertilization
embryo transfer, gamete GIFT and zygote ZIFT
Zygote transfer
Services and supplies related to excluded ART procedures

Cost of donor sperm
Cost of donor egg

All charges.

Allergy care
Testing and treatment
Allergy injection
$20 per office visit

$5 per office visit

Allergy serum Nothing
Not covered: provocative food testing and sublingual allergy desensitization All charges. 20.
20 Page 21 22
2003 Piedmont Community HealthCare 18 Section 5( a)
Treatment therapies You pay
Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone marrow transplants are limited to those transplants listed under

Organ/ Tissue Transplants on page 25.
Respiratory and inhalation therapy
Dialysis hemodialysis and peritoneal dialysis
Intravenous (IV)/ Infusion Therapy Home IV and antibiotic therapy

Growth hormone therapy (GHT)
Note: Growth hormone is covered under the prescription drug benefit.

Note: We will only cover GHT when we preauthorize the treatment. Call 434-947-3590 for preauthorization. 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.

$20 per visit (office visit)
20% of allowable charge (outpatient facility)

Not covered: All charges.
Early Intervention Services You pay
Benefits for speech and language therapy, occupational therapy, physical therapy and assistive technology services and devices for
dependents from birth to age three who are certified by the Department of Mental Health, Mental Retardation and Substance Abuse Services
as eligible for services under Part H of the Individuals with Disabilities Education Act are limited to $5,000 per member per calendar year.

$20 per office visit

Physical and occupational therapies You pay
90 visits per condition 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 due to illness or

injury. Services are limited to those which can be expected to result in significant improvement within a period of 90 days.

Cardiac rehabilitation following a heart transplant, bypass
surgery or a myocardial infarction, is provided for up to 90 sessions

$20 per visit (office visit)
20% of allowable charge (inpatient or outpatient facility) 21.
21 Page 22 23
2003 Piedmont Community HealthCare 19 Section 5( a)
Not covered:
long-term rehabilitative therapy
exercise programs

All charges.

Speech therapy
90 visits per condition
Note: Speech therapy services are limited to a $1000 per member per calendar year.
$20 per visit (office visit)

20% of allowable charge (inpatient or outpatient facility)

Not Covered: All Charges
Hearing services (testing, treatment, and supplies)
First hearing aid and testing only when necessitated by accidental injury

Hearing testing for children through age 17 (see Preventive care, children)
$20 per office visit

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

Vision services (testing, treatment, and supplies) You pay
One pair of eyeglasses or contact lenses to correct an impairment directly caused by accidental ocular injury or intraocular surgery

(such as for cataracts)
$20 per office visit

Eye exam to determine the need for vision correction for children through age 17 (see Preventive care, children)
Annual eye refractions
$20 per office visit

Not covered:
Eyeglasses or contact lenses and, after age 17, examinations for them

Eye exercises and orthoptics
Radial keratotomy and other refractive surgery

All charges.

Foot care
Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes.

See orthopedic and prosthetic devices for information on podiatric shoe inserts.
$20 per office visit 22.
22 Page 23 24
2003 Piedmont Community HealthCare 20 Section 5( a)
Not covered:
Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot,

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

treatment is by open cutting surgery)

All charges.

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

Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implant
following mastectomy. Note: We pay internal prosthetic devices as hospital benefits; see Section 5 (c) for payment information. See
5( b) for coverage of the surgery to insert the device.
Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.

20% of allowable charge

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

prosthetic replacements provided less than 3 years after the last one we covered

All charges. 23.
23 Page 24 25
2003 Piedmont Community HealthCare 21 Section 5( a)
Durable medical equipment (DME) You pay
Rental or purchase, at our option, including repair and adjustment, of durable medical equipment prescribed by your Plan physician, such as

oxygen and dialysis equipment. Limited to $2,000 per member per calendar year for any combination of items. Under this benefit, we also
cover:
hospital beds;
wheelchairs;
canes, crutches, walkers, slings, splints, cervical collars, and traction apparatus;

bedside commode, shower chair, and tub rails;
oxygen and oxygen equipment;
ostomy supplies, including bags, flanges, and belts;*
catheters and catheter bags;*
respirators;
jobst stockings or equivalent when prescribed by a vascular surgeon following vascular surgery;

the first pair of contact lenses or eyeglasses following approved cataract surgery without implant; and
prosthetic devices

* Supplies to be purchased in quantities or units equivalent to a 30-day supply.
Note: Call us at 434-947-3590 as soon as your Plan physician prescribes this equipment. We will arrange with a health care provider
to rent or sell you durable medical equipment at discounted rates and will tell you more about this service when you call.

20% of allowable charge

Not covered: Motorized wheel chairs
Any durable medical equipment not listed above is not covered.

All charges.

Home health services
Home health care ordered by a Plan physician and provided by a registered nurse (R. N.), licensed practical nurse (L. P. N.), licensed

vocational nurse (L. V. N.), or home health aide.
Services include oxygen therapy, intravenous therapy and medications.

20% of allowable charge

Not covered: 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.

All charges. 24.
24 Page 25 26
2003 Piedmont Community HealthCare 22 Section 5( a)
Chiropractic
Limited to $500 per calendar year
Manipulation of the spine and extremities
Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack application

$20 per visit

Not covered: maintenance services All charges.
Alternative treatments
Not covered: acupuncture services

naturopathic services hypnotherapy
biofeedback

All charges.

Educational classes and programs
Coverage is limited to:

Diabetes self-management
Diabetes nutritional counseling for newly diagnosed patients

$20 per office visit 25.
25 Page 26 27
2003 Piedmont Community HealthCare 23 Section 5( b)
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
I M
P O
R T
A N
T

Plan physicians must provide or arrange your care.
The calendar year deductible of $500 per individual and $1,000 per family only applies to out-of-plan point of service 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.
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.

YOU OR YOUR PRIMARY CARE PHYSICIAN MUST GET PRECERTIFICATION OF SOME SURGICAL PROCEDURES. Please refer to the precertification information shown in
Section 3 to be sure which services require precertification and identify which surgeries require precertification.

I M
P O
R T
A N
T

Benefit Description You pay After the calendar year deductible
Surgical procedures A comprehensive range of services, such as:
Operative procedures Treatment of fractures, including casting
Normal pre-and post-operative care by the surgeon Correction of amblyopia and strabismus
Endoscopy procedures Biopsy procedures
Removal of tumors and cysts Correction of congenital anomalies (see reconstructive surgery)
Surgical treatment of morbid obesity --a condition in which an individual weighs 100 pounds or 100% over his or her normal
weight according to current underwriting standards; eligible members must be age 18 or over

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

20% of allowable charge

Surgical procedures continued on next page. 26.
26 Page 27 28
2003 Piedmont Community HealthCare 24 Section 5( b)
Surgical procedures (Continued) You pay
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.

20% of allowable charge

Not covered: Reversal of voluntary sterilization
Routine treatment of conditions of the foot; see Foot care. Dorsal rhizotomy to treat spasticity
All charges.

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

the condition can reasonably be expected to be corrected by such surgery
Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of
congenital anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks; webbed fingers; and webbed toes.

All stages of breast reconstruction surgery following a mastectomy, such as:
surgery to produce a symmetrical appearance on the other breast;
treatment of any physical complications, such as lymphedemas;
breast prostheses and surgical bras and replacements (see Prosthetic devices)

Note: If you need a mastectomy you may choose to have the procedure on an inpatient basis and remain in the hospital up to 48 hours after
the procedure.

20% of allowable charge

Not covered: Cosmetic surgery any surgical procedure (or any portion of a
procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury

Surgeries related to sex transformation

All charges 27.
27 Page 28 29
2003 Piedmont Community HealthCare 25 Section 5( b)
Oral and maxillofacial surgery
Oral surgical procedures, limited to: Reduction of fractures of the jaws or facial bones;

Surgical correction of cleft lip, cleft palate or severe functional malocclusion;
Removal of stones from salivary ducts; Excision of leukoplakia or malignancies;
Excision of cysts and incision of abscesses when done as independent procedures; and
Other surgical procedures that do not involve the teeth or their supporting structures.

20% of allowable charge

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

Organ/ tissue transplants You pay
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Allogeneic bone marrow transplants

Autologous bone marrow transplants (autologous stem cell and peripheral stem cell support) for the following conditions: acute

lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's lymphoma; advanced non-Hodgkin's lymphoma; advanced
neuroblastoma; breast cancer; multiple myeloma; epithelial ovarian cancer; and testicular, mediastinal, retroperitoneal and ovarian germ
cell tumors
Intestinal transplants (small intestine) and the small intestine with the liver or small intestine with multiple organs such as the liver,
stomach, and pancreas.
Limited Benefits -Treatment for breast cancer, multiple myeloma, and epithelial ovarian cancer may be provided in an NCI-or NIH-approved

clinical trial at a Plan-designated center of excellence and if approved by the Plan's medical director in accordance with the Plan's protocols.

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

20% of allowable charge

Not covered: Donor screening tests and donor search expenses, except those
performed for the actual donor Implants of artificial organs
Transplants not listed as covered

All charges. 28.
28 Page 29 30
2003 Piedmont Community HealthCare 26 Section 5( b)
Anesthesia You pay
Professional services provided in Hospital (inpatient)

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

20% of allowable charge
20% of allowable charge 29.
29 Page 30 31
2003 Piedmont Community HealthCare 27 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
I M
P O
R T
A N
T

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

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

The calendar year deductible of $500 per individual and $1,000 per family only applies to out-of-plan point of service 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.
The amounts listed below are for the charges billed by the facility (i. e., hospital or surgical center) or ambulance service for your surgery or care. Any costs

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

YOU or YOUR PRIMARY CARE PHYSICIAN MUST GET PRECERTIFICATION OF HOSPITAL STAYS. Please refer to Section 3
to be sure which services require precertification.

I M
P O
R T
A N
T

Benefit Description You pay
Inpatient hospital
Room and board, such as ward, semiprivate, or intensive care accommodations;

general nursing care; and meals and special diets.

NOTE: If you want a private room when it is not medically necessary, you pay the additional charge above the semiprivate room rate.

20% of allowable charge

Inpatient hospital continued on next page. 30.
30 Page 31 32
2003 Piedmont Community HealthCare 28 Section 5( c)
Inpatient hospital (Continued) You pay
Other hospital services and supplies, such as: Operating, recovery, maternity, and other treatment rooms

Prescribed drugs and medicines Diagnostic laboratory tests and X-rays
Administration of blood and blood products Blood or blood plasma, if not donated or replaced
Dressings, splints, casts, and sterile tray services Medical supplies and equipment, including oxygen
Anesthetics, including nurse anesthetist services Take-home items
Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home

20% of allowable charge

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

All charges.

Outpatient hospital or ambulatory surgical center
Operating, recovery, and other treatment rooms Prescribed drugs and medicines

Diagnostic laboratory tests, X-rays, and pathology services Administration of blood, blood plasma, and other biologicals
Blood and blood plasma, if 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.

20% of allowable charge

Not covered: blood and blood derivatives not replaced by the member All charges
Extended care benefits/ skilled nursing care facility benefits You pay Skilled nursing facility (SNF): limited to 100 days per member per

calendar year 20% of allowable charge

Not covered: custodial care All charges 31.
31 Page 32 33
2003 Piedmont Community HealthCare 29 Section 5( c)
Hospice care
Hospice services include supportive or palliative care for a terminally ill member in the home or a hospice facility. Services include inpatient

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

20% of allowable charge

Not covered: Independent nursing, homemaker services All charges
Ambulance
Local professional ambulance service when medically appropriate 20% of allowable charge 32.
32 Page 33 34
2003 Piedmont Community HealthCare 30 Section 5( d)
Section 5 (d). Emergency services/ accidents
I M
P O
R T
A N
T

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

I M
P O
R T
A N
T

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

surgical care. Some 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: a. Medical care is available through your primary care physician 7 days a week, 24 hours a day. If
you need medical care, you should call your primary care physician immediately for instructions on how to receive care.
b. If the emergency is such that immediate medical attention is needed, you should be taken to the nearest appropriate medical facility.
c. The Plan covers services rendered by providers other than participating Piedmont providers when the condition treated is an emergency as defined above.
d. A telephone call from you to your primary care physician while at an urgent care center or emergency room will not be treated as a proper referral for urgent care or other non-emergency
services. e. Emergency services provided within our service area shall include covered services from non-participating
Piedmont providers only when a delay in receiving care from a participating Piedmont Provider could reasonably be expected to cause your condition to worsen if left
unattended.

Emergencies outside our service area: a. Urgent care and emergency services outside the service area are covered services if you sustain an
injury or become ill while temporarily away from the service area. Accordingly, benefits for these services are limited to care which is required immediately and unexpectedly. Neither elective care
nor care required as a result of circumstances which could reasonably have been foreseen prior to departure from the service area is a covered service. Benefits for maternity care do not cover
normal term delivery outside the service area, but do include earlier complications of pregnancy or unexpected delivery occurring outside the service area.
b. If an emergency or urgent situation occurs when you are temporarily outside the service area, you should obtain care at the nearest medical facility. You or your representative are responsible for
notifying your primary care physician on the next working day or within 48 hours. Failure to do so may result in reduced benefits or no benefits.
c. Benefits for continuing or follow-up treatment must be pre-arranged by your primary care physician and provided in the service area. 33.
33 Page 34 35
2003 Piedmont Community HealthCare 31 Section 5( d)
Benefit Description You pay
Emergency within our service area

Emergency care at a doctor's office
Emergency care at an urgent care center
Emergency care as an outpatient or inpatient at a hospital, including doctors' services

$20 per visit
$20 per visit

$50 per visit, (waived if admitted )subject to
inpatient coinsurance

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

Emergency care at a doctor's office Emergency care at an urgent care center

Emergency care as an outpatient or inpatient at a hospital, including doctors' services
$20 per visit
$20 per visit
$50 per visit, (waived if admitted) subject to

inpatient coinsurance

Not covered:
Elective care or non-emergency care
Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area

Medical and hospital costs resulting from a normal full-term delivery of a baby outside the service area

All charges.

Ambulance
Professional ambulance service when medically appropriate.
Air ambulance when medically necessary.
See 5( c) for non-emergency service.

20% of allowable charge 34.
34 Page 35 36
2003 Piedmont Community HealthCare 32 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
I M
P O
R T
A N
T

When you get our approval for services and follow a treatment plan we approve, cost-sharing and limitations for Plan mental health and substance abuse benefits will be no greater than for
similar benefits for other illnesses and conditions.
Here are some important things to keep in mind about these benefits:
All benefits are subject to the definitions, limitations, and exclusions in this brochure.
The calendar year deductible of $500 per individual and $1,000 per family only applies to out-of-plan point of service 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.
YOU MUST GET PREAUTHORIZATION OF THESE SERVICES. See the instructions after the benefits description below.

I M
P O
R T
A N
T

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

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

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

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

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

Medication management

$20 per office visit

Mental health and substance abuse benefits -Continued on next page 35.
35 Page 36 37
2003 Piedmont Community HealthCare 33 Section 5( e)
Mental health and substance abuse benefits (Continued) You pay
Diagnostic tests $20 per office visit
20% of allowable charge for services performed at a

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

20% of allowable charge

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

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

All charges.

Preauthorization To be eligible to receive these benefits you must obtain a treatment plan and follow all of the following authorization processes:
Contact Piedmont Community HealthCare for authorizaton. PCHP can be reached locally at (434) 947-4463 or toll free at 1-800-400-7247. 36.
36 Page 37 38
2003 Piedmont Community HealthCare 34 Section 5( f)
Section 5 (f). Prescription drug benefits
I M
P O
R T
A N
T

Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart beginning on the next page.

All benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with
other coverage, including with Medicare.

I M
P O
R T
A N
T

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

These are the dispensing limitations. Medically necessary prescribed legend drugs (drugs not available over the counter) incidental to outpatient care are covered services, including compound
medications of which at least one ingredient is a legend drug, injectable insulin and syringes and needles for the administration thereof. For each prescription filled at the pharmacy, we will cover up
to a 30-day or 100 unit supply, whichever is less. For maintenance medications received through the mail order benefit, we will cover up to a 90-day or 300 unit supply, whichever is less. Generic drugs
will be dispensed except when a participating physician requires brand name drugs. If the physician does not require a brand name drug, you may request a brand name drug and pay the difference
between the brand name drug and the generic drug, in addition to your appropriate copayment. Only maintenance medications may be ordered through the mail order benefit. You should allow two
weeks for delivery. At least 60% of the maintenance medication must be used before a refill can be issued.

Why use generic drugs? Generic drugs are lower-priced drugs that are the therapeutic equivalent to more expensive brand-name drugs. They must contain the same active ingredients and must be
equivalent in strength and dosage to the original brand-name product. Generics cost less than the equivalent brand-name product. The U. S. Food and Drug Administration sets quality standards for
generic drugs to ensure that these drugs meet the same standards of quality and strength as brand-name drugs.

You can save money by using generic drugs. However, you and your physician have the option to request a name-brand if a generic option is available. Using the most cost-effective medication saves
money.

When you have to file a claim. Our participating providers will file claims for you. If you need to file a claim, contact customer service at 1-888-674-3368 and request a medical claim form. Complete the
form, attach any receipts and mail it in to the address on the form. Prescription drug benefits begin on the next page. 37.
37 Page 38 39
2003 Piedmont Community HealthCare 35 Section 5( f)
Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan physician and obtained from a Plan pharmacy or through our mail order

program:

Drugs and medicines that by Federal law of the United States require a physician's prescription for their purchase, except as
excluded below. Insulin
Disposable needles and syringes for the administration of covered medications
Drugs for sexual dysfunction (see Prior authorization on page 11) Contraceptive drugs and devices
Fertility drugs Growth Hormone drugs

$10 per generic (30-day supply)
$20 per brand name (30-day supply)

$20 per generic (90-day supply through mail service)
$40 per brand name (90-day supply through mail service)
Note: If there is no generic equivalent available, you will still
have to pay the brand name copay.

Not covered:
Drugs and supplies for cosmetic purposes
Drugs to enhance athletic performance
Vitamins, nutrients and food supplements even if a physician prescribes or administers them

Nonprescription medicines
Drugs obtained from a non-Plan pharmacy, unless emergency
Tobacco cessation products
Anorexiants
Drugs and medications not approved by the FDA
DESI drugs (i. e. drugs which are of questionable therapeutic value as designated by the FDA's Federal Drug Efficacy Study)

Any other drug deemed not medically necessary by the Plan.

All Charges 38.
38 Page 39 40
2003 Piedmont Community HealthCare 36 Section 5( g)
Section 5 (g). Special features
Feature Description
Flexible benefits option Under the flexible benefits option, we determine the most effective way to provide services.
We may identify medically appropriate alternatives to traditional care and coordinate other benefits as a less costly alternative

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

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

Local Service and Assistance As a company located in the heart of its service area, which spans across the Central Virginia area only, we can offer our members local service and assistance. We are in the same community with you and
work with your medical providers on a daily basis. Customer service representatives and medical management staff are in the office and
available to assist you.

Eyewear Discounts By presenting your Piedmont Community HealthCare identification card at these Lynchburg locations: AG Jefferson, Inc.; Cooper & Elder Optical; Virginia Eye Clinic-Dr. Timothy J. Wilson and Associates,
Optometrists; Elegance in Eyewear; Dr. David a. West, OD; Dr. Victor Weatherholt; McBride & Blackburn Opticians, Inc.; Sears Optical and
Pearle Vision, you will receive discounts on eyewear. 39.
39 Page 40 41
2003 Piedmont Community HealthCare 37 Section 5( h)
Section 5 (h). Dental benefits
I M
P O
R T
A N
T

Here are some important things to keep in mind about these benefits:
We do not provide dental benefits except for accidental injury. I M

P O

R T
A N
T

Accidental injury benefit
We cover restorative services and supplies necessary to promptly repair (but not replace) sound natural teeth. The need for these services must result from an accidental injury if the jaw is broken, the accident occurred while you

were enrolled with the Plan and you submit a plan of treatment within 60 days of the date of your injury. You pay 20% of the allowable charge.

Dental benefits
We have no other dental benefits. 40.
40 Page 41 42
2003 Piedmont Community HealthCare 38 Section 5( i)
Section 5 (i). Point of service benefits
I M
P O
R T
A N
T

medically necessary.
Point of service benefits or out-of-network benefits will be provided when you receive services from providers other than your primary care physician without a

referral from your primary care physician. Exceptions are emergency care and two visits per year to participating Plan OB/ GYN physicians.

The calendar year deductible is $500 per individual, $1,000 per family. The calendar year deductible applies to all benefits in this Section.
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).

I M
P O
R T
A N
T

Point of Service (POS) Benefits
Facts about this Plan's POS option At your option, you may choose to obtain benefits covered by this Plan from non-Plan doctors and hospitals
whenever you need care, except for the benefits listed below under "What is not covered." Benefits not covered under Point of Service must either be received from or arranged by Plan doctors to be covered. When you obtain
covered non-emergency medical treatment from a non-Plan doctor or a Plan doctor without a referral from your primary care physician, you are subject to the deductibles, coinsurance and maximum benefit stated below.

What is covered
All medical services listed as covered in the previous sections are covered services under the point of service or out-of-plan benefit.

Once you receive services from a non-Plan provider or without a referral from your primary care physician, then all charges related to those services are paid at the point of service or out-of-plan level. For example, if you see a
specialist, Plan specialist or non-Plan specialist, without a referral from your primary care physician and then that specialist send you to a facility, Plan facility or non-Plan facility, then all of those charges will be paid at the point of
service or out-of-plan level. Therefore, point of service coverage may be obtained in the service area or out of the service area.

Precertification Precertification is not required for point of service or out-of-plan benefits.
Deductible $500 per individual per calendar year, $1,000 per family per calendar year.
Coinsurance You pay 40% of the allowable charge after the deductible for all covered services.
Maximum benefit There is no maximum benefit under the point of service benefits; however, you do have an out-of-pocket maximum
of $2,000 per individual per calendar year, and $4,000 per family per calendar year. Amounts over the allowable charge amounts, outpatient mental health services, prescription drug copayments and the vision exam copayment do
not count towards the out-of-pocket maximum. 41.
41 Page 42 43
2003 Piedmont Community HealthCare 39 Section 5( i)
Hospital/ extended care The same covered services listed in the previous sections are covered under the point of service benefits. The same
limitations apply. The allowable charge for facilities is the same as the actual charge so you will be responsible for 40% of those facility charges. The facility charge does not cover any charges for doctors' services.

Emergency benefits Non-emergent conditions treated at an emergency room are always payable as out-of-plan benefits.
What is not covered The same services listed as not covered in the previous sections, are not covered under the point of service or out-of-plan
benefits either. In addition, all charges over the allowable charge amount are not covered.
How to obtain benefits You may be required to file claim forms for services received from non-Plan providers. Contact customer service at
888-674-3368 to request claim forms. Complete the form, attach your receipt and mail in to the address on the form. 42.
42 Page 43 44
2003 Piedmont Community HealthCare Section 6 40
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:
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.
Experimental/ Investigative medical or surgical procedures and drugs, as determined by the Plan, in its sole discretion 43.
43 Page 44 45
2003 Piedmont Community HealthCare 41 Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at Plan pharmacies, you will not have to file claims. Just present your identification card and pay your copayment,
coinsurance, or deductible.
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 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 888-674-3368.

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

Covered member's name and ID number;
Name and address of the physician or facility that provided the service or supply;

Dates you received the services or supplies;
Diagnosis;
Type of each service or supply;
The charge for each service or supply;
A copy of the explanation of benefits, payments, or denial from any primary payer --such as the Medicare Summary Notice (MSN); and

Receipts, if you paid for your services.
Submit your claims to: Piedmont Community HealthCare, P. O. Box 14408, Cincinatti, Ohio 45250-0408

Prescription drugs Prescriptions must be received from Plan pharmacies in order to be covered. Plan pharmacies file the claims for you. If for some reason you
need to file a claim, contact customer service at 800-966-5772 to request a claim form, complete the form and mail it to the address below.

Submit your claims to: PCS Health Systems, Inc., PO Box 52116, Phoenix, Arizona 85072-2116

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. 44.
44 Page 45 46
2003 Piedmont Community HealthCare 42 Section 8
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your claim or request for services, drugs, or supplies including a request for preauthorization:

Step Description
1 Ask us in writing to reconsider our initial decision. You must: (a) Write to us within 6 months from the date of our decision; and
(b) Send your request to us at: Piedmont Community HealthCare, P. O. Box 2455, Lynchburg, VA 24501, ATTN: Operations Manager; 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, or if applicable, arrange for the health care provider to give you the care); or
(b) Write to you and maintain our denial --go to step 4; or (c) Ask you or your provider for more information. If we ask your provider, we will send you a copy of our
request go to step 3.

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

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

Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Contracts Division 3, 1900 E Street, NW, Washington, D. C. 20415-3630. 45.
45 Page 46 47
2003 Piedmont Community HealthCare 43 Section 8
Send OPM the following information:
A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;

Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms;
Copies of all letters you sent to us about the claim;
Copies of all letters we sent to you about the claim; and
Your daytime phone number and the best time to call.

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

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

5 OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct. OPM will send you a final decision within 60 days. There are no other administrative appeals.

If you do not agree with OPM's decision, your only recourse is to sue. If you decide to sue, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received
the disputed services, drugs, or supplies or from the year in which you were denied precertification or prior approval. This is the only deadline that may not be extended.

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

NOTE: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and
(a) We haven't responded yet to your initial request for care or preauthorization/ prior approval, then call us at 434-947-4463 or 800-400-7247 and we will expedite our review; or
(b) We denied your initial request for care or preauthorization/ prior approval, then:
If we expedite our review and maintain our denial, we will inform OPM so that they can give your claim expedited treatment too, or

You may call OPM's Health Benefits Contracts Division III at 202/ 606-0755 between 8 a. m. and 5 p. m. eastern time. 46.
46 Page 47 48
2003 Piedmont Community HealthCare 44 Section 9
Section 9. Coordinating benefits with other coverage
When you have other health coverage You must tell us if you or a covered family member have coverage under another group health plan or have automobile insurance that pays
medical 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. Limitations work the same way. We will not exceed our number of visits
where applicable.
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 managed care plan 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 or Part B) The Original Medicare Plan (Original Medicare) is a Medicare+ Choice
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 Part A and Part B benefits now. You may go to any doctor, specialist, or hospital that accepts Medicare. The Original
Medicare Plan pays its share and you pay your share. Some things are not covered under Original Medicare, like prescription drugs. 47.
47 Page 48 49

2003 Piedmont Community HealthCare 45 Section 9
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 waive some copayments, coinsurance,
and deductibles, as follows:
If Medicare pays more on the claim than the Plan, then you will not be required to pay your copayments, coinsurance, and deductibles under the
Plan benefits.

Claims process when you have the Original Medicare Plan --You probably will never have to file a claim form when you have both our
Plan and the Original Medicare Plan.
When we are the primary payer, we process the claim first.
When Original Medicare is the primary payer, Medicare processes
your claim first. In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for

covered charges up to the maximum benefit under our plan. You will not need to do anything. To find out if you need to do something
about filing your claim, call us at 1-888-674-3368 or contact us at www. pchp. net

We do not waive any costs if the Original Medicare Plan is your primary payer. 48.
48 Page 49 50
2003 Piedmont Community HealthCare 46 Section 9
The following chart illustrates whether the Original Medicare Plan or this Plan should be the primary payer for you according to your employment status and other factors determined by Medicare. It is critical that you
tell us if you or a covered family member has Medicare coverage so we can administer these requirements correctly.

Primary Payer Chart
Then the primary payer is A. When either you --or your covered spouse --are age 65 or over and

Original Medicare This Plan
1) Areanactiveemployee with theFederalgovernment(including whenyouora familymemberare eligibleforMedicaresolely becauseofadisability), !

2) Are an annuitant, !

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

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

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

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

!
(except for claims related to Workers'

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

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

b) Are an active employee, or !
c) Are a former spouse of an annuitant, or !
d) Are a former spouse of an active employee ! 49.
49 Page 50 51

2003 Piedmont Community HealthCare 47 Section 9
Medicare managed care plan If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits a Medicare managed care plan. These are health care
choices (like HMOs) in some areas of the country. In most Medicare managed care plans, you can only go to doctors, specialists, or hospitals
that are part of the plan. Medicare managed care plans provide all the benefits that Original medicare covers. Some cover extras, like
prescription drugs. To learn more about enrolling in a Medicare managed care plan, contact Medicare at 1-800-MEDICARE (1-800-633-
4227) or at www. medicare. gov.
If you enroll in a Medicare managed care plan, the following options are available to you:

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

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

TRICARE TRICARE is the health care program for eligible dependents of military persons and retirees of the military. TRICARE includes the CHAMPUS
program. If both TRICARE and this Plan cover you, we pay first. See your TRICARE Health Benefits Advisor if you have questions about
TRICARE coverage.

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. 50.
50 Page 51 52
2003 Piedmont Community HealthCare 48 Section 9
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.
When other Government agencies We do not cover services and supplies when a local, State, are responsible for your care or Federal Government agency directly or indirectly pays for them. 51.
51 Page 52 53
2003 Piedmont Community HealthCare 49 Section 10
Section 10. Definitions of terms we use in this brochure
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on
December 31 of the same year.

Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. See page 12.

Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 12.
Covered services Care we provide benefits for, as described in this brochure.
Custodial care Custodial care is care (including room and board needed to provide that care) that is given principally for personal hygiene or for assistance in
daily activities and can, according to generally accepted medical standards, be performed by persons who have no medical training.
Examples of custodial care are help in walking and getting out of bed; assistance in bathing, dressing, feeding; or supervision over medication
which could normally be self-administered. Custodial care that lasts 90 days or more is sometimes known as Long term care. Please see page 45
for your specific benefit.

Deductible A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for
those services. See page 12.

Experimental or Investigational services Experimental or investigative means any service or supply which is
determined to be experimental or investigative in the Plan's sole discretion. The Plan will apply the following criteria in exercising its
discretion: 1. Any supply or drug used must have received final approval to
market by the United States Food and Drug Administration; 2. There must be sufficient information in the peer reviewed medical
and scientific literature to enable the Plan to make conclusions about safety and efficacy;
3. The available scientific evidence must demonstrate a beneficial effect on health outcomes outside a research setting; and
4. The service or supply must be a safe and effective outside a research setting as existing diagnostic or therapeutic alternatives.
A service or supply will be experimental or investigative if the Plan determines that any one of the four criteria is not satisfied.

Medically necessary Medically necessary services mean those covered services received are consistent with the diagnosis and treatment of the member's condition ,
are efficacious, are in accordance with standards of good medical practice, are not simply for the convenience of the member of provider
and are performed in the most cost-effective setting available to the member. We will determine the medical necessity of a given service or
procedure.

Plan allowance Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. Plans determine their allowances in 52.
52 Page 53 54
2003 Piedmont Community HealthCare 50 Section 10
different ways. We determine our allowance by a set fee schedule for covered services. Our allowable charge means the amount determined by
the Plan for a specified covered service or the provider's actual charge for that service, whichever is less. We will never pay more than our
allowable charge for any covered service.

Us/ We Us and we refer to Piedmont Community HealthCare.
You You refers to the enrollee and each covered family member. 53.
53 Page 54 55
2003 Piedmont Community HealthCare 51 Section 11
Section 11. FEHB facts
No pre-existing condition We will not refuse to cover the treatment of a condition that you had limitation before you enrolled in this Plan solely because you had the condition before you enrolled.

Where you can get information See www. opm. gov/ insure. Also, your employing or retirement office about enrolling in the can answer your questions, and give you a Guide to Federal Employees
FEHB Program Health Benefits Plans, brochures for other plans, and other materials you need to make an informed decision about your FEHB coverage. These materials tell you:

When you may change your enrollment;
How you can cover your family members;
What happens when you transfer to another Federal agency, go on leave without pay, enter military service, or retire;

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

Types of coverage available Self Only coverage is for you alone. Self and Family coverage is for for you and your family you, your spouse, and your unmarried dependent children under age 22, including any
foster children or stepchildren your employing or retirement office authorizes coverage for. Under certain circumstances, you may also continue coverage for a disabled child 22
years of age or older who is incapable of self-support.
If you have a Self Only enrollment, you may change to a Self and Family enrollment if you marry, give birth, or add a child to your family. You may change your enrollment 31
days before to 60 days after that event. The Self and Family enrollment begins on the first day of the pay period in which the child is born or becomes an eligible family
member. When you change to Self and Family because you marry, the change is effective on the first day of the pay period that begins after your employing office receives your
enrollment form; benefits will not be available to your spouse until you marry.
Your employing or retirement office will not notify you when a family member is no longer eligible to receive health benefits, nor will we. Please tell us immediately when
you add or remove family members from your coverage for any reason, including divorce, or when your child under age 22 marries or turns 22.

If you or one of your family members is enrolled in one FEHB plan, that person may not be enrolled in or covered as a family member by another FEHB plan.

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: 54.
54 Page 55 56
2003 Piedmont Community HealthCare 52 Section 11
If you have no FEHB coverage, your employing office will enroll you for Self and Family coverage in the Blue Cross and Blue Shield Service Benefit Plan's Basic
Option, if you have a Self Only enrollment in a fee-for-service plan or in an HMO that serves
the area where your children live, your employing office will change your enrollment to Self and Family in the same option of the same plan; or
if you are enrolled in an HMO that does not serve the area where the children live, your employing office will change your enrollment to Self and Family in the Blue
Cross and Blue Shield Service Benefit Plan's Basic Option.
As long as the court/ administrative order is in effect, and you have at least one child identified in the order who is still eligible under the FEHB Program, you cannot cancel
your enrollment, change to Self Only, or change to a plan that doesn't serve the area in which your children live, unless you provide documentation that you have other coverage
for the children. If the court/ administrative order is still in effect when you retire, and you have at least one child still eligible for FEHB coverage, you must continue your
FEHB coverage into retirement (if eligible) and cannot make any changes after retirement. Contact you employing office for further information.

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

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

When you lose benefits
When FEHB coverage ends You will receive an additional 31 days of coverage, for no additional premium, when:
Your enrollment ends, unless you cancel your enrollment, or
You are a family member no longer eligible for coverage.
You may be eligible for spouse equity coverage or Temporary Continuation of Coverage.
Spouse equity If you are divorced from a Federal employee or annuitant, you may not coverage continue to get benefits under your former spouse's enrollment. This is the case even

when the court has ordered your former spouse to supply health coverage to you. But, you may be eligible for your own FEHB coverage under the spouse equity law or
Temporary continuation of Coverage (TCC). If you are recently divorced or are anticipating a divorce, contact your ex-spouse's employing or retirement office to get RI
70-5, the Guide to Federal Employees Health Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees, or other information about your coverage
choices. You can also download the guide from OPM's website, www. opm. gov/ insure.
Temporary continuation of coverage (TCC) If you leave Federal service, or if you lose coverage because you no longer qualify as a
family member, you may be eligible for Temporary Continuation of Coverage (TCC). For example, you can receive TCC if you are not able to continue your FEHB enrollment
after you retire, if you lose your job, if you are a covered dependent child and you turn 22 or marry, etc.

You may not elect TCC if you are fired from your Federal job due to gross misconduct. 55.
55 Page 56 57

2003 Piedmont Community HealthCare 53 Section 11
Enrolling in TCC. Get the RI 79-27, which describes TCC, and the RI 70-5, the Guide to Federal Employees Health Benefits Plans for Temporary Continuation of Coverage
and Former Spouse Enrollees, from your employing or retirement office or from www. opm. gov/ insure. It explains what you have to do to enroll.

Converting to You may convert to a non-FEHB individual policy if: individual coverage Your coverage under TCC or the spouse equity law ends (If you canceled your
coverage or did not pay your premium, you cannot convert);
You decided not to receive coverage under TCC or the spouse equity law; or
You are not eligible for coverage under TCC or the spouse equity law.
If you leave Federal service, your employing office will notify you of your right to convert. You must apply in writing to us within 31 days after you receive this notice.

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

Getting a Certificate of The Health Insurance Portability and Accountability Act of 1996. Group Health Plan Coverage (HIPAA) is a Federal law that offers limited Federal protections for health coverage
availability and continuity to people who lose employer group coverage. If you leave the FEHB Program, we will give you a Certificate of Group Health Plan Coverage that
indicates how long you have been enrolled with us. You can use this certificate when getting health insurance or other health care coverage. Your new plan must reduce or
eliminate waiting periods, limitations, or exclusions for health related conditions based on the information in the certificate, as long as you enroll within 63 days of losing
coverage under this Plan. If you have been enrolled with us for less than 12 months, but were previously 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. 56.
56 Page 57 58

2003 Piedmont Community HealthCare 54 Section 11
Long Term Care Insurance Is Still Available! Open Season for Long Term Care Insurance
You can protect yourself against the high cost of long term care by applying for insurance in the Federal Long Term Care Insurance Program.
Open Season to apply for long term care insurance through LTC Partners ends on December 31, 2002. If you're a Federal employee, you and your spouse need only answer a few questions about your health during Open Season.
If you apply during the Open Season, your premiums are based on your age as of July 1, 2002. After Open Season, your premiums are based on your age at the time LTC Partners receives your application.

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

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

Find Out More Contact LTC Partners by calling 1-800-LTC-FEDS (1-800-582-3337) (TDD for the hearing impaired: 1-800-843-3557) or visiting www. ltcfeds. com to get more information and to request an application. 57.
57 Page 58 59
2003 Piedmont Community HealthCare 55 Index
Index
Do not rely on this page; it is for your convenience and may not show all pages where the terms appear.
Accidental injury 19, 24, 37 Allergy 13, 17
Alternative treatment 13, 22, 49 Allogenetic (donor) bone marrow
transplant Ambulance 2, 11, 13, 27, 29, 31,
38 Anesthesia 2, 13, 23, 26, 28
Autologous bone marrow transplant 18, 25
Blood and blood plasma 14, 15, 28 Breast cancer screening 25
Casts 28 Changes for 2003 8
Chemotherapy 18 Cholesterol tests 15
Claims 3, 8, 12, 13, 34, 36, 38, 41, 42, 43, 47, 52
Coinsurance 2, 6, 9, 12, 38, 41, 45, 47, 49
Colorectal cancer screening 15 Congenital anomalies 23, 24
Contraceptive devices and drugs 16, 35 Coordination of benefits 43
Covered charges 47 Crutches 21
Deductible 2, 6, 9, 12, 14, 23, 27, 30, 32, 38, 41, 45, 47, 49
Definitions 3, 14, 23, 27, 30, 32, 34, 38, 49, 57
Dental care 13, 28, 34, 37 Diagnostic services 12, 13, 14, 16,
28, 32, 33, 45 Disputed claims review 36, 42, 43,
52 Dressings 28
Durable medical equipment (DME) 12, 13, 31
Educational classes and programs 13, 22
Emergency 2, 7, 11, 12, 13, 30, 31, 35, 38, 39
Experimental or investigational 40, 49
Eyeglasses 19, 21 Family planning 13, 16
Fecal occult blood test 15

General Exclusions 3, 13 Hearing services 13, 15, 19
Home health services 13, 14, 21 Hospice care 13, 29
Hospital 2, 4, 6, 8-12, 13, 14, 16, 20, 28, 31, 33, 38, 39, 41, 44,
47, 54, 57 Immunizations 6, 15
Infertility 12, 13, 17 Inpatient Hospital Benefits 12,
13, 26, 27, 28, 29, 31 Insulin 34, 35
Laboratory and pathological services 28
Magnetic Resonance Imagings (MRIs) 14
Mail Order Prescription Drugs 34, 35
Mammograms 14 Maternity Benefits 13, 16, 28, 30
Medicaid 3, 40, 48, 54 Medically necessary 11, 14, 16,
18, 23, 27, 29, 31-34, 38, 45 Medicare 3, 8, 14, 23, 27, 30, 32,
34, 38, 41, 44, 45, 46, 47, 54 Members 6, 9, 23, 36, 51, 54, 58
Mental Conditions/ Substance Abuse Benefits 2, 13, 18, 32,
33, 38 Newborn care 16
Nurse Licensed Practical Nurse 21
Nurse Anesthetist 28 Registered Nurse 21
Nursery charges 16 Obstetrical care 16
Occupational therapy 11, 13, 18 Ocular injury 19
Office visits 6, 12, 14, 15, 31 Oral and maxillofacial surgery 13, 25
Orthopedic devices 13, 19, 20, 23 Ostomy and catheter supplies 21
Out-of-pocket expenses 2, 6, 12, 38
Oxygen 21, 28 Pap test 14, 15
Physical therapy 11, 13, 18

Physician 2, 4, 6, 8, 12, 13, 14, 16, 27, 30-33, 34, 35,
38, 41-43, 57 Point of service (POS) 13, 14,
23, 27, 30, 32, 38 Precertification 11, 16, 23,
27, 38 Preventive care, adult 6, 13,
15 Preventive care, children 6, 13,
15, 19 Prescription drugs 2, 9, 12,
13, 16, 17, 18, 34, 35, 38, 41, 44, 47
Prior approval 2, 11, 35 Prosthetic devices 13, 19, 20,
21, 23, 24 Psychologist 32
Radiation therapy 18 Renal dialysis 44, 46
Room and board 27, 45 Second surgical opinion 14
Skilled nursing facility care 9, 13, 14, 26, 28
Speech therapy 8, 13, 18, 19 Splints 21, 28
Sterilization procedures 16, 24,
Substance abuse 2, 13, 18, 32, 33
Surgery 13, 16, 18, 19-21, 23, 24, 25, 27, 38
Anesthesia 2, 12, 13, 23, 26, 28
Oral 13, 25 Outpatient 12, 13, 28
Reconstructive 13, 23, 24 Syringes 34, 35
Transplants 8, 11, 12, 13, 16, 18, 25
Treatment therapies 13, 18 Vision services 12, 13, 15, 19,
28, 36, 38, Wheelchairs 21
X-rays 14, 28 58.
58 Page 59 60
2003 Piedmont Community HealthCare 56 Rates
Summary of benefits for the Piedmont Community Health Plan 2003
Do not rely on this chart alone. All benefits are provided in full unless indicated and are subject to the
definitions, limitations, and exclusions in this brochure. On this page we summarize specific expenses we cover; for more detail, look inside.

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

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

Benefits You Pay Page
Medical services provided by physicians:
Diagnostic and treatment services provided in the office ................ Office visit copay: $20 per office visit 14

Services provided by a hospital:
Inpatient ...........................................................................................
Outpatient.........................................................................................
20% of allowable charge
20% of allowable charge

27
28
Emergency benefits:
In-area .............................................................................................
Out-of-area ......................................................................................

$50 per visit (waived if admitted)
$50 per visit (waived if admitted)

30
30
Mental health and substance abuse treatment ..................................... Regular cost sharing. 32
Prescription drugs................................................................................. 30 day suppply $10.00 per generic
$20.00 per brand name
90 day supply ( mail service) $20.00 per generic
$40.00 per brand name

Dental Care....................................................................................... No benefit. 37
Vision Care....................................................................................... $20 per office visit 19
Special features: Flexible benefits option, Local Service and Assistance, and Eyewear Discounts 36

Protection against catastrophic costs (your out-of-pocket maximum) ........................................................ Nothing after $1,000/ Self Only or $2,000/ Family enrollment per year
(Some costs do not count toward this protection)
12

Point of Service benefits --38
Protection against catastrophic costs
(your point-of-service out of pocket maximum)

100% of allowable amount after $2,000/ Self Only or
$4,000/ Family enrollment per year (Some costs do not count
toward this protection)
38 59.
59 Page 60
2003 Piedmont Community HealthCare 57 Rates
2003 Rate Information for PIEDMONT COMMUNITY HEALTHCARE (VIRGINIA)
Non-Postal rates apply to most non-Postal enrollees. If you are in a special enrollment category, refer to the FEHB Guide for that category or contact the agency that maintains your health benefits
enrollment.
Postal rates apply to career Postal Service employees. Most employees should refer to the FEHB Guide for United States Postal Service Employees, RI 70-2. Different postal rates apply and a
special FEHB guide is published for Postal Service Inspectors and Office of Inspector General (OIG) employees (see RI 70-2IN).

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

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

Postal Premium
Biweekly

USPS Your Share Share

Self Only
Self & Family
2C1
2C2
$109.30 $ 51.56 $236.82 $111.71
$249.62 $118.74 $540.84 $257.27
$129.03 $31.83
$294.70 $ 73.66 60.

Page Navigation Panel

1 2 3 4 5 6 7 8 9
10 11 12 13 14 15 16 17 18 19
20 21 22 23 24 25 26 27 28 29
30 31 32 33 34 35 36 37 38 39
40 41 42 43 44 45 46 47 48 49
50 51 52 53 54 55 56 57 58 59
60