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UnitedHealthcare Coordinated Care Plan Nonrepresented Salaried | 2000 Edition 1

Plan HighlightsThis description of the UnitedHealthcare coordinated care plan and accompanying mental health andchemical dependency, prescription drug, and vision care programs, is a supplement to the currentedition Health Care Plans booklet for nonrepresented salaried employees of The Boeing Company.

Under the UnitedHealthcare coordinated care plan, you may choose any legally qualified physician orhospital each time you need health care services. However, when you have your network primary carephysician coordinate your care, you receive the highest benefits under the plan. The plan is available toyou if you live in the network service area (St. Louis and the surrounding counties).

Refer to your Health Care Plans booklet for information regarding

• Eligibility and enrollment provisions, including contribution information.

• Termination of coverage provisions.

• Special disclosure and other general plan information.

This supplement and the current edition Health Care Plans booklet for nonrepresented salariedemployees comprise the plan document and the summary plan description for the UnitedHealthcarecoordinated care plan and accompanying mental health and chemical dependency, prescription drug,and vision care programs.

Nonrepresented Salaried Employees / 2000 Edition

Your Health and Welfare PlansSupplement to the Health Care Plans

TotalCompensation

Health and Welfare

UnitedHealthcareCoordinated Care Plan


Table of ContentsUnitedHealthcare Coordinated Care Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Network Service Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Your Primary Care Physician . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Using Your Primary Care Physician . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Referrals for Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

When a Referral Is Not Required . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

How Medical Expenses Are Paid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Network Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Nonnetwork Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Coverage for a Child Who Does Not Reside With You . . . . . . . . . . . . . . . . . 9

Coverage When You Are Traveling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Network Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Payment Provisions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Copayments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Annual Copayment Maximum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Lifetime Maximum Benefit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Covered Network Services and Supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Preventive Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Physician Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Hospital Services and Supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Emergency/Urgent Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Hospital Alternatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Medical Services and Supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

How to File a Claim . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Nonnetwork Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Payment Provisions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Calendar Year Deductible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Coinsurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Stop-Loss Limit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Lifetime Maximum Benefit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Other Health Care Expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Reasonable and Customary Allowances . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Advance Estimate of Reasonable and Customary Allowance . . . . . . . 16

Special Provisions for Nonnetwork Care . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Preadmission Certification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Continued Stay Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Medical Case Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Covered Nonnetwork Services and Supplies . . . . . . . . . . . . . . . . . . . . . . . . 18

Acupuncture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Christian Science Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

4 UnitedHealthcare Coordinated Care Plan Nonrepresented Salaried | 2000 Edition

Emergency Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Skilled Nursing Facility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

How to File a Claim . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Noncovered Services and Supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Mental Health and Chemical Dependency Program . . . . . . . . . . . . . . . . . . . 22Assessment/Referral Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Payment Provisions With Assessment/Referral . . . . . . . . . . . . . . . . . . . . . . . . . 22

Payment Provisions Without Assessment/Referral . . . . . . . . . . . . . . . . . . . . . . . 22

Calendar Year Deductible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Coinsurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Mental Health Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Chemical Dependency Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Lifetime Limit for Chemical Dependency Treatment . . . . . . . . . . . . . . . . . . . . . 23

How to File a Claim . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Prescription Drug Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25Copayments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Maximum Quantity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

How to Fill a Prescription . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Local Participating Pharmacy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Nonparticipating Pharmacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Ordering Drugs by Mail . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

New Employees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Preauthorization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Voluntary Formulary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Covered Drugs and Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Noncovered Drugs and Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Vision Care Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29How to Get Vision Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Avesis Provider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Non-Avesis Provider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Other Ways to Get Vision Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Noncovered Services and Supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Review, Appeal, and Accelerated Appeal . . . . . . . . . . . . . . . . . . . . . . . . . . 32Claim Review and Appeal Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Accelerated Appeal Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

UnitedHealthcare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

ValueOptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Merck-Medco . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Avesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Eligibility Review and Appeal Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35


Coordination of Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

ExhibitsExhibit 1: Vision Benefits Payable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Exhibit 2: Where to Get Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42


UnitedHealthcareCoordinated Care PlanThe UnitedHealthcare coordinated care plan is offered to employees who live in the network servicearea. Under this plan, you may choose any legally qualified physician or hospital each time you needhealth care services.

You may

• Use a primary care physician from the plan’s network to coordinate all of your medical care, or

• Make your own arrangements for medical care without going through your primary care physician.

UnitedHealthcare is the service representative for this coordinated care plan. Boeing may change theservice representative at any time.

Network Service AreaThe plan’s network service area is St. Louis and the surrounding counties. The personalizedEnrollment Worksheet you receive from the Boeing Service Center as a newly eligible employee orduring the annual enrollment period will indicate whether you live within the network service area andare eligible to enroll in the plan.

Your Primary Care PhysicianWhen you enroll in this plan, you must choose a primary care physician from the list of networkphysicians (internists, family practice or general practice physicians, or pediatricians). You may notchoose a specialist as a primary care physician.

You may have one primary care physician for all family members or different primary care physiciansfor each family member. Call the service representative or the Boeing Service Center for specific rulesregarding the selection of primary care physicians for family members. Exhibit 2 on page 42 lists thetelephone numbers for the service representative and the Boeing Service Center.

Using Your Primary Care PhysicianIf you have all medical care coordinated through your primary care physician and you use networkproviders, the plan will pay the greatest level of benefits.

Here is some other information you need to know about primary care physicians:

• Your primary care physician is required to obtain approval from the service representative beforeproviding or authorizing certain services such as surgery and inpatient hospital care.

• Services that the plan limits or excludes are limited or excluded even if your primary care physicianrecommends them.

Referrals for TreatmentWhen your primary care physician determines you need the services of a specialist, he or she will issuea referral to the specialist. The referral will authorize the number of visits you may schedule within aspecific period of time. Although some primary care physicians may make a referral by telephone,generally it will be on a written form provided by the plan’s service representative with copies for thespecialist, the service representative, and you.


For certain ongoing treatment, such as prenatal and postnatal visits, allergy shots, some cancer therapy,and dialysis, your primary care physician may issue a referral for a longer period of time.

You need to know the following additional information about referrals:

• If your primary care physician is a member of an association of private practice physicians, aphysician’s hospital organization, or a member of a physician’s group practice, you may be requiredto receive care from specialists who belong to the same association or medical group. Your providerdirectory will indicate primary care physicians who belong to such a group.

• For some types of specialty care, your primary care physician may be required to make referrals onlyto certain providers in the plan’s network. For example, only certain hospitals within the plan’snetwork are authorized to perform transplants.

• In some cases, your primary care physician’s referral may require approval from the plan’s servicerepresentative or from the association or medical group to which the primary care physician belongs.

• If your primary care physician refers you to a specialist who is not in the network, the primary carephysician must have approval from the service representative.

The plan’s service representative can give you more information about any of these situations.

When a Referral Is Not RequiredYou are not required to obtain a referral from your primary care physician for

• An annual well-woman exam, but you must select an obstetrician/gynecologist from the plan’snetwork, and in some cases, from the same medical group as your primary care physician.

• Up to 15 chiropractic care visits in a calendar year (but you must select a chiropractor from theplan’s chiropractic network).

• Emergency care.

You also do not need a referral from your primary care physician for mental health and chemicaldependency care or routine vision care. These services are covered under separate programs and arediscussed in other sections of this supplement.

How Medical Expenses Are PaidNetwork BenefitsThe plan pays the greatest level of benefits (100 percent after applicable copayments) when you obtaincovered medical services and supplies through your primary care physician and you use networkproviders. Additional network payment provisions and network benefits are described beginning onpage 9.

Occasionally, a primary care physician might recommend services or supplies that the plan does notcover. The plan will not pay for such services or supplies, even if your primary care physicianrecommends them.

Certain services are covered only with prior plan approval or when you use network providersspecified by the plan.

If your primary care physician coordinates your care and refers you to nonnetwork providers afterreceiving prior approval from the plan, benefits will be paid at the network payment level.

Nonnetwork BenefitsIf you live in the network service area and obtain covered medical services or supplies from network ornonnetwork providers without going through your primary care physician, or if you fail to notify yourprimary care physician as required in connection with emergency treatment, your benefit coverage willbe much lower. In general, the plan pays 60 percent of reasonable and customary charges after you paya $500 calendar year deductible per person. Additional nonnetwork payment provisions andnonnetwork benefits are described beginning on page 14.


Coverage for a Child Who Does Not Reside With YouIf your dependent child lives away from home (for example, your child boards at college or lives withyour former spouse), contact the service representative for information about available coverage. (SeeExhibit 2 on page 42 for the service representative’s telephone number.)

Coverage When You Are TravelingThe plan covers treatment for illnesses or injuries that occur while you are traveling (business orpersonal) outside the network service area.

If you or a dependent will be out of the network service area for an extended period of time, checkwith the Boeing Service Center to see what options are available to you for continuing care.

In a medical emergency, get treatment as soon as possible, just as you would if you were in thenetwork service area. Then call your primary care physician as instructed on your health careidentification card.

For an unexpected urgent need that is not an emergency, call your primary care physician or otherappropriate number on your health care identification card. The plan will not reimburse nonemergencyservices if you do not call and get approval before incurring an expense.

The treating physician or hospital may require you to pay at the time of the service. If so, add yourSocial Security number to the bill for proper identification, and then send the bill to the servicerepresentative at the address on your health care identification card with a note to explain thecircumstances. If you used an emergency room, it is helpful to send a copy of the emergency roomreport. You do not need a claim form.

If you are sent on a business trip of more than 90 days, contact UnitedHealthcare to see what optionsare available to you for continuing care. (See Exhibit 2 on page 42 for UnitedHealthcare’s telephonenumber.)

Network BenefitsPayment ProvisionsWhen you obtain health care services through your primary care physician or as otherwise required bythe plan for network benefits, benefits are generally paid at 100 percent after the applicablecopayments, as described below.

CopaymentsFor covered medical expenses, you pay the following copayments:

• $10 copayment per office visit to a primary care physician. (The office visit copayment does notapply if the sole purpose of a visit is to receive the preventive care services described on page 10.)

• $10 copayment per office visit to a specialist when referred by your primary care physician. Thereare two exceptions:

• For pregnancy, you pay a copayment for the first prenatal visit. The plan covers in full all otherprenatal and postnatal visits for that pregnancy. If you change physicians during the term of thepregnancy, you must pay a copayment for the first visit to the new physician.

• You do not pay the office visit copayment if the sole purpose of a visit is to receive an allergyshot.

• $50 copayment for treatment of an emergency illness or injury in an emergency room. If the patientis admitted to the hospital as an inpatient from the emergency room, the $50 copayment does notapply. The plan will pay nonnetwork benefits if the illness or injury is not a true emergency. (See thedefinition of “emergency” on page 39.)

All of the above copayments are on a per patient, per visit basis. For example, if you take two childrenfor an office visit to a pediatrician, you pay a $10 copayment for each child.


Different payment provisions apply to mental health and chemical dependency services, prescriptiondrugs, and vision care services, as described in other sections of this supplement.

Annual Copayment MaximumYour copayments for covered expenses in a calendar year will not be more than

• $750 for one person, or

• $1,500 for a family.

The service representative does not keep a cumulative total of the copayments you make for networkservices in a calendar year. Although it is unlikely you would reach the copayment maximum in acalendar year, you should keep your own records of the copayments you make for yourself and eachfamily member. If you reach the individual or family copayment maximum, notify the servicerepresentative. After verifying the information, the plan will pay 100 percent of covered medicalexpenses obtained through the primary care physician or as otherwise required by the plan for the restof the calendar year for you or your family.

Amounts you pay for mental health and chemical dependency, prescription drugs, vision care, anddental care do not count toward your annual copayment maximum under this plan.

Lifetime Maximum BenefitThere is no lifetime maximum benefit for services obtained in and through the network.

Covered Network Services and SuppliesThe plan pays benefits for the following preventive care services and supplies and for the medicallynecessary treatment of illness, injury, and pregnancy, when obtained according to plan provisions. Theexclusions listed under “Noncovered Services and Supplies,” beginning on page 19, apply tonetwork benefits.

Preventive CareWith the exception of an annual well-woman exam, all preventive care services must be obtainedthrough your network primary care physician.

Your primary care physician will advise you of the preventive care services that are medicallyindicated for you based on your age, sex, and medical history. Generally, the following servicesare available:

• Pediatric examinations and well-baby care.

• Immunizations in accordance with accepted medical practice. (The plan does not pay forimmunizations required or recommended by third parties for employment, flight clearance, summercamp, insurance, foreign travel, and so forth.)

• Health assessments and examinations.

• Periodic mammograms.

• Well-woman exam. Once each calendar year, the plan allows a woman to obtain a well-woman examfrom a network obstetrician/gynecologist with no referral from her primary care physician. Refer toyour provider directory or call the service representative to determine whether you must select yourobstetrician/gynecologist from your primary care physician’s association or medical group.

• Vision screening from an ophthalmologist or optometrist (except eye refraction exams that arecovered under the vision care program described beginning on page 29).

Physician ServicesThe plan covers the services of a licensed physician for the medically necessary diagnosis or treatmentof nonoccupational accidental injuries, illnesses, or other covered conditions.


Physician services also are covered for

• Preventive care, as described on page 10.

• Injectable legend drugs administered in a physician’s office that are used to treat a covered condition.(Preventive injections and immunizations are not covered except as noted under the preventive carebenefit described on page 10.) Medical devices (including contraceptive injections, devices, andimplants) dispensed by a physician are covered.

• An eye examination (including refraction) if performed because of another medical condition such asdiabetes, glaucoma, or cataracts. (Routine eye examinations are covered under the vision careprogram described beginning on page 29.)

Hospital Services and SuppliesThe plan covers the following inpatient hospital services and supplies:

• Room and board for services provided in a ward, semiprivate room, operating room, intensive careunit, or other special care unit.

• Professional services including services of attending physicians, anesthesiologists, pathologists,radiologists, and nurses. Private duty nursing is covered only when approved by the plan’s servicerepresentative in advance.

• Supplies for treatment, including whole blood or blood components, oxygen, ordinary casts, splints,dressings, and prescription drugs and medicines used while in the hospital.

Following childbirth, mothers and newborns may stay in the hospital for 48 hours following a normaldelivery or for 96 hours following a cesarean section, unless a shorter stay is authorized by theattending health care provider in consultation with the mother.

Emergency/Urgent CareEmergency Care—The plan covers emergency treatment under network benefit provisions no matterwhen or where the emergency occurs and whether or not you use a network hospital, provided you callyour primary care physician as described below. See page 39 for the definition of an emergency.

Some examples of medical emergencies are

• Severe shortness of breath.

• Pain or severe squeezing sensation in the chest.

• Sudden paralysis or slurred speech.

• Seizure or loss of consciousness.

• Convulsions.

• Poisoning or suspected overdose of medication.

• Broken bone.

• Severe burn.

• Extreme bleeding.

• Severe cut.

In an emergency, take whatever action is required to obtain medical care. If the circumstances allowyou to call your primary care physician first, do so. If you cannot call your primary care physician inadvance, call 911 (or your local number for emergency medical assistance if 911 is not available inyour area) or take the patient to the nearest emergency room. After the patient is stabilized, call yourprimary care physician as directed on your health care identification card.

If you obtain medical treatment for an illness or injury that is not an emergency without a referral orauthorization from your primary care physician, you must pay for the services and file a claim forreimbursement under the nonnetwork payment provisions.


Urgent Care—Examples of medical conditions that may require urgent care, but not emergencycare are

• High fever.

• Severe vomiting.

• Intense pain.

• Sprains.

When the need for care is urgent, call your primary care physician or the number on your health careidentification card before receiving care. Your physician may suggest you go to his or her office, anurgent care facility, or an emergency room. These same guidelines apply if you are out of the networkservice area.

Hospital AlternativesThe plan covers the following hospital alternatives:

• Convalescent and long-term illness care facility services.

• Home health care services including skilled nursing care and other services provided by a networkhome health care agency (excluding custodial services such as meal preparation, personal comfortitems, housekeeping, and other services that are not treatment of the medical condition).

• Hospice care. A hospice program provides a group of interdisciplinary services designed to meet thephysical, psychological, spiritual, and social needs of dying persons and their families.

Services include pain control and supportive medical, nursing, mental health, and otherhealth services.

Services may be provided by the following network providers:

• A hospital.

• A skilled nursing facility or a similar institution.

• A home health care agency.

• A hospice facility.

• Any other facility or agency licensed to provide hospice care services.

• Outpatient hospital or ambulatory surgical center services and supplies.

• Skilled nursing facility care (except for custodial care and conditions of senile deterioration,mental retardation, and mental illness).

Medical Services and SuppliesThe plan covers the following medical services and supplies:

• Anesthesia.

• Autologous blood donation (elective harvesting and storage of blood from the member inanticipation of surgery).

• Chiropractic services. You may obtain services from any chiropractor in the plan’s chiropracticnetwork without a referral from your primary care physician. You pay a $10 copayment per visit forup to 15 visits in a calendar year. (The 15-visit limit is a combined limit for services received fromchiropractors that are/are not providers in the plan’s chiropractic network.) Covered services includethe initial diagnostic lab work and X-rays.

• Consumable supplies, as follows:

• Diabetic supplies, including lancets, test strips, and alcohol swabs.

• Catheters, including indwelling, intermittent, and external.

• Ostomy supplies.

• Irrigation kits.


• Jobst pressure garments for burn victims.

• Jobst full-length stockings for vascular problems.

• Dental services (limited). The following limited dental services are covered when approved inadvance by the plan:

• Hospital charges in connection with dental treatment when hospitalization is required due to aconcurrent medical condition.

• Treatment of sound natural teeth injured in an accident while covered by this plan, provided thetreatment is received within 12 months of the accident.

• Treatment of temporomandibular joint (TMJ) syndrome.

• Diagnostic services, laboratory services, and X-ray exams.

• Family planning services, including counseling, vasectomy, and tubal ligation.

• Genetic counseling and procedures necessary to determine the existence of gender-linked geneticdisorders. (Amniocentesis, ultrasound, or any other procedures used solely for sex determination of afetus are not covered.)

• Hearing aid services. The plan covers one otological and audiometric exam from an audiologist, andone standard hearing device per ear during a three-year benefit period. Hearing exams require a$10 copayment per visit. You do not need a referral from your primary care physician for hearingservices, but you must obtain hearing services from a network provider.

• Infertility diagnosis and treatment. The plan covers services for the diagnosis and treatment ofinfertility, except for drugs, injectables, and procedures that bypass (such as in vitro fertilization),rather than treat, a functional abnormality.

• Medical equipment. The plan covers the use of certain durable medical equipment such as hospitalbeds and wheelchairs. The list of covered medical equipment changes over time. Contact yourprimary care physician or the plan’s service representative to determine whether a certain piece ofdurable medical equipment is covered. Also, see the “personal comfort and convenience items orservices” information on page 20 for a list of equipment the plan currently does not cover.

• Nutritional evaluation. The plan covers nutritional evaluation and counseling if your primary carephysician determines that diet is a part of your medical treatment.

• Orthopedic and prosthetic devices, including replacement when due to a change in physicalcondition or wear and tear.

• Orthotics or other supportive devices of the feet when prescribed for treatment of an injury or othermedical condition of the foot, including braces, splints, insoles, and foot supports constructed ofacrylic, plastic, or metal, as well as impression casts required for the fitting of these devices. Thedevice must be intended for wear at all times that shoes are worn and not just for specific activities.The plan does not cover shoes, or supports that are available without prescription.

• Physical therapy, speech therapy, and occupational therapy if the plan’s service representativedetermines the services are restorative and significant improvement can be expected in a short periodof time, such as within two months.

• Post-mastectomy benefits. Following a mastectomy, the plan covers

• Reconstruction of the breast on which the mastectomy was performed.

• Surgery and reconstruction of the other breast to produce a symmetrical appearance.

• Prosthesis and treatment of physical complication of all stages of mastectomy, includinglymphedemas.


• Transplant benefits. The plan pays covered expenses for human bone marrow, cornea, kidney, liver,pancreas, heart, and heart/lung transplants, provided the transplant is

• Recommended by your network primary care physician.

• Approved by the plan.

• Performed at a facility selected by the health plan.

The plan does not cover experimental or investigational transplants.

If the selected transplant facility is out of the network service area, the plan pays transportationexpenses for the recipient and one family member to and from the center. (The IRS considerspayment of some transportation expenses to be taxable income.)

When the recipient is covered by this plan, the plan considers covered expenses of the recipient andthe donor, whether or not the donor is covered by this plan.

The plan considers expenses for the following services to obtain a donor organ:

• Compatibility testing of deceased donors and of live donors who are blood relatives of a recipient.

• Surgery and hospital expenses for removing the organ from a live donor.

• Acquisition cost of an organ from a deceased donor.

• Transportation services.

• Ambulance for emergency transportation to and from the nearest hospital able to provideappropriate care.

• Nonemergency use of an ambulance when recommended by your primary care physician andapproved in advance by the plan’s service representative.

• Transportation to and from a provider outside of the network service area only when the plan’sservice representative determines special treatment is not available in the network service area.

• Transportation expenses (to and from the transplant center for a live donor; to the transplant centerfor an organ from a deceased donor) in connection with a covered transplant when the donor isnot in the transplant center area.

How to File a ClaimWhen you obtain care from your network primary care physician or from a network provider referredby your primary care physician, you generally do not need to file claim forms. If you receiveemergency care outside the network service area, you must pay for the service and file a claim form forreimbursement. Claim forms are available from the plan’s service representative. See Exhibit 2 onpage 42 for the service representative’s address and telephone number.

Nonnetwork BenefitsWhen you or your dependents obtain medical services without a referral from your primary carephysician when the plan requires a referral, you

• Pay a larger share of the cost.

• Assume responsibility for several plan provisions that, if not followed properly, can increase yourout-of-pocket expenses. (See “Special Provisions for Nonnetwork Care” on page 16.)


Payment ProvisionsWhen you seek medical services without going through your primary care physician or as otherwiserequired for network benefits, you and the plan will pay covered expenses as shown in the followingtable. Refer also to the subsequent paragraphs for a more complete description of plan provisions.

Calendar Year DeductibleBefore the plan begins paying benefits during a calendar year, you must satisfy a deductible of $500per person; there is no family deductible maximum. Covered expenses incurred in the last quarter ofthe calendar year that are applied to the deductible also are applied to the deductible for the nextcalendar year. Payments you make for expenses above the reasonable and customary allowance, fornoncovered services and supplies, and any penalty you pay for inpatient hospital services obtainedwithout preadmission certification are not applied toward the deductible. See pages 16 and 17 forinformation about preadmission certification.

CoinsuranceCoinsurance means you and the plan each pay part of the cost of covered health care services. Afteryou pay the deductible, the plan pays 60 percent and you pay 40 percent of reasonable and customarycharges for covered nonnetwork services and supplies, up to stop-loss limits (described below).

Different coinsurance provisions apply to mental health and chemical dependency treatment. (See“Mental Health and Chemical Dependency Program,” beginning on page 22, for details.)

Stop-Loss LimitThe stop-loss limit is the point at which you stop paying your part of coinsurance and the plan beginsto pay 100 percent of covered medical expenses for the rest of the calendar year, up to the plan lifetimemaximum benefit. The stop-loss limit is $3,000 per person; there is no family stop-loss limit.

Payments you make for the calendar year deductible, expenses above the reasonable and customaryallowance, expenses for noncovered services and supplies, and any penalty you pay for inpatienthospital services that you obtain without preadmission certification are not applied toward thestop-loss limit.

Nonnetwork Payment ProvisionsPlan Feature For Each Person

Calendar year deductible

You pay the first covered expenses up to... $500

Coinsurance

Then the plan pays… 60% of the next $7,500 of coveredexpenses in a calendar year ($4,500)

And you pay… 40% of the next $7,500 of coveredexpenses in a calendar year ($3,000)

Stop-loss limit

After you pay the $500 deductible and 100% of covered expenses over$3,000 in coinsurance, the plan pays… $8,000 in a calendar year, up to the

plan lifetime maximum benefit

Lifetime maximum benefit $1,500,000


Lifetime Maximum BenefitThe plan pays a lifetime maximum benefit of $1,500,000 per person for covered nonnetworkmedical expenses.

Other Health Care ExpensesAmounts you pay for mental health and chemical dependency treatment, prescription drugs, and visioncare do not apply to the calendar year deductible, stop-loss limit, or $1,500,000 lifetime maximumbenefit. (See pages 22 through 31 for information about the separate mental health and chemicaldependency, prescription drug, and vision care programs.)

Reasonable and Customary AllowancesLike most medical plans, this plan pays benefits based on reasonable and customary allowances forcovered expenses. The plan’s service representative determines the reasonable and customaryallowance based on the 90th percentile of the charges for the same or similar services within ageographic area. Generally, this means that 90 percent of the physicians who perform a service ina geographic area charge the reasonable and customary amount or less. Fewer than 10 percent of thephysicians charge more than the reasonable and customary allowance.

If the charges submitted to the plan are more than the reasonable and customary allowance for aparticular service, the plan will pay your benefit based only on its reasonable and customary allowancefor that service. You must pay any amount that exceeds the reasonable and customary allowance.

Advance Estimate of Reasonable and Customary AllowanceYou can avoid incurring a charge that exceeds the reasonable and customary allowance by taking thefollowing steps:

• Ask ahead of time what the charge will be (for example, when you make an appointment).

• If the proposed charge is more than $200, ask your physician to complete an Advance Reasonableand Customary Estimation form describing the service. You can get the form from the servicerepresentative.

• Submit the completed Advance Reasonable and Customary Estimation form to the servicerepresentative.

The service representative will tell you if the charge is within the reasonable and customary allowancefor that service. If the charge is more than the reasonable and customary allowance, you will be toldhow much it exceeds the allowance. You may then want to discuss the matter with your physician orfind a physician who charges less.

Special Provisions for Nonnetwork CareWhen you live in a network service area and decide to manage your own medical care without goingthrough your primary care physician, you must follow these special benefit provisions.

Preadmission CertificationPreadmission certification is not required for hospital admissions outside the United States. A separatepreadmission process is required for mental health and chemical dependency treatments (seepage 22).

If your physician recommends an overnight hospital stay for you or a covered family member, you areresponsible for getting preadmission certification. Under preadmission certification, a medicalreviewer must certify the need for hospitalization. This is another way of ensuring that you obtain themost appropriate medical care at a reasonable cost.

To begin the certification process, the patient, a family member, or the physician must call thetelephone number on your health care identification card before any nonemergency admission.

After receiving the required information, a qualified medical reviewer will match the patient’sdiagnosis with the physician’s treatment plan. Based on nationally accepted criteria and the


information that the physician presents, the medical reviewer will decide whether the hospital is thebest place to provide treatment for the patient.

If the medical reviewer determines that the patient’s condition can be treated just as well elsewhere (forexample, in a physician’s office or an outpatient surgical center), hospitalization will be judgedunnecessary and inappropriate.

Hospital preadmission review for childbirth is not required for a mother or newborn for the first48 hours following a normal delivery or 96 hours following a cesarean section.

If the nonemergency hospitalization is certified as necessary and appropriate, the plan will pay normalnonnetwork benefits for hospital services. However, if certification is not requested on a timely basis,or if it is requested but is not approved and you incur inpatient hospital expenses, then the plan willreduce covered expenses for room and board charges by 20 percent before calculating the benefit.

The penalty you pay as a result of the reduction in room and board benefits will not exceed $750 perhospitalization. The plan will not apply the penalty you pay to your calendar year deductible or stop-loss limit.

In an emergency situation (as defined on page 39), the patient can and should be admitted to thehospital without delay. Then, the patient, a family member, the physician, or the hospital must call thetelephone number on your health care identification card as soon as reasonably possible. (Remember,the plan covers emergency treatment under network benefit provisions no matter when or where theemergency occurs, provided you call your primary care physician as instructed on your identificationcard.)

Continued Stay ReviewOnce the patient has been admitted to the hospital, the need to stay there also is certified. You do nothave to do anything to initiate the continued stay review. Instead, the medical reviewer will monitor thepatient’s time in the hospital. The medical reviewer will notify you in writing when, in the medicalreviewer’s opinion, further hospitalization becomes unnecessary.

You should understand that the medical reviewer’s notice does not necessarily mean you areconsidered well. Rather, the notice indicates that any additional care can be provided in a convalescentand long-term illness care facility, by a hospice program, in the physician’s office, or at home.

Normally, this notice is advisory and will not affect your benefits. However, if care becomes custodialin nature, the plan will no longer cover such a stay.

Medical Case ManagementThe plan offers medical case management as a service to a patient who has an illness or injury thatrequires rehabilitation or other long-term health care support. You do not pay for medical casemanagement services.

While your decision to participate is entirely voluntary, medical case management can result inimproved services for your benefit dollar.

During the preadmission certification process described on page 16 and above, the medical reviewerwill become aware of any potential need for long-term care and will refer the case to a medical casemanager for evaluation. If the evaluation shows that medical case management could be beneficial, themedical case manager will contact the patient (or responsible family member) regarding participation.

At no charge to you, medical case management provides personal counseling by experienced healthcare professionals. These medical case managers work with the physician evaluating, among otherthings, diagnosis and expectations for recovery, plan of care, and alternative forms of treatment.

If the patient needs special medical supplies and equipment, physical therapy and rehabilitation,outpatient treatment, and the like, the medical case manager will help arrange for them. The idea is toimprove the quality of care and reduce its cost by minimizing the time spent in the hospital.


If the patient’s physician and medical case manager prescribe alternative forms of treatment that arenot normally covered by the plan, the plan’s service representative must approve the alternative beforethe patient incurs the expense.

To request medical case management, contact the service representative at the telephone numbershown on your health care identification card or in Exhibit 2 on page 42.

Covered Nonnetwork Services and SuppliesYou and your dependents are entitled only to covered services and supplies that the plan determinesto be medically necessary, whether or not you use your primary care physician to manage yourhealth care.

Unless stated otherwise, the list of covered network services and supplies (shown beginning onpage 10) as well as the list of exclusions (shown under “Noncovered Services and Supplies” beginningon page 19) also apply to nonnetwork benefits.

When you choose to receive services without a referral from your primary care physician, the plan willnot pay for preventive care services, transplant benefits, or hearing aid benefits. You are responsible forobtaining preadmission certification for inpatient hospital stays and must pay up to an additional $750if you fail to do so. In addition, the plan places special limits on chiropractic care and skilled nursingfacility care.

The following special coverage provisions apply to nonnetwork benefits.

AcupunctureThe plan covers acupuncture only under nonnetwork benefit provisions (no network benefits areavailable) and only when services are provided by a person licensed to practice acupuncture.

Christian Science TreatmentThe plan covers treatment by a Christian Science practitioner, nurse, and sanatorium only undernonnetwork benefit provisions (no network benefits are available).

The practitioner, nurse, and sanatorium must be authorized as such by the Mother Church, the FirstChurch of Christ, Scientist, of Boston, Massachusetts.

Emergency CareIf you use the hospital emergency room for a nonemergency situation, the plan pays nonnetworkbenefits.

If you use the hospital emergency room for a true emergency (as defined on page 39), the plan payscovered expenses based on network benefit provisions whether or not you use a network hospital. Seepage 11 for details about emergency care.

Skilled Nursing FacilityThe plan pays nonnetwork benefits for services received in a nonnetwork skilled nursing facility(except for custodial care and conditions of senile deterioration, mental retardation, and mentalillness). Admission to the facility must be within 14 days after release from a hospital stay of at leastthree days or within 14 days of a previous confinement in a nursing home.

How to File a ClaimWhen you obtain nonnetwork services (either network provider services obtained without a referralfrom your primary care physician or nonnetwork provider services, including emergency services), yougenerally must pay for the services and then file a claim for reimbursement. Claim forms are availablefrom the plan’s service representative. Complete the claim form and attach an itemized bill that clearlyidentifies the patient, dates of service, types of services, and the charges. If the patient is yourdependent and you are not identified on the bill as a Boeing employee, add your name and SocialSecurity number to the bill. Submit the claim as instructed on the form, being sure to retain a copy ofall itemized bills for your records.


Noncovered Services and SuppliesThe plan does not cover the following services and supplies, whether obtained through networkproviders or through nonnetwork providers, except as specifically noted:

• Services and supplies the plan’s service representative determines are not medically necessary andappropriate for the therapeutic treatment of an illness, injury, or pregnancy, except for certainpreventive care and hospice care as authorized by the service representative.

• Expenses in excess of reasonable and customary charges as determined by the plan’s servicerepresentative.

• All surgery and other health care that the plan’s service representative determines to be experimentalor investigational. The plan will consider medical and scientific literature in making its decision andwill deny coverage for procedures or treatment that

• Does not conform to accepted medical practice.

• Is not proven to be effective for a particular medical condition.

• Has failed to be completely assessed by the scientific community.

• Has not been granted the required approval by a governmental agency when the services areprovided.

• Medical and surgical services for the treatment or control of obesity, unless medically necessary.

• Commercial weight loss programs.

• Treatment of injury or illness arising out of the course of employment.

• Cosmetic surgery or other surgical procedure that is primarily for the purpose of altering appearance.However, surgery that restores a normal bodily function or surgery that is medically necessary iscovered.

• Replacement or repair of lost, stolen, or willfully damaged artificial limbs, eyes, and braces for thearm, leg, back, or neck.

• Physical therapy, speech therapy, or occupational therapy if not restorative or if the plan’s servicerepresentative determines that continued therapy will not show evidence of significant continuedimprovement.

• Vocational or educational testing and/or therapy.

• Naturopathy or hypnotherapy.

• Routine trimming of nails, calluses, or corns unless medically necessary.

• Acupuncture, except as described on page 18 under “Covered Nonnetwork Services and Supplies.”

• Christian Science services, except as described on page 18 under “Covered Nonnetwork Servicesand Supplies.”

• Custodial or domiciliary care, rest cures, or transportation for such care.

• Skilled nursing care for conditions of senile deterioration, mental retardation, or mental illness.

• Care for conditions that state or local law requires to be treated in a public facility.

• Services or supplies to the extent they are covered under any federal, state, or other government plan,except where required by law.

• Confinement, surgical, medical, or other treatment, services, or supplies received in or from aU.S. Government hospital, except as required by law.

• Any accident or illness covered by a workers’ compensation law.

• Costs associated with the collection, preparation, or storage of sperm for artificial insemination,including donor fees.

• Artificial insemination, in vitro fertilization, gamete intrafallopian tube transfer, zygote intrafallopiantube transfer, or similar procedures, which bypass, rather than treat, a functional abnormality.


• Amniocentesis, ultrasound, or any other procedures when used solely for sex determination of afetus, except that genetic counseling and procedures necessary to determine the existence of gender-linked genetic disorders are covered.

• Sex change surgery, presurgery counseling, or hormone therapy.

• Tuboplasty or reversal of voluntary sterilization.

• Physical exams, immunizations, or diagnostic testing required or necessitated by third persons, suchas for employment, flight clearance, summer camp, insurance, foreign travel, and so forth.

• Court-ordered treatment or hospitalization, unless the order is being sought by a network physicianor unless the plan would normally cover it without the court order.

• Over-the-counter disposable or consumable supplies except as described under “Medical Servicesand Supplies” beginning on page 12.

• Services for which no charge is made or for which you are not, in the absence of this plan, legallyobligated to pay.

• Special medical reports not directly related to treatment.

• Appearances in court or at a hearing.

• Dental or orthodontia services except as specifically listed under “Medical Services and Supplies”on page 13.

• Radial keratotomy, vision therapy, eye exams, lenses, or frames for the correction of visiondeficiencies. (See “Vision Care Program,” beginning on page 29, for exam, frame, and lens benefits.)

• Hearing aid care, services or supplies for

• Replacement batteries or any other ancillary equipment obtained after the hearing aid ispurchased.

• Repairs, servicing, or altering of hearing aid equipment.

• Expenses incurred for a hearing aid after the termination of coverage, except for hearing aidsordered before termination and delivered within 30 days after termination.

• Outpatient prescription drugs. (See “Prescription Drug Program,” beginning on page 25, forprescription drug benefits).

• Diabetic supplies, except those noted under “Medical Services and Supplies” on page 12.

• Treatment and testing for mental health or chemical dependency. (See “Mental Health and ChemicalDependency Program,” beginning on page 22.)

• Expenses that you are not legally obligated to pay.

• Personal comfort and convenience items or services, including, but not limited to

• Television, telephone charges, guest meals, or cots for overnight guests while an inpatient.

• Meal preparation or housekeeping services in connection with home health care.

• Assistance in daily living activities such as eating, bathing, dressing, and services primarily forrest, domiciliary, or custodial care.

• Bathtub chairs, safety grab bars, stair gliders, elevators, over-the-bed tables, saunas, or exerciseequipment.

• Hygienic or self-help items or equipment.

• Environmental control equipment such as air purifiers, humidifiers, or electrostatic machines.

• Institutional equipment such as air-fluidized beds or diathermy machines.

• Equipment used for athletic activities, including braces and splints.

• Items not generally accepted by the medical profession as being therapeutically effective, such asauto-tilt chairs, paraffin bath units, or whirlpool baths.


• Charges by a physician, nurse or other medical practitioner who is a close relative or who lives withthe covered individual.

In addition, the plan will not pay benefits under nonnetwork provisions for the following servicesand supplies:

• Preventive care. (See page 10 for a description of preventive care services that are available throughyour network primary care physician.)

• Transplant benefits. (See page 14 for transplant benefits that are available through networkproviders.)

• Hearing aid benefits. (See page 13 for a description of hearing aid benefits that are available throughnetwork providers.)

• Medical expenses incurred to the extent the provider gives a discount, credit, or reduction to thecovered individual.

• Routine trimming of nails, calluses, or corns. (These services may be covered under network benefitswhen recommended by your primary care physician as necessary due to a concurrent medicalcondition.)

• Nutritional evaluations or counseling sessions.


Mental Health and ChemicalDependency ProgramValueOptions is the service representative for the mental health and chemical dependency program.Boeing may change the service representative at any time.

The payment provisions and maximums described in this section apply to the combination of mentalhealth and chemical dependency treatment, except as specifically noted.

Assessment/Referral ProcessTo receive the greatest benefits from the program, you must begin all nonemergency treatment formental health and chemical dependency by completing a confidential assessment/referral process. Youmust receive treatment from a ValueOptions network provider in order to receive network benefits. Allnetwork providers are responsible for having ValueOptions review the care for medical necessity.

To initiate the assessment/referral process, call

• The ValueOptions telephone number listed on your health care identification card, or

• Your local Boeing Employee Assistance Program (EAP).

In an emergency, obtain the necessary emergency care and then call (or have a family member oryour provider call) within 48 hours of receiving the emergency care to initiate the assessment/referral process.

Once you have started the assessment/referral process, the mental health case manager or EAP willprovide ongoing support and management for your treatment.

Use the assessment referral program to begin mental health or chemical dependency treatment.

Payment Provisions With Assessment/ReferralWhen you follow the assessment/referral process, the following payment provisions apply to treatmentof mental health or chemical dependency, or a combination of the two:

• You do not pay a calendar year deductible.

• The program pays 100 percent of certified inpatient care.

• You pay a $10 copayment for each certified outpatient visit; then, the program pays 100 percent.

See “Lifetime Limit for Chemical Dependency Treatment” on page 23 for additional chemicaldependency benefit limits.

Payment Provisions Without Assessment/ReferralIf you choose to see a nonnetwork provider, there is no case management through ValueOptions andthe following payment provisions apply.


Calendar Year DeductibleYou must pay a calendar year deductible of the first $500 of reasonable and customary charges forcovered mental health or chemical dependency services. One deductible satisfies the deductiblerequirement for both mental health and chemical dependency services for the individual; there is nofamily deductible limit for mental health and chemical dependency coverage. This deductible isseparate from the UnitedHealthcare coordinated care plan deductible.

CoinsuranceYou and the program pay reasonable and customary expenses as follows.

Mental Health TreatmentAfter you pay the deductible, the program pays

• 60 percent of inpatient hospital care, including partial hospitalization for up to 20 days per calendaryear. Each two days of partial hospitalization reduces the 20 days of inpatient hospital care byone day.

• 60 percent of an intensive outpatient care program for treatment of mental illness (if available inyour area). Each four days of intensive outpatient care reduces the 20 days available for inpatienthospital treatment of mental illness by one day.

• 60 percent of outpatient care for up to 20 visits per calendar year.

You pay all charges that the program does not pay.

Chemical Dependency TreatmentAfter you pay the deductible, the program pays

• 60 percent of inpatient hospital care. The maximum benefit payable is $200 per day for up to 20 daysper calendar year.

• 60 percent of outpatient care for up to 20 visits per calendar year.

• 60 percent of an intensive outpatient care program for treatment of chemical dependency (ifavailable in your area). The maximum benefit payable is $2,400. Each four days of intensiveoutpatient care reduces the 20 days available for inpatient hospital treatment of chemical dependencyby one day.

You pay all charges that the program does not pay.

See “Lifetime Limit for Chemical Dependency Treatment,” below, for additional chemical dependencybenefit limits.

Lifetime Limit for Chemical DependencyTreatmentEach covered person is eligible for two courses of chemical dependency treatment in a lifetime,whether or not that person uses the assessment/referral process. In addition, nonnetwork providerservices are limited to a $10,000 lifetime maximum.

A course of treatment may include some or all of the following:

• A period of detoxification, if necessary.

• A period of intensive treatment.

• Aftercare for a period of one year from the end of intensive treatment.

If a person suffers a relapse while participating in a course of treatment, further treatment will beconsidered a continuation of the same course of treatment.


The following events are considered to be a course of treatment under the program:

• Completion of intensive care (with or without detoxification) and the one-year aftercare program.

• Detoxification, without continued treatment after detoxification.

• Partial completion of the intensive phase of treatment (with or without detoxification).

• Completion of the intensive phase of treatment, but not the one-year aftercare program.

If a person suffers a relapse after ending any one of these courses of treatment, any new treatment isconsidered a second course of treatment under this program.

How to File a ClaimWhen you follow the assessment/referral process and receive care from a ValueOptions networkprovider, no claim forms are necessary. However, when you obtain care without a referral fromValueOptions or your EAP, you generally must pay for the services and then file a claim forreimbursement.

Claim forms are available from ValueOptions. (See Exhibit 2 on page 42 for ValueOptions’ telephonenumber and address.) Complete the claim form and attach an itemized bill that clearly identifies thepatient, dates of service, types of services, and the charges. If the patient is your dependent and you arenot identified on the bill as a Boeing employee, add your name and Social Security number to the bill.Submit the claim as instructed on the form, being sure to retain a copy of all itemized bills for yourrecords.


Prescription Drug ProgramThe prescription drug program offers benefits through two options: a local participating pharmacyoption and a mail service option. PAID Prescriptions, L.L.C., is the service representative for theparticipating pharmacy option. Merck-Medco Rx Services is the service representative for the mailservice option. Boeing may change the service representative at any time.

CopaymentsYou must pay the copayment amounts listed below for each prescription or refill you order from a localparticipating pharmacy or by mail.

• Generic drug—$5 copayment.

• Brand-name drug when required by the physician or where there is no generic equivalent—$15 copayment.

• Brand-name drug at your request when a generic equivalent is available—$5 copayment plus thedifference in retail cost between the brand-name drug and the service representative’s scheduledprice for the generic equivalent. If the generic drug does not have a scheduled price or yourphysician has requested that only a brand-name drug be used, you pay only a $15 copayment.

A brand-name drug can cost as much as 80 to 90 percent more than the generic equivalent drug. Whenyou request a brand-name drug that is not required by your physician, you will pay much more foryour prescription.

Maximum QuantityThe maximum drug quantity the program will allow for one copayment is a

• 30-day supply when purchased from a local participating pharmacy.

• 90-day supply when purchased through the mail service option.

How to Fill a PrescriptionLocal Participating PharmacyFor short-term prescription drug needs, use a local participating pharmacy. Call PAID Prescriptions tofind participating pharmacies in your area. (See Exhibit 2 on page 42 for PAID Prescriptions’telephone number).

Take your health care identification card and the prescription to the pharmacy. If the prescription is fora dependent, you will need to know the dependent’s date of birth.

The pharmacist will automatically fill your prescription with a generic drug, if available, unless yourphysician has specifically stated that only a brand-name drug should be used.

Pay the pharmacy the applicable copayment (see “Copayments” above). The program will pay thebalance of the cost.

Nonparticipating PharmacyIn most cases, no program benefits are available when you use a nonparticipating pharmacy. There aretwo exceptions:

• You have an emergency outside of your pharmacy’s normal hours, or

• You are traveling and are either unable to locate a participating pharmacy or are outside of theUnited States.


In these situations, you must pay the full cost of the prescription and file a claim for reimbursement ona PAID Prescriptions claim form. Claim forms are available upon request from PAID Prescriptions.(See Exhibit 2 on page 42 for PAID Prescriptions’ telephone number and address.)

Ordering Drugs by MailThe mail service option allows you to purchase up to a 90-day supply of maintenance medicationsprescribed by your physician. You pay only one copayment for each prescription or refill (see“Copayments” on page 25).

Merck-Medco Rx Services generally will deliver your prescription by U.S. mail or United ParcelService within 14 days of your order.

To order a prescription by mail, follow these steps:

• Ask your physician to prescribe up to a 90-day supply of your prescription, plus necessary refills.For example, for a year’s supply at one tablet a day, have the prescription written for 90 tablets plusthree refills, rather than 30 tablets with eleven refills.

• Obtain an order form from Merck-Medco Rx Services. (See Exhibit 2 on page 42 for Merck-Medco’s telephone number, address, and web site address.)

• Mail the original prescription, the order form, and your check, money order, or your authorization tocharge your VISA or Mastercard account to Merck-Medco Rx Services in the preaddressedenvelope.

• To order a refill of a prescription currently on file at Merck-Medco Rx Services, call Merck-Medcoor order through their web site. (See Exhibit 2 on page 42 for the telephone number and web siteaddress.)

When ordering drugs by mail, keep in mind that

• The pharmacist will fill your prescription with a generic drug unless your physician has directedotherwise.

• If you request a brand-name drug when your physician does not require it, the pharmacist willcharge you the $5 copayment plus the difference in retail cost between the brand-name drug and theservice representative’s scheduled price for the generic equivalent. If the generic drug does not havea scheduled price or your physician has requested that only a brand-name drug be used, you pay onlya $15 copayment.

• Some controlled substances are subject to special limitations. The pharmacist will tell you if yourprescription cannot be filled as written.

• The pharmacist may not dispense some prescriptions in a 90-day supply because they come in aprepackaged form.

• The mail order option can save you multiple copayments for some drugs.

New EmployeesIf you need a prescription drug before you receive your health care identification card, you may use aparticipating pharmacy by providing the pharmacist your Social Security number and your groupnumber for prescription drug benefits. If you do not know your group number, contact PAIDPrescriptions at the telephone number listed in Exhibit 2 on page 42.

You also may have your prescription filled through the mail service option.

PreauthorizationThe program requires certain drugs to be approved for medical necessity before they can be dispensed.Because this list changes from time to time, it is not included in this supplement. The pharmacist willcontact your physician to determine the medical necessity for the prescription. The pharmacist willissue the prescription when it is approved, or notify you if it is not approved.


Voluntary FormularyA formulary is a list of cost-effective, commonly prescribed medications from which your physicianmay prescribe when appropriate. You are not limited to using the drugs listed in the formulary, but youand your physician will help to control costs when you do.

A copy of the formulary is included when your health care identification card is issued. You also mayget a copy from PAID Prescriptions to take to your physician at your next visit.

Covered Drugs and ServicesThe program covers prescriptions that meet all of the following qualifications:

• The prescription is written by a physician or dentist who is licensed to prescribe drugs.

• The prescription is dispensed by a licensed pharmacy.

• The drug is a legend drug, which means that federal law requires it to bear the legend, “Caution:Federal Law Prohibits Dispensing Without a Prescription,” or it meets one of the followingrequirements:

• Any compound medication for which at least one ingredient is a legend drug.

• Oral or injectable insulin dispensed only with a physician’s written prescription.

• Syringes in conjunction with a prescription for injectable insulin. (Diabetic supplies are notcovered under the Prescription Drug Program; however, lancets, test strips, and alcohol swabsare covered under the UnitedHealthcare coordinated care plan, as described on page 12.)

Note that you pay a copayment for each item, or the full cost of the item if it costs less than thecopayment.

Noncovered Drugs and ServicesThe program does not cover the following drugs and services, except as specifically noted:

• Any drug that is not medically necessary, except the program covers birth control pills regardless ofmedical necessity.

• The part of a single purchase of a drug that exceeds a

• 30-day supply from a PAID Prescriptions participating pharmacy.

• 90-day supply under the mail service option.

• Drugs or injectable insulin purchased in a quantity greater than prescribed by the physician, or morethan one year after the date of the prescription.

• Drugs or injectable insulin provided by a hospital, convalescent and long-term illness care facility, ora similar facility while confined.

• Drugs given to the patient by the physician who prescribes them.

• Drugs labeled “Caution—Limited by Federal Law to Investigational Use” or drugs used as anexperiment.

• Drugs prescribed for treatment of sickness covered by workers’ compensation, occupational diseaselaw, or similar laws, or injury if it arises out of or in the course of employment.

• Healing devices, immunization agents, blood or blood plasma, health or beauty aids, birth controldevices or supplies, or delivery charges; however, medical devices (including contraceptiveinjections, devices, and implants) dispensed by a physician are covered under the UnitedHealthcarecoordinated care plan, as described on page 11.

• Drugs, supplements, or supplies purchased over the counter.


• Prescriptions from a nonparticipating pharmacy with the following exceptions:

• You have an emergency outside of your pharmacy’s normal hours.

• You are traveling and unable to locate a participating pharmacy or you are outside of the UnitedStates.

• For covered prescriptions from a nonparticipating pharmacy, cost in excess of what the programwould have paid if you had used a participating pharmacy.

• Anorexiants.

• Drugs whose sole purpose is to promote or stimulate hair growth (e.g., minoxidil or Rogaine).

• Lost or misplaced prescription drugs.


Vision Care ProgramVision care services are offered through Avesis Incorporated, the service representative. Boeing maychange the service representative at any time.

The program pays a scheduled amount for the following vision benefits:

• One eye exam every year, and

• In a two-year period, either

• Two sets of frames and lenses or two pairs of contact lenses, or

• One set of frames and lenses and one pair of contact lenses.

How to Get Vision ServicesYou may obtain services from an Avesis provider or from a provider who is not in the Avesis network;however, you will almost always pay less when you use an Avesis provider. The vision maximumbenefits listed in Exhibit 1 on page 30 cover the exam, eyeglass lenses, and many styles of frameswhen obtained through Avesis. You are free to select from any of the Avesis provider’s frames andpay the difference between the program’s maximum benefit and the wholesale price of the frames,if higher.

When you obtain services from a non-Avesis provider, you must pay the difference between theprogram’s maximum benefit and the retail cost of the frames and lenses.

A directory of Avesis providers is available from Avesis; call Avesis at the telephone number listed inExhibit 2 on page 43.

Avesis ProviderPresent your health care identification card to an Avesis provider to identify yourself as covered underthe program. Avesis will pay the program’s maximum benefits for the exam and/or lenses and frames.You will pay any cost in excess of the program’s maximum benefits based on wholesale costs. You donot have to file a claim form when you use an Avesis provider.

Non-Avesis ProviderYou pay the full cost of the service. You then must send the paid bill and a claim form to Avesis forreimbursement up to the program’s maximum benefits. Claim forms are available from Avesis. (SeeExhibit 2 on page 43 for Avesis’s telephone number and address.)

Other Ways to Get Vision CareIf you obtain your vision exam from a non-Avesis provider, you may take the eyeglass prescription toan Avesis provider to get your lenses and frames.

After you have used your vision benefit within a two-year benefit period, you can save money on anyadditional vision services during that period by using Avesis providers.

• Avesis providers will discount additional exams and eyeglasses not covered by the program.

• Most Avesis providers will replace lost or damaged contact lenses for the wholesale cost plus adispensing fee of $10 per lens.


Exhibit 1

Vision Benefits Payable

*The program will pay $125 per contact lens following cataract surgery when visual acuity is notcorrectable to 20/70 in the better eye.

**The fitting fee includes six months of follow-up care and a lens kit.

Vision benefits are payable as follows.

Maximum You Pay With You Pay WithService Benefit Avesis Non-Avesis

Vision exam $30 $0 Retail charges over$30

Frames $25 Charges over $25 Retail charges over$25

Lenses (per pair)Single vision $50 $0 Retail charges over

$50

Bifocal $60 $0 Retail charges over$60

Trifocal $70 $0 Retail charges over$70

Progressive $70 Charges over $70 Retail charges over$70

Lenticular $130 Charges over $70 Retail charges over$130

Contact lenses* (per pair)Standard hard/soft $60 Lens wholesale cost Retail charges over

only** $60

Disposable $60 Lens wholesale cost Retail charges overonly** $60

Semihard and gas $60 Lens wholesale cost Retail charges overpermeable plus $15** $60

Hard/soft for astigmatism $60 Lens wholesale cost Retail charges overplus $40** $60

Extended wear and bifocal $60 Lens wholesale cost Retail charges overplus $65** $60


Noncovered Services and SuppliesThe program does not cover the following services and supplies:

• High power lenses. (You may obtain certain high power lenses through Avesis by paying thelaboratory’s wholesale cost plus $12.)

• Oversize lenses (larger than 65-millimeter box measurement).

• Lens options (e.g., special coatings).

• Tinted lenses other than Rose #1 and Rose #2 tints.

• Medical or surgical treatments of the eye. (These may be covered as a medical expense.)

• Special procedures, such as services or materials for orthoptics and visual training.

• Nonprescription glasses or nonprescription sunglasses.

• Replacement or repair of broken or lost glasses.

• Routine eye exams required by a governmental body or as a condition of employment.

• Services or materials provided under workers’ compensation or similar laws.

• More than one benefit within a vision benefit period. (If you have used your benefit for a visionbenefit period, you can still get a discount for additional services from Avesis, including services forlost, stolen, or broken eyeglasses or contact lenses.)

• Any other treatment or service that is covered as a medical expense under the UnitedHealthcarecoordinated care plan, even if it is not specifically mentioned above.


Review, Appeal, and AcceleratedAppeal ProceduresThe Plan has established procedures for review and appeal of denied claims or eligibility to participateunder the UnitedHealthcare coordinated care plan and the mental health and chemical dependency(ValueOptions), prescription drug (Merck-Medco), and vision care (Avesis) programs described in thissupplement. In addition, these service representatives have established accelerated appeal proceduresthat provide for prompt review of complaints regarding treatment decisions, performance of medicalprocedures, quality of medical services or supplies, access to care, or administration of plan benefitsunder the coordinated care plan and accompanying programs. The addresses and telephone numbers ofall service representatives are listed in Exhibit 2 on pages 42 and 43.

Claim Review and Appeal ProceduresYour initial claim for reimbursement of covered medical, mental health, chemical dependency,prescription drug, or vision care expenses is considered a claim for benefits.

When you receive services from network (or participating) providers under the Plan, you generally donot need to submit a claim for benefits. The network provider will submit a claim to the appropriateservice representative on your behalf and the service representative will pay the network providerdirectly. You will receive an Explanation of Benefits form in the mail each time a claim is processed.

When you receive services from a nonnetwork (or nonparticipating) provider, you generally must paythe provider’s bill and submit a claim to the appropriate service representative for reimbursement. Seepages 14, 18, 24, 26, and 29 for additional information about how to submit a claim under theUnitedHealthcare coordinated care plan, mental health and chemical dependency program, prescriptiondrug program, and vision care program.

When you submit a claim for benefits, the service representative will respond within 90 days ofreceiving the claim. If special circumstances require more time, the review period may be extended upto an additional 90 days. You will be notified in writing of this extension. If your claim is denied, youwill be notified in writing and given the specific reasons for the denial and advised of yourappeal rights.

Often, you can resolve questions about a denied claim without a formal appeal. If you think a benefithas been denied in error, the issue often can be resolved by calling the service representative’s claimoffice and discussing the situation. If the claim is not resolved through an informal review process, youmay file a formal appeal seeking review of that decision.

You or a person you appoint may appeal any denial or partial denial by writing to the servicerepresentative identified on the claim denial notice within 60 days after receiving the denial or partialdenial of plan benefits. You must indicate the reason for your appeal and may include any informationor documents that you believe are relevant to the claim.

The service representative will review the appeal and render a decision. In reviewing your appeal, theservice representative will apply the terms of the plan and will, as appropriate, use its discretion ininterpreting the terms of the plan. The service representative will notify you of its decision within60 days after receiving your appeal. If special circumstances require more time, the review period maybe extended up to an additional 60 days. You will be notified in writing of this extension. The servicerepresentative will provide you with its final decision in writing and will indicate the specific planprovision upon which the decision is based.

If you have not received any notification after 120 days, you should consider your claim to be denied.


Accelerated Appeal ProceduresIf you have a concern or question regarding the provision of health services or benefits (includingtreatment decisions, performance of medical procedures, quality of medical services or supplies,access to care, or administration of plan benefits), you may contact the service representative for anaccelerated appeal at the telephone number or address shown in Exhibit 2 on pages 42 and 43.

UnitedHealthcareYou or your representative has the right to request an accelerated appeal by writing toUnitedHealthcare for a first-level review. A designated representative will contact you in writing toacknowledge receipt of the accelerated request within 10 working days. UnitedHealthcare will performan investigation of the accelerated request within 20 working days after receipt of the request. If theinvestigation cannot be completed within 20 working days, you will be notified in writing on or beforethe 20th working day that a decision will be reached within 30 working days. You will receive a writtennotice of the resolution within 15 working days.

You also have a right to a second-level review. Upon receipt of a request for a second-level review,UnitedHealthcare will submit the accelerated appeal request to a grievance advisory panelconsisting of

• Other plan participants.

• Representatives of UnitedHealthcare that were not involved in the circumstances giving rise to theaccelerated appeal request or in any subsequent investigation or determination of the request.

• A majority of appropriate clinical peers in the same or similar specialty as would typically managethe case being reviewed when the accelerated appeal request involves an adverse determination.These clinical peers will not have been involved in the circumstances giving rise to the acceleratedappeal request or in any subsequent investigation or determination of the request.

A second-level review by the grievance advisory panel will follow the same time frames as afirst-level review.

If you or your representative (i.e., physician or other provider) disagrees with the decision ofnoncertification of an admission or continued stay, the decision may be appealed. Case information isdiscussed within one business day with a medical director or second-level reviewer specializing in anappropriate or related area to the diagnosis or procedure in question. If necessary, the medical directoris available to discuss the case with the attending physician.

An expedited appeal is conducted when the treatment is ongoing or imminent and when not obtainingservices would seriously jeopardize your life or health or would jeopardize your ability to regainmaximum function.

In an expedited appeal, the reviewer tells your physician the decision by telephone. If your expeditedappeal is denied, the reviewer sends written documentation within one business day. Recommendationsof available alternative levels of care, options to receive the criteria in writing, and the standard appealprocess are described in the documentation.

ValueOptionsIn the event ValueOptions makes a decision that a mental health or chemical dependency treatment isnot medically necessary and you want to appeal, two levels of accelerated appeal are available.

A letter is sent to you and the treating provider and facility, if applicable, after each level of appeal,stating the ValueOptions Peer Advisor’s decision and rationale for that decision, as well as additionalappeal rights.


If a ValueOptions Peer Advisor determines that care is not medically necessary, your treating provideror facility, you, or your representative may immediately request a Level I Appeal. This level of appealoffers the provider an opportunity to review your clinical condition with a ValueOptions Peer Advisorwho has not already been involved in the case. Because the care is concurrent, the Level I Appeal mustbe requested immediately. The appeal will be completed within one business day of the request andletters of notification will be mailed within one business day of the decision.

When the Level I Appeal review is complete, the Peer Advisor will verbally inform your provider ofthe decision, including the length of authorization, the level of care authorized, and any alternatives/recommendations that can be authorized. Your provider also will be informed of the Level II Appealprocedure, if appropriate.

If you are discharged prior to a request or completion of a Level I Appeal, your treating provider and/oryou have the right to request a Retrospective Appeal. A complete medical record must accompany therequest. A ValueOptions Peer Advisor will review the record to determine medical necessity of thedays that were noncertified as a result of the peer review decision. The review will occur within sevencalendar days of the request, and letters of notification will be mailed within one business day ofthe decision.

If the determination of no medical necessity is upheld after a Level I Appeal review, your treatingprovider or facility, you, or your representative has the right to request a Level II Appeal. This level ofappeal involves a review by a multidisciplinary committee or independent external reviewer who hasnot previously reviewed the case. If you are in a current course of treatment, the appeal request and thecomplete medical record must be submitted to ValueOptions as soon as possible. A Level II Appealwill be conducted within seven calendar days of receipt of the required information. External Level IIAppeal reviews will be completed within 10 business days of receipt of required information.

If you are discharged prior to a request for completion of a Level II Appeal, your treating provider orfacility, you, or your representative has the right to request a Retrospective Appeal. A completemedical record must accompany the request. A ValueOptions Peer Advisor not previously involved willreview the record to determine medical necessity of the days that were noncertified as a result of theLevel I Appeal decision. The retrospective Level II Appeal will be completed according to the samestandards that apply to the concurrent Level II Appeal.

Letters of notification for all Level II Appeals will be mailed within one business day of the decision.

Merck-MedcoYour physician can submit a request for review of a pharmacy decision on your behalf, in writing, toMerck-Medco’s Appeals Decision Committee. The appeal request must include relevant clinicalinformation to support the request.

Merck-Medco may require additional information from the physician. Merck-Medco also may conductresearch to obtain additional information from online searches, the Merck-Medco Medical ResourceCenter, or physician specialists.

A review decision normally will be made within five working days of the date Merck-Medco receivesall requested information. The physician will be notified of the appeal decision by telephone, and youand the physician will be notified in writing.

AvesisIf you are dissatisfied with services received under the vision care program, a request for anaccelerated appeal must be submitted, in writing, by you or a participating provider to Avesis MemberServices or the Provider Relations Department within 120 days following accrual of a claim or action.The Avesis Grievance Committee will try to resolve an accelerated appeal request made by you or aparticipating provider within 30 days of receipt of the accelerated appeal request. If a resolution is not


reached within 30 days, the Grievance Committee will notify you or the participating provider of a30-day extension from the date the accelerated appeal request is received. If, however, circumstancesbeyond Avesis’s control make it impractical for a decision to be reached within 60 days, you or theparticipating provider will be advised of the reasons for the delay and the anticipated decision date.The Grievance Committee’s decision will be mailed to you or the participating provider within sevenworking days following the decision.

Eligibility Review and Appeal ProceduresIf you believe you have been improperly denied participation in this Plan or you have been improperlydenied the ability to make a qualified status change, you may follow the general appeal proceduredescribed in the preceding section. The only difference is that your initial appeal will be made to theBoeing Service Center for Health and Welfare Plans (instead of the service representative). Any appealmust be made within 60 days of the date you or your dependent are denied participation or are denied aqualified status change.

For eligibility or participation appeals, you or a person you appoint may request a review by theBoeing Employee Benefit Plans Committee, or its delegate, if the Boeing Service Center denies yourappeal. It is the Committee’s exclusive right to interpret the terms of the Plan and, exercising itsdiscretion, to determine all questions arising under the Plan. The decisions of the Committee are finaland binding.

Your request to the Committee must be in writing, and must be made within 60 days after you receivethe Boeing Service Center’s decision. You must indicate the reasons for your appeal, and you mayinclude any information or documents that you believe are relevant to the appeal. The Committee willadvise you of its decision, usually within 60 days of receiving your request. Up to an additional60 days may be required in special circumstances. You will be notified in writing of this extension.

The address of the Boeing Employee Benefit Plans Committee is Employee Benefit Plans Committee,The Boeing Company, 7755 East Marginal Way S., P.O. Box 3707, MC 11-57, Seattle, WA98124-2207.

You may not take legal action against the Company for any claim for benefits or denied participationunder this Plan unless you instigate the legal action within two years after the rendering of the servicesupon which the claim is based or within two years of the date you or your dependent is initially deniedparticipation in the Plan.


Coordination of BenefitsIf you or your dependents have medical, dental, or other health coverage in addition to being coveredunder the UnitedHealthcare coordinated care plan, mental health and chemical dependency program,or vision care program described in this supplement, these rules govern coordination of benefits withyour other coverage. Other coverage includes, whether insured or uninsured, another employer’s groupbenefit plan, other arrangement of individuals in a group, Medicare (to the extent allowed by law),individual insurance or health coverage, and insurance that pays without consideration of fault, such ashomeowners or automobile medical payments or personal injury protection.

The plan that pays its benefits first is considered the primary plan of coverage and pays its benefitswithout regard to benefits that may be payable under other plans.

When another plan is the primary plan for coverage, the UnitedHealthcare coordinated care plan,mental health and chemical dependency program, and vision care program (only for expenses incurredwith non-Avesis providers) pay the difference between the benefits paid by the primary plan and whatwould have been paid had these Boeing plans/programs been primary.

A plan is considered primary if

• It has no order of benefit determination rules.

• It has benefit determination rules that differ from coordination of benefit rules under stateregulations or, if not insured, that differ from these rules.

• All plans that cover an individual use the same coordination of benefit rules, and under those rules,the plan is primary.

If the above rules do not determine which group plan is considered primary, these Boeing plans/programs apply the following coordination of benefits rules:

1. A plan that covers a person as an employee, retiree, member, or subscriber pays before a plan thatcovers the person as a dependent.

2. A plan that covers a person as an active employee or dependent of an active employee is primary.The plan that covers a person as a retired, laid-off, or other inactive employee or dependent of aretired, laid-off, or other inactive employee is secondary.

3. If a dependent child is covered under both parents’ group plans, the child’s primary coverage isprovided through the parent whose birthday comes first in the calendar year, with secondarycoverage being provided through the parent whose birthday comes later in the calendar year.

4. If a dependent child’s parents are divorced or separated and a court decree establishes financialresponsibility for the health care coverage of the child, the plan of the parent with such financialresponsibility is the primary plan of coverage. If the divorce decree is silent on the issue ofcoverage, the following guidelines are used:

a. The plan of the parent with custody pays benefits first.

b. The plan of the spouse of the parent with custody pays second.

c. The plan of the parent without custody pays third.

d. The plan of the spouse of the parent without custody pays fourth.

5. If none of the above rules establishes which group plan should pay first, then the plan that hascovered the person for the longest period of time is considered the primary plan of coverage.


6. Continuation coverage provided under the Consolidated Omnibus Budget Reconciliation Act of1985 (COBRA) is always secondary to other coverage, except as required by law.

7. If you (or an eligible dependent) are confined to a hospital when you first become covered underthis plan, this plan is secondary to any plan already covering you (or your dependent) for theeligible expenses related to that hospital admission.

Benefits under the UnitedHealthcare coordinated care plan, mental health and chemical dependencyprogram, and vision care program described in this supplement are not coordinated with benefits paidunder any other group plan offered by Boeing.

Federal rules govern coordination of benefits with Medicare. Medicare is secondary to coverage as anactive employee or dependent of an active employee. Medicare is primary in most other circumstances.

Treatment of end-stage renal disease is covered by the UnitedHealthcare coordinated care plan for thefirst 30 months following Medicare entitlement due to end-stage renal disease, and Medicare providessecondary coverage. After this 30-month period, Medicare provides primary coverage and theUnitedHealthcare coordinated care plan provides secondary coverage.

The service representatives have the right to obtain and release any information or recover anypayment they consider necessary to administer these provisions.

The exclusion of government benefits and services under the UnitedHealthcare coordinated care plan isdescribed in “Noncovered Services and Supplies” on page 19.


DefinitionsAmbulatory Surgical Center An ambulatory surgical center is a licensed public or private facility withan organized medical staff of physicians that is equipped and operated mainly for performing surgeryand giving skilled nursing care on an outpatient basis. The facility must have registered nurses on dutywhen a patient is in the facility and may not provide services or beds for patients to stay overnight.

Audiologist An audiologist is any person who

• Possesses a master’s or doctorate degree in audiology or speech pathology from an accrediteduniversity.

• Possesses a Certificate of Clinical Competence in Audiology from the American Speech and HearingAssociation.

• Is qualified in the state in which the service is provided to conduct an audiometric examination andhearing aid evaluation test for measuring hearing acuity and determining and prescribing the typeof hearing aid that would best improve the covered person’s loss of hearing acuity. When a physicianperforms the services, the physician is considered an audiologist for purposes of this plan.

Center for Chemical Dependency A center for chemical dependency is a hospital, rehabilitativehospital, residential treatment facility, or an outpatient treatment facility licensed by the state in whichit operates and accredited by the Joint Commission on Accreditation of Healthcare Organizations(JCAHO) as a “rehabilitative facility” for the purpose of treating chemical dependency.

The term does not include institutions primarily engaged in providing custodial, recreational, or socialservices or any facility engaged primarily in providing mental health services not related to chemicaldependency.

Chiropractor A chiropractor is a physician of chiropractic (D.C.) licensed as such by the state inwhich he or she practices and whose scope of practice is the diagnosis and treatment of thesubluxations or misalignments of the spinal column and related bones and tissues that produce nerveinterference.

Christian Science Practitioner A Christian Science practitioner is a person authorized to be aChristian Science practitioner or a Christian Science nurse by the Mother Church, the First Church ofChrist, Scientist, of Boston, Massachusetts.

Christian Science Sanatorium A Christian Science sanatorium is a facility approved for inpatient careby the Mother Church, the First Church of Christ, Scientist, of Boston, Massachusetts.

Confined Confined means a person is admitted as a registered bed patient in a facility upon therecommendation of a physician for medical, mental health, or chemical dependency treatment.

Convalescent and Long-Term Illness Care Facility A convalescent and long-term illness carefacility is

• A ward, a wing, or other especially designated convalescent, chronic disease, or long-stay care unitoperated by or under the supervision of a hospital.

• A free-standing institution operating under the laws governing convalescent hospitals forconvalescent and long-term illness care. Such an institution must have an arrangement with one ormore hospitals for the transfer of patients between the hospital and the facility. It must also beequipped to care adequately for convalescing patients or patients not in need of inpatienthospital care.

Either facility above must be accredited by the Joint Commission on Accreditation of HealthcareOrganizations (JCAHO) or must qualify as an extended care facility under Title XVIII of the SocialSecurity Act of 1965, as amended.


The term does not include hospitals, rest homes, homes for custodial care, homes for the aged, oralcohol or drug rehabilitation centers.

Covered Expense Covered expense means only the expense incurred by a person who is covered bythe plan for medical services and supplies that are specifically allowed by the plan for preventive careor for hospice care, or that are

• Prescribed by a physician for the therapeutic treatment of injury, illness, or pregnancy.

• Medically necessary.

• Not in excess of the reasonable and customary charges as determined by the service representative.

Custodial Care Custodial care is the type of care or service that, even if ordered by a physician, isprimarily for the purpose of

• Meeting the personal needs of the patient.

• Maintaining a level of function (as opposed to specific medical, surgical, or psychiatric care orservices designed to reduce the disability to the extent necessary to enable the patient to live withoutsuch care or services).

This includes help in walking, bathing, dressing, preparing special diets, feeding, and givingmedications that do not require constant attention of trained medical personnel. The plan does notcover custodial care.

Dentist A dentist is a doctor of dental surgery or a doctor of dental medicine legally licensed topractice dentistry and to prescribe medications within the scope of that license.

Disability or Disabled Disability or disabled means that

• An employee cannot perform the material and substantial duties of regular work associated with hisor her age and sex due to injury, illness, or pregnancy.

• A dependent spouse cannot engage in all the normal activities of other people of the same age andsex and in good health, due to injury, illness, or pregnancy.

• Any other covered individual cannot engage in all the normal activities of other people of the sameage and sex and in good health, because of injury or illness.

Note that the definition of disability is somewhat different for the purposes of Social Securityand COBRA.

Doctor (See “Physician.”)

Emergency An emergency is the sudden onset of a medical, surgical, or psychiatric conditionmanifesting itself by acute symptoms of sufficient severity that in absence of immediate medicalattention could reasonably result in

• Placing the life of the patient or, by virtue of the patient’s psychiatric illness, the life of anotherindividual in jeopardy.

• Serious impairment to bodily functions or serious and permanent dysfunction of a bodily organor part.

Home Health Care Agency A home health care agency is a hospital or a nonprofit or public homehealth care agency that

• Primarily provides skilled nursing services and other therapeutic services under the supervision of aphysician or a registered graduate nurse.

• Is run according to rules established by a group of professional persons.

• Maintains clinical records of all patients.

• Does not primarily provide custodial care or mental health care and treatment of the mentally ill.

In those jurisdictions where licensing by statute exists, the home health care agency must be licensedand run according to the laws that regulate home health care.


Home Health Care Services Home health care services are the care and treatment of a person in his orher home. To qualify, the services must be established and approved in writing by a physician whocertifies that the person would require confinement in a hospital or skilled nursing facility if he or shedid not have the care and treatment prescribed for home health care.

Hospice Facility A hospice facility is an institution or part of an institution that

• Primarily provides care for terminally ill patients.

• Is accredited by the National Hospice Organization or Medicare.

• Fulfills any licensing requirements of the state or locality in which it operates.

Hospital A hospital is an institution that meets all of the following criteria:

• Maintains full-time, permanent facilities for the bed care of resident patients.

• Has a physician in regular attendance.

• Provides nursing services by professional registered nurses 24 hours a day, on duty or on call.

• Primarily provides diagnostic and therapeutic services for medical and surgical care of injuries,illnesses, or pregnancies.

• Maintains surgical facilities (not required when the facility is operated primarily for the treatment ofthe chronically and mentally ill).

• Qualifies as a hospital, a psychiatric hospital, or a tuberculosis hospital and as a provider of servicesunder Medicare, if such institution is accredited as a hospital by the Joint Commission onAccreditation of Healthcare Organizations (JCAHO).

• Operates lawfully as a hospital in its area.

Rest homes, nursing homes, convalescent homes, or homes for the aged are not hospitals underthis plan.

Medically Necessary Medically necessary care or treatment is medically necessary only if the medicalplan or service representative determines that it meets all of the following conditions:

• It is appropriate for the symptoms and consistent with the diagnosis. (Appropriate means the type,level, and length of service, and the setting in which the service is provided, are needed to providesafe and adequate care and treatment.)

• It is given in accordance with generally accepted medical practice and professionally recognizedstandards.

• It is not generally considered experimental or unproved.

• It is specifically allowed by the licensing statutes that apply to the provider who treats the patient.

The plan may designate a professional organization as its authorized representative for assessing thenecessity and appropriateness of medical care and treatment.

Mental Illness or Functional Nervous Disorder A mental illness or functional nervous disorder is acondition that is both

• Classified as such in the International Classification of Diseases of the U.S. Department of Health,Education and Welfare (V. Psychoneurotic and Personality Disorders No. 290-315, as amended).

• Considered by the medical profession to be amenable to favorable modification.

Network Provider A network provider (or “participating provider”) is a health care professional,institution, facility, agency, or other organization that has entered into a contract with a servicerepresentative to provide medical, mental health and chemical dependency, prescription drug, or visionservices or supplies at a predetermined cost according to the agreement between the plan/program anda service representative.

The providers qualifying as network or participating providers may change from time to time.


Nurse Nurse means a registered graduate nurse, a licensed practical nurse, or a licensed vocationalnurse who has the right to use the abbreviation R.N., L.P.N., or L.V.N.

Ophthalmologist An ophthalmologist is any licensed physician of medicine or osteopathy legallyqualified to practice medicine, including diagnosis, treatment, and prescribing of lenses to correctconditions of the eye.

Optometrist An optometrist is any person legally licensed to practice optometry as defined by the lawsof the state in which the service is provided.

Participating Provider (See “Network Provider.”)

Pharmacy A pharmacy is a business licensed to dispense prescription drugs by one or morepharmacists who are licensed under the laws of the state in which the pharmacy is located. The term“pharmacy” includes a hospital pharmacy.

Physician Physician means any legally qualified medical physician, surgeon, dentist, osteopath,optometrist, chiropractor, psychologist, or podiatrist practicing within the scope of his or her license.As used in this supplement, the term includes a social worker or counselor holding a graduate degreein counseling or a related field only when under the direction of a legally qualified physician.

Prescription Drug A prescription drug is a drug dispensed only with the written prescription of aphysician, including

• A drug bearing the legend “Caution: Federal law prohibits dispensing without a prescription.”

• Oral or injectable insulin, needles, and syringes.

• A compound medication of which at least one ingredient is a legend drug.

• Any other drug that may legally be dispensed only with the written prescription of a physician.

Reasonable and Customary Charge For medical care, mental health and chemical dependencytreatment, and vision services from nonparticipating providers, a charge will be considered reasonableand customary if it

• Is the normal charge made by the provider for the service or supply.

• Does not exceed the normal charge made by most providers for the same or similar service or supplyin the same geographic area where the service or supply is received.

Service Representative A service representative is an agent who has a contract with Boeing to makebenefit determinations and administer benefit payments under the plan/programs described in thissupplement. A list of service representatives appears in Exhibit 2 on pages 42 and 43. Boeing maychange a service representative at any time.

Skilled Nursing Care Skilled nursing care is care or services prescribed by a physician andfurnished by a licensed registered nurse (R.N.) or licensed practical nurse (L.P.N.). The services maybe provided on a continuous basis (as in a hospital or skilled nursing facility) or on an intermittent/part-time basis. The patient must be under treatment and/or convalescing from an illness or injury thatrequires ongoing evaluation and adjustment of care. The nature of the service and skills required forsafe and effective delivery, rather than the patient’s medical condition, determines whether the serviceis skilled.


Exhibit 2

Where to Get InformationBoeing Service Center for Health and Welfare Plans

Address: 100 Half Day RoadP.O. Box 1466Lincolnshire, IL 60069-1466

Telephone: Seven days a week, 24 hours a day1-888-747-20161-847-883-0746 (if calling from overseas)1-800-855-2880 (hearing impaired)

Representatives Monday through Fridayavailable: 9 a.m. – 8 p.m. (Eastern)

8 a.m. – 7 p.m. (Central)7 a.m. – 6 p.m. (Mountain)6 a.m. – 5 p.m. (Pacific)

Web site: http://resources.hewitt.com/boeing

Services: Participant eligibility processing and records

Coordinated Care Plan Service Representative

Address for claims UnitedHealthcare of the Midwest, Inc.and appeals: P.O. Box 419079

St. Louis, MO 63141-9079

Claim questions: 1-800-482-7115314-592-7930

Services: Claim administration and network management

Mental Health and Chemical Dependency Program Service Representative

Address for claims ValueOptionsand appeals: 340 Golden Shore

Long Beach, CA 90802-4246

Telephone: 1-800-643-4001


Prescription Drug Program Service Representatives

Address for claims Local participating pharmacy programand appeals: PAID Prescriptions, L.L.C.

P.O. Box 737Parsippany, NJ 07054-0737

Telephone: 1-800-841-2797


Address for claims Mail service programand appeals: Merck-Medco Rx Services, Inc.

P.O. Box 3918Spokane, WA 99220-9990

Telephone: 1-800-841-2797

Web site: http://www.merck-medco.com



Exhibit 2 (continued)

Vision Care Program Service Representative

Address for claims Avesis Incorporatedand appeals: Vision Claims Department

P.O. Box 15600Phoenix, AZ 85060

Telephone: 1-800-828-9341


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