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Dear Federal Employees Health Benefits Program Participant:

Welcome to the 2005 Open Season! By continuing to introduce pro-consumer
health care ideas, the Office of Personnel Management (OPM) team has
given you greater, cost effective choices. This year several national
and local health plans are offering new options, strengthening the
Federal Employees Health Benefits (FEHB) Program and highlighting once
again its unique and distinctive market-oriented features. I remain firm
in my belief that you, when fully informed as a Federal subscriber, are
in the best position to make the decisions that meet your needs and
those of your family. Plan brochures provide information to help
subscribers make these fully informed decisions. Please take the time to
review the plan's benefits, particularly Section 2, which explains plan
changes.

Exciting new features this year give you additional opportunities to
save and better manage your hard-earned dollars. For 2005, I am very
pleased and enthusiastic about the new High Deductible Health Plans
(HDHP) with a Health Savings Account (HSA) or Health Reimbursement
Arrangement (HRA) component. This combination of health plan and savings
vehicle provides a new opportunity to save and better manage your money.
If an HDHP/HSA is not for you and you are not retired, I encourage you
to consider a Flexible Spending Account (FSA) for health care. FSAs
allow you to reduce your out-of-pocket health care costs by 20 to more
than 40 percent by paying for certain health care expenses with tax-free
dollars, instead of after-tax dollars.

Since prevention remains a major factor in the cost of health care, last
year OPM launched the *HealthierFeds* campaign. Through this effort we
are encouraging Federal team members to take greater responsibility for
living a healthier lifestyle. The positive effect of a healthier life
style brings dividends for you and reduces the demands and costs within
the health care system. This campaign embraces four key "actions" that
can lead to a healthy America: be physically active every day, eat a
nutritious diet, seek out preventative screenings, and make healthy
lifestyle choices. Be sure to visit *HealthierFeds* at
[www.healthierfeds.opm.gov](http://www.healthierfeds.opm.gov/) for more
details on this important initiative. I also encourage you to visit the
Department of Health and Human Services website on Wellness and Safety,
[www.hhs.gov/safety/index.shtml](http://www.hhs.gov/safety/index.shtml),
which complements and broadens healthier lifestyle resources. The site
provides extensive information from health care experts and
organizations to support your personal interest is staying healthy.

The FEHB Program offers the Federal team the widest array of
cost-effective health care options and the information needed to make
the best choice for you and your family. You will find comprehensive
health plan information in this brochure, in the 2005 Guide to FEHB
Plans, and on the OPM Website at
[www.opm.gov/insure](http://www.opm.gov/insure). I hope you find these
resources useful, and thank you once again for your service to the
nation.

> Sincerely,
>
> Kay Coles James
>
> Director

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**Notice of the United States Office of Personnel Management's**

**Privacy Practices**

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW
IT CAREFULLY.

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

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

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

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

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

-   Where required by law.

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

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

-   To review, make a decision, or litigate your disputed claim.

-   For OPM and the General Accounting Office when conducting audits.

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

-   For Government health care oversight activities (such as fraud and
    abuse investigations),

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

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

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

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

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

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

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

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

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

-   Get a separate paper copy of this notice.

For more information on exercising your rights set out in this notice,
look at [www.opm.gov/insure](http://www.opm.gov/insure) on the Web. You
may also call 202-606-0745 and ask for OPM's FEHB Program privacy
official for this purpose.

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

Privacy Complaints

Unites States Office of Personnel Management

P.O. Box 707

Washington, DC 20004-0707

Filing a complaint will not affect your benefits under the FEHB Program.
You also may file a complaint with the Secretary of the United States
Department of Health and Human Services.

By law, OPM is required to follow the terms in this privacy notice. OPM
has the right to change the way your personal medical information is
used and given out. If OPM makes any changes, you will get a new notice
by mail within 60 days of the change. The privacy practices listed in
this notice are effective April 14, 2003.

Table of Contents

[Introduction 3](#introduction)

[Plain Language 3](#plain-language)

[Stop Health Care Fraud! 3](#stop-health-care-fraud)

[Preventing medical mistakes 4](#preventing-medical-mistakes)

[Section 1. Facts about this HMO plan
6](#section-1.-facts-about-this-hmo-plan)

[How we pay providers 6](#how-we-pay-providers)

[Your Rights 6](#your-rights)

[Service Area 7](#service-area)

[Section 2. How we change for 2005
8](#section-2.-how-we-change-for-2005)

[Program-wide changes 8](#program-wide-changes)

[Changes to this Plan 8](#changes-to-this-plan)

[Section 3. How you get care 9](#section-3.-how-you-get-care)

[Identification cards 9](#identification-cards)

[Where you get covered care 9](#where-you-get-covered-care)

[Plan providers 9](#plan-providers)

[Plan facilities 9](#plan-facilities)

[What you must do to get covered care
9](#what-you-must-do-to-get-covered-care)

[Primary care 9](#primary-care)

[Specialty care 10](#specialty-care)

[Hospital care 10](#hospital-care)

[Circumstances beyond our control 11](#circumstances-beyond-our-control)

[Services requiring our prior approval
11](#services-requiring-our-prior-approval)

[Section 4. Your costs for covered services
12](#section-4.-your-costs-for-covered-services)

[Copayments 12](#copayments)

[Deductible 12](#deductible)

[Coinsurance 12](#coinsurance)

[Your catastrophic protection out-of-pocket maximum
12](#your-catastrophic-protection-out-of-pocket-maximum)

[Section 5. Benefits -- OVERVIEW *(See page 8 for how our benefits
changed this year and page 64 for a benefits summary.)*
13](#section-5.-benefits-overview-see-page-8-for-how-our-benefits-changed-this-year-and-page-64-for-a-benefits-summary.)

[Section 5(a) Medical services and supplies provided by physicians and
other health care professionals
15](#section-5a-medical-services-and-supplies-provided-by-physicians-and-other-health-care-professionals)

[Section 5(b) Surgical and anesthesia services provided by physicians
and other health care professionals
25](#section-5b-surgical-and-anesthesia-services-provided-by-physicians-and-other-health-care-professionals)

[Section 5(c) Services provided by a hospital or other facility, and
ambulance services
30](#section-5c-services-provided-by-a-hospital-or-other-facility-and-ambulance-services)

[Section 5(d) Emergency services/accidents
33](#section-5d-emergency-servicesaccidents)

[Section 5(e) Mental health and substance abuse benefits
35](#section-5e-mental-health-and-substance-abuse-benefits)

[Section 5(f) Prescription drug benefits
37](#section-5f-prescription-drug-benefits)

[Section 5(g) Special features 40](#section-5g-special-features)

-   
-   
-   

[Flexible Benefits Option 40](#flexible-benefits-option)[Blue Access for
Members ^SM^ 40](#blue-access-for-members-sm)[Prenatal Education
40](#prenatal-education)[Section 5(h) Dental benefits
41](#section-5h-dental-benefits)

[Section 5(i) Non-FEHB benefits available to Plan members
44](#section-5i-non-fehb-benefits-available-to-plan-members)

[Section 6. General exclusions -- things we don't cover
45](#section-6.-general-exclusions-things-we-dont-cover)

[Section 7. Filing a claim for covered services
46](#section-7.-filing-a-claim-for-covered-services)

[Section 8. The disputed claims process
47](#section-8.-the-disputed-claims-process)

[Section 9. Coordinating benefits with other coverage
49](#section-9.-coordinating-benefits-with-other-coverage)

[When you have other health coverage
49](#when-you-have-other-health-coverage)

[What is Medicare? 49](#what-is-medicare)

[Should I enroll in Medicare? 49](#should-i-enroll-in-medicare)

[The Original Medicare Plan (Part A or Part B)
50](#the-original-medicare-plan-part-a-or-part-b)

[Medicare Advantage 52](#medicare-advantage)

[TRICARE and CHAMPVA 52](#tricare-and-champva)

[Workers' Compensation 52](#workers-compensation)

[Medicaid 53](#medicaid)

[When other Government agencies are responsible for your care
53](#when-other-government-agencies-are-responsible-for-your-care)

[When others are responsible for injuries
53](#when-others-are-responsible-for-injuries)

[Section 10. Definitions of terms we use in this brochure
54](#section-10.-definitions-of-terms-we-use-in-this-brochure)

[Section 11. FEHB Facts 56](#section-11.-fehb-facts)

[Coverage information 56](#coverage-information)

[No pre-existing condition limitation
56](#no-pre-existing-condition-limitation)

[Where you can get information about enrolling in the FEHB Program
56](#where-you-can-get-information-about-enrolling-in-the-fehb-program)

[Types of coverage available for you and your family
56](#types-of-coverage-available-for-you-and-your-family)

[Children's Equity Act 57](#childrens-equity-act)

[When benefits and premiums start 57](#when-benefits-and-premiums-start)

[When you retire 57](#when-you-retire)

[When you lose benefits 57](#when-you-lose-benefits)

[When FEHB coverage ends 57](#when-fehb-coverage-ends)

[Spouse equity coverage 58](#spouse-equity-coverage)

[Temporary Continuation of Coverage (TCC)
58](#temporary-continuation-of-coverage-tcc)

[Converting to individual coverage
58](#converting-to-individual-coverage)

[Getting a Certificate of Group Health Plan Coverage
58](#getting-a-certificate-of-group-health-plan-coverage)

[Section 12. Two Federal Programs complement FEHB benefits
59](#section-12.-two-federal-programs-complement-fehb-benefits)

[The Federal Flexible Spending Account Program -- *FSAFEDS*
59](#the-federal-flexible-spending-account-program-fsafeds)

[The Federal Long Term Care Insurance Program
62](#the-federal-long-term-care-insurance-program)

[Index 63](#index)

[Summary of benefits for HMO Blue Texas *-* 2005
64](#summary-of-benefits-for-hmo-blue-texas---2005)

[2005 Rate Information for HMO Blue Texas
65](#rate-information-for-hmo-blue-texas)

# Introduction

This brochure describes the benefits of HMO Blue Texas under our
contract (CS 1951) with the United States Office of Personnel
Management, as authorized by the Federal Employees Health Benefits law.
The address for HMO Blue Texas administrative offices is:

HMO Blue Texas

P. O. Box 660044

Dallas, TX 75266

This brochure is the official statement of benefits. No oral statement
can modify or otherwise affect the benefits, limitations, and exclusions
of this brochure. It is your responsibility to be informed about your
health benefits.

If you are enrolled in this Plan, you are entitled to the benefits
described in this brochure. If you are enrolled in Self and Family
coverage, each eligible family member is also entitled to these
benefits. You do not have a right to benefits that were available before
January 1, 2005, unless those benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefit
changes are effective January 1, 2005, and changes are summarized on
page 8. Rates are shown at the end of this brochure*.*.

# Plain Language

All FEHB brochures are written in plain language to make them
responsive, accessible, and understandable to the public. For instance,

-   Except for necessary technical terms, we use common words. For
    instance, "you" means the enrollee or family member, "we" means HMO
    Blue Texas.

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

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

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

# Stop Health Care Fraud!

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

OPM's Office of the Inspector General investigates all allegations of
fraud, waste, and abuse in the FEHB Program regardless of the agency
that employs you or from which you retired.

**[Protect Yourself From Fraud]{.underline}** -- Here are some things
that you can do to prevent fraud:

-   Be wary of giving your plan identification (ID) number over the
    telephone or to people you do not know, except to your doctor, other
    provider, or authorized plan or OPM representative.

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

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

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

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

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

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

    If the provider does not resolve the matter, call us at 877-299-2377
    and explain the situation.

    If we do not resolve the issue:

+-----------------------------------------------------------------------+
| **CALL THE HEALTH CARE FRAUD HOTLINE**                                |
|                                                                       |
| **202-418-3300**                                                      |
|                                                                       |
| **OR WRITE TO:**                                                      |
|                                                                       |
| **United States Office of Personnel Management**                      |
|                                                                       |
| **Office of the Inspector General Fraud Hotline**                     |
|                                                                       |
| **1900 E Street NW Room 6400**                                        |
|                                                                       |
| **Washington, DC 20415-1100**                                         |
+-----------------------------------------------------------------------+

-   Do not maintain as a family member on your policy:

    Your former spouse after a divorce decree or annulment is final
    (even if a court order stipulates otherwise); or

    Your child over age 22 (unless he/she is disabled and incapable of
    self support).

-   If you have any questions about the eligibility of a dependent,
    check with your personnel office if you are employed, with your
    retirement office (such as OPM) if you are retired, or with the
    National Finance Center if you are enrolled under Temporary
    Continuation of Coverage.

-   You can be prosecuted for fraud and your agency may take action
    against you if you falsify a claim to obtain FEHB benefits or try to
    obtain services for someone who is not an eligible family member or
    who is no longer enrolled in the Plan.

# Preventing medical mistakes

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

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

-   Ask questions and make sure you understand the answers.

-   Choose a doctor with whom you feel comfortable talking.

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

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

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

-   Tell them about any drug allergies you have.

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

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

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

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

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

-   Ask when and how you will get the results of tests or procedures.

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

-   Call your doctor and ask for your results.

-   Ask what the results mean for your care.

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

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

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

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

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

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

-   Ask your surgeon:

> Exactly what will you be doing?
>
> About how long will it take?
>
> What will happen after surgery?
>
> How can I expect to feel during recovery?

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

Want more information on patient safety?

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

-   [www.npsf.org](http://www.npsf.org/). The National Patient Safety
    Foundation has information on how to ensure safer health care for
    you and your family.

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

-   [www.leapfroggroup.org](http://www.leapfroggroup.org/). The Leapfrog
    Group is active in promoting safe practices in hospital care.

-   [www.ahqa.org](http://www.ahqa.org/). The American Health Quality
    Association represents organizations and health care professionals
    working to improve patient safety.

-   [www.quic.gov/report](http://www.quic.gov/report). Find out what
    federal agencies are doing to identify threats to patient safety and
    help prevent mistakes in the nation's health care delivery system.

# Section 1. Facts about this HMO plan

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

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

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

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

### How we pay providers

We contract with individual physicians, medical groups, and hospitals to
provide the benefits in this brochure. These Plan providers accept a
negotiated payment from us, and you will only be responsible for your
copayments or coinsurance. Some Primary Care Physicians (PCP) are paid
under a method known as capitation. Capitation pre-pays a physician
based on a fixed monthly amount per person, no matter how few or many
services a patient uses.

Most specialists are paid on a fee-for service basis (as set for
specific services).

### Your Rights

OPM requires that all FEHB Plans provide certain information to their
FEHB members. You may get information about us, our networks, providers,
and facilities. OPM's FEHB Web site
([www.opm.gov/insure](http://www.opm.gov/insure)) lists the specific
types of information that we must make available to you. Some of the
required information is listed below.

-   On January 1, 2004, Southwest Texas, Inc. d/b/a HMO Blue Texas
    merged with Health Care Service Corporation. HMO Blue Texas is
    offered by Blue Cross and Blue Shield of Texas, a Division of Health
    Care Service Corporation, a Mutual Legal Reserve Company, an
    Independent Licensee of the Blue Cross and Blue Shield Association;

-   Care management, including medical practice guidelines; and

-   Disease Management Programs

If you want more information about us, call 877-299-2377, or write HMO
Blue Texas @ P.O. Box 660044, Dallas, TX 75266-0044. You may also visit
our Web site at [www.bcbstx.com/fep/hbtx](http://www.xxx.xxx/).

### Service Area

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

**Houston Territory**

The Texas counties of: Austin, Brazoria, Chambers, Colorado, Fort Bend,
Galveston, Grimes, Harris, Liberty, Matagorda, Montgomery, San Jacinto,
Walker, Waller, Washington and Wharton.

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

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

# Section 2. How we change for 2005

Do not rely on these change descriptions; this page is not an official
statement of benefits. For that, go to Section 5 Benefits. Also, we
edited and clarified language throughout the brochure; any language
change not shown here is a clarification that does not change benefits.

### Program-wide changes

-   In Section 9, we revised the **Medicare Primary Payer Chart** and
    updated the language regarding Medicare Advantage plans (formerly
    called Medicare Advantage plans).

-   In Section 12, we revised the language regarding the Flexible
    Spending Account Program - *FSAFEDS* and the Federal Long Term Care
    Insurance Program.

### Changes to this Plan

-   Your share of the non-Postal premium will increase by 35.3% for Self
    Only or 48.1% for Self and Family.

-   We changed the mail order copay for diabetic supplies to \$20.
    Previously, the copay was \$80.

# Section 3. How you get care

+--------------------+-------------------------------------------------+
| ### Id             | We will send you an identification (ID) card    |
| entification cards | when you enroll. You should carry your ID card  |
|                    | with you at all times. You must show it         |
|                    | whenever you receive services from a Plan       |
|                    | provider, or fill a prescription at a Plan      |
|                    | pharmacy. Until you receive your ID card, use   |
|                    | your copy of the Health Benefits Election Form, |
|                    | SF-2809, your health benefits enrollment        |
|                    | confirmation (for annuitants), or your Employee |
|                    | Express confirmation letter.                    |
+--------------------+-------------------------------------------------+
|                    | If you do not receive your ID card within 30    |
|                    | days after the effective date of your           |
|                    | enrollment, or if you need replacement cards,   |
|                    | call us at 877-299-2377 or write to us at P. O. |
|                    | Box 660044; Dallas, Texas 75266-0044. You may   |
|                    | also request replacement cards through our Web  |
|                    | site at www.bcbstx.com/fep/hbtx.                |
+--------------------+-------------------------------------------------+
| ### Where yo       | You get care from "Plan providers" and "Plan    |
| u get covered care | facilities." You will only pay copayments,      |
|                    | and/or coinsurance and you will not have to     |
|                    | file claims.                                    |
+--------------------+-------------------------------------------------+
| #                  | Plan providers are physicians and other health  |
| ### Plan providers | care professionals in our service area that we  |
|                    | contract with to provide covered services to    |
|                    | our members. We credential Plan providers       |
|                    | according to national standards.                |
|                    |                                                 |
|                    | We list Plan providers in the provider          |
|                    | directory, which we update periodically. The    |
|                    | list is also on our Web site,                   |
|                    | www.bcbstx.com/fep/hbtx.com.                    |
+--------------------+-------------------------------------------------+
| ##                 | Plan facilities are hospitals and other         |
| ## Plan facilities | facilities in our service area that we contract |
|                    | with to provide covered services to our         |
|                    | members. We list these in the provider          |
|                    | directory, which we update periodically. The    |
|                    | list is also on our Web site,                   |
|                    | www.bcbstx.com/fep/hbtx.                        |
+--------------------+-------------------------------------------------+
| ###                | It depends on the type of care you need. First, |
| What you must do t | you and each family member must choose a        |
| o get covered care | primary care physician (PCP). This decision is  |
|                    | important since your PCP provides or arranges   |
|                    | for most of your health care. To select a PCP,  |
|                    | refer to the provider directory or website to   |
|                    | find a doctor that meets your personal criteria |
|                    | and preferences (provider type, location, etc). |
+--------------------+-------------------------------------------------+
| #### Primary care  | Your PCP can be a family practitioner,          |
|                    | internist, pediatrician. Your PCP will provide  |
|                    | most of your health care or give you a referral |
|                    | to see a specialist. Your PCP is part of a      |
|                    | Limited Provider Network. This means all of     |
|                    | your medical care must come from providers who  |
|                    | are in the same Limited Provider Network. You   |
|                    | will not be able to select any physician or     |
|                    | provider outside of your PCP network, even if   |
|                    | that physician is participating in HMO Blue     |
|                    | Texas. For more information on Limited Provider |
|                    | Networks, please refer to the Provider          |
|                    | Directory.                                      |
|                    |                                                 |
|                    | If you want to change PCPs or if your PCP       |
|                    | leaves the Plan, call us. We will help you      |
|                    | select a new one.                               |
+--------------------+-------------------------------------------------+
| #                  | Your PCP will refer you to a specialist for     |
| ### Specialty care | needed care. When you receive a referral from   |
|                    | your PCP, you must return to the PCP after the  |
|                    | consultation, unless your PCP authorized a      |
|                    | certain number of visits without additional     |
|                    | referrals. The PCP must provide or authorize    |
|                    | all follow-up care. Do not go to the specialist |
|                    | for return visits unless your PCP gives you a   |
|                    | referral. However, you may see a Plan OB/GYN or |
|                    | mental health substance abuse provider without  |
|                    | a referral.                                     |
|                    |                                                 |
|                    | Here are some other things you should know      |
|                    | about specialty care:                           |
|                    |                                                 |
|                    | -   If you need to see a specialist frequently  |
|                    |     because of a chronic, complex, or serious   |
|                    |     medical condition, your PCP will work with  |
|                    |     the specialist, to develop a treatment plan |
|                    |     that allows you to see your specialist for  |
|                    |     a certain number of visits without          |
|                    |     additional referrals. Your PCP will use our |
|                    |     criteria when creating your treatment plan  |
|                    |     (the physician may have to get an           |
|                    |     authorization or approval beforehand).      |
|                    |                                                 |
|                    | -   If you are seeing a specialist when you     |
|                    |     enroll in our Plan, talk to your primary    |
|                    |     care physician. PCP will decide what        |
|                    |     treatment you need. If he or she decides to |
|                    |     refer you to a specialist, ask if you can   |
|                    |     see your current specialist. If your        |
|                    |     current specialist does not participate     |
|                    |     with us, you must receive treatment from a  |
|                    |     specialist who does. Generally, we will not |
|                    |     pay for you to see a specialist who does    |
|                    |     not participate with our Plan.              |
|                    |                                                 |
|                    | -   If you are seeing a specialist and your     |
|                    |     specialist leaves the Plan, call your PCP,  |
|                    |     who will arrange for you to see another     |
|                    |     specialist. You may receive services from   |
|                    |     your current specialist until we can make   |
|                    |     arrangements for you to see someone else.   |
|                    |                                                 |
|                    | -   If you have a chronic and disabling         |
|                    |     condition and lose access to your           |
|                    |     specialist because we:                      |
|                    |                                                 |
|                    | ```{=html}                                      |
|                    | <!-- -->                                        |
|                    | ```                                             |
|                    | -   Terminate our contract with your specialist |
|                    |     for other than cause; or                    |
|                    |                                                 |
|                    | -   Drop out of the Federal Employees Health    |
|                    |     Benefits (FEHB) Program and you enroll in   |
|                    |     another FEHB program Plan; or               |
|                    |                                                 |
|                    | -   Reduce our service area and you enroll in   |
|                    |     another FEHB Plan.                          |
|                    |                                                 |
|                    | you may be able to continue seeing your         |
|                    | specialist for up to 90 days after you receive  |
|                    | notice of the change. Contact us, or if we drop |
|                    | out of the Program, contact your new plan.      |
|                    |                                                 |
|                    | If you are in the second or third trimester of  |
|                    | pregnancy and you lose access to your           |
|                    | specialist based on the above circumstances,    |
|                    | you can continue to see your specialist until   |
|                    | the end of your postpartum care, even if it is  |
|                    | beyond the 90 days.                             |
+--------------------+-------------------------------------------------+
| #### Hospital care | Your Plan PCP or specialist will make necessary |
|                    | hospital arrangements and supervise your care.  |
|                    | This includes admission to a skilled nursing or |
|                    | other type of facility.                         |
|                    |                                                 |
|                    | If you are in the hospital when your enrollment |
|                    | in our Plan begins, call our customer service   |
|                    | department immediately at 877-299-2377. If you  |
|                    | are new to the FEHB Program, we will arrange    |
|                    | for you to receive care.                        |
|                    |                                                 |
|                    | If you changed from another FEHB plan to us,    |
|                    | your former plan will pay for the hospital stay |
|                    | until:                                          |
|                    |                                                 |
|                    | -   You are discharged, not merely moved to an  |
|                    |     alternative care center; or                 |
|                    |                                                 |
|                    | -   The day your benefits from your former plan |
|                    |     run out; or                                 |
|                    |                                                 |
|                    | -   The 92^nd^ day after you become a member of |
|                    |     this Plan, whichever happens first.         |
|                    |                                                 |
|                    | These provisions apply only to the benefits of  |
|                    | the hospitalized person. If your plan           |
|                    | terminates participation in the FEHB Program in |
|                    | whole or in part, or if OPM orders an           |
|                    | enrollment change, this continuation of         |
|                    | coverage provision does not apply. In such      |
|                    | case, the hospitalized family member's benefits |
|                    | under the new plan begin on the effective date  |
|                    | of enrollment.                                  |
+--------------------+-------------------------------------------------+
| ### Circumstances  | Under certain extraordinary circumstances, such |
| beyond our control | as natural disasters, we may have to delay your |
|                    | services or we may be unable to provide them.   |
|                    | In that case, we will make all reasonable       |
|                    | efforts to provide you with the necessary care. |
+--------------------+-------------------------------------------------+
| ### S              | Your primary care physician has authority to    |
| ervices requiring  | refer you for most services. For certain        |
| our prior approval | services, however, your physician must obtain   |
|                    | approval from us. Before giving approval, we    |
|                    | consider if the service is covered, medically   |
|                    | necessary, and follows generally accepted       |
|                    | medical practice.                               |
|                    |                                                 |
|                    | We call this review and approval process        |
|                    | preauthorization*.* Your physician must obtain  |
|                    | preauthorization for the following services:    |
|                    |                                                 |
|                    | -   Hospitalization                             |
|                    |                                                 |
|                    | -   Outpatient Facility                         |
|                    |                                                 |
|                    | -   Ancillary Facility                          |
|                    |                                                 |
|                    | -   Referral to non-participating provider      |
|                    |                                                 |
|                    | -   Surgical procedures                         |
|                    |                                                 |
|                    | -   Durable Medical Equipment                   |
+--------------------+-------------------------------------------------+

# Section 4. Your costs for covered services

You must share the costs of some services. You are responsible for:

+------------------+---------------------------------------------------+
| ### Copayments   | A copayment is a fixed amount of money you pay to |
|                  | the provider, facility, pharmacy, etc., when you  |
|                  | receive services.                                 |
|                  |                                                   |
|                  | Example: When you see your primary care physician |
|                  | you pay a copayment of \$20 per office visit and  |
|                  | when you go in the hospital, you pay \$100 per    |
|                  | admission.                                        |
+------------------+---------------------------------------------------+
| ### Deductible   | We do not have a deductible                       |
+------------------+---------------------------------------------------+
| ### Coinsurance  | Coinsurance is the percentage of our allowance    |
|                  | that you must pay for your care.                  |
|                  |                                                   |
|                  | Example: In our Plan, you pay 20% of our          |
|                  | allowance for durable medical equipment.          |
+------------------+---------------------------------------------------+
| ### You          | After your copayments total \$1,000 per person or |
| r catastrophic p | \$3,000 per family enrollment in any calendar     |
| rotection out-of | year, you do not have to pay any more for covered |
| -pocket maximum  | services. However, copayments for the following   |
|                  | services do not count toward your catastrophic    |
|                  | protection out-of-pocket maximum, and you must    |
|                  | continue to pay copayments for these services:    |
|                  |                                                   |
|                  | -   Prescription Drugs                            |
|                  |                                                   |
|                  | -   Durable Medical Equipment                     |
|                  |                                                   |
|                  | -   Dental                                        |
|                  |                                                   |
|                  | -   Vision                                        |
|                  |                                                   |
|                  | -   Blood and Blood Products                      |
|                  |                                                   |
|                  | -   Prosthetic Devices                            |
|                  |                                                   |
|                  | -   Allergy Serum and Injections                  |
|                  |                                                   |
|                  | Be sure to keep accurate records of your          |
|                  | copayments since you are responsible for          |
|                  | informing us when you reach the maximum.          |
+------------------+---------------------------------------------------+

# Section 5. Benefits -- OVERVIEW *(See page 8 for how our benefits changed this year and page 64 for a benefits summary.)*

*Note: This benefits section is divided into subsections. Please read
the important things you should keep in mind at the beginning of each
subsection. Also read the General Exclusions in Section 6; they apply to
the benefits in the following subsections. To obtain claim forms, claims
filing advice, or more information about our benefits, contact us at
877-299-2377 or at our Web site at
[www.bcbstx.com/fep/hbtx](http://www.xxx.xxx/) .*

[Section 5(a) Medical services and supplies provided by physicians and
other health care professionals
15](#section-5a-medical-services-and-supplies-provided-by-physicians-and-other-health-care-professionals)

[Diagnostic and treatment services
15](#diagnostic-and-treatment-services)

[Lab, X-ray and other diagnostic tests
16](#lab-x-ray-and-other-diagnostic-tests)

[Preventive care, adult 16](#preventive-care-adult)

[Preventive care, children 17](#preventive-care-children)

[Maternity care 17](#maternity-care)

[Family planning 18](#family-planning)

[Infertility services 18](#infertility-services)

[Allergy care 19](#allergy-care)

[Treatment therapies 20](#treatment-therapies)

[Physical and occupational therapies
20](#physical-and-occupational-therapies)

[Speech therapy 21](#speech-therapy)

[Hearing services (testing, treatment, and supplies)
21](#hearing-services-testing-treatment-and-supplies)

[Vision services (testing, treatment, and supplies)
21](#vision-services-testing-treatment-and-supplies)

[Foot care 21](#foot-care)

[Orthopedic and prosthetic devices
22](#orthopedic-and-prosthetic-devices)

[Durable medical equipment (DME) 23](#durable-medical-equipment-dme)

[Home health services 24](#home-health-services)

[Chiropractic 24](#chiropractic)

[Alternative treatments 24](#alternative-treatments)

[Educational classes and programs 24](#educational-classes-and-programs)

[Section 5(b) Surgical and anesthesia services provided by physicians
and other health care professionals
25](#section-5b-surgical-and-anesthesia-services-provided-by-physicians-and-other-health-care-professionals)

[Surgical procedures 25](#surgical-procedures)

[Reconstructive surgery 26](#reconstructive-surgery)

[Oral and maxillofacial surgery 27](#oral-and-maxillofacial-surgery)

[Organ/tissue transplants 28](#organtissue-transplants)

[Anesthesia 29](#anesthesia)

[Section 5(c) Services provided by a hospital or other facility, and
ambulance services
30](#section-5c-services-provided-by-a-hospital-or-other-facility-and-ambulance-services)

[Inpatient hospital 30](#inpatient-hospital)

[Outpatient hospital or ambulatory surgical center
31](#outpatient-hospital-or-ambulatory-surgical-center)

[Extended care benefits/Skilled nursing care facility benefits
31](#extended-care-benefitsskilled-nursing-care-facility-benefits)

[Hospice care 32](#hospice-care)

[Ambulance 32](#ambulance)

[Section 5(d) Emergency services/accidents
33](#section-5d-emergency-servicesaccidents)

[Emergency within our service area 34](#__RefHeading___Toc81986560)

[Emergency outside our service area 34](#__RefHeading___Toc81986561)

[Ambulance 34](#__RefHeading___Toc81986562)

[Section 5(e) Mental health and substance abuse benefits
35](#section-5e-mental-health-and-substance-abuse-benefits)

[Mental health and substance abuse benefits
35](#mental-health-and-substance-abuse-benefits)

[Section 5(f) Prescription drug benefits
37](#section-5f-prescription-drug-benefits)

[Covered medications and supplies 38](#covered-medications-and-supplies)

[Section 5(g) Special features 40](#section-5g-special-features)

[Flexible benefits option 40](#flexible-benefits-option)

[Blue Access for Members ^SM^ 40](#blue-access-for-members-sm)

[Prenatal Education 40](#prenatal-education)

[Section 5(h) Dental benefits 41](#section-5h-dental-benefits)

[Accidental injury benefit 41](#accidental-injury-benefit)

[Section 5(i) Non-FEHB benefits available to Plan members
44](#section-5i-non-fehb-benefits-available-to-plan-members)

[Summary of benefits for the HMO Blue Texas *-* 2005
64](#summary-of-benefits-for-hmo-blue-texas---2005)

[2005 Rate Information for HMO Blue Texas
65](#rate-information-for-hmo-blue-texas)

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

+---+---+-------------------------------------+---------------------+---+---+
|   | * | **Here are some important things    |                     | * |   |
|   | * | you should keep in mind about these |                     | * |   |
|   | I | benefits:**                         |                     | I |   |
|   | * |                                     |                     | * |   |
|   | * | -   Please remember that all        |                     | * |   |
|   |   |     benefits are subject to the     |                     |   |   |
|   | * |     definitions, limitations, and   |                     | * |   |
|   | * |     exclusions in this brochure and |                     | * |   |
|   | M |     are payable only when we        |                     | M |   |
|   | * |     determine they are medically    |                     | * |   |
|   | * |     necessary.                      |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * | -   Plan physicians must provide or |                     | * |   |
|   | * |     arrange your care.              |                     | * |   |
|   | P |                                     |                     | P |   |
|   | * | -   We have no calendar year        |                     | * |   |
|   | * |     deductible.                     |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * | -   Be sure to read Section 4,      |                     | * |   |
|   | * |     *Your costs for covered         |                     | * |   |
|   | O |     services*, for valuable         |                     | O |   |
|   | * |     information about how cost      |                     | * |   |
|   | * |     sharing works. Also read        |                     | * |   |
|   |   |     Section 9 about coordinating    |                     |   |   |
|   | * |     benefits with other coverage,   |                     | * |   |
|   | * |     including with Medicare.        |                     | * |   |
|   | R |                                     |                     | R |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   | T |                                     |                     | T |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   | A |                                     |                     | A |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   | N |                                     |                     | N |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   | T |                                     |                     | T |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
+---+---+-------------------------------------+---------------------+---+---+
| B |   |                                     | You pay             |   |   |
| e |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| f |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| D |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| p |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| # |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| D |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| g |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| d |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| m |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| v |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| P |   |                                     | \$20 per office     |   |   |
| r |   |                                     | visit               |   |   |
| o |   |                                     |                     |   |   |
| f |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| l |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| v |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| f |   |                                     |                     |   |   |
| p |   |                                     |                     |   |   |
| h |   |                                     |                     |   |   |
| y |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| - |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| I |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| p |   |                                     |                     |   |   |
| h |   |                                     |                     |   |   |
| y |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| ' |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| f |   |                                     |                     |   |   |
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| e |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| - |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| C |   |                                     |                     |   |   |
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| u |   |                                     |                     |   |   |
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| t |   |                                     |                     |   |   |
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| s |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| b |   |                                     |                     |   |   |
| y |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
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| t |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
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| o |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| - |   |                                     | \$35 per office     |   |   |
|   |   |                                     | visit               |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| I |   |                                     |                     |   |   |
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| r |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| - |   |                                     | Nothing             |   |   |
|   |   |                                     |                     |   |   |
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|   |   |                                     |                     |   |   |
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| a |   |                                     |                     |   |   |
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| a |   |                                     |                     |   |   |
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+---+---+-------------------------------------+---------------------+---+---+
| A |   |                                     | \$20 per visit      |   |   |
| t |   |                                     |                     |   |   |
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| o |   |                                     |                     |   |   |
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| V |   |                                     |                     |   |   |
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| b |   |                                     |                     |   |   |
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| e |   |                                     |                     |   |   |
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|   |   |                                     |                     |   |   |
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| a |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| d |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
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| t |   |                                     |                     |   |   |
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|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| d |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+

+------------------------------------------+---------------------------+
| ####                                     | You pay                   |
| ## Lab, X-ray and other diagnostic tests |                           |
+------------------------------------------+---------------------------+
| Tests, such as:                          | Nothing                   |
|                                          |                           |
| -   Blood tests                          |                           |
|                                          |                           |
| -   Urinalysis                           |                           |
|                                          |                           |
| -   Non-routine pap tests                |                           |
|                                          |                           |
| -   Pathology                            |                           |
|                                          |                           |
| -   X-rays                               |                           |
|                                          |                           |
| -   Non-routine Mammograms               |                           |
|                                          |                           |
| -   CAT Scans/MRI                        |                           |
|                                          |                           |
| -   Ultrasound                           |                           |
|                                          |                           |
| -   Electrocardiogram and EEG            |                           |
+------------------------------------------+---------------------------+
| ###### Preventive care, adult            |                           |
+------------------------------------------+---------------------------+
| Routine screenings, such as:             | Nothing, based on         |
|                                          | physician's recommended   |
| -   Periodic Health Assessments          | schedule                  |
|                                          |                           |
| -   Total Blood Cholesterol -- once      |                           |
|     every year                           |                           |
|                                          |                           |
| -   Colorectal Cancer Screening,         |                           |
|     including                            |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   Fecal occult blood test              |                           |
|                                          |                           |
| -   Sigmoidoscopy, screening -- every    |                           |
|     five years starting at age 50        |                           |
|                                          |                           |
| -   Double contrast barium enema --      |                           |
|     every five starting at age 50        |                           |
|                                          |                           |
| -   Colonoscopy screening -- every ten   |                           |
|     years starting at age 50             |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   Chlamydial infection screening       |                           |
|                                          |                           |
| -   Routine Prostate Specific Antigen    |                           |
|     (PSA) Test -- one annually for men   |                           |
|     age 40 or older                      |                           |
|                                          |                           |
| -   Osteoporosis Screenings -- one       |                           |
|     annually for women age 65 and over.  |                           |
|     The screening is covered at age 60   |                           |
|     for women at increased risk.         |                           |
+------------------------------------------+---------------------------+
| Routine pap test                         | Nothing, for annual exam; |
|                                          | otherwise \$20 for each   |
|                                          | additional visit          |
+------------------------------------------+---------------------------+
| Routine mammogram -- covered for women   | Nothing                   |
| age 35 and older, as follows:            |                           |
|                                          |                           |
| -   From age 35 through 39, one during   |                           |
|     this five year period                |                           |
|                                          |                           |
| -   From age 40 through 64, one every    |                           |
|     calendar year                        |                           |
|                                          |                           |
| -   At age 65 and older, one every two   |                           |
|     consecutive calendar years           |                           |
+------------------------------------------+---------------------------+
|                                          | *Preventive care, adult   |
|                                          | continued on next page*   |
+------------------------------------------+---------------------------+

+------------------------------------------+---------------------------+
| Preventive care, adult *(continued)*     | You pay                   |
+------------------------------------------+---------------------------+
| Routine immunizations, limited to:       | Nothing                   |
|                                          |                           |
| -   Tetanus-diphtheria (Td) booster --   |                           |
|     once every 10 years, ages19 and over |                           |
|     (except as provided for under        |                           |
|     Childhood immunizations)             |                           |
|                                          |                           |
| -   Influenza vaccine, annually          |                           |
|                                          |                           |
| -   Pneumoccal vaccine, age 65 and older |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Physical exams required for         |                           |
|     obtaining or continuing employment   |                           |
|     or insurance, attending schools or   |                           |
|     camp, or travel.*                    |                           |
|                                          |                           |
| -   *Treatment for work related injury   |                           |
|     (if covered by workmen's             |                           |
|     compensation), educational testing   |                           |
|     and therapy and nutritional          |                           |
|     counseling and diet planning.*       |                           |
+------------------------------------------+---------------------------+
| ###### Preventive care, children         |                           |
+------------------------------------------+---------------------------+
| -   Childhood immunizations recommended  | Nothing                   |
|     by the American Academy of           |                           |
|     Pediatrics                           |                           |
+------------------------------------------+---------------------------+
| -   Well-child care charges for routine  | Nothing                   |
|     examinations, immunizations and care |                           |
|     (up to age 22)                       |                           |
|                                          |                           |
| -   Examinations, such as:               |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   Eye exams through age 17 to          |                           |
|     determine the need for vision        |                           |
|     correction                           |                           |
|                                          |                           |
| -   Ear exams through age 17 to          |                           |
|     determine the need for hearing       |                           |
|     correction                           |                           |
|                                          |                           |
| -   Examinations done on the day of      |                           |
|     immunizations (up to age 22)         |                           |
+------------------------------------------+---------------------------+
| ###### Maternity care                    | You pay                   |
+------------------------------------------+---------------------------+
| Complete maternity (obstetrical) care,   | \$20 for initial visit    |
| such as:                                 | only and nothing for      |
|                                          | delivery                  |
| -   Prenatal care                        |                           |
|                                          |                           |
| -   Delivery                             |                           |
|                                          |                           |
| -   Postpartum care                      |                           |
|                                          |                           |
| Note: Here are some things to keep in    |                           |
| mind:                                    |                           |
|                                          |                           |
| -   Plan Physicians must provide or      |                           |
|     arrange your care and you must be    |                           |
|     hospitalized in a Plan facility.     |                           |
|                                          |                           |
| -   You may remain in the hospital up to |                           |
|     48 hours after a regular delivery    |                           |
|     and 96 hours after a cesarean        |                           |
|     delivery. We will extend your        |                           |
|     inpatient stay if medically          |                           |
|     necessary.                           |                           |
|                                          |                           |
| -   We cover routine nursery care of the |                           |
|     newborn child during the covered     |                           |
|     portion of the mother's maternity    |                           |
|     stay. We will cover other care of an |                           |
|     infant who requires non-routine      |                           |
|     treatment only if we cover the       |                           |
|     infant under a Self and Family       |                           |
|     enrollment.                          |                           |
|                                          |                           |
| -   We pay hospitalization and surgeon   |                           |
|     services (delivery) the same as for  |                           |
|     illness and injury. See Hospital     |                           |
|     benefits (Section 5c) and Surgery    |                           |
|     benefits (Section 5b).               |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Routine sonograms to determine      |                           |
|     fetal age, size or sex.*             |                           |
|                                          |                           |
| -   *Charges for normal delivery outside |                           |
|     of the service area.*                |                           |
+------------------------------------------+---------------------------+
| ###### Family planning                   |                           |
+------------------------------------------+---------------------------+
| A range of voluntary family planning     | \$20 per office visit     |
| services, limited to:                    | plus \$25 per procedure   |
|                                          |                           |
| -   Voluntary sterilization (See         |                           |
|     Surgical procedures Section 5 (b))   |                           |
|                                          |                           |
| -   Injectible contraceptive drugs (such |                           |
|     as Depo provera)                     |                           |
|                                          |                           |
| -   Intrauterine device (IUDS)           |                           |
+------------------------------------------+---------------------------+
| -   Surgically implanted contraceptives  | \$20 per office visit     |
|     (such as Norplant)                   | plus 50% of our allowance |
+------------------------------------------+---------------------------+
| Note: A diaphragm and oral               | See page 37 for           |
| contraceptives are covered under the     | prescription drug         |
| prescription drug benefit                | benefit.                  |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   Reversal of voluntary surgical       |                           |
|     sterilization                        |                           |
|                                          |                           |
| -   Genetic counseling.                  |                           |
+------------------------------------------+---------------------------+
| ###### Infertility services              | You pay                   |
+------------------------------------------+---------------------------+
| Diagnostic testing to determine the      | \$20 per office visit     |
| cause of infertility.                    |                           |
|                                          |                           |
| Note: We cover injectible fertility      |                           |
| drugs under medical benefits and oral    |                           |
| fertility drugs under the prescription   |                           |
| drug benefit.                            |                           |
+------------------------------------------+---------------------------+
| Treatment of infertility such as:        | \$20 per office visit     |
|                                          | plus 50% of the Plan's    |
| -   Artificial insemination:             | allowance for each        |
|                                          | service as determined by  |
| ```{=html}                               | us, including physician   |
| <!-- -->                                 | office visit and          |
| ```                                      | laboratory testing.       |
| -   *intravaginal insemination (IVI)*    |                           |
|                                          |                           |
| -   *intracervical insemination (ICI)*   |                           |
|                                          |                           |
| -   *intrauterine insemination (IUI)*    |                           |
+------------------------------------------+---------------------------+
| -   Oral Fertility drugs                 | Note: See page 37 for     |
|                                          | prescription drug benefit |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Assisted reproductive technology    |                           |
|     (ART) procedures, such as:*          |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   *in vitro fertilization*             |                           |
|                                          |                           |
| -   *embryo transfer, gamete             |                           |
|     intra-fallopian transfer (GIFT) and  |                           |
|     zygote intra-fallopian transfer      |                           |
|     (ZIFT)*                              |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   *Services and supplies related to    |                           |
|     ART procedures*                      |                           |
|                                          |                           |
| -   *Donation, preservation, analysis    |                           |
|     and storage of sperm, eggs or        |                           |
|     embryos*                             |                           |
|                                          |                           |
| -   *Cost of donor sperm*                |                           |
|                                          |                           |
| -   *Injectible Fertility Drugs*         |                           |
|                                          |                           |
| -   *Infertility services after          |                           |
|     voluntary sterilization*             |                           |
+------------------------------------------+---------------------------+
| ###### Allergy care                      |                           |
+------------------------------------------+---------------------------+
| -   Testing and treatment                | \$25 for each session of  |
|                                          | testing;                  |
|                                          |                           |
|                                          | \$20 copay for treatment  |
+------------------------------------------+---------------------------+
| -   Allergy injections                   | \$20 copay                |
+------------------------------------------+---------------------------+
| Allergy serum                            | Nothing                   |
+------------------------------------------+---------------------------+
| *Not covered: Provocative food testing   | *All charges.*            |
| and sublingual allergy desensitization*  |                           |
+------------------------------------------+---------------------------+
| ###### Treatment therapies               | You pay                   |
+------------------------------------------+---------------------------+
| -   Chemotherapy and radiation therapy   | \$20 per office visit     |
|                                          |                           |
| Note: High dose chemotherapy in          |                           |
| association with autologous bone marrow  |                           |
| transplants is limited to those          |                           |
| transplants listed under Organ/Tissue    |                           |
| Transplants on page 28.                  |                           |
|                                          |                           |
| -   Respiratory and inhalation therapy   |                           |
|                                          |                           |
| -   Dialysis -- hemodialysis and         |                           |
|     peritoneal dialysis                  |                           |
|                                          |                           |
| -   Intravenous (IV)/Infusion Therapy -- |                           |
|     Home IV and antibiotic therapy       |                           |
+------------------------------------------+---------------------------+
| -   Growth hormone therapy (GHT)         | See page 37 for           |
|                                          | prescription drug benefit |
| Note: Growth hormone is covered under    |                           |
| the prescription drug benefit.           |                           |
|                                          |                           |
| Note: -- We will only cover GHT when we  |                           |
| preauthorize the treatment. The          |                           |
| attending physician must obtain          |                           |
| preauthorization. We will ask your       |                           |
| physician to submit information that     |                           |
| establishes that the GHT is medically    |                           |
| necessary. Ask us to authorize GHT       |                           |
| before you begin treatment; otherwise,   |                           |
| we will only cover GHT services from the |                           |
| date you submit the information. If you  |                           |
| do not ask or if we determine GHT is not |                           |
| medically necessary, we will not cover   |                           |
| the GHT or related services and          |                           |
| supplies. See *Services requiring our    |                           |
| prior approval* in Section 3.            |                           |
+------------------------------------------+---------------------------+
| ###                                      | You pay                   |
| ### Physical and occupational therapies  |                           |
+------------------------------------------+---------------------------+
| Services of each of the following:       | Outpatient: \$20 per      |
|                                          | office visit              |
| -   Qualified physical therapists,       |                           |
|                                          | Inpatient: Nothing --     |
| -   Occupational therapists, and         | included in admission     |
|                                          |                           |
| -   Chiropractic care as physical        |                           |
|     therapy when performed by a          |                           |
|     qualified physical therapist         |                           |
|                                          |                           |
| Note: Physical and occupational therapy  |                           |
| is limited to services that assist the   |                           |
| member to achieve and maintain self-care |                           |
| and improved functioning in other        |                           |
| activities of daily living.              |                           |
|                                          |                           |
| -   Cardiac rehabilitation following a   |                           |
|     heart transplant, bypass surgery or  |                           |
|     a myocardial infarction, is also     |                           |
|     provided subject to limitations      |                           |
|     below..                              |                           |
|                                          |                           |
| Note: We only cover therapy to restore   |                           |
| bodily function when there has been a    |                           |
| total or partial loss of bodily function |                           |
| due to illness or injury.                |                           |
|                                          |                           |
| Note: Your coverage is limited to        |                           |
| services that continue to meet or exceed |                           |
| the treatment goals established for you  |                           |
| by your physician. For the physically    |                           |
| disabled maintenance of functioning or   |                           |
| prevention of or slowing of further      |                           |
| deterioration.                           |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Long-term rehabilitative therapy*   |                           |
|                                          |                           |
| -   *Exercise programs*                  |                           |
+------------------------------------------+---------------------------+
| ###### Speech therapy                    |                           |
+------------------------------------------+---------------------------+
| -   Services of a Speech Therapist       | \$20 per office visit     |
|                                          |                           |
| Note: Speech therapy includes coverage   |                           |
| for rehabilitation or developmental      |                           |
| medical care.                            |                           |
|                                          |                           |
| Note: Your coverage is limited to        |                           |
| service that continue to be medically    |                           |
| necessary.                               |                           |
+------------------------------------------+---------------------------+
| ###### Hearing ser                       |                           |
| vices (testing, treatment, and supplies) |                           |
+------------------------------------------+---------------------------+
| -   One audiogram if medically indicated | Nothing                   |
|     per year                             |                           |
|                                          |                           |
| -   Initial placement of hearing aid     |                           |
|     when medically necessary             |                           |
|                                          |                           |
|     Note: Fitting and purchase of        |                           |
|     hearing aid device(s) is limited to  |                           |
|     \$800 per ear, one cleaning of the   |                           |
|     hearing device(s) per year, and      |                           |
|     replacement every 4 years if         |                           |
|     medically indicated.                 |                           |
|                                          |                           |
| -   Hearing testing for children through |                           |
|     age 17 (see *Preventive care,        |                           |
|     children)*                           |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Replacement for loss, damage or     |                           |
|     functional defect*                   |                           |
+------------------------------------------+---------------------------+
| ###### Vision ser                        | You pay                   |
| vices (testing, treatment, and supplies) |                           |
+------------------------------------------+---------------------------+
| Eye exam (vision screening) to determine | Nothing                   |
| the need for vision correction for       |                           |
| children through age 17 (see Preventive  |                           |
| care, children)                          |                           |
+------------------------------------------+---------------------------+
| -   Implantable lenses following         | Nothing                   |
|     intraocular surgery for cataracts.   |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Eyeglasses or contact lenses and    |                           |
|     after age 17, and examinations for   |                           |
|     them (See page 44 Non-FEHB           |                           |
|     Benefits)*                           |                           |
|                                          |                           |
| -   *Eye exercises and orthoptics*       |                           |
|                                          |                           |
| -   *Radial keratotomy and other         |                           |
|     refractive surgery*                  |                           |
+------------------------------------------+---------------------------+
| ###### Foot care                         |                           |
+------------------------------------------+---------------------------+
| Routine foot care when you are under     | \$20 per office visit     |
| active treatment for a metabolic or      |                           |
| peripheral vascular disease, such as     |                           |
| diabetes.                                |                           |
|                                          |                           |
| Note: See Orthopedic and prosthetic      |                           |
| devices for information on podiatric     |                           |
| shoe inserts.                            |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Cutting, trimming or removal of     |                           |
|     corns, calluses, or the free edge of |                           |
|     toenails, and similar routine        |                           |
|     treatment of conditions of the foot, |                           |
|     except as stated above*              |                           |
|                                          |                           |
| -   *Treatment of weak, strained or flat |                           |
|     feet or bunions or spurs; and of any |                           |
|     instability, imbalance or            |                           |
|     subluxation of the foot (unless the  |                           |
|     treatment is by open cutting         |                           |
|     surgery)*                            |                           |
|                                          |                           |
| -   *Corrective orthopedic shoes, arch   |                           |
|     supports, braces, splints or other   |                           |
|     foot care items.*                    |                           |
+------------------------------------------+---------------------------+
| #                                        | You pay                   |
| ##### Orthopedic and prosthetic devices  |                           |
+------------------------------------------+---------------------------+
| -   Artificial limbs and eyes; stump     | Nothing                   |
|     hose                                 |                           |
|                                          |                           |
| -   Externally worn breast prostheses    |                           |
|     and surgical bras, including         |                           |
|     necessary replacements following a   |                           |
|     mastectomy                           |                           |
|                                          |                           |
| -   Terminal devices such as a hand or   |                           |
|     hook                                 |                           |
|                                          |                           |
| -   Braces for arms, legs, back or neck  |                           |
|                                          |                           |
| -   External cardiac pacemaker           |                           |
|                                          |                           |
| -   Internal prosthetic devices, such as |                           |
|     artificial joints, pacemakers,       |                           |
|     cochlear implants, and surgically    |                           |
|     implanted breast implant following   |                           |
|     mastectomy. Note: Internal           |                           |
|     prosthetic devices are paid as       |                           |
|     hospital benefits; see Section 5(c)  |                           |
|     for payment information. Insertion   |                           |
|     of the device is paid as surgery;    |                           |
|     see Section 5(b) for coverage of the |                           |
|     surgery to insert the device.        |                           |
|                                          |                           |
| -   Foot orthotics when medically        |                           |
|     necessary                            |                           |
|                                          |                           |
|     Note: Coverage is limited to the     |                           |
|     initial device                       |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Orthopedic and corrective shoes     |                           |
|     (unless built into a leg brace) or   |                           |
|     other foot care items*               |                           |
|                                          |                           |
| -   *Arch supports*                      |                           |
|                                          |                           |
| -   *Heel pads and heel cups*            |                           |
|                                          |                           |
| -   *Lumbosacral supports*               |                           |
|                                          |                           |
| -   *Corsets, trusses, elastic           |                           |
|     stockings, support hose, and other   |                           |
|     supportive devices*                  |                           |
|                                          |                           |
| -   *Replacement of external prosthetic  |                           |
|     devices, except for standard         |                           |
|     replacements needed because of       |                           |
|     physical growth by members who are   |                           |
|     under 18 years of age*               |                           |
|                                          |                           |
| -   *Repair or periodic maintenance of   |                           |
|     any external prosthetic devices*     |                           |
|                                          |                           |
| -   *Devices provided solely for         |                           |
|     cosmetic purposes that have no       |                           |
|     functional applications*             |                           |
|                                          |                           |
| -   *Dentures*                           |                           |
|                                          |                           |
| -   *Corrective orthopedic appliances    |                           |
|     for non-dental treatment of          |                           |
|     temporomandibular joint (TMJ) pain   |                           |
|     dysfunction syndrome*                |                           |
+------------------------------------------+---------------------------+
| ###### Durable medical equipment (DME)   | You pay                   |
+------------------------------------------+---------------------------+
| Rental or purchase, at our option,       | 20% of the allowed amount |
| including repair and adjustment, of      |                           |
| durable medical equipment prescribed by  |                           |
| your Plan physician, such as oxygen and  |                           |
| dialysis equipment. Under this benefit,  |                           |
| we also cover                            |                           |
|                                          |                           |
| -   Hospital beds;                       |                           |
|                                          |                           |
| -   Standard Wheelchairs;                |                           |
|                                          |                           |
| -   Crutches;                            |                           |
|                                          |                           |
| -   Walkers;                             |                           |
|                                          |                           |
| -   Bedside Commodes;                    |                           |
|                                          |                           |
| -   Suction Machines;                    |                           |
|                                          |                           |
| -   Orthopedic Tractions                 |                           |
|                                          |                           |
| -   Oxygen; and                          |                           |
|                                          |                           |
| -   Annual audiogram (if medically       |                           |
|     indicated)                           |                           |
|                                          |                           |
| Note: Call us at 877-299-2377 as soon as |                           |
| your Plan physician prescribes this      |                           |
| equipment. Blood Glucose Monitors and    |                           |
| Insulin Pumps are covered under your     |                           |
| pharmacy benefits.                       |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Motorized Wheelchairs*              |                           |
|                                          |                           |
| -   *Deluxe equipment such as motor      |                           |
|     driven hospital beds*                |                           |
|                                          |                           |
| -   *Comfort items*                      |                           |
|                                          |                           |
| -   *Bed boards*                         |                           |
|                                          |                           |
| -   *Bathtub lifts*                      |                           |
|                                          |                           |
| -   *Over bed tables*                    |                           |
|                                          |                           |
| -   *Air Purifiers*                      |                           |
|                                          |                           |
| -   *Disposable supplies*                |                           |
|                                          |                           |
| -   *Elastic stockings*                  |                           |
|                                          |                           |
| -   *Sauna baths*                        |                           |
|                                          |                           |
| -   *Repair, replacement or maintenance  |                           |
|     of equipment purchased by Plan*      |                           |
|                                          |                           |
| -   *Exercise equipment*                 |                           |
|                                          |                           |
| -   *Stethoscopes*                       |                           |
|                                          |                           |
| -   *Sphygmomanometers*                  |                           |
+------------------------------------------+---------------------------+
| ###### Home health services              |                           |
+------------------------------------------+---------------------------+
| -   Home health care ordered by a Plan   | \$20 per office visit     |
|     physician and provided by a          |                           |
|     registered nurse (R.N.), licensed    |                           |
|     practical nurse (L.P.N.), licensed   |                           |
|     vocational nurse (L.V.N.), or home   |                           |
|     health aide.                         |                           |
|                                          |                           |
| -   Services include oxygen therapy,     |                           |
|     intravenous therapy and medications. |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Nursing care requested by, or for   |                           |
|     the convenience of, the patient or   |                           |
|     the patient's family;*               |                           |
|                                          |                           |
| -   *Home care primarily for personal    |                           |
|     assistance that does not include a   |                           |
|     medical component and is not         |                           |
|     diagnostic, therapeutic, or          |                           |
|     rehabilitative*.                     |                           |
+------------------------------------------+---------------------------+
| ###### Chiropractic                      | You pay                   |
+------------------------------------------+---------------------------+
| No benefit                               | *All charges.*            |
|                                          |                           |
| Note: Chiropractic care provided by a    |                           |
| Chiropractor is not covered. However,    |                           |
| chiropractic care for physical therapy   |                           |
| is included in Physical and Occupational |                           |
| Therapies on page 20.                    |                           |
+------------------------------------------+---------------------------+
| ###### Alternative treatments            |                           |
+------------------------------------------+---------------------------+
| No benefit                               | *All charges.*            |
+------------------------------------------+---------------------------+
| ###### Educational classes and programs  |                           |
+------------------------------------------+---------------------------+
| Coverage is limited to classes and       | Nothing                   |
| programs for the following conditions:   |                           |
|                                          |                           |
| -   Diabetes                             |                           |
|                                          |                           |
| -   Asthma                               |                           |
|                                          |                           |
| -   Congestive heart failure             |                           |
|                                          |                           |
| -   Mothers-to-be program (pregnancy     |                           |
|     management)                          |                           |
|                                          |                           |
|     Note: Program must be provided or    |                           |
|     arranged by our Plan.                |                           |
+------------------------------------------+---------------------------+

## **Section** 5(b) Surgical and anesthesia services provided by physicians and other health care professionals

+---+---+------------------------------------+--------------------+---+---+
|   | * | **Here are some important things   |                    | * |   |
|   | * | you should keep in mind about      |                    | * |   |
|   | I | these benefits:**                  |                    | I |   |
|   | * |                                    |                    | * |   |
|   | * | -   Please remember that all       |                    | * |   |
|   |   |     benefits are subject to the    |                    |   |   |
|   | * |     definitions, limitations, and  |                    | * |   |
|   | * |     exclusions in this brochure    |                    | * |   |
|   | M |     and are payable only when we   |                    | M |   |
|   | * |     determine they are medically   |                    | * |   |
|   | * |     necessary.                     |                    | * |   |
|   |   |                                    |                    |   |   |
|   | * | -   Plan physicians must provide   |                    | * |   |
|   | * |     or arrange your care.          |                    | * |   |
|   | P |                                    |                    | P |   |
|   | * | -   We have no calendar year       |                    | * |   |
|   | * |     deductible.                    |                    | * |   |
|   |   |                                    |                    |   |   |
|   | * | -   Be sure to read Section 4,     |                    | * |   |
|   | * |     Your costs for covered         |                    | * |   |
|   | O |     services, for valuable         |                    | O |   |
|   | * |     information about how cost     |                    | * |   |
|   | * |     sharing works. Also read       |                    | * |   |
|   |   |     Section 9 about coordinating   |                    |   |   |
|   | * |     benefits with other coverage,  |                    | * |   |
|   | * |     including with Medicare.       |                    | * |   |
|   | R |                                    |                    | R |   |
|   | * | -   The amounts listed below are   |                    | * |   |
|   | * |     for the charges billed by a    |                    | * |   |
|   |   |     physician or other health care |                    |   |   |
|   | * |     professional for your surgical |                    | * |   |
|   | * |     care. Look in Section 5(c) for |                    | * |   |
|   | T |     charges associated with the    |                    | T |   |
|   | * |     facility (i.e. hospital,       |                    | * |   |
|   | * |     surgical center, etc.).        |                    | * |   |
|   |   |                                    |                    |   |   |
|   | * | -   YOUR PHYSICIAN MUST GET        |                    | * |   |
|   | * |     PREAUTHORIZATION OF SOME       |                    | * |   |
|   | A |     SURGICAL PROCEDURES. Please    |                    | A |   |
|   | * |     refer to the preauthorization  |                    | * |   |
|   | * |     information shown in Section 3 |                    | * |   |
|   |   |     to be sure which services      |                    |   |   |
|   | * |     require preauthorization and   |                    | * |   |
|   | * |     identify which surgeries       |                    | * |   |
|   | N |     require preauthorization.      |                    | N |   |
|   | * |                                    |                    | * |   |
|   | * |                                    |                    | * |   |
|   |   |                                    |                    |   |   |
|   | * |                                    |                    | * |   |
|   | * |                                    |                    | * |   |
|   | T |                                    |                    | T |   |
|   | * |                                    |                    | * |   |
|   | * |                                    |                    | * |   |
+---+---+------------------------------------+--------------------+---+---+
| B |   |                                    | You pay            |   |   |
| e |   |                                    |                    |   |   |
| n |   |                                    |                    |   |   |
| e |   |                                    |                    |   |   |
| f |   |                                    |                    |   |   |
| i |   |                                    |                    |   |   |
| t |   |                                    |                    |   |   |
| D |   |                                    |                    |   |   |
| e |   |                                    |                    |   |   |
| s |   |                                    |                    |   |   |
| c |   |                                    |                    |   |   |
| r |   |                                    |                    |   |   |
| i |   |                                    |                    |   |   |
| p |   |                                    |                    |   |   |
| t |   |                                    |                    |   |   |
| i |   |                                    |                    |   |   |
| o |   |                                    |                    |   |   |
| n |   |                                    |                    |   |   |
+---+---+------------------------------------+--------------------+---+---+
| # |   |                                    |                    |   |   |
| # |   |                                    |                    |   |   |
| # |   |                                    |                    |   |   |
| # |   |                                    |                    |   |   |
| # |   |                                    |                    |   |   |
| # |   |                                    |                    |   |   |
|   |   |                                    |                    |   |   |
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|   |   |                                    |                    |   |   |
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| r |   |                                    |                    |   |   |
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| s |   |                                    |                    |   |   |
+---+---+------------------------------------+--------------------+---+---+
| A |   |                                    | Nothing            |   |   |
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| . |   |                                    |                    |   |   |
+---+---+------------------------------------+--------------------+---+---+

*Surgical procedures - continued on next page*

+------------------------------------------+---------------------------+
| Surgical procedures *(continued)*        | You pay                   |
+------------------------------------------+---------------------------+
| -   Voluntary sterilization (e.g., Tubal | \$20 office visit plus    |
|     ligation, Vasectomy)                 |                           |
|                                          | \$25 per procedure        |
+------------------------------------------+---------------------------+
| -   Treatment of burns                   | \$20 per office visit     |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Reversal of voluntary               |                           |
|     sterilization*                       |                           |
|                                          |                           |
| -   *Routine treatment of conditions of  |                           |
|     the foot; see Foot care*             |                           |
+------------------------------------------+---------------------------+
| ###### Reconstructive surgery            |                           |
+------------------------------------------+---------------------------+
| -   Surgery to correct a functional      | \$20 per office visit     |
|     defect                               |                           |
|                                          |                           |
| -   Surgery to correct a condition       |                           |
|     caused by injury or illness if:      |                           |
|                                          |                           |
|     -- the condition produced a major    |                           |
|     effect on the member's appearance    |                           |
|     and                                  |                           |
|                                          |                           |
|     -- the condition can reasonably be   |                           |
|     expected to be corrected by such     |                           |
|     surgery                              |                           |
|                                          |                           |
| -   Surgery to correct a condition that  |                           |
|     existed at or from birth and is a    |                           |
|     significant deviation from the       |                           |
|     common form or norm. Examples of     |                           |
|     congenital anomalies are: protruding |                           |
|     ear deformities; cleft lip; cleft    |                           |
|     palate; birth marks; webbed fingers; |                           |
|     and webbed toes.                     |                           |
|                                          |                           |
| -   All stages of breast reconstruction  |                           |
|     surgery following a mastectomy, such |                           |
|     as:                                  |                           |
|                                          |                           |
|     -- surgery to produce a symmetrical  |                           |
|     appearance of breasts;               |                           |
|                                          |                           |
|     -- treatment of any physical         |                           |
|     complications, such as lymphedemas;  |                           |
|                                          |                           |
|     -- breast prostheses and surgical    |                           |
|     bras and replacements (see           |                           |
|     Prosthetic devices)                  |                           |
|                                          |                           |
| Note: If you need a mastectomy, you may  |                           |
| choose to have the procedure performed   |                           |
| on an inpatient basis and remain in the  |                           |
| hospital up to 48 hours after the        |                           |
| procedure.                               |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Cosmetic surgery -- any surgical    |                           |
|     procedure (or any portion of a       |                           |
|     procedure) performed primarily to    |                           |
|     improve physical appearance through  |                           |
|     change in bodily form, except repair |                           |
|     of accidental injury*                |                           |
|                                          |                           |
| -   *Surgeries related to sex            |                           |
|     transformation*                      |                           |
+------------------------------------------+---------------------------+
| ###### Oral and maxillofacial surgery    | You pay                   |
+------------------------------------------+---------------------------+
| Oral surgical procedures, limited to:    | \$20 per office visit     |
|                                          |                           |
| -   Reduction of fractures of the jaws   |                           |
|     or facial bones;                     |                           |
|                                          |                           |
| -   Surgical correction of cleft lip,    |                           |
|     cleft palate or severe functional    |                           |
|     malocclusion;                        |                           |
|                                          |                           |
| -   Removal of stones from salivary      |                           |
|     ducts;                               |                           |
|                                          |                           |
| -   Excision of leukoplakia or           |                           |
|     malignancies;                        |                           |
|                                          |                           |
| -   Excision of cysts and incision of    |                           |
|     abscesses when done as independent   |                           |
|     procedures; and                      |                           |
|                                          |                           |
| -   Other surgical procedures that do    |                           |
|     not involve the teeth or their       |                           |
|     supporting structures.               |                           |
|                                          |                           |
| -   Diagnostic and /or surgical          |                           |
|     treatment of conditions affecting    |                           |
|     the temporomandibular joint          |                           |
|     (including the jaw or                |                           |
|     craniomandibular joint) as a result  |                           |
|     of an accident, a trauma, a          |                           |
|     congenital defect, a development     |                           |
|     defect or a pathology.               |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Oral implants and transplants*      |                           |
|                                          |                           |
| -   *Procedures that involve the teeth   |                           |
|     or their supporting structures (such |                           |
|     as the periodontal membrane,         |                           |
|     gingiva, and alveolar bone)*         |                           |
|                                          |                           |
| -   *Dental care or dental appliances    |                           |
|     involved in treatment of TMJ*        |                           |
|                                          |                           |
| -   *Procedures to improve the           |                           |
|     appearance of a functioning          |                           |
|     structure*                           |                           |
+------------------------------------------+---------------------------+
| ###### Organ/tissue transplants          | You pay                   |
+------------------------------------------+---------------------------+
| Limited to:                              | Nothing                   |
|                                          |                           |
| -   Cornea                               |                           |
|                                          |                           |
| -   Heart                                |                           |
|                                          |                           |
| -   Heart/lung                           |                           |
|                                          |                           |
| -   Kidney                               |                           |
|                                          |                           |
| -   Kidney/Pancreas                      |                           |
|                                          |                           |
| -   Liver                                |                           |
|                                          |                           |
| -   Lung: Single -- Double               |                           |
|                                          |                           |
| -   Pancreas                             |                           |
|                                          |                           |
| -   Allogenic donor bone marrow          |                           |
|     transplants                          |                           |
|                                          |                           |
| -   Autologous tandem transplants        |                           |
|     (treatment of testicular and other   |                           |
|     germ cell tumors)                    |                           |
|                                          |                           |
| -   Autologous bone marrow transplants   |                           |
|     (autologous stem cell and peripheral |                           |
|     stem cell support) for the following |                           |
|     conditions: acute lymphocytic or     |                           |
|     non-lymphocytic leukemia; advanced   |                           |
|     Hodgkin's lymphoma; advanced         |                           |
|     non-Hodgkin's lymphoma; advanced     |                           |
|     neuroblastoma; breast cancer;        |                           |
|     multiple myeloma; epithelial ovarian |                           |
|     cancer; and testicular, mediastinal, |                           |
|     retroperitoneal and ovarian germ     |                           |
|     cell tumors                          |                           |
|                                          |                           |
| -   Intestinal transplants (small        |                           |
|     intestine) and the small intestine   |                           |
|     with the liver or small intestine    |                           |
|     with multiple organs such as the     |                           |
|     liver, stomach, and pancreas         |                           |
|                                          |                           |
| -   National Transplant Program (NTP) -  |                           |
|     A nationally recognized medical      |                           |
|     facility designated by our Plan must |                           |
|     evaluate the case and determine that |                           |
|     the proposed transplant is           |                           |
|     appropriate for treatment of the     |                           |
|     condition and has agreed to perform  |                           |
|     the transplant.                      |                           |
|                                          |                           |
| Limited Benefits -- Treatment for breast |                           |
| cancer, multiple myeloma, and epithelial |                           |
| ovarian cancer may be provided in a      |                           |
| National Cancer Institute -- or National |                           |
| Institutes of Health-approved clinical   |                           |
| trial at a Plan-designated center of     |                           |
| excellence and if approved by the Plan's |                           |
| medical director in accordance with the  |                           |
| Plan's protocols.                        |                           |
|                                          |                           |
| Note: We cover related medical and       |                           |
| hospital expenses of the donor when we   |                           |
| cover the recipient.                     |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Donor screening tests and donor     |                           |
|     search expenses, except those        |                           |
|     performed for the actual donor*      |                           |
|                                          |                           |
| -   *Implants of artificial organs*      |                           |
|                                          |                           |
| -   *Transplants not listed as covered*  |                           |
+------------------------------------------+---------------------------+
| ###### Anesthesia                        |                           |
+------------------------------------------+---------------------------+
| Professional services provided in --     | Nothing                   |
|                                          |                           |
| -   Hospital (inpatient)                 |                           |
|                                          |                           |
| -   Hospital outpatient department       |                           |
|                                          |                           |
| -   Skilled nursing facility             |                           |
|                                          |                           |
| -   Ambulatory surgical center           |                           |
|                                          |                           |
| -   Office                               |                           |
+------------------------------------------+---------------------------+

## **Section** 5(c) Services provided by a hospital or other facility, and ambulance services 

+---+---+-------------------------------------+---------------------+---+---+
|   | * | **Here are some important things    |                     | * |   |
|   | * | you should keep in mind about these |                     | * |   |
|   | I | benefits:**                         |                     | I |   |
|   | * |                                     |                     | * |   |
|   | * | -   Please remember that all        |                     | * |   |
|   |   |     benefits are subject to the     |                     |   |   |
|   | * |     definitions, limitations, and   |                     | * |   |
|   | * |     exclusions in this brochure and |                     | * |   |
|   | M |     are payable only when we        |                     | M |   |
|   | * |     determine they are medically    |                     | * |   |
|   | * |     necessary.                      |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * | -   Plan physicians must provide or |                     | * |   |
|   | * |     arrange your care and you must  |                     | * |   |
|   | P |     be hospitalized in a Plan       |                     | P |   |
|   | * |     facility.                       |                     | * |   |
|   | * |                                     |                     | * |   |
|   |   | -   We have no calendar year        |                     |   |   |
|   | * |     deductible*.*                   |                     | * |   |
|   | * |                                     |                     | * |   |
|   | O | -   Be sure to read Section 4,      |                     | O |   |
|   | * |     *Your costs for covered         |                     | * |   |
|   | * |     services* for valuable          |                     | * |   |
|   |   |     information about how cost      |                     |   |   |
|   | * |     sharing works. Also read        |                     | * |   |
|   | * |     Section 9 about coordinating    |                     | * |   |
|   | R |     benefits with other coverage,   |                     | R |   |
|   | * |     including with Medicare.        |                     | * |   |
|   | * |                                     |                     | * |   |
|   |   | -   The amounts listed below are    |                     |   |   |
|   | * |     for the charges billed by the   |                     | * |   |
|   | * |     facility (i.e., hospital or     |                     | * |   |
|   | T |     surgical center) or ambulance   |                     | T |   |
|   | * |     service for your surgery or     |                     | * |   |
|   | * |     care. Any costs associated with |                     | * |   |
|   |   |     the professional charge (i.e.,  |                     |   |   |
|   | * |     physicians, etc.) are in        |                     | * |   |
|   | * |     Sections 5(a) or (b).           |                     | * |   |
|   | A |                                     |                     | A |   |
|   | * | -   **YOUR PHYSICIAN MUST GET       |                     | * |   |
|   | * |     PREAUTHORIZATION OF HOSPITAL    |                     | * |   |
|   |   |     STAYS.** Please refer to        |                     |   |   |
|   | * |     Section 3 to be sure which      |                     | * |   |
|   | * |     services require                |                     | * |   |
|   | N |     preauthorization.               |                     | N |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   | T |                                     |                     | T |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
+---+---+-------------------------------------+---------------------+---+---+
| B |   |                                     | You pay             |   |   |
| e |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| f |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| D |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| p |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| # |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| I |   |                                     |                     |   |   |
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| n |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
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| p |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| l |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| R |   |                                     | \$100 per day with  |   |   |
| o |   |                                     | a maximum of \$400  |   |   |
| o |   |                                     | per admission       |   |   |
| m |   |                                     |                     |   |   |
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| n |   |                                     |                     |   |   |
| 5 |   |                                     |                     |   |   |
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+---+---+-------------------------------------+---------------------+---+---+

*Inpatient hospital - continued on next page.*

+------------------------------------------+---------------------------+
| Inpatient hospital *(continued)*         | You pay                   |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Custodial care, rest cures or       |                           |
|     domiciliary care*                    |                           |
|                                          |                           |
| -   *Non-covered facilities, such as     |                           |
|     nursing homes, schools*              |                           |
|                                          |                           |
| -   *Personal comfort items, such as     |                           |
|     telephone, television, barber        |                           |
|     services, guest meals and beds*      |                           |
|                                          |                           |
| -   *Private nursing care*               |                           |
+------------------------------------------+---------------------------+
| ###### Outpatien                         | You pay                   |
| t hospital or ambulatory surgical center |                           |
+------------------------------------------+---------------------------+
| -   Operating, recovery, and other       | \$150 per surgery         |
|     treatment rooms                      |                           |
|                                          |                           |
| -   Prescribed drugs and medicines       |                           |
|                                          |                           |
| -   Diagnostic laboratory tests, X-rays, |                           |
|     and pathology services               |                           |
|                                          |                           |
| -   Administration of blood, blood       |                           |
|     plasma, and other biologicals        |                           |
|                                          |                           |
| -   Blood and blood plasma,              |                           |
|                                          |                           |
| -   Pre-surgical testing                 |                           |
|                                          |                           |
| -   Dressings, casts, and sterile tray   |                           |
|     services                             |                           |
|                                          |                           |
| -   Medical supplies, including oxygen   |                           |
|                                          |                           |
| -   Anesthetics and anesthesia service   |                           |
|                                          |                           |
| Note***:*** -- We cover hospital         |                           |
| services and supplies related to dental  |                           |
| procedures when necessitated by a        |                           |
| non-dental physical impairment. We do    |                           |
| not cover the dental inpatient           |                           |
| procedures.                              |                           |
+------------------------------------------+---------------------------+
| ###### Extended care benefit             |                           |
| s/Skilled nursing care facility benefits |                           |
+------------------------------------------+---------------------------+
| Extended care benefit in a Skilled       | \$25 per day              |
| Nursing Facility (SNF):                  |                           |
|                                          |                           |
| Up to 60 days consecutive days for each  |                           |
| illness or injury when:                  |                           |
|                                          |                           |
| -   Full-time skilled nursing care is    |                           |
|     necessary and confinement in a       |                           |
|     skilled nursing facility is          |                           |
|     medically appropriate as determined  |                           |
|     by the Plan doctor.                  |                           |
|                                          |                           |
| All necessary services are covered,      |                           |
| including:                               |                           |
|                                          |                           |
| -   Bed, board, general nursing care,    |                           |
|     drugs, biologicals, supplies, and    |                           |
|     equipment ordinarily provided or     |                           |
|     arranged by the skilled nursing      |                           |
|     facility when prescribed by a Plan   |                           |
|     doctor.                              |                           |
+------------------------------------------+---------------------------+
| *Not covered: Custodial care, rest       | *All charges.*            |
| cures, care for persistent illness and   |                           |
| disorders.*                              |                           |
+------------------------------------------+---------------------------+
| ###### Hospice care                      |                           |
+------------------------------------------+---------------------------+
| Supportive and palliative care for the   | Nothing                   |
| terminally ill is covered in the home or |                           |
| hospice facility. Services include       |                           |
| inpatient and outpatient care and family |                           |
| counseling; these services are provided  |                           |
| under the direction of a Plan doctor who |                           |
| certifies the terminal stages of         |                           |
| illness, with a life expectancy of       |                           |
| approximately six months or less.        |                           |
+------------------------------------------+---------------------------+
| *Not covered: Independent nursing,       | *All charges.*            |
| homemaker services, custodial care*      |                           |
+------------------------------------------+---------------------------+
| ###### Ambulance                         |                           |
+------------------------------------------+---------------------------+
| -   Local professional ambulance service | \$25 per service          |
|     when medically appropriate           |                           |
+------------------------------------------+---------------------------+

## Section 5(d) Emergency services/accidents

+---+---+-----------------------------------------------------------+---+---+
| # | * | **Here are some important things to keep in mind about    | * |   |
| # | * | these benefits:**                                         | * |   |
| # | I |                                                           | I |   |
| # | * | -   Please remember that all benefits are subject to the  | * |   |
| # | * |     definitions, limitations, and exclusions in this      | * |   |
|   |   |     brochure and are payable only when we determine they  |   |   |
|   | * |     are medically necessary.                              | * |   |
|   | * |                                                           | * |   |
|   | M | -   We have no calendar year deductible.                  | M |   |
|   | * |                                                           | * |   |
|   | * | -   Be sure to read Section 4, Your costs for covered     | * |   |
|   |   |     services, for valuable information about how cost     |   |   |
|   | * |     sharing works. Also read Section 9 about coordinating | * |   |
|   | * |     benefits with other coverage, including with          | * |   |
|   | P |     Medicare.                                             | P |   |
|   | * |                                                           | * |   |
|   | * | #####                                                     | * |   |
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+---+---+-----------------------------------------------------------+---+---+
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|   |   |                                                           |   |   |
|   |   |                                                           |   |   |
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|   |   |                                                           |   |   |
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| s |   |                                                           |   |   |
| . |   |                                                           |   |   |
+---+---+-----------------------------------------------------------+---+---+

+-------------------------------------------+--------------------------+
| Benefit Description                       | You pay                  |
+-------------------------------------------+--------------------------+
| Emergency within our service              |                          |
| area[]{#__RefHeading___Toc81986560        |                          |
| .anchor}                                  |                          |
+-------------------------------------------+--------------------------+
| -   Emergency care at a doctor's office   | \$35 per office visit    |
|                                           | after normal business    |
|                                           | hours                    |
+-------------------------------------------+--------------------------+
| -   Emergency care at an urgent care      | \$35 per office visit    |
|     center                                |                          |
+-------------------------------------------+--------------------------+
| -   Emergency care as an outpatient or    | \$100 per office visit   |
|     inpatient at a hospital, including    |                          |
|     doctors' services                     |                          |
+-------------------------------------------+--------------------------+
| Note: Copayment waived when admitted to   |                          |
| hospital. If admitted, refer to Section   |                          |
| 5(c) on Inpatient Hospitalization.        |                          |
+-------------------------------------------+--------------------------+
| *Not covered: Elective care or            | *All charges.*           |
| non-emergency care*                       |                          |
+-------------------------------------------+--------------------------+
| Emergency outside our service             |                          |
| area[]{#__RefHeading___Toc81986561        |                          |
| .anchor}                                  |                          |
+-------------------------------------------+--------------------------+
| -   Emergency care at a doctors office    | \$35 per office visit    |
|                                           | after normal business    |
|                                           | hours                    |
+-------------------------------------------+--------------------------+
| -   Emergency care at an urgent care      | \$35 per office visit    |
|     center                                |                          |
+-------------------------------------------+--------------------------+
| -   Emergency care as an outpatient or    | \$100 per office visit   |
|     inpatient at a hospital, including    |                          |
|     doctors' services                     |                          |
+-------------------------------------------+--------------------------+
| Note: Copayment waived when admitted to   | *All charges.*           |
| hospital. If admitted, refer to Section   |                          |
| 5(c) on Inpatient Hospitalization.        |                          |
+-------------------------------------------+--------------------------+
| *Not covered:*                            |                          |
|                                           |                          |
| -   *Elective care or non-emergency care* |                          |
|                                           |                          |
| -   *Emergency care provided outside the  |                          |
|     service area if the need for care     |                          |
|     could have been foreseen before       |                          |
|     leaving the service area*             |                          |
|                                           |                          |
| -   *Medical and hospital costs resulting |                          |
|     from a normal full-term delivery of a |                          |
|     baby outside the service area*        |                          |
+-------------------------------------------+--------------------------+
| Ambulance[]{#__RefHeading___Toc81986562   |                          |
| .anchor}                                  |                          |
+-------------------------------------------+--------------------------+
| Professional ambulance service when       | \$25 per service         |
| medically appropriately.                  |                          |
|                                           |                          |
| Air Ambulance if medically necessary.     |                          |
|                                           |                          |
| Note: See 5(c) for non-emergency service. |                          |
+-------------------------------------------+--------------------------+

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

+---+---+-----------------------------------+----------------------+---+---+
|   | * | When you get our approval for     |                      | * |   |
|   | * | services and follow a treatment   |                      | * |   |
|   | I | plan we approve, cost-sharing and |                      | I |   |
|   | * | limitations for Plan mental       |                      | * |   |
|   | * | health and substance abuse        |                      | * |   |
|   |   | benefits will be no greater than  |                      |   |   |
|   | * | for similar benefits for other    |                      | * |   |
|   | * | illnesses and conditions.         |                      | * |   |
|   | M |                                   |                      | M |   |
|   | * | **Here are some important things  |                      | * |   |
|   | * | to keep in mind about these       |                      | * |   |
|   |   | benefits:**                       |                      |   |   |
|   | * |                                   |                      | * |   |
|   | * | -   Please remember that all      |                      | * |   |
|   | P |     benefits are subject to the   |                      | P |   |
|   | * |     definitions, limitations, and |                      | * |   |
|   | * |     exclusions in this brochure   |                      | * |   |
|   |   |     and are payable only when we  |                      |   |   |
|   | * |     determine they are medically  |                      | * |   |
|   | * |     necessary.                    |                      | * |   |
|   | O |                                   |                      | O |   |
|   | * | -   We have no calendar year      |                      | * |   |
|   | * |     deductible.                   |                      | * |   |
|   |   |                                   |                      |   |   |
|   | * | -   Be sure to read Section 4,    |                      | * |   |
|   | * |     *Your costs for covered       |                      | * |   |
|   | R |     services*, for valuable       |                      | R |   |
|   | * |     information about how cost    |                      | * |   |
|   | * |     sharing works. Also read      |                      | * |   |
|   |   |     Section 9 about coordinating  |                      |   |   |
|   | * |     benefits with other coverage, |                      | * |   |
|   | * |     including with Medicare.      |                      | * |   |
|   | T |                                   |                      | T |   |
|   | * | -   **YOU MUST GET                |                      | * |   |
|   | * |     PREAUTHORIZATION OF THESE     |                      | * |   |
|   |   |     SERVICES.** See the           |                      |   |   |
|   | * |     instructions after the        |                      | * |   |
|   | * |     benefits description below.   |                      | * |   |
|   | A |                                   |                      | A |   |
|   | * |                                   |                      | * |   |
|   | * |                                   |                      | * |   |
|   |   |                                   |                      |   |   |
|   | * |                                   |                      | * |   |
|   | * |                                   |                      | * |   |
|   | N |                                   |                      | N |   |
|   | * |                                   |                      | * |   |
|   | * |                                   |                      | * |   |
|   |   |                                   |                      |   |   |
|   | * |                                   |                      | * |   |
|   | * |                                   |                      | * |   |
|   | T |                                   |                      | T |   |
|   | * |                                   |                      | * |   |
|   | * |                                   |                      | * |   |
+---+---+-----------------------------------+----------------------+---+---+
| B |   |                                   | You pay              |   |   |
| e |   |                                   |                      |   |   |
| n |   |                                   |                      |   |   |
| e |   |                                   |                      |   |   |
| f |   |                                   |                      |   |   |
| i |   |                                   |                      |   |   |
| t |   |                                   |                      |   |   |
| D |   |                                   |                      |   |   |
| e |   |                                   |                      |   |   |
| s |   |                                   |                      |   |   |
| c |   |                                   |                      |   |   |
| r |   |                                   |                      |   |   |
| i |   |                                   |                      |   |   |
| p |   |                                   |                      |   |   |
| t |   |                                   |                      |   |   |
| i |   |                                   |                      |   |   |
| o |   |                                   |                      |   |   |
| n |   |                                   |                      |   |   |
+---+---+-----------------------------------+----------------------+---+---+
| # |   |                                   |                      |   |   |
| # |   |                                   |                      |   |   |
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+---+---+-----------------------------------+----------------------+---+---+
| A |   |                                   | Your cost sharing    |   |   |
| l |   |                                   | responsibilities are |   |   |
| l |   |                                   | no greater than for  |   |   |
| d |   |                                   | other illnesses or   |   |   |
| i |   |                                   | conditions.          |   |   |
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+---+---+-----------------------------------+----------------------+---+---+
| - |   |                                   | \$20 per office      |   |   |
|   |   |                                   | visit.               |   |   |
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| e |   |                                   |                      |   |   |
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| n |   |                                   |                      |   |   |
| t |   |                                   |                      |   |   |
+---+---+-----------------------------------+----------------------+---+---+
| - |   |                                   | \$20 per office      |   |   |
|   |   |                                   | visit.               |   |   |
|   |   |                                   |                      |   |   |
|   |   |                                   |                      |   |   |
| D |   |                                   |                      |   |   |
| i |   |                                   |                      |   |   |
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| t |   |                                   |                      |   |   |
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+---+---+-----------------------------------+----------------------+---+---+
| - |   |                                   | \$100 per day with a |   |   |
|   |   |                                   | maximum of \$400 per |   |   |
|   |   |                                   | admission.           |   |   |
|   |   |                                   |                      |   |   |
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|   |   |                                   |                      |   |   |
| o |   |                                   |                      |   |   |
| u |   |                                   |                      |   |   |
| t |   |                                   |                      |   |   |
| p |   |                                   |                      |   |   |
| a |   |                                   |                      |   |   |
| t |   |                                   |                      |   |   |
| i |   |                                   |                      |   |   |
| e |   |                                   |                      |   |   |
| n |   |                                   |                      |   |   |
| t |   |                                   |                      |   |   |
|   |   |                                   |                      |   |   |
|   |   |                                   |                      |   |   |
|   |   |                                   |                      |   |   |
|   |   |                                   |                      |   |   |
| t |   |                                   |                      |   |   |
| r |   |                                   |                      |   |   |
| e |   |                                   |                      |   |   |
| a |   |                                   |                      |   |   |
| t |   |                                   |                      |   |   |
| m |   |                                   |                      |   |   |
| e |   |                                   |                      |   |   |
| n |   |                                   |                      |   |   |
| t |   |                                   |                      |   |   |
+---+---+-----------------------------------+----------------------+---+---+

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

+------------------------------------------+---------------------------+
| Mental health and substance abuse        | You pay                   |
| benefits *(continued)*                   |                           |
+------------------------------------------+---------------------------+
| *Not covered: Services we have not       | *All charges.*            |
| approved.*                               |                           |
|                                          |                           |
| *Note: OPM will base its review of       |                           |
| disputes about treatment plans on the    |                           |
| treatment plan\'s clinical               |                           |
| appropriateness. OPM will generally not  |                           |
| order us to pay or provide one           |                           |
| clinically appropriate treatment plan in |                           |
| favor of another.*                       |                           |
+------------------------------------------+---------------------------+
| **Preauthorization** To be eligible to   |                           |
| receive these benefits you must obtain a |                           |
| treatment plan and follow all of the     |                           |
| following network authorization          |                           |
| processes:                               |                           |
|                                          |                           |
| -   If you need treatment, you may       |                           |
|     contact your PCP and he or she will  |                           |
|     assist you in obtaining care.        |                           |
|                                          |                           |
| -   A referral from your PCP for mental  |                           |
|     health and chemical dependency       |                           |
|     services is not needed.              |                           |
|     Preauthorization for the mental      |                           |
|     health/chemical dependency provider  |                           |
|     that delivers these services must be |                           |
|     obtained by telephone prior to the   |                           |
|     delivery of all behavioral health    |                           |
|     care, including chemical dependency, |                           |
|     by calling toll-free (800) 729-2422. |                           |
|                                          |                           |
| -   Certain medical groups or            |                           |
|     Independent Physician Associations   |                           |
|     (IPAs) may have selected a different |                           |
|     provider for mental health/chemical  |                           |
|     dependency services.                 |                           |
|                                          |                           |
| -   Members who wish to verify that      |                           |
|     their mental health/chemical         |                           |
|     dependency provider is a Network     |                           |
|     Provider need to call Magellan       |                           |
|     Behavioral Health at (800) 729-2422. |                           |
|                                          |                           |
| > Note: Prior authorization is not       |                           |
| > required for coverage of emergency     |                           |
| > services. For emergencies outside the  |                           |
| > service area, benefits are available   |                           |
| > for all necessary emergency care       |                           |
| > services including those necessary to  |                           |
| > screen and stabilize members when it   |                           |
| > is believed that an emergency          |                           |
| > condition exists.                      |                           |
+------------------------------------------+---------------------------+
| **Limitation** We may limit your         |                           |
| benefits if you do not obtain a          |                           |
| treatment plan.                          |                           |
+------------------------------------------+---------------------------+

## **Section** 5(f) Prescription drug benefits

+---+---+--------------------------------------------------------+---+---+
|   | * | **Here are some important things to keep in mind about | * |   |
|   | * | these benefits:**                                      | * |   |
|   | I |                                                        | I |   |
|   | * | -   We cover prescribed drugs and medications, as      | * |   |
|   | * |     described in the chart beginning on the next page. | * |   |
|   |   |                                                        |   |   |
|   | * | ```{=html}                                             | * |   |
|   | * | <!-- -->                                               | * |   |
|   | M | ```                                                    | M |   |
|   | * | -   All benefits are subject to the definitions,       | * |   |
|   | * |     limitations and exclusions in this brochure and    | * |   |
|   |   |     are payable only when we determine they are        |   |   |
|   | * |     medically necessary.                               | * |   |
|   | * |                                                        | * |   |
|   | P | -   We have no calendar year deductible                | P |   |
|   | * |                                                        | * |   |
|   | * | -   Be sure to read Section 4, *Your costs for covered | * |   |
|   |   |     services,* for valuable information about how cost |   |   |
|   | * |     sharing works. Also read Section 9 about           | * |   |
|   | * |     coordinating benefits with other coverage,         | * |   |
|   | O |     including with Medicare.                           | O |   |
|   | * |                                                        | * |   |
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| d |   |                                                        |   |   |
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|   |   |                                                        |   |   |
|   |   |                                                        |   |   |
| f |   |                                                        |   |   |
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|   |   |                                                        |   |   |
|   |   |                                                        |   |   |
| n |   |                                                        |   |   |
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| c |   |                                                        |   |   |
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|   |   |                                                        |   |   |
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| i |   |                                                        |   |   |
| t |   |                                                        |   |   |
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|   |   |                                                        |   |   |
|   |   |                                                        |   |   |
|   |   |                                                        |   |   |
|   |   |                                                        |   |   |
| c |   |                                                        |   |   |
| o |   |                                                        |   |   |
| v |   |                                                        |   |   |
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| d |   |                                                        |   |   |
|   |   |                                                        |   |   |
|   |   |                                                        |   |   |
|   |   |                                                        |   |   |
|   |   |                                                        |   |   |
| E |   |                                                        |   |   |
| m |   |                                                        |   |   |
| e |   |                                                        |   |   |
| r |   |                                                        |   |   |
| g |   |                                                        |   |   |
| e |   |                                                        |   |   |
| n |   |                                                        |   |   |
| c |   |                                                        |   |   |
| y |   |                                                        |   |   |
|   |   |                                                        |   |   |
|   |   |                                                        |   |   |
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|   |   |                                                        |   |   |
| a |   |                                                        |   |   |
| n |   |                                                        |   |   |
| d |   |                                                        |   |   |
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|   |   |                                                        |   |   |
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| u |   |                                                        |   |   |
| t |   |                                                        |   |   |
| - |   |                                                        |   |   |
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| f |   |                                                        |   |   |
| - |   |                                                        |   |   |
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| a |   |                                                        |   |   |
|   |   |                                                        |   |   |
|   |   |                                                        |   |   |
|   |   |                                                        |   |   |
|   |   |                                                        |   |   |
| U |   |                                                        |   |   |
| r |   |                                                        |   |   |
| g |   |                                                        |   |   |
| e |   |                                                        |   |   |
| n |   |                                                        |   |   |
| t |   |                                                        |   |   |
|   |   |                                                        |   |   |
|   |   |                                                        |   |   |
|   |   |                                                        |   |   |
|   |   |                                                        |   |   |
| C |   |                                                        |   |   |
| a |   |                                                        |   |   |
| r |   |                                                        |   |   |
| e |   |                                                        |   |   |
|   |   |                                                        |   |   |
|   |   |                                                        |   |   |
|   |   |                                                        |   |   |
|   |   |                                                        |   |   |
| s |   |                                                        |   |   |
| e |   |                                                        |   |   |
| r |   |                                                        |   |   |
| v |   |                                                        |   |   |
| i |   |                                                        |   |   |
| c |   |                                                        |   |   |
| e |   |                                                        |   |   |
| s |   |                                                        |   |   |
| . |   |                                                        |   |   |
+---+---+--------------------------------------------------------+---+---+

+------------------------------------------+---------------------------+
| **Benefit Description**                  | **You pay**               |
+------------------------------------------+---------------------------+
| ###### Covered medications and supplies  | You Pay                   |
+------------------------------------------+---------------------------+
| We cover the following medications and   | \$10 per 30 day supply    |
| supplies prescribed by a Plan physician  | for generic               |
| and obtained from a Participating        |                           |
| pharmacy for up to a 30-day supply       | \$25 per 30 day supply    |
|                                          | for preferred brand name  |
| Or                                       |                           |
|                                          | \$40 per 30 day supply    |
| through our Mail Order Service for up to | for non-preferred brand   |
| a 90-day supply:                         | name                      |
|                                          |                           |
| -   Drugs and medicines for which a      | \$20 per 90 day supply    |
|     prescription is required by State    | for generic               |
|     law, except those listed as not      |                           |
|     covered;                             | \$50 per 90 day supply    |
|                                          | for preferred brand name  |
| -   Oral contraceptive drugs;            |                           |
|                                          | \$80 per for 90 day       |
| -   FDA approved prescriptions for birth | supply for non-preferred  |
|     control;                             | brand name                |
|                                          |                           |
| -   Intravenous fluids and medications   |                           |
|     for home use;                        |                           |
|                                          |                           |
| -   Oral fertility drugs;                |                           |
|                                          |                           |
| -   Smoking cessation drugs, limited to  |                           |
|     \$185.00 lifetime maximum;           |                           |
|                                          |                           |
| -   Disposable needles and syringes      |                           |
|     needed to inject covered prescribed  |                           |
|     medication;                          |                           |
|                                          |                           |
| -   Drugs to treat sexual dysfunction    |                           |
|     (limited benefits); and              |                           |
|                                          |                           |
| -   Insulin (including prescription and  |                           |
|     non-prescription oral agents for     |                           |
|     controlling blood glucose levels and |                           |
|     glucagons emergency kits).           |                           |
|                                          |                           |
|     **Note: Bioequivalent Generic Drugs  |                           |
|     will be dispensed with this Plan. If |                           |
|     the member requests a name brand     |                           |
|     when a generic is available, the     |                           |
|     member will pay the generic          |                           |
|     copayment plus the difference        |                           |
|     between the cost of the generic and  |                           |
|     the cost of the name brand           |                           |
|     product.**                           |                           |
|                                          |                           |
| Note: Drugs to treat sexual dysfunction  |                           |
| have limited benefits, contact Plan for  |                           |
| dose limits; for these medications, you  |                           |
| pay the applicable copay up to the dose  |                           |
| limit and all charges thereafter.        |                           |
| Injectible contraceptives, birth control |                           |
| devices (except diaphragms) are covered  |                           |
| under family planning. Diabetic          |                           |
| supplies, equipment and education are    |                           |
| covered as basic Plan benefits, even     |                           |
| those they may be received from          |                           |
| Participating pharmacies. See section on |                           |
| next page.                               |                           |
+------------------------------------------+---------------------------+

*Covered medications and supplies -- continued on next page*

+------------------------------------------+---------------------------+
| Covered medications and supplies         | You pay                   |
| *(continued)*                            |                           |
+------------------------------------------+---------------------------+
| Diabetic supplies                        | \$10 up to a 30-day       |
|                                          | supply at participating   |
| -   Blood glucose test strips            | pharmacy or \$20 for up   |
|                                          | to a 90-day supply        |
| -   Lancets                              | through mail order        |
|                                          | service                   |
| -   Lancet devices                       |                           |
|                                          |                           |
| -   Insulin syringes and needles         |                           |
|                                          |                           |
| -   Urine test strips                    |                           |
|                                          |                           |
| -   Visual reading                       |                           |
+------------------------------------------+---------------------------+
| Diabetic equipment                       | Nothing                   |
|                                          |                           |
| -   Insulin pump and associated          |                           |
|     appurtenances                        |                           |
|                                          |                           |
| -   Insulin infusion device              |                           |
|                                          |                           |
| -   Blood glucose monitor                |                           |
|                                          |                           |
| -   Podiatric appliance for the          |                           |
|     intervention of complications        |                           |
|     associated with diabetes             |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Drugs and supplies for cosmetic     |                           |
|     purposes*                            |                           |
|                                          |                           |
| -   *Vitamins, nutrients and food        |                           |
|     supplements even if a physician      |                           |
|     prescribes or administers them*      |                           |
|                                          |                           |
| -   *Non-prescription drugs*             |                           |
|                                          |                           |
| -   *Drugs obtained at a non-Plan        |                           |
|     pharmacy; except for out-of-area     |                           |
|     emergencies*                         |                           |
|                                          |                           |
| -   *Medical supplies such as dressings  |                           |
|     and antiseptics*                     |                           |
|                                          |                           |
| -   *Drugs to enhance athletic           |                           |
|     performance*                         |                           |
|                                          |                           |
| -   *Implanted time-release medications, |                           |
|     except Norplant*                     |                           |
|                                          |                           |
| -   *Injectibles, aerosol inhalers and   |                           |
|     inhalant solutions except when       |                           |
|     purchased through the Home Delivery  |                           |
|     Pharmacy Service*                    |                           |
|                                          |                           |
| -   *Fertility drugs other than oral*    |                           |
|                                          |                           |
| -   *Topical fluoride*                   |                           |
|                                          |                           |
| -   *Prescription Drugs prescribed as    |                           |
|     anorexients (appetite suppressants)  |                           |
|     or for weight reduction*             |                           |
|                                          |                           |
| -   *Blood and urine testing devices*    |                           |
|                                          |                           |
| -   *Oxygen gas*                         |                           |
|                                          |                           |
| -   *Prescription drugs intended for use |                           |
|     in a practitioner's office or a      |                           |
|     clinical setting*                    |                           |
|                                          |                           |
| -   *Prescription drugs which a member   |                           |
|     is entitled to receive without       |                           |
|     charge from any worker's             |                           |
|     compensation laws, or similar        |                           |
|     municipal, state or federal          |                           |
|     programs*                            |                           |
|                                          |                           |
| -   *Prescription drugs dispensed prior  |                           |
|     to the effective date of coverage*   |                           |
|                                          |                           |
| -   *Therapeutic devices or appliances,  |                           |
|     including hypodermic needles and     |                           |
|     syringes, support garments, and drug |                           |
|     infusion/metering devices*           |                           |
+------------------------------------------+---------------------------+

## **Section** 5(g) Special features

+----------------------+-----------------------------------------------+
| Feature              | Description                                   |
+----------------------+-----------------------------------------------+
| ##### Flex           | Under the flexible benefits option, we        |
| ible Benefits Option | determine the most effective way to provide   |
|                      | services.                                     |
|                      |                                               |
|                      | -   We may identify medically appropriate     |
|                      |     alternatives to traditional care and      |
|                      |     coordinate other benefits as a less       |
|                      |     costly alternative benefit.               |
|                      |                                               |
|                      | -   Alternative benefits are subject to our   |
|                      |     ongoing review.                           |
|                      |                                               |
|                      | -   By approving an alternative benefit, we   |
|                      |     cannot guarantee you will get it in the   |
|                      |     future.                                   |
|                      |                                               |
|                      | -   The decision to offer an alternative      |
|                      |     benefit is solely ours, and we may        |
|                      |     withdraw it at any time and resume        |
|                      |     regular contract benefits.                |
|                      |                                               |
|                      | -   Our decision to offer or withdraw         |
|                      |     alternative benefits is not subject to    |
|                      |     OPM review under the disputed claims      |
|                      |     process.                                  |
+----------------------+-----------------------------------------------+
| ##### Blue Acc       | Personalized information about your health    |
| ess for Members ^SM^ | care coverage is immediate and secure on the  |
|                      | web. Go to                                    |
|                      | [www.bcbstx.com](http://www.bcbstx.com/) and  |
|                      | login to Blue Access for Members. Create a    |
|                      | user ID and password for immediate and secure |
|                      | access to your personal information.          |
|                      |                                               |
|                      | You can:                                      |
|                      |                                               |
|                      | -   Confirm who in your family is covered     |
|                      |     under your plan                           |
|                      |                                               |
|                      | -   Locate a hospital or doctor in your       |
|                      |     network                                   |
|                      |                                               |
|                      | -   Request a new or replacement member ID    |
|                      |     card or print a temporary member ID card  |
|                      |                                               |
|                      | -   Access Health & Wellness information from |
|                      |     the Mayo Clinic                           |
|                      |                                               |
|                      | -   Compare hospitals                         |
|                      |                                               |
|                      | -   E-mail us                                 |
|                      |                                               |
|                      | You can use Blue Web for Members from 6 a.m.  |
|                      | to 3 a.m. (CT), Monday through Friday and 6   |
|                      | a.m. to 12 a.m. (CT) on Saturday and Sunday.  |
+----------------------+-----------------------------------------------+
| ####                 | Our prenatal education program, Special       |
| # Prenatal Education | Beginnings^®,^ is designed to promote         |
|                      | specialty care, education, and monitoring to  |
|                      | help you toward the goal of delivering a      |
|                      | health, full-term baby.                       |
|                      |                                               |
|                      | Special Beginnings^®^ offers pregnant HMO     |
|                      | Blue Texas members;                           |
|                      |                                               |
|                      | -   The support of an obstetrical nurse       |
|                      |     throughout your pregnancy,                |
|                      |                                               |
|                      | -   Risk screening and ongoing monitoring and |
|                      |     evaluation,                               |
|                      |                                               |
|                      | -   Educational materials designed to help    |
|                      |     you understand each stage of your         |
|                      |     pregnancy.                                |
|                      |                                               |
|                      | -   Nutritional advice, and                   |
|                      |                                               |
|                      | -   Coordination of your prenatal care under  |
|                      |     the HMO Blue Texas Plan with your         |
|                      |     participating doctor.                     |
+----------------------+-----------------------------------------------+

## **Section** 5(h) Dental benefits 

+---+---+------------------------------------+---------------------+---+---+
|   | * | **Here are some important things   |                     | * |   |
|   | * | to keep in mind about these        |                     | * |   |
|   | I | benefits:**                        |                     | I |   |
|   | * |                                    |                     | * |   |
|   | * | -   Please remember that all       |                     | * |   |
|   |   |     benefits are subject to the    |                     |   |   |
|   | * |     definitions, limitations, and  |                     | * |   |
|   | * |     exclusions in this brochure    |                     | * |   |
|   | M |     and are payable only when we   |                     | M |   |
|   | * |     determine they are medically   |                     | * |   |
|   | * |     necessary                      |                     | * |   |
|   |   |                                    |                     |   |   |
|   | * | -   Plan dentists must provide or  |                     | * |   |
|   | * |     arrange your care.             |                     | * |   |
|   | P |                                    |                     | P |   |
|   | * | -   We have no calendar year       |                     | * |   |
|   | * |     deductibles.                   |                     | * |   |
|   |   |                                    |                     |   |   |
|   | * | -   We cover hospitalization for   |                     | * |   |
|   | * |     dental procedures only when a  |                     | * |   |
|   | O |     non-dental physical impairment |                     | O |   |
|   | * |     exists which makes             |                     | * |   |
|   | * |     hospitalization necessary to   |                     | * |   |
|   |   |     safeguard the health of the    |                     |   |   |
|   | * |     patient. See Section 5(c) for  |                     | * |   |
|   | * |     inpatient hospital benefits.   |                     | * |   |
|   | R |     We do not cover the dental     |                     | R |   |
|   | * |     procedure unless it is         |                     | * |   |
|   | * |     described below.               |                     | * |   |
|   |   |                                    |                     |   |   |
|   | * | -   Be sure to read Section 4,     |                     | * |   |
|   | * |     *Your costs for covered        |                     | * |   |
|   | T |     services,* for valuable        |                     | T |   |
|   | * |     information about how cost     |                     | * |   |
|   | * |     sharing works. Also read       |                     | * |   |
|   |   |     Section 9 about coordinating   |                     |   |   |
|   | * |     benefits with other coverage,  |                     | * |   |
|   | * |     including with Medicare.       |                     | * |   |
|   | A |                                    |                     | A |   |
|   | * |                                    |                     | * |   |
|   | * |                                    |                     | * |   |
|   |   |                                    |                     |   |   |
|   | * |                                    |                     | * |   |
|   | * |                                    |                     | * |   |
|   | N |                                    |                     | N |   |
|   | * |                                    |                     | * |   |
|   | * |                                    |                     | * |   |
|   |   |                                    |                     |   |   |
|   | * |                                    |                     | * |   |
|   | * |                                    |                     | * |   |
|   | T |                                    |                     | T |   |
|   | * |                                    |                     | * |   |
|   | * |                                    |                     | * |   |
+===+===+====================================+=====================+===+===+
| # |   |                                    | You pay             |   |   |
| # |   |                                    |                     |   |   |
| # |   |                                    |                     |   |   |
| # |   |                                    |                     |   |   |
| # |   |                                    |                     |   |   |
| # |   |                                    |                     |   |   |
|   |   |                                    |                     |   |   |
| A |   |                                    |                     |   |   |
| c |   |                                    |                     |   |   |
| c |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| d |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| l |   |                                    |                     |   |   |
|   |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| j |   |                                    |                     |   |   |
| u |   |                                    |                     |   |   |
| r |   |                                    |                     |   |   |
| y |   |                                    |                     |   |   |
|   |   |                                    |                     |   |   |
| b |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| f |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
+---+---+------------------------------------+---------------------+---+---+
| W |   |                                    | Outpatient: \$20    |   |   |
| e |   |                                    | per visit.          |   |   |
| c |   |                                    |                     |   |   |
| o |   |                                    | Inpatient: \$100    |   |   |
| v |   |                                    | per day with a      |   |   |
| e |   |                                    | maximum of \$400    |   |   |
| r |   |                                    | per admission.      |   |   |
| r |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| s |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| o |   |                                    |                     |   |   |
| r |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
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+---+---+------------------------------------+---------------------+---+---+
| * |   |                                    | \$2                 |   |   |
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| * |   |                                    | \$5                 |   |   |
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| r |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| d |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| r |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| m |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| ( |   |                                    |                     |   |   |
| o |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| c |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| c |   |                                    |                     |   |   |
| h |   |                                    |                     |   |   |
| 6 |   |                                    |                     |   |   |
| m |   |                                    |                     |   |   |
| o |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| h |   |                                    |                     |   |   |
| s |   |                                    |                     |   |   |
| ) |   |                                    |                     |   |   |
+---+---+------------------------------------+---------------------+---+---+

+------------------------------------------+---------------------------+
| Dental benefits                          |                           |
+------------------------------------------+---------------------------+
| Service                                  | You pay                   |
+------------------------------------------+---------------------------+
| Non-routine and emergency dentistry      | \$3                       |
|                                          |                           |
| X-rays, single (per film)                |                           |
+------------------------------------------+---------------------------+
| Non-routine and emergency office visits  | \$9                       |
|                                          |                           |
| During regular office hours              | \$15                      |
|                                          |                           |
| Not during regular office hours          |                           |
|                                          |                           |
| Note: The office visit copayment is in   |                           |
| addition to the applicable copayment(s)  |                           |
| for treatment                            |                           |
+------------------------------------------+---------------------------+
| Missed appointment (By Primary Dentist)  | \$15                      |
|                                          |                           |
| Without 24-hour notice except in case of |                           |
| unforeseen emergency                     |                           |
+------------------------------------------+---------------------------+
| Restorative (fillings) by Primary        | \$10                      |
| Dentist                                  |                           |
|                                          | \$15                      |
| Amalgam (silver) restorations            |                           |
|                                          | \$18                      |
| 1 surface (primary of permanent)         |                           |
|                                          |                           |
| 2 surfaces (primary or permanent)        |                           |
|                                          |                           |
| 3 or more surfaces (primary or           |                           |
| permanent)                               |                           |
+------------------------------------------+---------------------------+
| Composite resin (white) restorations     | \$18                      |
| (anterior teeth only)                    |                           |
|                                          | \$21                      |
| 1 surface                                |                           |
|                                          | \$26                      |
| 2 surfaces                               |                           |
|                                          |                           |
| 3 or more surfaces                       |                           |
+------------------------------------------+---------------------------+
| Cosmetic by Primary Dentist              | \$50                      |
|                                          |                           |
| Acid etch bonding for repair of incisal  |                           |
| edge                                     |                           |
+------------------------------------------+---------------------------+
| Endodontics (Root canal therapy) by      | (per tooth)               |
| Primary Dentist                          |                           |
|                                          | \$170                     |
| 1 canal (anterior)                       |                           |
|                                          | \$200                     |
| 2 canals (bicuspid)                      |                           |
|                                          | \$260                     |
| 3 or more canals (molar)                 |                           |
+------------------------------------------+---------------------------+
| Oral Surgery by Primary Dentist          | (per tooth)               |
|                                          |                           |
| Single tooth extraction                  | \$35                      |
|                                          |                           |
| Each additional tooth                    | \$35                      |
|                                          |                           |
| Surgical extraction -- erupted tooth     | \$40                      |
|                                          |                           |
| Surgical extraction -- soft tissue       | \$55                      |
| impaction                                |                           |
|                                          | \$75                      |
| Surgical extraction -- partial bony      |                           |
| impaction                                | \$100                     |
|                                          |                           |
| Surgical extraction -- full bony         |                           |
| impaction                                |                           |
+------------------------------------------+---------------------------+
| Anesthesia by Primary Dentist            | \$10                      |
|                                          |                           |
| Nitrous Oxide (per ½ hour)               | Nothing                   |
|                                          |                           |
| Local Anesthetic                         |                           |
+------------------------------------------+---------------------------+

+------------------------------------------+---------------------------+
| Dental benefits (continued)              |                           |
+------------------------------------------+---------------------------+
| Service                                  | You pay                   |
+------------------------------------------+---------------------------+
| Periodontics (Gum treatment) by Primary  | \$280                     |
| Dentist                                  |                           |
|                                          | \$60                      |
| Osseous surgery (per quadrant)           |                           |
|                                          | \$130                     |
| Occlusal Adjustment -- Limited           |                           |
|                                          | \$70                      |
| Occlusal Adjustment -- Complete          |                           |
|                                          |                           |
| Periodontal scaling and root planning    |                           |
| (per quadrant)                           |                           |
+------------------------------------------+---------------------------+
| Major restorative dentistry by Primary   | \$235                     |
| Dentist                                  |                           |
|                                          | \$225                     |
| Crown and Bridge (per unit)              |                           |
|                                          | \$175                     |
| All gold is charged at market price      |                           |
|                                          | \$200                     |
| Porcelain veneer crown (with             |                           |
| non-precious)                            | \$10                      |
|                                          |                           |
| Full-cast crown (non-precious)           | \$60                      |
|                                          |                           |
| Inlay -- 2 surfaces                      | \$60                      |
|                                          |                           |
| Inlay -- 3 surfaces                      |                           |
|                                          |                           |
| Re-cement crown/bridge                   |                           |
|                                          |                           |
| Post for crown                           |                           |
|                                          |                           |
| Stainless steel crown                    |                           |
+------------------------------------------+---------------------------+
| Prosthodontics (dentures) by Primary     | \$235 plus lab fee        |
| Dentist                                  |                           |
|                                          | \$320 plus lab fee        |
| Complete Dentures (upper or lower; plus  |                           |
| lab fee)                                 |                           |
|                                          |                           |
| Partial Denture (plus lab fee)           |                           |
+------------------------------------------+---------------------------+
| Orthodontics (braces) by Primary Dentist | 75% of our allowance of   |
|                                          | the Dentist's fee         |
| Note: Patient pays 20% in advance of     |                           |
| treatment. The balance is to be paid in  |                           |
| equal monthly installment during course  |                           |
| of treatment. Treatment schedule for     |                           |
| more than 24 months is to be paid at     |                           |
| \$65.00 per month.                       |                           |
+------------------------------------------+---------------------------+

-   The copayments listed above apply when services are performed by
    your Primary Dentist.

-   Any unlisted procedures and services provided by your Primary
    Dentist will be charged to the Member at 75% of the Plan's
    allowance.

-   All procedures and services provided by a Specialist Dentist will be
    charged to you at 75% of the Plan allowance for the Specialist
    Dentist's fees.

-   Primary and Specialist Dentist services may not be available in your
    immediate area. Refer to your provider directory or call Customer
    Service at (877) 854-2583 to find out where Primary and Specialist
    Dentists are located.

**General Provisions**

-   No referral is needed to see a Participating Specialist Dentist.

-   Each family member may select a different Primary Dentist.

-   Schedule appointments must be canceled at least 24 hours in advance
    or the member may be liable for a missed appointment fee, as charged
    by the dentist.

-   In case of an emergency, contact your Primary Dentist if possible or
    obtain services from any licensed dentist. HMO Blue Texas will
    reimburse the member for the actual cost of such emergency dental
    services, less applicable copayments, and are limited to palliative
    treatment to control pain, bleeding or infection. (See "exclusions")

***Not covered***

-   *Emergency services provided at a hospital, outpatient care facility
    or otherwise than in a dentist's office.*

-   *Non-emergency services provided by a non-participant dentist.*

-   *Services and related fees for services performed any place other
    than a dental office, except the oral surgery services described in
    the Schedule of Dental Benefits.*

-   *Services and supplies ordered or received when the person is not a
    member.*

## **Section** 5(i) Non-FEHB benefits available to Plan members 

The benefits on this page are not part of the FEHB contract or premium,
**and you cannot file an FEHB disputed claim about them.** Fees you pay
for these services do not count toward FEHB catastrophic protection
out-of-pocket maximums.

**Vision Benefits**

Enrollees are entitled to the following vision benefits from Plan
optometrists:

-   One eye examination for eyeglasses every 12 months; you pay a \$10
    copay;

-   Eyeglass lenses and frames available at discount prices;

-   Contact lenses and materials are also available at discount prices;
    and

-   One eye examination for contact lenses every 12 months; you pay a
    \$20 copay.

Note: Coverage is for routine eye examination only when conducted in a
single visit. Benefits for medical treatment of eye disease are provided
under your basic medical plan when deemed medically necessary by your
PCP. Your Cole Managed Vision provider will provide you with information
regarding the cost of contact lenses and fitting services.

**Vision Providers**

To be covered, the exam must be provided by a Cole Managed Vision
provider. The prescription for lenses (or contacts) must be filled by a
participating Cole Vision provider in order to receive the reduced
rates. A referral from your PCP is not necessary.

**What to do ...**

When vision services are needed, call Cole Managed Vision at (800)
228-2020 for assistance in locating a participating vision provider
close to you.

Schedule an appointment if you need an eye exam by calling a
participating provider, otherwise simply go to the provider's office for
services.

**Areas Not Included in Your Coverage**

-   Medical treatment of eyes or special procedures, such as orthoptics
    training;

-   Eyeglass lenses, eyeglass frames or contact lenses;

-   Contact lens fitting services;

-   Eye examinations required by an employer or services for which no
    charge is made;

-   Vision examinations performed more frequently that every twelve (12)
    months;

-   Vision examinations performed by non participating providers; and

-   Special purpose vision aids.

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

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

We do not cover the following:

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

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

-   Services, drugs or supplies not medically necessary;

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

-   Experimental or investigational procedures, treatments, drugs or
    devices;

-   Services, drugs, or supplies related to abortions, except when the
    life of the mother would be endangered if the fetus were carried to
    term or when the pregnancy is the result of an act of rape or
    incest;

-   Services, drugs or supplies related to sex transformations;

-   Services, drugs or supplies you receive from a provider or facility
    barred from the FEHB Program; or

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

# Section 7. Filing a claim for covered services

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

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

+------------------+---------------------------------------------------+
| Medical and      | In most cases, providers and facilities file      |
| hospital         | claims for you. Physicians must file on the form  |
| benefits         | HCFA-1500, Health Insurance Claim Form. Your      |
|                  | facility will file on the UB-92 form. For claims  |
|                  | questions and assistance, call us at              |
|                  | 877-299-2377.                                     |
|                  |                                                   |
|                  | When you must file a claim -- such as for         |
|                  | services you receive outside the Plan's service   |
|                  | area -- submit it on the HCFA-1500 or a claim     |
|                  | form that includes the information shown below.   |
|                  | Bills and receipts should be itemized and show:   |
|                  |                                                   |
|                  | -   Covered member's name and ID number;          |
|                  |                                                   |
|                  | -   Name and address of the physician or facility |
|                  |     that provided the service or supply;          |
|                  |                                                   |
|                  | -   Dates you received the services or supplies;  |
|                  |                                                   |
|                  | -   Diagnosis;                                    |
|                  |                                                   |
|                  | -   Type of each service or supply;               |
|                  |                                                   |
|                  | -   The charge for each service or supply;        |
|                  |                                                   |
|                  | -   A copy of the explanation of benefits,        |
|                  |     payments, or denial from any primary payer -- |
|                  |     such as the Medicare Summary Notice (MSN);    |
|                  |     and                                           |
|                  |                                                   |
|                  | -   Receipts, if you paid for your services.      |
|                  |                                                   |
|                  | **Submit your claims to:**                        |
|                  |                                                   |
|                  | HMO Blue Texas                                    |
|                  |                                                   |
|                  | Claims Dept.                                      |
|                  |                                                   |
|                  | P. O. Box 660044                                  |
|                  |                                                   |
|                  | Dallas, TX 75266-0044                             |
+------------------+---------------------------------------------------+
| Prescription     | If you purchase items covered by this benefit     |
| drugs            | from a non-participating pharmacy, you have to    |
|                  | submit a reimbursement request to HMO Blue Texas  |
|                  | in order to get your benefits.                    |
|                  |                                                   |
|                  | **Submit your claims to:**                        |
|                  |                                                   |
|                  | HMO Blue Texas                                    |
|                  |                                                   |
|                  | P. O. Box 660044                                  |
|                  |                                                   |
|                  | Dallas, TX 75266-0044                             |
+------------------+---------------------------------------------------+
| Deadline for     | Send us all of the documents for your claim as    |
| filing your      | soon as possible. You must submit the claim by    |
| claim            | December 31 of the year after the year you        |
|                  | received the service, unless timely filing was    |
|                  | prevented by administrative operations of         |
|                  | Government or legal incapacity, provided the      |
|                  | claim was submitted as soon as reasonably         |
|                  | possible.                                         |
+------------------+---------------------------------------------------+
| When we need     | Please reply promptly when we ask for additional  |
| more information | information. We may delay processing or deny your |
|                  | claim if you do not respond.                      |
+------------------+---------------------------------------------------+

# Section 8. The disputed claims process

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

+----+-----------------------------------------------------------------+
| St | Description                                                     |
| ep |                                                                 |
+----+-----------------------------------------------------------------+
| 1  | Ask us in writing to reconsider our initial decision. You must: |
|    |                                                                 |
|    | a)  Write to us within 6 months from the date of our decision;  |
|    |     and                                                         |
|    |                                                                 |
|    | b)  Send your request to us at: P.O. Box 90602 San Angelo, TX   |
|    |     76906 and                                                   |
|    |                                                                 |
|    | c)  Include a statement about why you believe our initial       |
|    |     decision was wrong, based on specific benefit provisions in |
|    |     this brochure; and                                          |
|    |                                                                 |
|    | d)  Include copies of documents that support your claim, such   |
|    |     as physicians\' letters, operative reports, bills, medical  |
|    |     records, and explanation of benefits (EOB) forms.           |
+----+-----------------------------------------------------------------+
| 2  | We have 30 days from the date we receive your request to:       |
|    |                                                                 |
|    | a)  Pay the claim (or, if applicable, arrange for the health    |
|    |     care provider to give you the care); or                     |
|    |                                                                 |
|    | b)  Write to you and maintain our denial go to step 4; or       |
|    |                                                                 |
|    | c)  Ask you or your provider for more information. If we ask    |
|    |     your provider, we will send you a copy of our request---go  |
|    |     to step 3.                                                  |
+----+-----------------------------------------------------------------+
| 3  | You or your provider must send the information so that we       |
|    | receive it within 60 days of our request. We will then decide   |
|    | within 30 more days.                                            |
|    |                                                                 |
|    | If we do not receive the information within 60 days, we will    |
|    | decide within 30 days of the date the information was due. We   |
|    | will base our decision on the information we already have.      |
|    |                                                                 |
|    | We will write to you with our decision.                         |
+----+-----------------------------------------------------------------+
| 4  | If you do not agree with our decision, you may ask OPM to       |
|    | review it.                                                      |
+----+-----------------------------------------------------------------+
|    | You must write to OPM within:                                   |
|    |                                                                 |
|    | -   90 days after the date of our letter upholding our initial  |
|    |     decision; or                                                |
|    |                                                                 |
|    | -   120 days after you first wrote to us if we did not answer   |
|    |     that request in some way within 30 days; or                 |
|    |                                                                 |
|    | -   120 days after we asked for additional information.         |
+----+-----------------------------------------------------------------+
|    | Write to OPM at: United States Office of Personnel Management,  |
|    | Insurance Services Programs, Health Insurance Group 2, 1900 E   |
|    | Street, NW, Washington, DC 20415-3620.                          |
+----+-----------------------------------------------------------------+

+----+-----------------------------------------------------------------+
| T  |                                                                 |
| he |                                                                 |
| di |                                                                 |
| sp |                                                                 |
| ut |                                                                 |
| ed |                                                                 |
| cl |                                                                 |
| ai |                                                                 |
| ms |                                                                 |
| p  |                                                                 |
| ro |                                                                 |
| ce |                                                                 |
| ss |                                                                 |
| *  |                                                                 |
| (c |                                                                 |
| on |                                                                 |
| ti |                                                                 |
| nu |                                                                 |
| ed |                                                                 |
| )* |                                                                 |
+----+-----------------------------------------------------------------+
|    | Send OPM the following information:                             |
|    |                                                                 |
|    | -   A statement about why you believe our decision was wrong,   |
|    |     based on specific benefit provisions in this brochure;      |
|    |                                                                 |
|    | -   Copies of documents that support your claim, such as        |
|    |     physicians\' letters, operative reports, bills, medical     |
|    |     records, and explanation of benefits (EOB) forms;           |
|    |                                                                 |
|    | -   Copies of all letters you sent to us about the claim;       |
|    |                                                                 |
|    | -   Copies of all letters we sent to you about the claim; and   |
|    |                                                                 |
|    | -   Your daytime phone number and the best time to call.        |
|    |                                                                 |
|    | Note: If you want OPM to review more than one claim, you must   |
|    | clearly identify which documents apply to which claim.          |
+----+-----------------------------------------------------------------+
|    | Note: You are the only person who has a right to file a         |
|    | disputed claim with OPM. Parties acting as your representative, |
|    | such as medical providers, must include a copy of your specific |
|    | written consent with the review request.                        |
|    |                                                                 |
|    | Note: The above deadlines may be extended if you show that you  |
|    | were unable to meet the deadline because of reasons beyond your |
|    | control.                                                        |
+----+-----------------------------------------------------------------+
| *  | OPM will review your disputed claim request and will use the    |
| *5 | information it collects from you and us to decide whether our   |
| ** | decision is correct. OPM will send you a final decision within  |
|    | 60 days. There are no other administrative appeals.             |
+----+-----------------------------------------------------------------+
|    | If you do not agree with OPM's decision, your only recourse is  |
|    | to sue. If you decide to sue, you must file the suit against    |
|    | OPM in Federal court by December 31 of the third year after the |
|    | year in which you received the disputed services, drugs, or     |
|    | supplies or from the year in which you were denied              |
|    | precertification or prior approval. This is the only deadline   |
|    | that may not be extended.                                       |
|    |                                                                 |
|    | OPM may disclose the information it collects during the review  |
|    | process to support their disputed claim decision. This          |
|    | information will become part of the court record.               |
+----+-----------------------------------------------------------------+
|    | You may not sue until you have completed the disputed claims    |
|    | process. Further, Federal law governs your lawsuit, benefits,   |
|    | and payment of benefits. The Federal court will base its review |
|    | on the record that was before OPM when OPM decided to uphold or |
|    | overturn our decision. You may recover only the amount of       |
|    | benefits in dispute.                                            |
+----+-----------------------------------------------------------------+

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

a)  We haven't responded yet to your initial request for care or
    preauthorization/prior approval, then call us at (800) 441-9188and
    we will expedite our review; or

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

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

-   You may call OPM's Health Insurance Group x at 202/606-3818 between
    8 a.m. and 5 p.m. Eastern Time.

# Section 9. Coordinating benefits with other coverage

+------------------+---------------------------------------------------+
| ### Whe          | You must tell us if you or a covered family       |
| n you have other | member have coverage under another group health   |
|  health coverage | plan or have automobile insurance that pays       |
|                  | health care expenses without regard to fault.     |
|                  | This is called "double coverage".                 |
|                  |                                                   |
|                  | When you have double coverage, one plan normally  |
|                  | pays its benefits in full as the primary payer    |
|                  | and the other plan pays a reduced benefit as the  |
|                  | secondary payer. We, like other insurers,         |
|                  | determine which coverage is primary according to  |
|                  | the National Association of Insurance             |
|                  | Commissioners' guidelines.                        |
|                  |                                                   |
|                  | When we are the primary payer, we will pay the    |
|                  | benefits described in this brochure.              |
|                  |                                                   |
|                  | When we are the secondary payer, we will          |
|                  | determine our allowance. After the primary plan   |
|                  | pays, we will pay what is left of our allowance,  |
|                  | up to our regular benefit. We will not pay more   |
|                  | than our allowance. Visit limits will apply even  |
|                  | when the plan is the secondary payer.             |
+------------------+---------------------------------------------------+
| ### W            | Medicare is a Health Insurance Program for:       |
| hat is Medicare? |                                                   |
|                  | -   People 65 years of age or older.              |
|                  |                                                   |
|                  | -   Some people with disabilities under 65 years  |
|                  |     of age.                                       |
|                  |                                                   |
|                  | -   People with End-Stage Renal Disease           |
|                  |     (permanent kidney failure requiring dialysis  |
|                  |     or a transplant).                             |
|                  |                                                   |
|                  | Medicare has two parts:                           |
|                  |                                                   |
|                  | -   Part A (Hospital Insurance). Most people do   |
|                  |     not have to pay for Part A. If you or your    |
|                  |     spouse worked for at least 10 years in        |
|                  |     Medicare-covered employment, you should be    |
|                  |     able to qualify for premium-free Part A       |
|                  |     insurance. (Someone who was a Federal         |
|                  |     employee on January 1, 1983 or since          |
|                  |     automatically qualifies.) Otherwise, if you   |
|                  |     are age 65 or older, you may be able to buy   |
|                  |     it. Contact 1-800-MEDICARE for more           |
|                  |     information.                                  |
|                  |                                                   |
|                  | -   Part B (Medical Insurance). Most people pay   |
|                  |     monthly for Part B. Generally, Part B         |
|                  |     premiums are withheld from your monthly       |
|                  |     Social Security check or your retirement      |
|                  |     check.                                        |
+------------------+---------------------------------------------------+
| #                | The decision to enroll in Medicare is yours. We   |
| ### Should I enr | encourage you to apply for Medicare benefits 3    |
| oll in Medicare? | months before you turn age 65. It's easy. Just    |
|                  | call the Social Security Administration toll-free |
|                  | number 1-800-772-1213 to set up an appointment to |
|                  | apply. If you do not apply for one or both Parts  |
|                  | of Medicare, you can still be covered under the   |
|                  | FEHB Program.                                     |
|                  |                                                   |
|                  | If you can get premium-free Part A coverage, we   |
|                  | advise you to enroll in it. Most Federal          |
|                  | employees and annuitants are entitled to Medicare |
|                  | Part A at age 65 **without cost**. When you don't |
|                  | have to pay premiums for Medicare Part A, it      |
|                  | makes good sense to obtain the coverage. It can   |
|                  | reduce your out-of-pocket expenses as well as     |
|                  | costs to the FEHB, which can help keep FEHB       |
|                  | premiums down.                                    |
|                  |                                                   |
|                  | Everyone is charged a premium for Medicare Part B |
|                  | coverage. The Social Security Administration can  |
|                  | provide you with premium and benefit information. |
|                  | Review the information and decide if it makes     |
|                  | sense for you to buy the Medicare Part B          |
|                  | coverage.                                         |
|                  |                                                   |
|                  | If you are eligible for Medicare, you may have    |
|                  | choices in how you get your health care. Medicare |
|                  | Advantage is the term used to describe the        |
|                  | various health plan choices available to Medicare |
|                  | beneficiaries. The information in the next few    |
|                  | pages shows how we coordinate benefits with       |
|                  | Medicare, depending on whether you are in         |
|                  | Original Medicare Plan or a private Medicare      |
|                  | Advantage Plan.                                   |
+------------------+---------------------------------------------------+

+------------------+---------------------------------------------------+
| ##               | The Original Medicare Plan (Original Medicare) is |
| ## The Original  | available everywhere in the United States. It is  |
| Medicare Plan (P | the way everyone used to get Medicare benefits    |
| art A or Part B) | and is the way most people get their Medicare     |
|                  | Part A and Part B benefits now. You may go to any |
|                  | doctor, specialist, or hospital that accepts      |
|                  | Medicare. The Original Medicare Plan pays its     |
|                  | share and you pay your share. Some things are not |
|                  | covered under Original Medicare, such as most     |
|                  | prescription drugs (but coverage through private  |
|                  | prescription drug plans will be available         |
|                  | starting in 2006).                                |
|                  |                                                   |
|                  | When you are enrolled in Original Medicare along  |
|                  | with this Plan, you still need to follow the      |
|                  | rules in this brochure for us to cover your care. |
|                  | Your care must continue to be authorized by your  |
|                  | Plan PCP, or precertified as required.            |
+------------------+---------------------------------------------------+
|                  | **Claims process when you have the Original       |
|                  | Medicare Plan** -- You probably will never have   |
|                  | to file a claim form when you have both our Plan  |
|                  | and the Original Medicare Plan.                   |
|                  |                                                   |
|                  | -   When we are the primary payer, we process the |
|                  |     claim first.                                  |
|                  |                                                   |
|                  | -   When Original Medicare is the primary payer,  |
|                  |     Medicare processes your claim first. In most  |
|                  |     cases, your claim will be coordinated         |
|                  |     automatically and we will then provide        |
|                  |     secondary benefits for covered charges. You   |
|                  |     will not need to do anything. To find out if  |
|                  |     you need to do something to file your claim,  |
|                  |     call us at (877) 299-2377.                    |
|                  |                                                   |
|                  | **We do not waive any costs if the Original       |
|                  | Medicare Plan is your primary payer.**            |
+------------------+---------------------------------------------------+

Medicare always makes the final determination as to whether they are the
primary payer. The following chart illustrates whether Medicare or this
Plan should be the primary payer for you according to your employment
status and other factors determined by Medicare. It is critical that you
tell us if you or a covered family member has Medicare coverage so we
can administer these requirements correctly.

+----------------------------------------------------+-------+--------+
| > **Primary Payer Chart**                          |       |        |
+----------------------------------------------------+-------+--------+
| **A. When you - or your covered spouse - are age   | **The |        |
| 65 or over and have Medicare and you...**          | pr    |        |
|                                                    | imary |        |
|                                                    | payer |        |
|                                                    | for   |        |
|                                                    | the   |        |
|                                                    | indiv |        |
|                                                    | idual |        |
|                                                    | with  |        |
|                                                    | Med   |        |
|                                                    | icare |        |
|                                                    | is    |        |
|                                                    | ...** |        |
+----------------------------------------------------+-------+--------+
|                                                    | **    | **This |
|                                                    | Medic | Plan** |
|                                                    | are** |        |
+----------------------------------------------------+-------+--------+
| 1)  Have FEHB coverage on your own as an active    |       |        |
|     employee or through your spouse who is an      |       |        |
|     active employee                                |       |        |
+----------------------------------------------------+-------+--------+
| 2)  Have FEHB coverage on your own as an annuitant |       |        |
|     or through your spouse who is an annuitant     |       |        |
+----------------------------------------------------+-------+--------+
| 3)  Are a reemployed annuitant with the Federal    |       |        |
|     government and your position is excluded from  |       |        |
|     the FEHB (your employing office will know if   |       |        |
|     this is the case) and you are not covered      |       |        |
|     under FEHB through your spouse under #1 above. |       |        |
+----------------------------------------------------+-------+--------+
| 4)  Are a reemployed annuitant with the Federal    |       |        |
|     government and your position is not excluded   |       |        |
|     from the FEHB (your employing office will know |       |        |
|     if this is the case) and...                    |       |        |
|                                                    |       |        |
| -   You have FEHB coverage on your own or through  |       |        |
|     your spouse who is also an active employee     |       |        |
+----------------------------------------------------+-------+--------+
| -   You have FEHB coverage through your spouse who |       |        |
|     is an annuitant                                |       |        |
+----------------------------------------------------+-------+--------+
| 5)  Are a Federal judge who retired under title    | ##    |        |
|     28, U.S.C., or a Tax Court judge who retired   | ####  |        |
|     under Section 7447 of title 26, U.S.C. (or if  |       |        |
|     your covered spouse is this type of judge) and |       |        |
|     you are not covered under FEHB through your    |       |        |
|     spouse under #1 above                          |       |        |
+----------------------------------------------------+-------+--------+
| 6)  Are enrolled in Part B only, regardless of     | for   | for    |
|     your employment status                         | Part  | other  |
|                                                    | B     | se     |
|                                                    | ser   | rvices |
|                                                    | vices |        |
+----------------------------------------------------+-------+--------+
| 7)  Are a former Federal employee receiving        | *     |        |
|     Workers' Compensation and the Office of        | *\*** |        |
|     Workers' Compensation Programs has determined  |       |        |
|     that you are unable to return to duty          |       |        |
+----------------------------------------------------+-------+--------+
| **B. When you or a covered family member...**      |       |        |
+----------------------------------------------------+-------+--------+
| 1)  Have Medicare solely based on end stage renal  |       |        |
|     disease (ESRD) and...                          |       |        |
|                                                    |       |        |
| -   It is within the first 30 months of            |       |        |
|     eligibility for or entitlement to Medicare due |       |        |
|     to ESRD (30-month coordination period)         |       |        |
+----------------------------------------------------+-------+--------+
| -   It is beyond the 30-month coordination period  |       |        |
|     and you or a family member are still entitled  |       |        |
|     to Medicare due to ESRD                        |       |        |
+----------------------------------------------------+-------+--------+
| 2)  Become eligible for Medicare due to ESRD while |       | for    |
|     already a Medicare beneficiary and**...**      |       | 30     |
|                                                    |       | -month |
| -   This Plan was the primary payer before         |       | coordi |
|     eligibility due to ESRD                        |       | nation |
|                                                    |       | period |
+----------------------------------------------------+-------+--------+
| -   Medicare was the primary payer before          |       |        |
|     eligibility due to ESRD                        |       |        |
+----------------------------------------------------+-------+--------+
| **C. When either you or a covered family member    |       |        |
| are eligible for Medicare solely due to disability |       |        |
| and you...**                                       |       |        |
+----------------------------------------------------+-------+--------+
| 1)  Have FEHB coverage on your own as an active    |       |        |
|     employee or through a family member who is an  |       |        |
|     active employee                                |       |        |
+----------------------------------------------------+-------+--------+
| 2)  Have FEHB coverage on your own as an annuitant |       | []{    |
|     or through a family member who is an annuitant |       | .mark} |
+----------------------------------------------------+-------+--------+
| **D. When you are covered under the FEHB Spouse    |       |        |
| Equity provision as a former spouse**              |       |        |
+----------------------------------------------------+-------+--------+

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

+--------------------+-------------------------------------------------+
| ####               | If you are eligible for Medicare, you may       |
| Medicare Advantage | choose to enroll in and get your Medicare       |
|                    | benefits from a Medicare Advantage plan. These  |
|                    | are private health care choices (like HMOs) in  |
|                    | some areas of the country. In most Medicare     |
|                    | Advantage plans, you can only go to doctors,    |
|                    | specialists, or hospitals that are part of the  |
|                    | plan. Medicare Advantage plans provide all the  |
|                    | benefits that Original Medicare covers. Some    |
|                    | cover extras, like prescription drugs. To learn |
|                    | more about enrolling in a Medicare Advantage    |
|                    | plan, contact Medicare at 1-800-MEDICARE        |
|                    | (1-800-633-4227) or at                          |
|                    | [www.medicare.gov](http://www.medicare.gov/).   |
|                    |                                                 |
|                    | If you enroll in a Medicare Advantage plan, the |
|                    | following options are available to you:         |
|                    |                                                 |
|                    | **This Plan and another plan's Medicare         |
|                    | Advantage plan:** You may enroll in another     |
|                    | plan's Medicare Advantage plan and also remain  |
|                    | enrolled in our FEHB plan. We will still        |
|                    | provide benefits when your Medicare Advantage   |
|                    | plan is primary, even out of the Medicare       |
|                    | Advantage plan's network and/or service area    |
|                    | (if you use our Plan providers), but we will    |
|                    | not waive any of our copayments, coinsurance,   |
|                    | or deductibles. If you enroll in a Medicare     |
|                    | Advantage plan, tell us. We will need to know   |
|                    | whether you are in the Original Medicare Plan   |
|                    | or in a Medicare Advantage plan so we can       |
|                    | correctly coordinate benefits with Medicare.    |
|                    |                                                 |
|                    | **Suspended FEHB coverage to enroll in a        |
|                    | Medicare Advantage plan:** If you are an        |
|                    | annuitant or former spouse, you can suspend     |
|                    | your FEHB coverage to enroll in a Medicare      |
|                    | Advantage plan, eliminating your FEHB premium.  |
|                    | (OPM does not contribute to your Medicare       |
|                    | Advantage plan premium.) For information on     |
|                    | suspending your FEHB enrollment, contact your   |
|                    | retirement office. If you later want to         |
|                    | re-enroll in the FEHB Program, generally you    |
|                    | may do so only at the next Open Season unless   |
|                    | you involuntarily lose coverage or move out of  |
|                    | the Medicare Advantage plan's service area.     |
+--------------------+-------------------------------------------------+
| ### T              | TRICARE is the health care program for eligible |
| RICARE and CHAMPVA | dependents of military persons, and retirees of |
|                    | the military. TRICARE includes the CHAMPUS      |
|                    | program. CHAMPVA provides health coverage to    |
|                    | disabled Veterans and their eligible            |
|                    | dependents. IF TRICARE or CHAMPVA and this Plan |
|                    | cover you, we pay first. See your TRICARE or    |
|                    | CHAMPVA Health Benefits Advisor if you have     |
|                    | questions about these programs.                 |
|                    |                                                 |
|                    | **Suspended FEHB coverage to enroll in TRICARE  |
|                    | or CHAMPVA:** If you are an annuitant or former |
|                    | spouse, you can suspend your FEHB coverage to   |
|                    | enroll in one of these programs, eliminating    |
|                    | your FEHB premium. (OPM does not contribute to  |
|                    | any applicable plan premiums.) For information  |
|                    | on suspending your FEHB enrollment, contact     |
|                    | your retirement office. If you later want to    |
|                    | re-enroll in the FEHB Program, generally you    |
|                    | may do so only at the next Open Season unless   |
|                    | you involuntarily lose coverage under the       |
|                    | program.                                        |
+--------------------+-------------------------------------------------+
| ### Wor            | We do not cover services that:                  |
| kers' Compensation |                                                 |
|                    | -   You need because of a workplace-related     |
|                    |     illness or injury that the Office of        |
|                    |     Workers' Compensation Programs (OWCP) or a  |
|                    |     similar Federal or State agency determines  |
|                    |     they must provide; or                       |
|                    |                                                 |
|                    | -   OWCP or a similar agency pays for through a |
|                    |     third-party injury settlement or other      |
|                    |     similar proceeding that is based on a claim |
|                    |     you filed under OWCP or similar laws.       |
|                    |                                                 |
|                    | Once OWCP or similar agency pays its maximum    |
|                    | benefits for your treatment, we will cover your |
|                    | care.                                           |
+--------------------+-------------------------------------------------+

+--------------------+-------------------------------------------------+
| ### Medicaid       | When you have this Plan and Medicaid, we pay    |
|                    | first.                                          |
|                    |                                                 |
|                    | **Suspended FEHB coverage to enroll in Medicaid |
|                    | or a similar State-sponsored program of medical |
|                    | assistance:** If you are an annuitant or former |
|                    | spouse, you can suspend your FEHB coverage to   |
|                    | enroll in one of these State programs,          |
|                    | eliminating your FEHB premium. For information  |
|                    | on suspending your FEHB enrollment, contact     |
|                    | your retirement office. If you later want to    |
|                    | re-enroll in the FEHB Program, generally you    |
|                    | may do so only at the next Open Season unless   |
|                    | you involuntarily lose coverage under the State |
|                    | program.                                        |
+--------------------+-------------------------------------------------+
| ### When o         | We do not cover services and supplies when a    |
| ther Government ag | local, State, or Federal government agency      |
| encies are respons | directly or indirectly pays for them.           |
| ible for your care |                                                 |
+--------------------+-------------------------------------------------+
| ### When           | When you receive money to compensate you for    |
|  others are respon | medical or hospital care for injuries or        |
| sible for injuries | illness caused by another person, you must      |
|                    | reimburse us for any expenses we paid. However, |
|                    | we will cover the cost of treatment that        |
|                    | exceeds the amount you received in the          |
|                    | settlement.                                     |
|                    |                                                 |
|                    | If you do not seek damages you must agree to    |
|                    | let us try. This is called subrogation. If you  |
|                    | need more information, contact us for our       |
|                    | subrogation procedures.                         |
+--------------------+-------------------------------------------------+

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

+------------------+---------------------------------------------------+
| Calendar year    | January 1 through December 31 of the same year.   |
|                  | For new enrollees, the calendar year begins on    |
|                  | the effective date of their enrollment and ends   |
|                  | on December 31 of the same year.                  |
+------------------+---------------------------------------------------+
| Coinsurance      | Coinsurance is the percentage of our allowance    |
|                  | that you must pay for your care. You may also be  |
|                  | responsible for additional amounts. See page 12.  |
+------------------+---------------------------------------------------+
| Copayment        | A copayment is a fixed amount of money you pay    |
|                  | when you receive covered services. See page 12.   |
+------------------+---------------------------------------------------+
| Covered services | Care we provide benefits for, as described in     |
|                  | this brochure.                                    |
+------------------+---------------------------------------------------+
| Custodial care   | Care that primarily helps with or supports daily  |
|                  | living activities (such as bathing, dressing,     |
|                  | eating and eliminating body wastes) and can be    |
|                  | given by people other than trained medical        |
|                  | personnel. Custodial care that lasts 90 days or   |
|                  | more is sometimes known as Long Term Care.        |
+------------------+---------------------------------------------------+
| Experimental or  | Experimental or Investigational drugs, devices,   |
| investigational  | treatments or procedures includes any drug,       |
| services         | device, treatment or procedure that would not be  |
|                  | used in the absence of the experimental or        |
|                  | investigational drug, device, treatment or        |
|                  | procedure. We consider a drug, device, treatment  |
|                  | of procedure to e experimental or investigational |
|                  | if:                                               |
|                  |                                                   |
|                  | -   It cannot be lawfully marketed without the    |
|                  |     approval of the U.S. Food and Drug            |
|                  |     Administration and approval for marketing has |
|                  |     been given at the time it is provided; or     |
|                  |                                                   |
|                  | -   It was reviewed and approved by the treating  |
|                  |     facility's Institutional Review Board or      |
|                  |     similar committee, or if federal laws         |
|                  |     requires it to be reviewed and approved by    |
|                  |     that committee. This exclusion also applies   |
|                  |     if the informed consent form used with the    |
|                  |     drug, device, treatment or procedure was (or  |
|                  |     was required by federal law to be) reviewed   |
|                  |     and approved by that committee; or.           |
|                  |                                                   |
|                  | -   Reliable evidence shows that the drug,        |
|                  |     device, treatment or procedure is the subject |
|                  |     of ongoing Phase I or Phase II clinical       |
|                  |     trials; is the research, experimental, study  |
|                  |     or investigational arm of ongoing Phase III   |
|                  |     clinical trials; or is otherwise under study  |
|                  |     to determine its maximum tolerated dose, its  |
|                  |     toxicity, its safety, its effectiveness, or   |
|                  |     its effectiveness compared to a standard      |
|                  |     method of treatment or diagnosis.             |
|                  |                                                   |
|                  | -   Reliable evidence shows that the prevailing   |
|                  |     opinion among experts is that further studies |
|                  |     or clinical trials of the drug, device,       |
|                  |     treatment or procedure are needed to          |
|                  |     determine its maximum tolerated dose, its     |
|                  |     toxicity, its safety, its effectiveness, or   |
|                  |     its ineffectiveness compared to a standard    |
|                  |     method of treatment or diagnosis.             |
|                  |                                                   |
|                  | ("Reliable evidence" includes only published      |
|                  | reports and articles in authoritative medical and |
|                  | scientific literature and written protocols and   |
|                  | informed consent forms used by the treating       |
|                  | facility or by another facility studying          |
|                  | substantially the same drug, device, treatment or |
|                  | procedure.)                                       |
+------------------+---------------------------------------------------+

+------------------+---------------------------------------------------+
| Medical          | By "medically necessary", we mean that the        |
| necessity        | service meets *all* of the following conditions:  |
|                  |                                                   |
|                  | -   The service is required for diagnosis,        |
|                  |     treating or preventing an illness or injury,  |
|                  |     or a medical condition such as pregnancy;     |
|                  |                                                   |
|                  | -   If you are ill or injured, it is a service    |
|                  |     you need in order to improve your condition   |
|                  |     or to keep your condition from getting worse; |
|                  |                                                   |
|                  | -   It is generally accepted as safe and          |
|                  |     effective under standard medical practice in  |
|                  |     your community; and                           |
|                  |                                                   |
|                  | -   The service is provided in the most           |
|                  |     cost-efficient way, while still giving you an |
|                  |     appropriate level of care.                    |
|                  |                                                   |
|                  | Not every service that fits this definition is    |
|                  | covered under your Plan. To be covered, a service |
|                  | that is medically necessary must also be          |
|                  | described in this document. For example, we *do   |
|                  | not* cover any preventative, family planning or   |
|                  | infertility services that are not specified. Just |
|                  | because a physician or other health care provider |
|                  | has performed, prescribed or recommended a        |
|                  | service does not mean it is necessary or that it  |
|                  | is covered under your Plan.                       |
+------------------+---------------------------------------------------+
| Us/We            | Us and We refer to HMO Blue Texas.                |
+------------------+---------------------------------------------------+
| You              | You refers to the enrollee and each covered       |
|                  | family member.                                    |
+------------------+---------------------------------------------------+

# Section 11. FEHB Facts

### Coverage information

+------------------+---------------------------------------------------+
| #### No p        | We will not refuse to cover the treatment of a    |
| re-existing cond | condition you had before you enrolled in this     |
| ition limitation | Plan solely because you had the condition before  |
|                  | you enrolled.                                     |
+------------------+---------------------------------------------------+
| #### W           | See                                               |
| here you can get | [www.opm.gov/insure](http://www.opm.gov/insure).  |
|  information abo | Also, your employing or retirement office can     |
| ut enrolling in  | answer your questions, and give you a *Guide to   |
| the FEHB Program | Federal Employees Health Benefits Plans,*         |
|                  | brochures for other plans, and other materials    |
|                  | you need to make an informed decision about your  |
|                  | FEHB coverage. These materials tell you:          |
|                  |                                                   |
|                  | -   When you may change your enrollment;          |
|                  |                                                   |
|                  | -   How you can cover your family members;        |
|                  |                                                   |
|                  | -   What happens when you transfer to another     |
|                  |     Federal agency, go on leave without pay,      |
|                  |     enter military service, or retire;            |
|                  |                                                   |
|                  | -   When your enrollment ends; and                |
|                  |                                                   |
|                  | -   When the next open season for enrollment      |
|                  |     begins.                                       |
|                  |                                                   |
|                  | We don't determine who is eligible for coverage   |
|                  | and, in most cases, cannot change your enrollment |
|                  | status without information from your employing or |
|                  | retirement office.                                |
+------------------+---------------------------------------------------+
| #### Typ         | Self Only coverage is for you alone. Self and     |
| es of coverage a | Family coverage is for you, your spouse, and your |
| vailable for you | unmarried dependent children under age 22,        |
|  and your family | including any foster children or stepchildren     |
|                  | your employing or retirement office authorizes    |
|                  | coverage for. Under certain circumstances, you    |
|                  | may also continue coverage for a disabled child   |
|                  | 22 years of age or older who is incapable of      |
|                  | self-support.                                     |
|                  |                                                   |
|                  | If you have a Self Only enrollment, you may       |
|                  | change to a Self and Family enrollment if you     |
|                  | marry, give birth, or add a child to your family. |
|                  | You may change your enrollment 31 days before to  |
|                  | 60 days after that event. The Self and Family     |
|                  | enrollment begins on the first day of the pay     |
|                  | period in which the child is born or becomes an   |
|                  | eligible family member. When you change to Self   |
|                  | and Family because you marry, the change is       |
|                  | effective on the first day of the pay period that |
|                  | begins after your employing office receives your  |
|                  | enrollment form; benefits will not be available   |
|                  | to your spouse until you marry.                   |
|                  |                                                   |
|                  | Your employing or retirement office will **not**  |
|                  | notify you when a family member is no longer      |
|                  | eligible to receive benefits, nor will we. Please |
|                  | tell us immediately when you add or remove family |
|                  | members from your coverage for any reason,        |
|                  | including divorce, or when your child under age   |
|                  | 22 marries or turns 22.                           |
|                  |                                                   |
|                  | If you or one of your family members is enrolled  |
|                  | in one FEHB plan, that person may not be enrolled |
|                  | in or covered as a family member by another FEHB  |
|                  | plan.                                             |
+------------------+---------------------------------------------------+
| #### Child       | OPM has implemented the Federal Employees Health  |
| ren's Equity Act | Benefits Children's Equity Act of 2000. This law  |
|                  | mandates that you be enrolled for Self and Family |
|                  | coverage in the FEHB Program, if you are an       |
|                  | employee subject to a court or administrative     |
|                  | order requiring you to provide health benefits    |
|                  | for your child(ren).                              |
|                  |                                                   |
|                  | If this law applies to you, you must enroll for   |
|                  | Self and Family coverage in a health plan that    |
|                  | provides full benefits in the area where your     |
|                  | children live or provide documentation to your    |
|                  | employing office that you have obtained other     |
|                  | health benefits coverage for your children. If    |
|                  | you do not do so, your employing office will      |
|                  | enroll you involuntarily as follows:              |
|                  |                                                   |
|                  | -   If you have no FEHB coverage, your employing  |
|                  |     office will enroll you for Self and Family    |
|                  |     coverage in the Blue Cross and Blue Shield    |
|                  |     Service Benefit Plan's Basic Option;          |
|                  |                                                   |
|                  | -   If you have a Self Only enrollment in a       |
|                  |     fee-for-service plan or in an HMO that serves |
|                  |     the area where your children live, your       |
|                  |     employing office will change your enrollment  |
|                  |     to Self and Family in the same option of the  |
|                  |     same plan; or                                 |
|                  |                                                   |
|                  | -   If you are enrolled in an HMO that does not   |
|                  |     serve the area where the children live, your  |
|                  |     employing office will change your enrollment  |
|                  |     to Self and Family in the Blue Cross and Blue |
|                  |     Shield Service Benefit Plan's Basic Option.   |
|                  |                                                   |
|                  | As long as the court/administrative order is in   |
|                  | effect, and you have at least one child           |
|                  | identified in the order who is still eligible     |
|                  | under the FEHB Program, you cannot cancel your    |
|                  | enrollment, change to Self Only, or change to a   |
|                  | plan that doesn't serve the area in which your    |
|                  | children live, unless you provide documentation   |
|                  | that you have other coverage for the children. If |
|                  | the court/administrative order is still in effect |
|                  | when you retire, and you have at least one child  |
|                  | still eligible for FEHB coverage, you must        |
|                  | continue your FEHB coverage into retirement (if   |
|                  | eligible) and cannot cancel your coverage, change |
|                  | to Self Only, or change to a plan that doesn't    |
|                  | serve the area in which your children live as     |
|                  | long as the court/administrative order is in      |
|                  | effect. Contact your employing office for further |
|                  | information.                                      |
+------------------+---------------------------------------------------+
| ####             | The benefits in this brochure are effective       |
| When benefits an | January 1. If you joined this Plan during Open    |
| d premiums start | Season, your coverage begins on the first day of  |
|                  | your first pay period that starts on or after     |
|                  | January 1. If you changed plans or plan options   |
|                  | during Open Season and you receive care between   |
|                  | January 1 and the effective date of coverage      |
|                  | under your new plan or option, your claims will   |
|                  | be paid according to the 2005 benefits of your    |
|                  | old plan or option. However, if your old plan     |
|                  | left the FEHB Program at the end of the year, you |
|                  | are covered under that plan's 2004 benefits until |
|                  | the effective date of your coverage with your new |
|                  | plan. Annuitants' coverage and premiums begin on  |
|                  | January 1. If you joined at any other time during |
|                  | the year, your employing office will tell you the |
|                  | effective date of coverage.                       |
+------------------+---------------------------------------------------+
| ####             | When you retire, you can usually stay in the FEHB |
|  When you retire | Program. Generally, you must have been enrolled   |
|                  | in the FEHB Program for the last five years of    |
|                  | your Federal service. If you do not meet this     |
|                  | requirement, you may be eligible for other forms  |
|                  | of coverage, such as Temporary Continuation of    |
|                  | Coverage (TCC).                                   |
+------------------+---------------------------------------------------+

### When you lose benefits

+------------------+---------------------------------------------------+
| #### When FE     | You will receive an additional 31 days of         |
| HB coverage ends | coverage, for no additional premium, when:        |
|                  |                                                   |
|                  | -   Your enrollment ends, unless you cancel your  |
|                  |     enrollment, or                                |
|                  |                                                   |
|                  | -   You are a family member no longer eligible    |
|                  |     for coverage.                                 |
|                  |                                                   |
|                  | You may be eligible for spouse equity coverage or |
|                  | Temporary Continuation of Coverage (TCC), or a    |
|                  | conversion policy (a non-FEHB individual policy.) |
+------------------+---------------------------------------------------+
| #### Spouse      | If you are divorced from a Federal employee or    |
|  equity coverage | annuitant, you may not continue to get benefits   |
|                  | under your former spouse's enrollment. This is    |
|                  | the case even when the court has ordered your     |
|                  | former spouse to provide health coverage to you.  |
|                  | But, you may be eligible for your own FEHB        |
|                  | coverage under the spouse equity law or Temporary |
|                  | Continuation of Coverage (TCC). If you are        |
|                  | recently divorced or are anticipating a divorce,  |
|                  | contact your ex-spouse's employing or retirement  |
|                  | office to get RI 70-5, the *Guide To Federal      |
|                  | Employees Health Benefits Plans for Temporary     |
|                  | Continuation of Coverage and Former Spouse        |
|                  | Enrollees,* or other information about your       |
|                  | coverage choices. You can also download the guide |
|                  | from OPM's Web site,                              |
|                  | [www.opm.gov/insure](http://www.opm.gov/insure).  |
+------------------+---------------------------------------------------+
| #### Temporar    | If you leave Federal service, or if you lose      |
| y Continuation o | coverage because you no longer qualify as a       |
| f Coverage (TCC) | family member, you may be eligible for Temporary  |
|                  | Continuation of Coverage (TCC). For example, you  |
|                  | can receive TCC if you are not able to continue   |
|                  | your FEHB enrollment after you retire, if you     |
|                  | lose your Federal job, if you are a covered       |
|                  | dependent child and you turn 22 or marry, etc.    |
|                  |                                                   |
|                  | You may not elect TCC if you are fired from your  |
|                  | Federal job due to gross misconduct.              |
|                  |                                                   |
|                  | **Enrolling in TCC.** Get the RI 79-27, which     |
|                  | describes TCC, and the RI 70-5, the *Guide to     |
|                  | Federal Employees Health Benefits Plans for       |
|                  | Temporary Continuation of Coverage and Former     |
|                  | Spouse Enrollees,* from your employing or         |
|                  | retirement office or from                         |
|                  | [www.opm.gov/insure](http://www.opm/gov/insure).  |
|                  | It explains what you have to do to enroll.        |
+------------------+---------------------------------------------------+
| #### C           | You may convert to a non-FEHB individual policy   |
| onverting to ind | if:                                               |
| ividual coverage |                                                   |
|                  | -   Your coverage under TCC or the spouse equity  |
|                  |     law ends (If you canceled your coverage or    |
|                  |     did not pay your premium, you cannot          |
|                  |     convert);                                     |
|                  |                                                   |
|                  | -   You decided not to receive coverage under TCC |
|                  |     or the spouse equity law; or                  |
|                  |                                                   |
|                  | -   You are not eligible for coverage under TCC   |
|                  |     or the spouse equity law.                     |
|                  |                                                   |
|                  | If you leave Federal service, your employing      |
|                  | office will notify you of your right to convert.  |
|                  | You must apply in writing to us within 31 days    |
|                  | after you receive this notice. However, if you    |
|                  | are a family member who is losing coverage, the   |
|                  | employing or retirement office will **not**       |
|                  | notify you. You must apply in writing to us       |
|                  | within 31 days after you are no longer eligible   |
|                  | for coverage.                                     |
|                  |                                                   |
|                  | Your benefits and rates will differ from those    |
|                  | under the FEHB Program; however, you will not     |
|                  | have to answer questions about your health, and   |
|                  | we will not impose a waiting period or limit your |
|                  | coverage due to pre-existing conditions.          |
+------------------+---------------------------------------------------+
| #### Get         | The Health Insurance Portability and              |
| ting a Certifica | Accountability Act of 1996 (HIPAA) is a Federal   |
| te of Group Heal | law that offers limited Federal protections for   |
| th Plan Coverage | health coverage availability and continuity to    |
|                  | people who lose employer group coverage. If you   |
|                  | leave the FEHB Program, we will give you a        |
|                  | Certificate of Group Health Plan Coverage that    |
|                  | indicates how long you have been enrolled with    |
|                  | us. You can use this certificate when getting     |
|                  | health insurance or other health care coverage.   |
|                  | Your new plan must reduce or eliminate waiting    |
|                  | periods, limitations, or exclusions for health    |
|                  | related conditions based on the information in    |
|                  | the certificate, as long as you enroll within 63  |
|                  | days of losing coverage under this Plan. If you   |
|                  | have been enrolled with us for less than 12       |
|                  | months, but were previously enrolled in other     |
|                  | FEHB plans, you may also request a certificate    |
|                  | from those plans.                                 |
|                  |                                                   |
|                  | For more information, get OPM pamphlet RI 79-27,  |
|                  | *Temporary Continuation of Coverage* *(TCC) under |
|                  | the FEHB Program*. See also the FEHB Web site at  |
|                  | [www.opm.gov/                                     |
|                  | insure/health](http://www.opm.gov/insure/health); |
|                  | refer to the "TCC and HIPAA" frequently asked     |
|                  | questions. These highlight HIPAA rules, such as   |
|                  | the requirement that Federal employees must       |
|                  | exhaust any TCC eligibility as one condition for  |
|                  | guaranteed access to individual health coverage   |
|                  | under HIPAA, and information about Federal and    |
|                  | State agencies you can contact for more           |
|                  | information.                                      |
+------------------+---------------------------------------------------+

# Section 12. Two Federal Programs complement FEHB benefits

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

  ------------------- ---------------------------------------------------

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

+------------------+--------------------------------+--------+--------+
| -   What is an   | It is a tax-favored benefit    |        |        |
|     FSA?         | that allows you to set aside   |        |        |
|                  | pre-tax money from your        |        |        |
|                  | paychecks to pay for a variety |        |        |
|                  | of eligible expenses. *By      |        |        |
|                  | using an FSA, you can reduce   |        |        |
|                  | your taxes while paying for    |        |        |
|                  | services you would have to pay |        |        |
|                  | for anyway, producing a        |        |        |
|                  | discount that can be over      |        |        |
|                  | 40%.*                          |        |        |
|                  |                                |        |        |
|                  | There are two types of FSAs    |        |        |
|                  | offered by FSAFEDS:            |        |        |
+------------------+--------------------------------+--------+--------+
| Health Care      | -   Covers eligible health     |        |        |
| Flexible         |     care expenses not          |        |        |
| Spending Account |     reimbursed by this Plan,   |        |        |
| (HCFSA)          |     or any other medical,      |        |        |
|                  |     dental, or vision care     |        |        |
|                  |     plan you or your           |        |        |
|                  |     dependents may have.       |        |        |
|                  |                                |        |        |
|                  | -   Eligible dependents for    |        |        |
|                  |     this account include       |        |        |
|                  |     anyone you claim on your   |        |        |
|                  |     Federal income tax return  |        |        |
|                  |     as a qualified dependent   |        |        |
|                  |     under the U.S. Internal    |        |        |
|                  |     Revenue Service (IRS)      |        |        |
|                  |     definition and/or with     |        |        |
|                  |     whom you jointly file your |        |        |
|                  |     Federal Income Tax return, |        |        |
|                  |     even if you don't have     |        |        |
|                  |     self and family health     |        |        |
|                  |     benefits coverage.         |        |        |
|                  |     ***Note:*** The IRS has a  |        |        |
|                  |     broader definition of a    |        |        |
|                  |     "family member" than is    |        |        |
|                  |     used under the FEHB        |        |        |
|                  |     Program to provide         |        |        |
|                  |     benefits by your FEHB      |        |        |
|                  |     Plan.                      |        |        |
|                  |                                |        |        |
|                  | -   The maximum annual amount  |        |        |
|                  |     that can be allotted for   |        |        |
|                  |     the HCFSA is \$4,000.      |        |        |
|                  |     *Note:* The Federal        |        |        |
|                  |     workforce includes a       |        |        |
|                  |     number of employees        |        |        |
|                  |     married to each other. If  |        |        |
|                  |     each spouse/employee is    |        |        |
|                  |     eligible for FEHB          |        |        |
|                  |     coverage, both may enroll  |        |        |
|                  |     for a HCFSA up to the      |        |        |
|                  |     maximum of 4,000 each      |        |        |
|                  |     (\$8,000 total). Both are  |        |        |
|                  |     covered under each other's |        |        |
|                  |     HCFSA. The minimum annual  |        |        |
|                  |     amount is \$250.           |        |        |
+------------------+--------------------------------+--------+--------+
| Dependent Care   | -   Covers eligible dependent  |        |        |
| Flexible         |     care expenses incurred so  |        |        |
| Spending Account |     you and your spouse, if    |        |        |
| (DCFSA)          |     married, can work, look    |        |        |
|                  |     for work or attend school  |        |        |
|                  |     full-time.                 |        |        |
|                  |                                |        |        |
|                  | -   Qualifying dependents for  |        |        |
|                  |     this account include your  |        |        |
|                  |     dependent children under   |        |        |
|                  |     age 13, or any person of   |        |        |
|                  |     any age whom you claim as  |        |        |
|                  |     a dependent on your        |        |        |
|                  |     Federal Income Tax return  |        |        |
|                  |     (and who is mentally or    |        |        |
|                  |     physically incapable of    |        |        |
|                  |     self care).                |        |        |
|                  |                                |        |        |
|                  | -   The maximum annual amount  |        |        |
|                  |     that can be allotted for   |        |        |
|                  |     the DCFSA is \$5,000. The  |        |        |
|                  |     minimum annual amount is   |        |        |
|                  |     \$250. ***Note:*** The IRS |        |        |
|                  |     limits contributions to a  |        |        |
|                  |     DCFSA. For single          |        |        |
|                  |     taxpayers and taxpayers    |        |        |
|                  |     filing a joint return, the |        |        |
|                  |     maximum is \$5,000 per     |        |        |
|                  |     year. For taxpayers who    |        |        |
|                  |     file their taxes           |        |        |
|                  |     separately with a spouse,  |        |        |
|                  |     the maximum is \$2,500 per |        |        |
|                  |     year. The limit includes   |        |        |
|                  |     any child care subsidy you |        |        |
|                  |     may receive.               |        |        |
+------------------+--------------------------------+--------+--------+
| -   Enroll       | You **must make an election**  |        |        |
|     during Open  | to enroll in an FSA during the |        |        |
|     Season       | 2005 FEHB Open Season. Even if |        |        |
|                  | you enrolled during 2004, you  |        |        |
|                  | must make a new election to    |        |        |
|                  | continue participating in      |        |        |
|                  | 2005. Enrollment is easy!      |        |        |
|                  |                                |        |        |
|                  | -   **Online: visit            |        |        |
|                  |     [www.FSAFEDS.c             |        |        |
|                  | om](http://www.FSAFEDS.com/)** |        |        |
|                  |     **and click on**           |        |        |
|                  |     [**Enroll**.]{.underline}  |        |        |
|                  |                                |        |        |
|                  | -   Telephone: call an FSAFEDS |        |        |
|                  |     Benefit Counselor          |        |        |
|                  |     toll-free 1-877-FSAFEDS    |        |        |
|                  |     (372-3337), Monday through |        |        |
|                  |     Friday, from 9 a.m. until  |        |        |
|                  |     9 p.m. Eastern Time. TTY:  |        |        |
|                  |     1-800-952-0450.            |        |        |
+------------------+--------------------------------+--------+--------+
| What is SHPS?    | SHPS is a third-party          |        |        |
|                  | administrator hired by OPM to  |        |        |
|                  | manage the FSAFEDS Program.    |        |        |
|                  | SHPS is the largest FSA        |        |        |
|                  | administrator in the nation    |        |        |
|                  | and is responsible for         |        |        |
|                  | enrollment, claims processing, |        |        |
|                  | customer service, and          |        |        |
|                  | day-to-day operations of       |        |        |
|                  | FSAFEDS.                       |        |        |
+------------------+--------------------------------+--------+--------+
| Who is eligible  | If you are a Federal employee  |        |        |
| to enroll?       | eligible for FEHB -- even if   |        |        |
|                  | you're not enrolled in FEHB -- |        |        |
|                  | you can choose to participate  |        |        |
|                  | in either, or both, of the     |        |        |
|                  | FSAs. However if you enroll in |        |        |
|                  | a High Deductible Health Plan  |        |        |
|                  | (HDHP) with a Health Savings   |        |        |
|                  | Account (HSA), you are not     |        |        |
|                  | eligible to participate in an  |        |        |
|                  | HCFSA.                         |        |        |
|                  |                                |        |        |
|                  | Almost all Federal employees   |        |        |
|                  | are eligible to enroll for a   |        |        |
|                  | DCFSA. The only exception is   |        |        |
|                  | intermittent (also called      |        |        |
|                  | "when actually employed"       |        |        |
|                  | \[WAE\]) employees expected to |        |        |
|                  | work fewer than 180 days       |        |        |
|                  | during the year.               |        |        |
|                  |                                |        |        |
|                  | *Note:* FSAFEDS is the FSA     |        |        |
|                  | Program established for all    |        |        |
|                  | Executive Branch employees and |        |        |
|                  | Legislative Branch employees   |        |        |
|                  | whose employers have signed on |        |        |
|                  | to participate. Under IRS law, |        |        |
|                  | FSAs are not available to      |        |        |
|                  | annuitants. Also, the U.S.     |        |        |
|                  | Postal Service and the         |        |        |
|                  | Judicial Branch, among others, |        |        |
|                  | have their own plans with      |        |        |
|                  | slightly different rules.      |        |        |
|                  | However, the advantages of     |        |        |
|                  | having an FSA are the same     |        |        |
|                  | regardless of the agency for   |        |        |
|                  | which you work.                |        |        |
+------------------+--------------------------------+--------+--------+
| -   How much     | Plan carefully when deciding   |        |        |
|     should I     | how much to contribute to an   |        |        |
|     contribute   | FSA. Because of the tax        |        |        |
|     to my FSA?   | benefits an FSA provides, the  |        |        |
|                  | IRS places strict guidelines   |        |        |
|                  | on how the money can be used.  |        |        |
|                  | Under current IRS tax rules,   |        |        |
|                  | you are required to forfeit    |        |        |
|                  | any money for which you did    |        |        |
|                  | not incur an eligible expense  |        |        |
|                  | under your FSA account(s)      |        |        |
|                  | during the Plan Year. This is  |        |        |
|                  | known as the                   |        |        |
|                  | "use-it-or-lose-it" rule. You  |        |        |
|                  | will have until April 30,      |        |        |
|                  | following the end of the Plan  |        |        |
|                  | Year to submit claims for your |        |        |
|                  | eligible expenses incurred     |        |        |
|                  | from January 1through December |        |        |
|                  | 31. For example if you enroll  |        |        |
|                  | in FSAFEDS for the 2005 Plan   |        |        |
|                  | Year, you will have until      |        |        |
|                  | April 30, 2006, to submit      |        |        |
|                  | claims for eligible expenses.  |        |        |
|                  |                                |        |        |
|                  | The [FSAFEDS                   |        |        |
|                  | Calculator]{.underline} at     |        |        |
|                  | [www.FSAFEDS                   |        |        |
|                  | .com](http://www.FSAFEDS.com/) |        |        |
|                  | will help you plan your FSA    |        |        |
|                  | allocations and provide an     |        |        |
|                  | estimate of your tax savings   |        |        |
|                  | based on your individual       |        |        |
|                  | situation.                     |        |        |
+------------------+--------------------------------+--------+--------+
| -   What can my  | Every FEHB plan includes cost  |        |        |
|     HCFSA pay    | sharing features, such as      |        |        |
|     for?         | deductibles you must meet      |        |        |
|                  | before the Plan provides       |        |        |
|                  | benefits, coinsurance or       |        |        |
|                  | copayments that you pay when   |        |        |
|                  | you and the Plan share costs,  |        |        |
|                  | and medical services and       |        |        |
|                  | supplies that are not covered  |        |        |
|                  | by the Plan and for which you  |        |        |
|                  | must pay. These out-of-pocket  |        |        |
|                  | costs are summarized on page   |        |        |
|                  | 64 and detailed throughout     |        |        |
|                  | this brochure. Your HCFSA will |        |        |
|                  | reimburse you when those costs |        |        |
|                  | are for qualified medical care |        |        |
|                  | that you, your spouse and/or   |        |        |
|                  | your dependents receive that   |        |        |
|                  | is NOT covered or reimbursed   |        |        |
|                  | by this FEHB Plan or any other |        |        |
|                  | coverage that you have.        |        |        |
|                  |                                |        |        |
|                  | Under this Plan, typical       |        |        |
|                  | out-of-pockets expenses        |        |        |
|                  | include: office visit,         |        |        |
|                  | hospital and prescription drug |        |        |
|                  | copayments. Common expenses    |        |        |
|                  | not covered by this Plan       |        |        |
|                  | include: sterilization         |        |        |
|                  | reversal (male or female),     |        |        |
|                  | services received from a       |        |        |
|                  | chiropractor and cosmetic      |        |        |
|                  | surgery.                       |        |        |
|                  |                                |        |        |
|                  | The IRS governs expenses       |        |        |
|                  | reimbursable by a HCFSA. See   |        |        |
|                  | Publication 502 for a          |        |        |
|                  | comprehensive list of          |        |        |
|                  | tax-deductible medical         |        |        |
|                  | expenses. ***Note:* While you  |        |        |
|                  | will see insurance premiums    |        |        |
|                  | listed in Publication 502,     |        |        |
|                  | they are NOT a reimbursable    |        |        |
|                  | expense for FSA purposes.**    |        |        |
|                  | Publication 502 can be found   |        |        |
|                  | on the IRS Web site at         |        |        |
|                  | <http://www.                   |        |        |
|                  | irs.gov/pub/irs-pdf/p502.pdf>. |        |        |
|                  | The FSAFEDS Web site also has  |        |        |
|                  | a comprehensive list of        |        |        |
|                  | eligible expenses at           |        |        |
|                  | [www.FSAFE                     |        |        |
|                  | DS.com/fsafeds/eligibleexpense |        |        |
|                  | s.asp](http://www.FSAFEDS.com/ |        |        |
|                  | fsafeds/eligibleexpenses.asp). |        |        |
|                  | If you do not see your service |        |        |
|                  | or expense listed, please call |        |        |
|                  | an FSAFEDS Benefits Counselor  |        |        |
|                  | at 1-877-FSAFEDS (372-3337),   |        |        |
|                  | who will be able to answer     |        |        |
|                  | your specific questions.       |        |        |
+------------------+--------------------------------+--------+--------+
| -   Tax savings  | An FSA lets you allot money    |        |        |
|     with an FSA  | for eligible expenses          |        |        |
|                  | ***before*** your agency       |        |        |
|                  | deducts taxes from your        |        |        |
|                  | paycheck. This means the       |        |        |
|                  | amount of income that your     |        |        |
|                  | taxes are based on will be     |        |        |
|                  | lower, so your tax liability   |        |        |
|                  | will be less. Without an FSA,  |        |        |
|                  | you would still pay for these  |        |        |
|                  | expenses, but you would do so  |        |        |
|                  | using money remaining in your  |        |        |
|                  | paycheck after Federal (and    |        |        |
|                  | often state and local) taxes   |        |        |
|                  | are deducted. The following    |        |        |
|                  | chart illustrates a typical    |        |        |
|                  | tax savings example:           |        |        |
+------------------+--------------------------------+--------+--------+
|                  | **Annual Tax Savings Example** | **With | **Wi   |
|                  |                                | FSA**  | thout\ |
|                  |                                |        | FSA**  |
+------------------+--------------------------------+--------+--------+
|                  | If your taxable income is:     | \$     | \$     |
|                  |                                | 50,000 | 50,000 |
+------------------+--------------------------------+--------+--------+
|                  | And you deposit this amount    | \      | -\$0-  |
|                  | into an FSA:                   | $2,000 |        |
+------------------+--------------------------------+--------+--------+
|                  | Your taxable income is now:    | \$     | \$     |
|                  |                                | 48,000 | 50,000 |
+------------------+--------------------------------+--------+--------+
|                  | Subtract Federal & Social      | \$     | \$     |
|                  | Security taxes:                | 13,807 | 14,383 |
+------------------+--------------------------------+--------+--------+
|                  | If you spend after-tax dollars | -\$0-  | \      |
|                  | for expenses:                  |        | $2,000 |
+------------------+--------------------------------+--------+--------+
|                  | Your real spendable income is: | \$     | \$     |
|                  |                                | 34,193 | 33,617 |
+------------------+--------------------------------+--------+--------+
|                  | **Your tax savings:**          | **\    | **-    |
|                  |                                | $576** | \$0-** |
+------------------+--------------------------------+--------+--------+
|                  | **Note:** This example is      |        |        |
|                  | intended to demonstrate a      |        |        |
|                  | typical tax savings based on   |        |        |
|                  | 27% Federal and 7.65% FICA     |        |        |
|                  | taxes. Actual savings will     |        |        |
|                  | vary based upon the retirement |        |        |
|                  | system in which you are        |        |        |
|                  | enrolled (CSRS or FERS), your  |        |        |
|                  | state of residence, and your   |        |        |
|                  | individual tax situation. In   |        |        |
|                  | this example, the individual   |        |        |
|                  | received \$2,000 in services   |        |        |
|                  | for \$1,424, a discount of     |        |        |
|                  | almost 36%! You may also wish  |        |        |
|                  | to consult a tax professional  |        |        |
|                  | for more information on the    |        |        |
|                  | tax implications of an FSA.    |        |        |
+------------------+--------------------------------+--------+--------+
| -   Tax credits  | You *cannot* claim expenses on |        |        |
|     and          | your Federal Income Tax return |        |        |
|     deductions   | if you receive reimbursement   |        |        |
|                  | for them from your HCFSA or    |        |        |
|                  | DCFSA. Below are some          |        |        |
|                  | guidelines that may help you   |        |        |
|                  | decide whether to participate  |        |        |
|                  | in FSAFEDS.                    |        |        |
+------------------+--------------------------------+--------+--------+
| Health care      | The HCFSA is Federal Income    |        |        |
| expenses         | Tax-free from the first        |        |        |
|                  | dollar. In addition, you may   |        |        |
|                  | be reimbursed from your HCFSA  |        |        |
|                  | at any time during the year    |        |        |
|                  | for expenses up to the annual  |        |        |
|                  | amount you've elected to       |        |        |
|                  | contribute.                    |        |        |
|                  |                                |        |        |
|                  | Only health care expenses      |        |        |
|                  | exceeding 7.5% of your         |        |        |
|                  | adjusted gross income are      |        |        |
|                  | eligible to be deducted on     |        |        |
|                  | your Federal Income Tax        |        |        |
|                  | return. Using the example      |        |        |
|                  | shown above, only health care  |        |        |
|                  | expenses exceeding \$3,750     |        |        |
|                  | (7.5% of \$50,000) would be    |        |        |
|                  | eligible to be deducted on     |        |        |
|                  | your Federal Income Tax        |        |        |
|                  | return. In addition, money set |        |        |
|                  | aside through an HCFSA is also |        |        |
|                  | exempt from FICA taxes. This   |        |        |
|                  | exemption is not available on  |        |        |
|                  | your Federal Income Tax        |        |        |
|                  | return.                        |        |        |
+------------------+--------------------------------+--------+--------+
| Dependent care   | The DCFSA generally allows     |        |        |
| expenses         | many families to save more     |        |        |
|                  | than they would with the       |        |        |
|                  | Federal tax credit for         |        |        |
|                  | dependent care expenses. Note  |        |        |
|                  | that you may only be           |        |        |
|                  | reimbursed from the DCFSA up   |        |        |
|                  | to your current account        |        |        |
|                  | balance. If you file a claim   |        |        |
|                  | for more than your current     |        |        |
|                  | balance, it will be held until |        |        |
|                  | additional payroll allotments  |        |        |
|                  | have been added to your        |        |        |
|                  | account.                       |        |        |
|                  |                                |        |        |
|                  | Visit                          |        |        |
|                  | [www.FSAFEDS                   |        |        |
|                  | .com](http://www.FSAFEDS.com/) |        |        |
|                  | and download the [Dependent    |        |        |
|                  | Care Tax Credit                |        |        |
|                  | Worksheet]{.underline} from    |        |        |
|                  | the Forms and Literature page  |        |        |
|                  | to help you determine what is  |        |        |
|                  | best for your situation. You   |        |        |
|                  | may also wish to consult a tax |        |        |
|                  | professional for more details. |        |        |
+------------------+--------------------------------+--------+--------+
| -   Does it cost | No. Section 1127 of the        |        |        |
|     me anything  | National Defense Authorization |        |        |
|     to           | ACT (Public Law 108-136)       |        |        |
|     participate  | requires agencies that offer   |        |        |
|     in FSAFEDS?  | FSAFEDS to employees to cover  |        |        |
|                  | the administrative fee(s) on   |        |        |
|                  | behalf of their employees.     |        |        |
|                  | However, remember that         |        |        |
|                  | participating in FSAFEDS can   |        |        |
|                  | cost you money if you don't    |        |        |
|                  | spend your entire account      |        |        |
|                  | balance by the end of the Plan |        |        |
|                  | Year, resulting in the         |        |        |
|                  | forfeiture of funds remaining  |        |        |
|                  | in your account (the IRS       |        |        |
|                  | "use-it-or-lose-it" rule).     |        |        |
+------------------+--------------------------------+--------+--------+
| -   Contact us   | To learn more or to enroll,    |        |        |
|                  | please visit the **FSAFEDS Web |        |        |
|                  | site** at                      |        |        |
|                  | [www.FSAFEDS.                  |        |        |
|                  | com](http://www.FSAFEDS.com/), |        |        |
|                  | or contact SHPS directly via   |        |        |
|                  | email or by phone. FSAFEDS     |        |        |
|                  | Benefits Counselors are        |        |        |
|                  | available Monday through       |        |        |
|                  | Friday, from 9:00 a.m. until   |        |        |
|                  | 9:00 p.m. Eastern Time, Monday |        |        |
|                  | through Friday.                |        |        |
|                  |                                |        |        |
|                  | -   E-mail: <FSAFEDS@shps.net> |        |        |
|                  |                                |        |        |
|                  | -   Telephone: 1-877-FSAFEDS   |        |        |
|                  |     (1-877-372-3337)           |        |        |
|                  |                                |        |        |
|                  | -   TTY: 1-800-952-0450        |        |        |
+------------------+--------------------------------+--------+--------+

### The Federal Long Term Care Insurance Program

+------------------+---------------------------------------------------+
| -   It's         | Why should you consider applying for coverage     |
|     important    | under the Federal Long Term Care Insurance        |
|     protection   | Program (FLTCIP)?                                 |
|                  |                                                   |
|                  | -   **FEHB plans do not cover the cost of long    |
|                  |     term care.** Also called "custodial care,"    |
|                  |     long term care is help you receive to perform |
|                  |     activities of daily living -- such as bathing |
|                  |     or dressing yourself - or supervision you     |
|                  |     receive because of a severe cognitive         |
|                  |     impairment. The need for long term care can   |
|                  |     strike anyone at any age and the cost of care |
|                  |     can be substantial.                           |
|                  |                                                   |
|                  | -   **The Federal Long Term Care Insurance        |
|                  |     Program can help protect you from the         |
|                  |     potentially high cost of long term care.**    |
|                  |     This coverage gives you options regarding the |
|                  |     type of care you receive and where you        |
|                  |     receive it. With FLTCIP coverage, you won't   |
|                  |     have to worry about relying on your loved     |
|                  |     ones to provide or pay for your care.         |
|                  |                                                   |
|                  | -   **It's to your advantage to apply sooner      |
|                  |     rather than later. In order to qualify for    |
|                  |     coverage under the FLTCIP,** you must apply   |
|                  |     and pass a medical screening (called          |
|                  |     underwriting). Certain medical conditions, or |
|                  |     combinations of conditions, will prevent some |
|                  |     people from being approved for coverage. By   |
|                  |     applying while you're in good health, you     |
|                  |     could avoid the risk of having a future       |
|                  |     change in your health disqualify you from     |
|                  |     obtaining coverage. Also, the younger you are |
|                  |     when you apply, the lower your premiums.      |
|                  |                                                   |
|                  | -   **You don't have to wait for an open season   |
|                  |     to apply.** The Federal Long Term Care        |
|                  |     Insurance Program accepts applications from   |
|                  |     eligible persons at any time. You will have   |
|                  |     to complete a full underwriting application,  |
|                  |     which asks a number of questions about your   |
|                  |     health. However, if you are a new or newly    |
|                  |     eligible employee, you (and your spouse, if   |
|                  |     applicable) have a limited opportunity to     |
|                  |     apply using the abbreviated underwriting      |
|                  |     application, which asks fewer questions.      |
|                  |     Newly married spouses of employees also have  |
|                  |     a limited opportunity to apply using          |
|                  |     abbreviated underwriting.                     |
|                  |                                                   |
|                  | -   **Qualified relatives are also eligible to    |
|                  |     apply.** Qualified relatives include spouses  |
|                  |     and adult children of employees and           |
|                  |     annuitants, and parents, parents-in-law, and  |
|                  |     stepparents of employees.                     |
+------------------+---------------------------------------------------+
| -   To find out  | Call 1-800-LTC-FEDS (1-800-582-3337) (TTY         |
|     more and to  | 1-800-843-3557) or visit                          |
|     request an   | [www.ltcfeds.com](http://www.ltcfeds.com/).       |
|     application  |                                                   |
+------------------+---------------------------------------------------+

# Index

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

Accidental injury 26, 41

Allergy tests 19

Allogeneic (donor) bone marrow transplant 28

Ambulance 30, 32

Anesthesia 5, 25

Autologous bone marrow transplant 20, 28

Biopsy 25

Blood and blood plasma 31

Casts 30, 31

Catastrophic protection out-of-pocket maximum 12, 31, 44, 64

**Changes for 2005** 8

Chemotherapy 20

Cholesterol tests 16

Claims 9, 13, 46, 47, 51, 57

Coinsurance 6, 9, 12, 46, 52, 54, 60

Colorectal cancer screening 16

Congenital anomalies 25, 26

Contraceptive drugs and devices 18

Covered charges 50

Crutches 23

Deductible 6, 44, 52, 60

Definitions 15, 25, 30, 33, 35, 37, 41, 54, 64

Dental care 41, 64

Diagnostic services 15, 30, 35, 64

Disputed claims review 40

Donor expenses 28

Dressings 30

Durable medical equipment 23

Effective date of enrollment 10

Emergency 6, 33, 34, 45, 46, 64

Experimental or investigational 45

Eyeglasses 21

Family planning 18

Fecal occult blood test 16

Fraud 3, 4

General exclusions 45

General Exclusions 13

Home health services 24

Hospital 4, 5, 6, 9, 10, 22, 23, 25, 26, 28, 30, 31, 34, 35, 41, 46, 50,
52, 53, 64

Immunizations 6, 17

Infertility 18

Inpatient hospital benefits 46

Magnetic Resonance Imagings (MRIs) 16

Mammograms 16

Maternity benefits 17

Medicaid 53

Medically necessary 15, 17, 20, 25, 30, 33, 35, 37, 41, 45

Medicare 35, 49, 51

Medicare + Choice 52

Original 50, 52

Members

Associate 65

Family 56

Plan 9, 25, 44

Mental Health/Substance Abuse Benefits 35

Newborn care 17

Non-FEHB benefits 44

Nurse

Licensed Practical Nurse (LPN) 24

Nurse Anesthetist (NA) 30

Occupational therapy 20

Office visits 6, 12

Oral and maxillofacial surgical 27

Out-of-pocket expenses 49

Oxygen 23, 24, 30, 31

Pap test 16

Physician 23, 25

Precertification 48

Prescription drugs 20, 46, 52, 64

Preventive care, adult 16

Preventive care, children 17

Preventive services 6

Prior approval 47, 48

Prosthetic devices 25

Psychologist 35

Radiation therapy 20

Room and board 30

Second surgical opinion 15

Skilled nursing facility care 10, 15, 29

Social worker 35

Splints 30

Subrogation 53

Substance abuse 64

Surgery 5, 17, 20, 25

Anesthesia 31

Oral 27

Outpatient 31

Reconstructive 25, 26

Temporary Continuation of Coverage (TCC) 57

Transplants 20, 28

Treatment therapies 20

Vision care 64

Wheelchairs 23

Workers Compensation 52

X-rays 16, 30, 31

# Summary of benefits for HMO Blue Texas *-* 2005

-   **Do not rely on this chart alone.** All benefits are provided in
    full unless indicated and are subject to the definitions,
    limitations, and exclusions in this brochure. On this page we
    summarize specific expenses we cover; for more detail, look inside.

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

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

+----------------------------------------+-----------------------+----+
| **Benefits**                           | **You pay**           | ** |
|                                        |                       | Pa |
|                                        |                       | ge |
|                                        |                       | ** |
+----------------------------------------+-----------------------+----+
| Medical services provided by           | Office visit copay:   | 15 |
| physicians:                            | \$20 primary care;    |    |
|                                        | \$20 specialist       |    |
| -   Diagnostic and treatment services  |                       |    |
|     provided in the office             |                       |    |
+----------------------------------------+-----------------------+----+
| Services provided by a hospital:       | \$100 per day with a  | 30 |
|                                        | maximum of \$400 per  |    |
| -   Inpatient                          | admission             | 31 |
|                                        |                       |    |
| -   Outpatient                         | \$150 per surgery     |    |
+----------------------------------------+-----------------------+----+
| Emergency benefits                     | \$100 per visit       | 34 |
|                                        |                       |    |
| -   In-area                            | \$100 per visit       | 34 |
|                                        |                       |    |
| -   Out-of-area                        |                       |    |
+----------------------------------------+-----------------------+----+
| Mental health and substance abuse      | Regular cost sharing  | 35 |
| treatment                              |                       |    |
+----------------------------------------+-----------------------+----+
| Prescription drugs                     | \$10 per generic      | 38 |
|                                        |                       |    |
|                                        | \$25 per preferred    |    |
|                                        | brand                 |    |
|                                        |                       |    |
|                                        | \$40 per              |    |
|                                        | non-preferred brand   |    |
+----------------------------------------+-----------------------+----+
| Dental care .                          | Nothing for           | 41 |
|                                        | preventive services;  |    |
|                                        | scheduled cost for    |    |
|                                        | other services        |    |
+----------------------------------------+-----------------------+----+
| Vision care .                          | One eye examination   | 44 |
|                                        | for eyeglasses every  |    |
|                                        | 12 months; you pay a  |    |
|                                        | \$10 copay; Eyeglass  |    |
|                                        | lenses and frames     |    |
|                                        | available at discount |    |
|                                        | prices;               |    |
|                                        |                       |    |
|                                        | Contact lenses and    |    |
|                                        | materials are also    |    |
|                                        | available at discount |    |
|                                        | prices; and one eye   |    |
|                                        | examination for       |    |
|                                        | contact lenses every  |    |
|                                        | 12 months; you pay a  |    |
|                                        | \$20 copay            |    |
+----------------------------------------+-----------------------+----+
| Special features: Flexible benefits    |                       | 40 |
| option, Blue Access for Members and    |                       |    |
| Prenatal Education                     |                       |    |
+----------------------------------------+-----------------------+----+
| Protection against catastrophic costs  | Nothing after         | 12 |
|                                        | \$1,000/Self Only or  |    |
| (your catastrophic protection          | \$3,000/Family        |    |
| out-of-pocket maximum)                 | enrollment per year   |    |
|                                        |                       |    |
|                                        | Some costs do not     |    |
|                                        | count toward this     |    |
|                                        | protection            |    |
+----------------------------------------+-----------------------+----+

# 2005 Rate Information for HMO Blue Texas

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

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

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

+-------------+----------+--------------------------+-----------------+
| **Type**    | **Code** | ***Non-Postal Premium*** | ***Postal       |
|             |          |                          | Premium***      |
| **of**      |          | **                       |                 |
|             |          | [Biweekly]{.underline}** | **[Biweekly     |
| **E         |          | *                        | ]{.underline}** |
| nrollment** |          | *[Monthly]{.underline}** |                 |
|             |          |                          | **USPS Your**   |
|             |          | **Gov't Your Gov't       |                 |
|             |          | Your**                   | **Share Share** |
|             |          |                          |                 |
|             |          | **Share Share Share      |                 |
|             |          | Share**                  |                 |
+-------------+----------+--------------------------+-----------------+

**Houston area**

+-------------+----------+--------------------------+-----------------+
| **Self      | **YM1**  | **\$131.08 \$52.38       | **\$154.74      |
| Only**      |          | \$284.01 \$113.49**      | \$28.72**       |
|             | **YM2**  |                          |                 |
| **Self &    |          | **\$298.23 \$150.85      | **\$352.08      |
| Family**    |          | \$646.17 \$326.84**      | \$97.00**       |
+-------------+----------+--------------------------+-----------------+

*A Division of Health Care Service Corporation, a Mutual Legal Reserve
Company,\
an Independent Licensee of the Blue Cross and Blue Shield Association*