+-----------------------------------------------------------------------+
| **Section 5. Benefits \-- OVERVIEW**                                  |
|                                                                       |
| ***(See page xx for how our benefits changed this year and page xx    |
| for a benefits summary.)***                                           |
+-----------------------------------------------------------------------+

**NOTE**: This benefits section is broken into subsections. Please read
the important things you should keep in mind at the beginning of each
subsection. To obtain claims forms, claims filing advice, or more
information about our benefits, contact us at *{phone number}* or at our
website at [www.{insert]() *web address}.*

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

*{page numbers of section}*

+----------------------------------+-----------------------------------+
| -   Diagnostic and treatment     | -   Vision services (testing,     |
|     services                     |     treatment, and supplies)      |
|                                  |                                   |
| -   Lab, X-ray, and other        | -   Foot care                     |
|     diagnostic tests             |                                   |
|                                  | -   Orthopedic and prosthetic     |
| -   Preventive care, adult       |     devices                       |
|                                  |                                   |
| -   Preventive care, children    | -   Durable medical equipment     |
|                                  |     (DME)                         |
| -   Maternity care               |                                   |
|                                  | -   Home health services          |
| -   Family planning              |                                   |
|                                  | -   Alternative treatments        |
| -   Infertility services         |                                   |
|                                  | -   Educational classes and       |
| -   Allergy care                 |     programs                      |
|                                  |                                   |
| -   Treatment therapies          |                                   |
|                                  |                                   |
| -   Rehabilitative therapies     |                                   |
|                                  |                                   |
| -   Hearing services (testing,   |                                   |
|     treatment, and supplies)     |                                   |
+----------------------------------+-----------------------------------+

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

+----------------------------------+-----------------------------------+
| -   Surgical procedures          | -   Organ/tissue transplants      |
|                                  |                                   |
| -   Reconstructive surgery       | -   Anesthesia                    |
|                                  |                                   |
| -   Oral and maxillofacial       |                                   |
|     surgery                      |                                   |
+----------------------------------+-----------------------------------+

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

+----------------------------------+-----------------------------------+
| -   Inpatient hospital           | -   Hospice care                  |
|                                  |                                   |
| ```{=html}                       | -   Ambulance                     |
| <!-- -->                         |                                   |
| ```                              |                                   |
| -   Outpatient hospital or       |                                   |
|     ambulatory surgical center   |                                   |
|                                  |                                   |
| -   Extended care                |                                   |
|     benefits/Skilled nursing     |                                   |
|     care facility benefit        |                                   |
+----------------------------------+-----------------------------------+

(d) Emergency services/Accidents xx-xx

+----------------------------------+-----------------------------------+
| -   Medical emergency            | -   Ambulance                     |
|                                  |                                   |
| -   Accidental injury            |                                   |
+----------------------------------+-----------------------------------+

(e) Mental health and substance abuse benefits xx-xx

(f) Prescription drug benefits xx-xx

(g) Special features xx-xx

*{bullet list your features}*

(h) Dental benefits xx-xx

(i) Point of Service benefits *{remove this & renumber next, if you
    don\'t have POS benefits} xx-xx*

(j) Non-FEHB benefits available to Plan members xx-xx

*SUMMARY OF BENEFITS* xx*{page \# from summary*

*at back of brochure}*

+---+---+----------------------------------+------------------+---+----+
| * |   |                                  |                  |   |    |
| * |   |                                  |                  |   |    |
| S |   |                                  |                  |   |    |
| e |   |                                  |                  |   |    |
| c |   |                                  |                  |   |    |
| t |   |                                  |                  |   |    |
| i |   |                                  |                  |   |    |
| o |   |                                  |                  |   |    |
| n |   |                                  |                  |   |    |
| 5 |   |                                  |                  |   |    |
| ( |   |                                  |                  |   |    |
| a |   |                                  |                  |   |    |
| ) |   |                                  |                  |   |    |
| . |   |                                  |                  |   |    |
| M |   |                                  |                  |   |    |
| e |   |                                  |                  |   |    |
| d |   |                                  |                  |   |    |
| i |   |                                  |                  |   |    |
| c |   |                                  |                  |   |    |
| a |   |                                  |                  |   |    |
| l |   |                                  |                  |   |    |
| s |   |                                  |                  |   |    |
| e |   |                                  |                  |   |    |
| r |   |                                  |                  |   |    |
| v |   |                                  |                  |   |    |
| i |   |                                  |                  |   |    |
| c |   |                                  |                  |   |    |
| e |   |                                  |                  |   |    |
| s |   |                                  |                  |   |    |
| a |   |                                  |                  |   |    |
| n |   |                                  |                  |   |    |
| d |   |                                  |                  |   |    |
| s |   |                                  |                  |   |    |
| u |   |                                  |                  |   |    |
| p |   |                                  |                  |   |    |
| p |   |                                  |                  |   |    |
| l |   |                                  |                  |   |    |
| i |   |                                  |                  |   |    |
| e |   |                                  |                  |   |    |
| s |   |                                  |                  |   |    |
| p |   |                                  |                  |   |    |
| r |   |                                  |                  |   |    |
| o |   |                                  |                  |   |    |
| v |   |                                  |                  |   |    |
| i |   |                                  |                  |   |    |
| d |   |                                  |                  |   |    |
| e |   |                                  |                  |   |    |
| d |   |                                  |                  |   |    |
| b |   |                                  |                  |   |    |
| y |   |                                  |                  |   |    |
| p |   |                                  |                  |   |    |
| h |   |                                  |                  |   |    |
| y |   |                                  |                  |   |    |
| s |   |                                  |                  |   |    |
| i |   |                                  |                  |   |    |
| c |   |                                  |                  |   |    |
| i |   |                                  |                  |   |    |
| a |   |                                  |                  |   |    |
| n |   |                                  |                  |   |    |
| s |   |                                  |                  |   |    |
| a |   |                                  |                  |   |    |
| n |   |                                  |                  |   |    |
| d |   |                                  |                  |   |    |
| o |   |                                  |                  |   |    |
| t |   |                                  |                  |   |    |
| h |   |                                  |                  |   |    |
| e |   |                                  |                  |   |    |
| r |   |                                  |                  |   |    |
| h |   |                                  |                  |   |    |
| e |   |                                  |                  |   |    |
| a |   |                                  |                  |   |    |
| l |   |                                  |                  |   |    |
| t |   |                                  |                  |   |    |
| h |   |                                  |                  |   |    |
| c |   |                                  |                  |   |    |
| a |   |                                  |                  |   |    |
| r |   |                                  |                  |   |    |
| e |   |                                  |                  |   |    |
| p |   |                                  |                  |   |    |
| r |   |                                  |                  |   |    |
| o |   |                                  |                  |   |    |
| f |   |                                  |                  |   |    |
| e |   |                                  |                  |   |    |
| s |   |                                  |                  |   |    |
| s |   |                                  |                  |   |    |
| i |   |                                  |                  |   |    |
| o |   |                                  |                  |   |    |
| n |   |                                  |                  |   |    |
| a |   |                                  |                  |   |    |
| l |   |                                  |                  |   |    |
| s |   |                                  |                  |   |    |
| * |   |                                  |                  |   |    |
| * |   |                                  |                  |   |    |
+---+---+----------------------------------+------------------+---+----+
|   | * | **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       |                  | * |    |
|   | M |     brochure and are payable     |                  | M |    |
|   | * |     only when we determine they  |                  | * |    |
|   | * |     are medically necessary.     |                  | * |    |
|   |   |                                  |                  |   |    |
|   | * | -   The calendar year deductible |                  | * |    |
|   | * |     is: *{plan specific}* \$275  |                  | * |    |
|   | P |     per person (\$550 per        |                  | P |    |
|   | * |     family). The calendar year   |                  | * |    |
|   | * |     deductible applies to almost |                  | * |    |
|   |   |     all benefits in this         |                  |   |    |
|   | * |     Section. We added "(No       |                  | * |    |
|   | * |     deductible)" to show when    |                  | * |    |
|   | O |     the calendar year deductible |                  | O |    |
|   | * |     does not apply. *{If you     |                  | * |    |
|   | * |     want, you can say, "We added |                  | * |    |
|   |   |     asterisks - \* - to show     |                  |   |    |
|   | * |     when the calendar year       |                  | * |    |
|   | * |     deductible does not          |                  | * |    |
|   | R |     apply."}*                    |                  | R |    |
|   | * |                                  |                  | * |    |
|   | * | ```{=html}                       |                  | * |    |
|   |   | <!-- -->                         |                  |   |    |
|   | * | ```                              |                  | * |    |
|   | * | -   Be sure to read Section 4,   |                  | * |    |
|   | T |     *Your costs for covered      |                  | T |    |
|   | * |     services* for valuable       |                  | * |    |
|   | * |     information about how cost   |                  | * |    |
|   |   |     sharing works, with special  |                  |   |    |
|   | * |     sections for members who are |                  | * |    |
|   | * |     age 65 or over. Also read    |                  | * |    |
|   | A |     Section 9 about coordinating |                  | A |    |
|   | * |     benefits with other          |                  | * |    |
|   | * |     coverage, including with     |                  | * |    |
|   |   |     Medicare.                    |                  |   |    |
|   | * |                                  |                  | * |    |
|   | * |                                  |                  | * |    |
|   | N |                                  |                  | N |    |
|   | * |                                  |                  | * |    |
|   | * |                                  |                  | * |    |
|   |   |                                  |                  |   |    |
|   | * |                                  |                  | * |    |
|   | * |                                  |                  | * |    |
|   | T |                                  |                  | T |    |
|   | * |                                  |                  | * |    |
|   | * |                                  |                  | * |    |
+---+---+----------------------------------+------------------+---+----+
| * |   |                                  | **You pay**      |   |    |
| * |   |                                  |                  |   |    |
| B |   |                                  | **After the      |   |    |
| e |   |                                  | calendar year    |   |    |
| n |   |                                  | deductible...**  |   |    |
| e |   |                                  |                  |   |    |
| f |   |                                  |                  |   |    |
| i |   |                                  |                  |   |    |
| t |   |                                  |                  |   |    |
| D |   |                                  |                  |   |    |
| e |   |                                  |                  |   |    |
| s |   |                                  |                  |   |    |
| c |   |                                  |                  |   |    |
| r |   |                                  |                  |   |    |
| i |   |                                  |                  |   |    |
| p |   |                                  |                  |   |    |
| t |   |                                  |                  |   |    |
| i |   |                                  |                  |   |    |
| o |   |                                  |                  |   |    |
| n |   |                                  |                  |   |    |
| * |   |                                  |                  |   |    |
| * |   |                                  |                  |   |    |
+---+---+----------------------------------+------------------+---+----+
| # |   |                                  |                  |   |    |
| # |   |                                  |                  |   |    |
| # |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| * |   |                                  |                  |   |    |
| * |   |                                  |                  |   |    |
| N |   |                                  |                  |   |    |
| O |   |                                  |                  |   |    |
| T |   |                                  |                  |   |    |
| E |   |                                  |                  |   |    |
| : |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| T |   |                                  |                  |   |    |
| h |   |                                  |                  |   |    |
| e |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| c |   |                                  |                  |   |    |
| a |   |                                  |                  |   |    |
| l |   |                                  |                  |   |    |
| e |   |                                  |                  |   |    |
| n |   |                                  |                  |   |    |
| d |   |                                  |                  |   |    |
| a |   |                                  |                  |   |    |
| r |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| y |   |                                  |                  |   |    |
| e |   |                                  |                  |   |    |
| a |   |                                  |                  |   |    |
| r |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| d |   |                                  |                  |   |    |
| e |   |                                  |                  |   |    |
| d |   |                                  |                  |   |    |
| u |   |                                  |                  |   |    |
| c |   |                                  |                  |   |    |
| t |   |                                  |                  |   |    |
| i |   |                                  |                  |   |    |
| b |   |                                  |                  |   |    |
| l |   |                                  |                  |   |    |
| e |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| a |   |                                  |                  |   |    |
| p |   |                                  |                  |   |    |
| p |   |                                  |                  |   |    |
| l |   |                                  |                  |   |    |
| i |   |                                  |                  |   |    |
| e |   |                                  |                  |   |    |
| s |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| t |   |                                  |                  |   |    |
| o |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| a |   |                                  |                  |   |    |
| l |   |                                  |                  |   |    |
| m |   |                                  |                  |   |    |
| o |   |                                  |                  |   |    |
| s |   |                                  |                  |   |    |
| t |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| a |   |                                  |                  |   |    |
| l |   |                                  |                  |   |    |
| l |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| b |   |                                  |                  |   |    |
| e |   |                                  |                  |   |    |
| n |   |                                  |                  |   |    |
| e |   |                                  |                  |   |    |
| f |   |                                  |                  |   |    |
| i |   |                                  |                  |   |    |
| t |   |                                  |                  |   |    |
| s |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| i |   |                                  |                  |   |    |
| n |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| t |   |                                  |                  |   |    |
| h |   |                                  |                  |   |    |
| i |   |                                  |                  |   |    |
| s |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| S |   |                                  |                  |   |    |
| e |   |                                  |                  |   |    |
| c |   |                                  |                  |   |    |
| t |   |                                  |                  |   |    |
| i |   |                                  |                  |   |    |
| o |   |                                  |                  |   |    |
| n |   |                                  |                  |   |    |
| . |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| W |   |                                  |                  |   |    |
| e |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| s |   |                                  |                  |   |    |
| a |   |                                  |                  |   |    |
| y |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| " |   |                                  |                  |   |    |
| N |   |                                  |                  |   |    |
| o |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| d |   |                                  |                  |   |    |
| e |   |                                  |                  |   |    |
| d |   |                                  |                  |   |    |
| u |   |                                  |                  |   |    |
| c |   |                                  |                  |   |    |
| t |   |                                  |                  |   |    |
| i |   |                                  |                  |   |    |
| b |   |                                  |                  |   |    |
| l |   |                                  |                  |   |    |
| e |   |                                  |                  |   |    |
| " |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| w |   |                                  |                  |   |    |
| h |   |                                  |                  |   |    |
| e |   |                                  |                  |   |    |
| n |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| i |   |                                  |                  |   |    |
| t |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| d |   |                                  |                  |   |    |
| o |   |                                  |                  |   |    |
| e |   |                                  |                  |   |    |
| s |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| n |   |                                  |                  |   |    |
| o |   |                                  |                  |   |    |
| t |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| a |   |                                  |                  |   |    |
| p |   |                                  |                  |   |    |
| p |   |                                  |                  |   |    |
| l |   |                                  |                  |   |    |
| y |   |                                  |                  |   |    |
| . |   |                                  |                  |   |    |
| * |   |                                  |                  |   |    |
| * |   |                                  |                  |   |    |
+---+---+----------------------------------+------------------+---+----+
| # |   |                                  | ###              |   |    |
| # |   |                                  |                  |   |    |
| # |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| * |   |                                  |                  |   |    |
| * |   |                                  |                  |   |    |
| 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 |   |                                  |                  |   |    |
| * |   |                                  |                  |   |    |
| * |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
+---+---+----------------------------------+------------------+---+----+
| > |   |                                  | > PPO: \$15      |   |    |
|   |   |                                  | > copayment (No  |   |    |
| P |   |                                  | > deductible)    |   |    |
| r |   |                                  | >                |   |    |
| o |   |                                  | > Non-PPO: 30%   |   |    |
| f |   |                                  | > of the Plan    |   |    |
| e |   |                                  | > allowance and  |   |    |
| s |   |                                  | > any difference |   |    |
| s |   |                                  | > between our    |   |    |
| i |   |                                  | > allowance and  |   |    |
| o |   |                                  | > the billed     |   |    |
| n |   |                                  | > amount         |   |    |
| 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 |   |                                  |                  |   |    |
| f |   |                                  |                  |   |    |
| i |   |                                  |                  |   |    |
| c |   |                                  |                  |   |    |
| e |   |                                  |                  |   |    |
+---+---+----------------------------------+------------------+---+----+
| > |   |                                  | > PPO: 15% of    |   |    |
|   |   |                                  | > the Plan       |   |    |
| P |   |                                  | > allowance      |   |    |
| r |   |                                  | >                |   |    |
| o |   |                                  | > Non-PPO: 30%   |   |    |
| f |   |                                  | > of the Plan    |   |    |
| e |   |                                  | > allowance and  |   |    |
| s |   |                                  | > any difference |   |    |
| s |   |                                  | > between our    |   |    |
| i |   |                                  | > allowance and  |   |    |
| o |   |                                  | > the billed     |   |    |
| n |   |                                  | > amount         |   |    |
| a |   |                                  |                  |   |    |
| l |   |                                  |                  |   |    |
| > |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| s |   |                                  |                  |   |    |
| e |   |                                  |                  |   |    |
| r |   |                                  |                  |   |    |
| v |   |                                  |                  |   |    |
| i |   |                                  |                  |   |    |
| c |   |                                  |                  |   |    |
| e |   |                                  |                  |   |    |
| s |   |                                  |                  |   |    |
| > |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| o |   |                                  |                  |   |    |
| f |   |                                  |                  |   |    |
| > |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| p |   |                                  |                  |   |    |
| h |   |                                  |                  |   |    |
| y |   |                                  |                  |   |    |
| s |   |                                  |                  |   |    |
| i |   |                                  |                  |   |    |
| c |   |                                  |                  |   |    |
| i |   |                                  |                  |   |    |
| a |   |                                  |                  |   |    |
| n |   |                                  |                  |   |    |
| s |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| - |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| I |   |                                  |                  |   |    |
| n |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| a |   |                                  |                  |   |    |
| n |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| u |   |                                  |                  |   |    |
| r |   |                                  |                  |   |    |
| g |   |                                  |                  |   |    |
| e |   |                                  |                  |   |    |
| n |   |                                  |                  |   |    |
| t |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| c |   |                                  |                  |   |    |
| a |   |                                  |                  |   |    |
| r |   |                                  |                  |   |    |
| e |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| c |   |                                  |                  |   |    |
| e |   |                                  |                  |   |    |
| n |   |                                  |                  |   |    |
| t |   |                                  |                  |   |    |
| e |   |                                  |                  |   |    |
| r |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| - |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| D |   |                                  |                  |   |    |
| u |   |                                  |                  |   |    |
| r |   |                                  |                  |   |    |
| i |   |                                  |                  |   |    |
| n |   |                                  |                  |   |    |
| g |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| a |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| h |   |                                  |                  |   |    |
| o |   |                                  |                  |   |    |
| s |   |                                  |                  |   |    |
| p |   |                                  |                  |   |    |
| i |   |                                  |                  |   |    |
| t |   |                                  |                  |   |    |
| a |   |                                  |                  |   |    |
| l |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| s |   |                                  |                  |   |    |
| t |   |                                  |                  |   |    |
| a |   |                                  |                  |   |    |
| y |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| - |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| I |   |                                  |                  |   |    |
| n |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| a |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| s |   |                                  |                  |   |    |
| k |   |                                  |                  |   |    |
| i |   |                                  |                  |   |    |
| l |   |                                  |                  |   |    |
| l |   |                                  |                  |   |    |
| e |   |                                  |                  |   |    |
| d |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| n |   |                                  |                  |   |    |
| u |   |                                  |                  |   |    |
| r |   |                                  |                  |   |    |
| s |   |                                  |                  |   |    |
| i |   |                                  |                  |   |    |
| n |   |                                  |                  |   |    |
| g |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| f |   |                                  |                  |   |    |
| a |   |                                  |                  |   |    |
| c |   |                                  |                  |   |    |
| i |   |                                  |                  |   |    |
| l |   |                                  |                  |   |    |
| i |   |                                  |                  |   |    |
| t |   |                                  |                  |   |    |
| y |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| - |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| I |   |                                  |                  |   |    |
| n |   |                                  |                  |   |    |
| i |   |                                  |                  |   |    |
| t |   |                                  |                  |   |    |
| i |   |                                  |                  |   |    |
| a |   |                                  |                  |   |    |
| l |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| e |   |                                  |                  |   |    |
| x |   |                                  |                  |   |    |
| a |   |                                  |                  |   |    |
| m |   |                                  |                  |   |    |
| i |   |                                  |                  |   |    |
| n |   |                                  |                  |   |    |
| a |   |                                  |                  |   |    |
| t |   |                                  |                  |   |    |
| i |   |                                  |                  |   |    |
| o |   |                                  |                  |   |    |
| n |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| o |   |                                  |                  |   |    |
| f |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| a |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| n |   |                                  |                  |   |    |
| e |   |                                  |                  |   |    |
| w |   |                                  |                  |   |    |
| b |   |                                  |                  |   |    |
| o |   |                                  |                  |   |    |
| r |   |                                  |                  |   |    |
| n |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| c |   |                                  |                  |   |    |
| h |   |                                  |                  |   |    |
| i |   |                                  |                  |   |    |
| l |   |                                  |                  |   |    |
| d |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| c |   |                                  |                  |   |    |
| o |   |                                  |                  |   |    |
| v |   |                                  |                  |   |    |
| e |   |                                  |                  |   |    |
| r |   |                                  |                  |   |    |
| e |   |                                  |                  |   |    |
| d |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| u |   |                                  |                  |   |    |
| n |   |                                  |                  |   |    |
| d |   |                                  |                  |   |    |
| e |   |                                  |                  |   |    |
| r |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| a |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| f |   |                                  |                  |   |    |
| a |   |                                  |                  |   |    |
| m |   |                                  |                  |   |    |
| i |   |                                  |                  |   |    |
| l |   |                                  |                  |   |    |
| y |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| e |   |                                  |                  |   |    |
| n |   |                                  |                  |   |    |
| r |   |                                  |                  |   |    |
| o |   |                                  |                  |   |    |
| l |   |                                  |                  |   |    |
| l |   |                                  |                  |   |    |
| m |   |                                  |                  |   |    |
| e |   |                                  |                  |   |    |
| n |   |                                  |                  |   |    |
| t |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| - |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| O |   |                                  |                  |   |    |
| f |   |                                  |                  |   |    |
| f |   |                                  |                  |   |    |
| i |   |                                  |                  |   |    |
| c |   |                                  |                  |   |    |
| e |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| m |   |                                  |                  |   |    |
| e |   |                                  |                  |   |    |
| d |   |                                  |                  |   |    |
| i |   |                                  |                  |   |    |
| c |   |                                  |                  |   |    |
| a |   |                                  |                  |   |    |
| l |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| c |   |                                  |                  |   |    |
| o |   |                                  |                  |   |    |
| n |   |                                  |                  |   |    |
| s |   |                                  |                  |   |    |
| u |   |                                  |                  |   |    |
| l |   |                                  |                  |   |    |
| t |   |                                  |                  |   |    |
| a |   |                                  |                  |   |    |
| t |   |                                  |                  |   |    |
| i |   |                                  |                  |   |    |
| o |   |                                  |                  |   |    |
| n |   |                                  |                  |   |    |
| s |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| - |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| S |   |                                  |                  |   |    |
| e |   |                                  |                  |   |    |
| c |   |                                  |                  |   |    |
| o |   |                                  |                  |   |    |
| n |   |                                  |                  |   |    |
| d |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| s |   |                                  |                  |   |    |
| u |   |                                  |                  |   |    |
| r |   |                                  |                  |   |    |
| g |   |                                  |                  |   |    |
| i |   |                                  |                  |   |    |
| c |   |                                  |                  |   |    |
| a |   |                                  |                  |   |    |
| l |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| o |   |                                  |                  |   |    |
| p |   |                                  |                  |   |    |
| i |   |                                  |                  |   |    |
| n |   |                                  |                  |   |    |
| i |   |                                  |                  |   |    |
| o |   |                                  |                  |   |    |
| n |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| ` |   |                                  |                  |   |    |
| ` |   |                                  |                  |   |    |
| ` |   |                                  |                  |   |    |
| { |   |                                  |                  |   |    |
| = |   |                                  |                  |   |    |
| h |   |                                  |                  |   |    |
| t |   |                                  |                  |   |    |
| m |   |                                  |                  |   |    |
| l |   |                                  |                  |   |    |
| } |   |                                  |                  |   |    |
| < |   |                                  |                  |   |    |
| ! |   |                                  |                  |   |    |
| - |   |                                  |                  |   |    |
| - |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| - |   |                                  |                  |   |    |
| - |   |                                  |                  |   |    |
| > |   |                                  |                  |   |    |
| ` |   |                                  |                  |   |    |
| ` |   |                                  |                  |   |    |
| ` |   |                                  |                  |   |    |
| - |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| A |   |                                  |                  |   |    |
| t |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| h |   |                                  |                  |   |    |
| o |   |                                  |                  |   |    |
| m |   |                                  |                  |   |    |
| e |   |                                  |                  |   |    |
+---+---+----------------------------------+------------------+---+----+
| > |   |                                  | > *All charges*  |   |    |
|   |   |                                  |                  |   |    |
| * |   |                                  |                  |   |    |
| N |   |                                  |                  |   |    |
| o |   |                                  |                  |   |    |
| t |   |                                  |                  |   |    |
| > |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| c |   |                                  |                  |   |    |
| o |   |                                  |                  |   |    |
| v |   |                                  |                  |   |    |
| e |   |                                  |                  |   |    |
| r |   |                                  |                  |   |    |
| e |   |                                  |                  |   |    |
| d |   |                                  |                  |   |    |
| : |   |                                  |                  |   |    |
| > |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| R |   |                                  |                  |   |    |
| o |   |                                  |                  |   |    |
| u |   |                                  |                  |   |    |
| t |   |                                  |                  |   |    |
| i |   |                                  |                  |   |    |
| n |   |                                  |                  |   |    |
| e |   |                                  |                  |   |    |
| > |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| p |   |                                  |                  |   |    |
| h |   |                                  |                  |   |    |
| y |   |                                  |                  |   |    |
| s |   |                                  |                  |   |    |
| i |   |                                  |                  |   |    |
| c |   |                                  |                  |   |    |
| a |   |                                  |                  |   |    |
| l |   |                                  |                  |   |    |
| > |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| c |   |                                  |                  |   |    |
| h |   |                                  |                  |   |    |
| e |   |                                  |                  |   |    |
| c |   |                                  |                  |   |    |
| k |   |                                  |                  |   |    |
| u |   |                                  |                  |   |    |
| p |   |                                  |                  |   |    |
| s |   |                                  |                  |   |    |
| > |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| a |   |                                  |                  |   |    |
| n |   |                                  |                  |   |    |
| d |   |                                  |                  |   |    |
| > |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| r |   |                                  |                  |   |    |
| e |   |                                  |                  |   |    |
| l |   |                                  |                  |   |    |
| a |   |                                  |                  |   |    |
| t |   |                                  |                  |   |    |
| e |   |                                  |                  |   |    |
| d |   |                                  |                  |   |    |
| > |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| t |   |                                  |                  |   |    |
| e |   |                                  |                  |   |    |
| s |   |                                  |                  |   |    |
| t |   |                                  |                  |   |    |
| s |   |                                  |                  |   |    |
| * |   |                                  |                  |   |    |
+---+---+----------------------------------+------------------+---+----+

+------------------------------------------+---------------------------+
| # Lab, X-ray and other diagnostic tests  | ### **You pay**           |
+------------------------------------------+---------------------------+
| > Laboratory tests, such as:             | > PPO: \$5 copayment (No  |
|                                          | > deductible)             |
| -   Blood tests                          | >                         |
|                                          | > Non-PPO: 15% of the     |
| -   Urinalysis                           | > Plan allowance and any  |
|                                          | > difference between our  |
| -   Non-routine pap tests                | > allowance and the       |
|                                          | > billed amount           |
| -   Pathology                            | > *{describe benefits     |
|                                          | > using plan allowance    |
| -   X-rays                               | > instead of R&C, etc}*   |
|                                          | >                         |
| -   Non-routine Mammograms               | > Note: If your PPO       |
|                                          | > provider uses a non-PPO |
| -   CAT Scans/MRI                        | > lab or radiologist, we  |
|                                          | > will pay non-PPO        |
| -   Ultrasound                           | > benefits for any lab    |
|                                          | > and X-ray charges.      |
| -   Electrocardiogram and EEG            | > *{standard paragraph}*  |
+------------------------------------------+---------------------------+
| ##### Preventive care, adult             | ###                       |
+------------------------------------------+---------------------------+
| > Routine screenings, limited to:        | > PPO: \$x copayment (No  |
|                                          | > deductible)             |
| -   Blood lead level -- One annually     | >                         |
|                                          | > Non-PPO: 15% of the     |
| -   Total Blood Cholesterol -- once      | > Plan allowance and any  |
|     every three years, ages 19 through   | > difference between our  |
|     64                                   | > allowance and the       |
|                                          | > billed amount           |
| -   Colorectal Cancer Screening,         |                           |
|     including                            |                           |
|                                          |                           |
| > Fecal occult blood test                |                           |
+------------------------------------------+---------------------------+
| > Sigmoidoscopy, screening -- every five | > PPO: 15% of the Plan    |
| > years starting at age 50               | > allowance               |
|                                          | >                         |
|                                          | > Non-PPO: 15% of the     |
|                                          | > Plan allowance and any  |
|                                          | > difference between our  |
|                                          | > allowance and the       |
|                                          | > billed amount           |
+------------------------------------------+---------------------------+
| > Prostate Specific Antigen (PSA test)   | > PPO: \$25 copayment (No |
| > -- one annually for men age 40 and     | > deductible)             |
| > older                                  | >                         |
|                                          | > Non-PPO: 15% of the     |
|                                          | > Plan allowance and any  |
|                                          | > difference between our  |
|                                          | > allowance and the       |
|                                          | > billed amount           |
+------------------------------------------+---------------------------+
| > Routine pap test                       | > PPO: Nothing for first  |
| >                                        | > \$35 in charges (No     |
| > Note: The office visit is covered if   | > deductible), then xx%   |
| > pap test is received on the same day;  | > of the Plan allowance   |
| > see Diagnosis and Treatment, above.    | >                         |
|                                          | > Non-PPO: 15% of the     |
|                                          | > Plan allowance and any  |
|                                          | > difference between our  |
|                                          | > allowance and the       |
|                                          | > billed amount           |
+------------------------------------------+---------------------------+
| > Routine mammogram -- covered for women | > PPO: \$25 copayment (No |
| > age 35 and older, as follows:          | > deductible)             |
|                                          | >                         |
| -   From age 35 through 39, one during   | > Non-PPO: 15% of the     |
|     this five year period                | > Plan allowance and any  |
|                                          | > difference between our  |
| ```{=html}                               | > allowance and the       |
| <!-- -->                                 | > billed amount           |
| ```                                      |                           |
| -   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*

+------------------------------------------+---------------------------+
| ##                                       | ### **You pay**           |
| ### Preventive care, adult - *Continued* |                           |
+------------------------------------------+---------------------------+
| > Routine Immunizations, limited to:     | > PPO: \$x copayment (No  |
|                                          | > deductible)             |
| -   Tetanus-diphtheria (Td) booster --   | >                         |
|     once every 10 years, ages19 and over | > Non-PPO: 15% of the     |
|     (except as provided for under        | > Plan allowance and any  |
|     Childhood immunizations)             | > difference between our  |
|                                          | > allowance and the       |
| -   Influenza/Pneumococcal vaccines,     | > billed amount           |
|     annually, age 65 and over            |                           |
+------------------------------------------+---------------------------+
| > *Not covered: .. . . . .*              | > *All charges.*          |
+------------------------------------------+---------------------------+
| ##### Preventive care, children          | ###                       |
+------------------------------------------+---------------------------+
| -   Childhood immunizations recommended  | > PPO: Nothing (No        |
|     by the American Academy of           | > deductible)             |
|     Pediatrics                           | >                         |
|                                          | > Non-PPO: Nothing (No    |
|                                          | > deductible)             |
+------------------------------------------+---------------------------+
| -   For well-child care charges for      | > PPO: Nothing (No        |
|     routine examinations, immunizations  | > deductible)             |
|     and care (to age 3)                  | >                         |
|                                          | > Non-PPO: Nothing (No    |
|                                          | > deductible)             |
+------------------------------------------+---------------------------+
| -   Examinations, limited to:            | > PPO: \$15 copayment (No |
|                                          | > deductible)             |
| > Examinations for amblyopia and         | >                         |
| > strabismus -- limited to one screening | > Non-PPO: 15% of the     |
| > examination (ages 2 through 6)         | > Plan allowance and any  |
| >                                        | > difference between our  |
| > Examinations done on the day of        | > allowance and the       |
| > immunizations (ages 3 through 22)      | > billed amount           |
+------------------------------------------+---------------------------+
| ######## Maternity care                  | ###                       |
+------------------------------------------+---------------------------+
| > Complete maternity (obstetrical) care, | > PPO: 15% of the Plan    |
| > such as:                               | > allowance               |
|                                          | >                         |
| -   Prenatal care                        | > Non-PPO: 30% of the     |
|                                          | > Plan allowance and any  |
| -   Delivery                             | > difference between our  |
|                                          | > allowance and the       |
| -   Postnatal care                       | > billed amount           |
|                                          |                           |
| > Note: Here are some things to keep in  |                           |
| > mind:                                  |                           |
|                                          |                           |
| -   You do not need to precertify your   |                           |
|     normal delivery; see page xx for     |                           |
|     other circumstances, such as         |                           |
|     extended stays for you or your baby. |                           |
|                                          |                           |
| -   You may remain in the hospital up to |                           |
|     48 hours after a regular delivery    |                           |
|     and 96 hours after a cesarean        |                           |
|     delivery. We will cover an extended  |                           |
|     stay, if medically necessary, but    |                           |
|     you must precertify.                 |                           |
+------------------------------------------+---------------------------+

Maternity care \-- Continued on next page.

+------------------------------------------+---------------------------+
| ######## Maternity care *- Continued*    | ### **You pay**           |
+------------------------------------------+---------------------------+
| -   Routine nursery care of the newborn  | > *(see above)*           |
|     child during the covered portion of  |                           |
|     the mother's maternity stay. We will |                           |
|     cover other care of an infant who    |                           |
|     requires non-routine treatment 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: Routine sonograms to     | > *All charges*           |
| > determine fetal age, size or sex*      |                           |
+------------------------------------------+---------------------------+
| ######## Family planning                 | ###                       |
+------------------------------------------+---------------------------+
| -   Voluntary sterilization              | > PPO: 15% of the Plan    |
|                                          | > allowance               |
| -   Surgically implanted contraceptives  | >                         |
|                                          | > Non-PPO: 30% of the     |
| -   Injectable contraceptive drugs       | > Plan allowance and any  |
|                                          | > difference between our  |
| -   Intrauterine devices (IUDs)          | > allowance and the       |
|                                          | > billed amount           |
| > Note: We cover contraceptive drugs in  |                           |
| > Section 5(f).                          |                           |
+------------------------------------------+---------------------------+
| > *Not covered: reversal of voluntary    | > *All charges.*          |
| > surgical sterilization, genetic        |                           |
| > counseling,*                           |                           |
+------------------------------------------+---------------------------+
| ######## Infertility services            | ###                       |
+------------------------------------------+---------------------------+
| > Diagnosis and treatment of             | > PPO: 15% of the Plan    |
| > infertility, except as excluded.       | > allowance               |
|                                          | >                         |
|                                          | > Non-PPO: 30% of the     |
|                                          | > Plan allowance and any  |
|                                          | > difference between our  |
|                                          | > allowance and the       |
|                                          | > billed amount           |
+------------------------------------------+---------------------------+
| > *Not covered:*                         | > *All charges.*          |
|                                          |                           |
| -   *Fertility drugs*                    |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   *Assisted reproductive technology    |                           |
|     (ART) procedures, such as:*          |                           |
|                                          |                           |
| > *artificial insemination*              |                           |
| >                                        |                           |
| > *in vitro fertilization*               |                           |
| >                                        |                           |
| > *embryo transfer and GIFT*             |                           |
| >                                        |                           |
| > *intravaginal insemination (IVI)*      |                           |
| >                                        |                           |
| > *intra­cervical insemination (ICI)*     |                           |
| >                                        |                           |
| > *intrauterine insemina­tion (IUI)*      |                           |
|                                          |                           |
| -   *Services and supplies related to    |                           |
|     ART procedures.*                     |                           |
+------------------------------------------+---------------------------+

+------------------------------------------+---------------------------+
| > **Allergy care**                       | ### **You pay**           |
+------------------------------------------+---------------------------+
| > Testing and treatment, including       | > PPO: 15% of the Plan    |
| > materials (such as allergy serum)      | > allowance               |
|                                          | >                         |
|                                          | > Non-PPO: 30% of the     |
|                                          | > Plan allowance and any  |
|                                          | > difference between our  |
|                                          | > allowance and the       |
|                                          | > billed amount           |
+------------------------------------------+---------------------------+
| > Allergy injection                      | > PPO: \$x copayment each |
|                                          | > (No deductible)         |
|                                          | >                         |
|                                          | > Non-PPO: 30% of the     |
|                                          | > Plan allowance and any  |
|                                          | > difference between our  |
|                                          | > allowance and the       |
|                                          | > billed amount           |
+------------------------------------------+---------------------------+
| > *Not covered: provocative food testing | > *All charges*           |
| > and sublingual allergy                 |                           |
| > desensitization*                       |                           |
+------------------------------------------+---------------------------+
| ######## Treatment therapies             | ###                       |
+------------------------------------------+---------------------------+
| -   Chemotherapy and radiation therapy   | > PPO: 15% of the Plan    |
|                                          | > allowance               |
| > Note: High dose chemotherapy in        | >                         |
| > association with autologous bone       | > Non-PPO: 30% of the     |
| > marrow transplants is limited to those | > Plan allowance and any  |
| > transplants listed on page xx.         | > difference between our  |
|                                          | > allowance and the       |
| -   Dialysis -- Hemodialysis and         | > billed amount           |
|     peritoneal dialysis                  |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   Intravenous (IV)/Infusion Therapy -- |                           |
|     Home IV and antibiotic therapy       |                           |
|                                          |                           |
| -   Growth hormone therapy (GHT)         |                           |
|                                          |                           |
| > Note: -- We only cover GHT when we     |                           |
| > preauthorize the treatment. *{Plan     |                           |
| > specific; summarize instructions on    |                           |
| > how to get authorization \-- here is   |                           |
| > one plan\'s example}* Call xxx for     |                           |
| > preauthorization. We will ask you to   |                           |
| > submit information that establishes    |                           |
| > that the GHT is medically necessary.   |                           |
| > Ask us to authorize GHT before you     |                           |
| > begin treatment; otherwise, we will    |                           |
| > only cover GHT services from the date  |                           |
| > you submit the information. If you do  |                           |
| > not ask or if we determine GHT is not  |                           |
| > medically necessary, we will not cover |                           |
| > the GHT or related services and        |                           |
| > supplies. See *Services requiring our  |                           |
| > prior approval* in Section 3.          |                           |
|                                          |                           |
| -   Respiratory and inhalation therapies |                           |
+------------------------------------------+---------------------------+
| > *Not covered:*                         | > *All charges.*          |
+------------------------------------------+---------------------------+
| > **Rehabilitative therapies**           | ###                       |
+------------------------------------------+---------------------------+
| > Physical therapy, occupational         | > PPO: 15% of the Plan    |
| > therapy, and speech therapy --         | > allowance               |
|                                          | >                         |
| -   90 visits per calendar year for the  | > Non-PPO: 30% of the     |
|     services of each of the following:   | > Plan allowance and any  |
|                                          | > difference between our  |
| > qualified physical therapists;         | > allowance and the       |
| >                                        | > billed amount           |
| > speech therapists; and                 |                           |
| >                                        |                           |
| > occupational therapists.               |                           |
+------------------------------------------+---------------------------+

*Rehabilitative therapies - Continued on next page*

+------------------------------------------+---------------------------+
| > **Rehabilitative therapies**           | ### **You pay**           |
+------------------------------------------+---------------------------+
| > Note: We only cover therapy to restore |                           |
| > bodily function or speech when there   |                           |
| > has been a total or partial loss of    |                           |
| > bodily function or functional speech   |                           |
| > due to illness or injury and when a    |                           |
| > physician:                             |                           |
|                                          |                           |
| 1)  orders the care;                     |                           |
|                                          |                           |
| 2)  identifies the specific professional |                           |
|     skills the patient requires and the  |                           |
|     medical necessity for skilled        |                           |
|     services; and                        |                           |
|                                          |                           |
| 3)  indicates the length of time the     |                           |
|     services are needed.                 |                           |
|                                          |                           |
| > *{definition is standard}*             |                           |
+------------------------------------------+---------------------------+
| > *Not covered:*                         | > *All charges.*          |
|                                          |                           |
| -   *long-term rehabilitative therapy*   |                           |
|                                          |                           |
| -   *exercise programs*                  |                           |
+------------------------------------------+---------------------------+
| > **Hearing services (testing,           | ###                       |
| > treatment, and supplies)**             |                           |
+------------------------------------------+---------------------------+
| > First hearing aid and testing only     | > PPO: 15% of the Plan    |
| > when necessitated by accidental injury | > allowance               |
|                                          | >                         |
|                                          | > Non-PPO: 30% of the     |
|                                          | > Plan allowance and any  |
|                                          | > difference between our  |
|                                          | > allowance and the       |
|                                          | > billed amount           |
+------------------------------------------+---------------------------+
| > *Not covered:*                         | > *All charges.*          |
|                                          |                           |
| -   *hearing testing*                    |                           |
|                                          |                           |
| -   *hearing aids, testing and           |                           |
|     examinations for them, except for    |                           |
|     accidental injury*                   |                           |
+------------------------------------------+---------------------------+
| > **Vision services (testing, treatment, | ###                       |
| > and supplies)**                        |                           |
+------------------------------------------+---------------------------+
| -   One pair of eyeglasses or contact    | > PPO: 15% of the Plan    |
|     lenses to correct an impairment      | > allowance               |
|     directly caused by accidental ocular | >                         |
|     injury or intraocular surgery (such  | > Non-PPO: 30% of the     |
|     as for cataracts)                    | > Plan allowance and any  |
|                                          | > difference between our  |
| > Note: See Preventive care, children    | > allowance and the       |
| > for eye exams for children             | > billed amount           |
+------------------------------------------+---------------------------+
| > *Not covered:*                         | > *All charges.*          |
|                                          |                           |
| -   *Eyeglasses or contact lenses and    |                           |
|     examinations for them*               |                           |
|                                          |                           |
| -   *Eye exercises and orthoptics*       |                           |
|                                          |                           |
| -   *Radial keratotomy and other         |                           |
|     refractive surgery*                  |                           |
+------------------------------------------+---------------------------+

+------------------------------------------+---------------------------+
| ######## Foot care                       | ### **You pay**           |
+------------------------------------------+---------------------------+
| > Routine foot care when you are under   | > PPO: \$15 copayment for |
| > active treatment for a metabolic or    | > the office visit (No    |
| > peripheral vascular disease, such as   | > deductible) plus xx% of |
| > diabetes.                              | > the Plan allowance for  |
| >                                        | > other services          |
| > See orthopedic and prosthetic devices  | > performed during the    |
| > for information on podiatric shoe      | > visit                   |
| > inserts.                               | >                         |
|                                          | > Non-PPO: 30% of the     |
|                                          | > Plan allowance and any  |
|                                          | > difference between our  |
|                                          | > allowance and the       |
|                                          | > billed amount           |
+------------------------------------------+---------------------------+
| > *Not covered:*                         | > *. All charges*         |
|                                          |                           |
| -   *Cutting, trimming or removal of     |                           |
|     corns, calluses, or the free edge of |                           |
|     toenails, and similar routine        |                           |
|     treatment of conditions of the foot, |                           |
|     except as stated above*              |                           |
|                                          |                           |
| -   *Treatment of weak, strained or flat |                           |
|     feet or bunions or spurs; and of any |                           |
|     instability, imbalance or            |                           |
|     subluxation of the foot (unless the  |                           |
|     treatment is by open cutting         |                           |
|     surgery)*                            |                           |
+------------------------------------------+---------------------------+
| > **Orthopedic and prosthetic devices**  | ###                       |
+------------------------------------------+---------------------------+
| -   Artificial limbs and eyes; stump     | > PPO: 15% of the Plan    |
|     hose                                 | > allowance               |
|                                          | >                         |
| -   Externally worn breast prostheses    | > Non-PPO: 30% of the     |
|     and surgical bras, including         | > Plan allowance and any  |
|     necessary replacements following a   | > difference between our  |
|     mastectomy                           | > allowance and the       |
|                                          | > billed amount           |
| > *{{Plan -- if you pay for devices      |                           |
| > here, use this language:}}*            |                           |
|                                          |                           |
| -   Internal prosthetic devices, such as |                           |
|     artificial joints, pacemakers,       |                           |
|     cochlear implants, and surgically    |                           |
|     implanted breast implant following   |                           |
|     mastectomy. Note: See 5(b) for       |                           |
|     coverage of the surgery to insert    |                           |
|     the device.                          |                           |
+------------------------------------------+---------------------------+
| > *{Plan -- if you pay for devices under |                           |
| > hospital benefits, use this            |                           |
| > language:}*                            |                           |
|                                          |                           |
| -   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).                    |                           |
+------------------------------------------+---------------------------+
| > *Not covered:*                         | > *All charges.*          |
|                                          |                           |
| -   *Orthopedic and corrective shoes*    |                           |
|                                          |                           |
| -   *Arch supports*                      |                           |
|                                          |                           |
| -   *Foot orthotics*                     |                           |
|                                          |                           |
| -   *Heel pads and heel cups*            |                           |
|                                          |                           |
| -   *Lumbosacral supports*               |                           |
|                                          |                           |
| -   *Corsets, trusses, elastic           |                           |
|     stockings, support hose, and other   |                           |
|     supportive devices*                  |                           |
|                                          |                           |
| -   *Prosthetic replacements provided    |                           |
|     less than 3 years after the last one |                           |
|     we covered*                          |                           |
+------------------------------------------+---------------------------+

+------------------------------------------+---------------------------+
| ######## Durable medical equipment (DME) | ### **You pay**           |
+------------------------------------------+---------------------------+
| > *{use this standard benefit            | > PPO: 15% of the Plan    |
| > description **}***                     | > allowance               |
| >                                        | >                         |
| > Durable medical equipment (DME) is     | > Non-PPO: 30% of the     |
| > equipment and supplies that:           | > Plan allowance and any  |
|                                          | > difference between our  |
| 1.  Are prescribed by your attending     | > allowance and the       |
|     physician (i.e., the physician who   | > billed amount           |
|     is treating your illness or injury); |                           |
|                                          |                           |
| 2.  Are medically necessary;             |                           |
|                                          |                           |
| 3.  Are primarily and customarily used   |                           |
|     only for a medical purpose;          |                           |
|                                          |                           |
| 4.  Are generally useful only to a       |                           |
|     person with an illness or injury;    |                           |
|                                          |                           |
| 5.  Are designed for prolonged use; and  |                           |
|                                          |                           |
| 6.  Serve a specific therapeutic purpose |                           |
|     in the treatment of an illness or    |                           |
|     injury.                              |                           |
|                                          |                           |
| > We cover rental or purchase, at our    |                           |
| > option, including repair and           |                           |
| > adjustment, of durable medical         |                           |
| > equipment, such as oxygen and dialysis |                           |
| > equipment. Under this benefit, we also |                           |
| > cover: *{List plan specific}*          |                           |
|                                          |                           |
| -   Hospital beds;                       |                           |
|                                          |                           |
| -   Wheelchairs;*{show what you do cover |                           |
|     here, and what you don't, below}}*   |                           |
|                                          |                           |
| -   Crutches; and                        |                           |
|                                          |                           |
| -   Walkers.                             |                           |
|                                          |                           |
| > Note: Call us at xxx as soon as your   |                           |
| > physician prescribes this equipment.   |                           |
| > We arrange with a health care provider |                           |
| > to rent or sell you durable medical    |                           |
| > equipment at discounted rates and will |                           |
| > tell you more about this service when  |                           |
| > you call.                              |                           |
+------------------------------------------+---------------------------+
| -   *Not covered: {Plan specific}*       | > *All charges*           |
+------------------------------------------+---------------------------+
| ######## Home health services            | ###                       |
+------------------------------------------+---------------------------+
| > 90 days per calendar year up to a      | > PPO: 20% (No            |
| > maximum plan payment of \$75 per day   | > deductible); all        |
| > when:                                  | > charges after we pay    |
|                                          | > \$75 per day            |
| -   A registered nurse (R.N.), licensed  | >                         |
|     practical nurse (L.P.N.) or licensed | > Non-PPO: 20% (No        |
|     vocational nurse (L.V.N.) provides   | > deductible); all        |
|     the services;                        | > charges after we pay    |
|                                          | > \$75 per day            |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   The attending physician orders the   |                           |
|     care;                                |                           |
|                                          |                           |
| -   The physician identifies the         |                           |
|     specific professional skills         |                           |
|     required by the patient and the      |                           |
|     medical necessity for skilled        |                           |
|     services; and                        |                           |
|                                          |                           |
| -   The physician indicates the length   |                           |
|     of time the services are needed.     |                           |
+------------------------------------------+---------------------------+
| > Not covered:                           | > *All charges.*          |
|                                          |                           |
| -   *Nursing care requested by, or for   |                           |
|     the convenience of, the patient or   |                           |
|     the patient's family;*               |                           |
|                                          |                           |
| -   *nursing care primarily for hygiene, |                           |
|     feeding, exercising, moving the      |                           |
|     patient, homemaking, companionship   |                           |
|     or giving oral medication.*          |                           |
+------------------------------------------+---------------------------+

+------------------------------------------+---------------------------+
| ######## Alternative treatments          | ### **You pay**           |
+------------------------------------------+---------------------------+
| > Acupuncture -- by a doctor of medicine | > PPO: 15% of the Plan    |
| > or osteopathy for: anesthesia, pain    | > allowance               |
| > relief,                                | >                         |
|                                          | > Non-PPO: 30% of the     |
|                                          | > Plan allowance and any  |
|                                          | > difference between our  |
|                                          | > allowance and the       |
|                                          | > billed amount           |
+------------------------------------------+---------------------------+
| ## Not covered:                          | > *.*                     |
|                                          | >                         |
| -   Chiropractic services                | > *All charges*           |
|                                          |                           |
| ## naturopathic services                 |                           |
|                                          |                           |
| ##                                       |                           |
|                                          |                           |
| > (Note: benefits of certain alternative |                           |
| > treatment providers may be covered in  |                           |
| > medically underserved areas; see page  |                           |
| > \_\_\_)                                |                           |
+------------------------------------------+---------------------------+
| #                                        | ###                       |
| ### **Educational classes and programs** |                           |
+------------------------------------------+---------------------------+
| > Coverage is limited to:                | > PPO: Nothing            |
|                                          | >                         |
| -   Smoking Cessation -- Up to \$100 for | > Non-PPO: Nothing        |
|     one smoking cessation program per    |                           |
|     member per lifetime, including all   |                           |
|     related expenses such as drugs.      |                           |
|                                          |                           |
| -   Diabetes self management.            |                           |
+------------------------------------------+---------------------------+

+---+---+----------------------------------+------------------+---+---+
| * |   |                                  |                  |   |   |
| * |   |                                  |                  |   |   |
| S |   |                                  |                  |   |   |
| e |   |                                  |                  |   |   |
| c |   |                                  |                  |   |   |
| t |   |                                  |                  |   |   |
| i |   |                                  |                  |   |   |
| o |   |                                  |                  |   |   |
| n |   |                                  |                  |   |   |
| 5 |   |                                  |                  |   |   |
| ( |   |                                  |                  |   |   |
| b |   |                                  |                  |   |   |
| ) |   |                                  |                  |   |   |
| . |   |                                  |                  |   |   |
| S |   |                                  |                  |   |   |
| u |   |                                  |                  |   |   |
| r |   |                                  |                  |   |   |
| g |   |                                  |                  |   |   |
| i |   |                                  |                  |   |   |
| c |   |                                  |                  |   |   |
| a |   |                                  |                  |   |   |
| l |   |                                  |                  |   |   |
| a |   |                                  |                  |   |   |
| n |   |                                  |                  |   |   |
| d |   |                                  |                  |   |   |
| a |   |                                  |                  |   |   |
| n |   |                                  |                  |   |   |
| e |   |                                  |                  |   |   |
| s |   |                                  |                  |   |   |
| t |   |                                  |                  |   |   |
| h |   |                                  |                  |   |   |
| e |   |                                  |                  |   |   |
| s |   |                                  |                  |   |   |
| i |   |                                  |                  |   |   |
| a |   |                                  |                  |   |   |
| s |   |                                  |                  |   |   |
| e |   |                                  |                  |   |   |
| r |   |                                  |                  |   |   |
| v |   |                                  |                  |   |   |
| i |   |                                  |                  |   |   |
| c |   |                                  |                  |   |   |
| e |   |                                  |                  |   |   |
| s |   |                                  |                  |   |   |
| p |   |                                  |                  |   |   |
| r |   |                                  |                  |   |   |
| o |   |                                  |                  |   |   |
| v |   |                                  |                  |   |   |
| i |   |                                  |                  |   |   |
| d |   |                                  |                  |   |   |
| e |   |                                  |                  |   |   |
| d |   |                                  |                  |   |   |
| b |   |                                  |                  |   |   |
| y |   |                                  |                  |   |   |
| p |   |                                  |                  |   |   |
| h |   |                                  |                  |   |   |
| y |   |                                  |                  |   |   |
| s |   |                                  |                  |   |   |
| i |   |                                  |                  |   |   |
| c |   |                                  |                  |   |   |
| i |   |                                  |                  |   |   |
| a |   |                                  |                  |   |   |
| n |   |                                  |                  |   |   |
| s |   |                                  |                  |   |   |
| a |   |                                  |                  |   |   |
| n |   |                                  |                  |   |   |
| d |   |                                  |                  |   |   |
| o |   |                                  |                  |   |   |
| t |   |                                  |                  |   |   |
| h |   |                                  |                  |   |   |
| e |   |                                  |                  |   |   |
| r |   |                                  |                  |   |   |
| h |   |                                  |                  |   |   |
| e |   |                                  |                  |   |   |
| a |   |                                  |                  |   |   |
| l |   |                                  |                  |   |   |
| t |   |                                  |                  |   |   |
| h |   |                                  |                  |   |   |
| c |   |                                  |                  |   |   |
| a |   |                                  |                  |   |   |
| r |   |                                  |                  |   |   |
| e |   |                                  |                  |   |   |
| p |   |                                  |                  |   |   |
| r |   |                                  |                  |   |   |
| o |   |                                  |                  |   |   |
| f |   |                                  |                  |   |   |
| e |   |                                  |                  |   |   |
| s |   |                                  |                  |   |   |
| s |   |                                  |                  |   |   |
| i |   |                                  |                  |   |   |
| o |   |                                  |                  |   |   |
| n |   |                                  |                  |   |   |
| a |   |                                  |                  |   |   |
| l |   |                                  |                  |   |   |
| s |   |                                  |                  |   |   |
| * |   |                                  |                  |   |   |
| * |   |                                  |                  |   |   |
+---+---+----------------------------------+------------------+---+---+
|   | * | **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       |                  | * |   |
|   | M |     brochure and are payable     |                  | M |   |
|   | * |     only when we determine they  |                  | * |   |
|   | * |     are medically necessary.     |                  | * |   |
|   |   |                                  |                  |   |   |
|   | * | -   The calendar year deductible |                  | * |   |
|   | * |     is: \$275 per person (\$550  |                  | * |   |
|   | P |     per family). The calendar    |                  | P |   |
|   | * |     year deductible applies to   |                  | * |   |
|   | * |     almost all benefits in this  |                  | * |   |
|   |   |     Section. We added "No        |                  |   |   |
|   | * |     deductible" to show when the |                  | * |   |
|   | * |     calendar year deductible     |                  | * |   |
|   | O |     does not apply. *{If you     |                  | O |   |
|   | * |     want, you can say, "We added |                  | * |   |
|   | * |     asterisks - \* - to show     |                  | * |   |
|   |   |     when the calendar year       |                  |   |   |
|   | * |     deductible does not          |                  | * |   |
|   | * |     apply."}*                    |                  | * |   |
|   | R |                                  |                  | R |   |
|   | * | -   Be sure to read Section 4,   |                  | * |   |
|   | * |     *Your costs for covered      |                  | * |   |
|   |   |     services* for valuable       |                  |   |   |
|   | * |     information about how cost   |                  | * |   |
|   | * |     sharing works, with special  |                  | * |   |
|   | T |     sections for members who are |                  | T |   |
|   | * |     age 65 or over. Also read    |                  | * |   |
|   | * |     Section 9 about coordinating |                  | * |   |
|   |   |     benefits with other          |                  |   |   |
|   | * |     coverage, including with     |                  | * |   |
|   | * |     Medicare.                    |                  | * |   |
|   | A |                                  |                  | A |   |
|   | * | -   The amounts listed below are |                  | * |   |
|   | * |     for the charges billed by a  |                  | * |   |
|   |   |     physician or other health    |                  |   |   |
|   | * |     care professional for your   |                  | * |   |
|   | * |     surgical care. Any costs     |                  | * |   |
|   | N |     associated with the facility |                  | N |   |
|   | * |     charge (i.e. hospital,       |                  | * |   |
|   | * |     surgical center, etc.) are   |                  | * |   |
|   |   |     in Section 5 (c).            |                  |   |   |
|   | * |                                  |                  | * |   |
|   | * | ```{=html}                       |                  | * |   |
|   | T | <!-- -->                         |                  | T |   |
|   | * | ```                              |                  | * |   |
|   | * | -   YOU MUST GET                 |                  | * |   |
|   |   |     PRECERTIFICATION OF SOME     |                  |   |   |
|   |   |     SURGICAL PROCEDURES. Please  |                  |   |   |
|   |   |     refer to the                 |                  |   |   |
|   |   |     precertification information |                  |   |   |
|   |   |     shown in Section 3 to be     |                  |   |   |
|   |   |     sure which services require  |                  |   |   |
|   |   |     precertification. *{Plan     |                  |   |   |
|   |   |     specific; identify which     |                  |   |   |
|   |   |     surgeries require            |                  |   |   |
|   |   |     pecertification -- delete if |                  |   |   |
|   |   |     not applicable}*             |                  |   |   |
+---+---+----------------------------------+------------------+---+---+
| * |   |                                  | **You pay**      |   |   |
| * |   |                                  |                  |   |   |
| B |   |                                  | **After the      |   |   |
| e |   |                                  | calendar year    |   |   |
| n |   |                                  | deductible...**  |   |   |
| e |   |                                  |                  |   |   |
| f |   |                                  |                  |   |   |
| i |   |                                  |                  |   |   |
| t |   |                                  |                  |   |   |
| D |   |                                  |                  |   |   |
| e |   |                                  |                  |   |   |
| s |   |                                  |                  |   |   |
| c |   |                                  |                  |   |   |
| r |   |                                  |                  |   |   |
| i |   |                                  |                  |   |   |
| p |   |                                  |                  |   |   |
| t |   |                                  |                  |   |   |
| i |   |                                  |                  |   |   |
| o |   |                                  |                  |   |   |
| n |   |                                  |                  |   |   |
| * |   |                                  |                  |   |   |
| * |   |                                  |                  |   |   |
+---+---+----------------------------------+------------------+---+---+
| # |   |                                  |                  |   |   |
| # |   |                                  |                  |   |   |
| # |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| * |   |                                  |                  |   |   |
| * |   |                                  |                  |   |   |
| N |   |                                  |                  |   |   |
| O |   |                                  |                  |   |   |
| T |   |                                  |                  |   |   |
| E |   |                                  |                  |   |   |
| : |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| T |   |                                  |                  |   |   |
| h |   |                                  |                  |   |   |
| e |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| c |   |                                  |                  |   |   |
| a |   |                                  |                  |   |   |
| l |   |                                  |                  |   |   |
| e |   |                                  |                  |   |   |
| n |   |                                  |                  |   |   |
| d |   |                                  |                  |   |   |
| a |   |                                  |                  |   |   |
| r |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| y |   |                                  |                  |   |   |
| e |   |                                  |                  |   |   |
| a |   |                                  |                  |   |   |
| r |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| d |   |                                  |                  |   |   |
| e |   |                                  |                  |   |   |
| d |   |                                  |                  |   |   |
| u |   |                                  |                  |   |   |
| c |   |                                  |                  |   |   |
| t |   |                                  |                  |   |   |
| i |   |                                  |                  |   |   |
| b |   |                                  |                  |   |   |
| l |   |                                  |                  |   |   |
| e |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| a |   |                                  |                  |   |   |
| p |   |                                  |                  |   |   |
| p |   |                                  |                  |   |   |
| l |   |                                  |                  |   |   |
| i |   |                                  |                  |   |   |
| e |   |                                  |                  |   |   |
| s |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| t |   |                                  |                  |   |   |
| o |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| a |   |                                  |                  |   |   |
| l |   |                                  |                  |   |   |
| m |   |                                  |                  |   |   |
| o |   |                                  |                  |   |   |
| s |   |                                  |                  |   |   |
| t |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| a |   |                                  |                  |   |   |
| l |   |                                  |                  |   |   |
| l |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| b |   |                                  |                  |   |   |
| e |   |                                  |                  |   |   |
| n |   |                                  |                  |   |   |
| e |   |                                  |                  |   |   |
| f |   |                                  |                  |   |   |
| i |   |                                  |                  |   |   |
| t |   |                                  |                  |   |   |
| s |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| i |   |                                  |                  |   |   |
| n |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| t |   |                                  |                  |   |   |
| h |   |                                  |                  |   |   |
| i |   |                                  |                  |   |   |
| s |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| S |   |                                  |                  |   |   |
| e |   |                                  |                  |   |   |
| c |   |                                  |                  |   |   |
| t |   |                                  |                  |   |   |
| i |   |                                  |                  |   |   |
| o |   |                                  |                  |   |   |
| n |   |                                  |                  |   |   |
| . |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| W |   |                                  |                  |   |   |
| e |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| s |   |                                  |                  |   |   |
| a |   |                                  |                  |   |   |
| y |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| " |   |                                  |                  |   |   |
| N |   |                                  |                  |   |   |
| o |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| d |   |                                  |                  |   |   |
| e |   |                                  |                  |   |   |
| d |   |                                  |                  |   |   |
| u |   |                                  |                  |   |   |
| c |   |                                  |                  |   |   |
| t |   |                                  |                  |   |   |
| i |   |                                  |                  |   |   |
| b |   |                                  |                  |   |   |
| l |   |                                  |                  |   |   |
| e |   |                                  |                  |   |   |
| " |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| w |   |                                  |                  |   |   |
| h |   |                                  |                  |   |   |
| e |   |                                  |                  |   |   |
| n |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| i |   |                                  |                  |   |   |
| t |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| d |   |                                  |                  |   |   |
| o |   |                                  |                  |   |   |
| e |   |                                  |                  |   |   |
| s |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| n |   |                                  |                  |   |   |
| o |   |                                  |                  |   |   |
| t |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| a |   |                                  |                  |   |   |
| p |   |                                  |                  |   |   |
| p |   |                                  |                  |   |   |
| l |   |                                  |                  |   |   |
| y |   |                                  |                  |   |   |
| . |   |                                  |                  |   |   |
| * |   |                                  |                  |   |   |
| * |   |                                  |                  |   |   |
| * |   |                                  |                  |   |   |
| { |   |                                  |                  |   |   |
| P |   |                                  |                  |   |   |
| l |   |                                  |                  |   |   |
| a |   |                                  |                  |   |   |
| n |   |                                  |                  |   |   |
| - |   |                                  |                  |   |   |
| c |   |                                  |                  |   |   |
| a |   |                                  |                  |   |   |
| n |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| s |   |                                  |                  |   |   |
| a |   |                                  |                  |   |   |
| y |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| \ |   |                                  |                  |   |   |
| " |   |                                  |                  |   |   |
| W |   |                                  |                  |   |   |
| e |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| a |   |                                  |                  |   |   |
| d |   |                                  |                  |   |   |
| d |   |                                  |                  |   |   |
| e |   |                                  |                  |   |   |
| d |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| a |   |                                  |                  |   |   |
| s |   |                                  |                  |   |   |
| t |   |                                  |                  |   |   |
| e |   |                                  |                  |   |   |
| r |   |                                  |                  |   |   |
| i |   |                                  |                  |   |   |
| s |   |                                  |                  |   |   |
| k |   |                                  |                  |   |   |
| s |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| - |   |                                  |                  |   |   |
| \ |   |                                  |                  |   |   |
| * |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| - |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| w |   |                                  |                  |   |   |
| h |   |                                  |                  |   |   |
| e |   |                                  |                  |   |   |
| n |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| i |   |                                  |                  |   |   |
| t |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| d |   |                                  |                  |   |   |
| o |   |                                  |                  |   |   |
| e |   |                                  |                  |   |   |
| s |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| n |   |                                  |                  |   |   |
| o |   |                                  |                  |   |   |
| t |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| a |   |                                  |                  |   |   |
| p |   |                                  |                  |   |   |
| p |   |                                  |                  |   |   |
| l |   |                                  |                  |   |   |
| y |   |                                  |                  |   |   |
| \ |   |                                  |                  |   |   |
| " |   |                                  |                  |   |   |
| } |   |                                  |                  |   |   |
| * |   |                                  |                  |   |   |
+---+---+----------------------------------+------------------+---+---+
| # |   |                                  |                  |   |   |
| # |   |                                  |                  |   |   |
| # |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| * |   |                                  |                  |   |   |
| * |   |                                  |                  |   |   |
| S |   |                                  |                  |   |   |
| u |   |                                  |                  |   |   |
| r |   |                                  |                  |   |   |
| g |   |                                  |                  |   |   |
| i |   |                                  |                  |   |   |
| c |   |                                  |                  |   |   |
| a |   |                                  |                  |   |   |
| l |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| p |   |                                  |                  |   |   |
| r |   |                                  |                  |   |   |
| o |   |                                  |                  |   |   |
| c |   |                                  |                  |   |   |
| e |   |                                  |                  |   |   |
| d |   |                                  |                  |   |   |
| u |   |                                  |                  |   |   |
| r |   |                                  |                  |   |   |
| e |   |                                  |                  |   |   |
| s |   |                                  |                  |   |   |
| * |   |                                  |                  |   |   |
| * |   |                                  |                  |   |   |
+---+---+----------------------------------+------------------+---+---+
| - |   |                                  | PPO: 15% of the  |   |   |
|   |   |                                  | Plan allowance   |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  | Non-PPO: 30% of  |   |   |
| O |   |                                  | the Plan         |   |   |
| p |   |                                  | allowance and    |   |   |
| e |   |                                  | any difference   |   |   |
| r |   |                                  | between our      |   |   |
| a |   |                                  | allowance and    |   |   |
| t |   |                                  | the billed       |   |   |
| i |   |                                  | amount           |   |   |
| v |   |                                  |                  |   |   |
| e |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| p |   |                                  |                  |   |   |
| r |   |                                  |                  |   |   |
| o |   |                                  |                  |   |   |
| c |   |                                  |                  |   |   |
| e |   |                                  |                  |   |   |
| d |   |                                  |                  |   |   |
| u |   |                                  |                  |   |   |
| r |   |                                  |                  |   |   |
| e |   |                                  |                  |   |   |
| s |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| - |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| T |   |                                  |                  |   |   |
| r |   |                                  |                  |   |   |
| e |   |                                  |                  |   |   |
| a |   |                                  |                  |   |   |
| t |   |                                  |                  |   |   |
| m |   |                                  |                  |   |   |
| e |   |                                  |                  |   |   |
| n |   |                                  |                  |   |   |
| t |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| o |   |                                  |                  |   |   |
| f |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| f |   |                                  |                  |   |   |
| r |   |                                  |                  |   |   |
| a |   |                                  |                  |   |   |
| c |   |                                  |                  |   |   |
| t |   |                                  |                  |   |   |
| u |   |                                  |                  |   |   |
| r |   |                                  |                  |   |   |
| e |   |                                  |                  |   |   |
| s |   |                                  |                  |   |   |
| , |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| i |   |                                  |                  |   |   |
| n |   |                                  |                  |   |   |
| c |   |                                  |                  |   |   |
| l |   |                                  |                  |   |   |
| u |   |                                  |                  |   |   |
| d |   |                                  |                  |   |   |
| i |   |                                  |                  |   |   |
| n |   |                                  |                  |   |   |
| g |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| c |   |                                  |                  |   |   |
| a |   |                                  |                  |   |   |
| s |   |                                  |                  |   |   |
| t |   |                                  |                  |   |   |
| i |   |                                  |                  |   |   |
| n |   |                                  |                  |   |   |
| g |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| - |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| N |   |                                  |                  |   |   |
| o |   |                                  |                  |   |   |
| r |   |                                  |                  |   |   |
| m |   |                                  |                  |   |   |
| a |   |                                  |                  |   |   |
| l |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| p |   |                                  |                  |   |   |
| r |   |                                  |                  |   |   |
| e |   |                                  |                  |   |   |
| - |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| a |   |                                  |                  |   |   |
| n |   |                                  |                  |   |   |
| d |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| p |   |                                  |                  |   |   |
| o |   |                                  |                  |   |   |
| s |   |                                  |                  |   |   |
| t |   |                                  |                  |   |   |
| - |   |                                  |                  |   |   |
| o |   |                                  |                  |   |   |
| p |   |                                  |                  |   |   |
| e |   |                                  |                  |   |   |
| r |   |                                  |                  |   |   |
| a |   |                                  |                  |   |   |
| t |   |                                  |                  |   |   |
| i |   |                                  |                  |   |   |
| v |   |                                  |                  |   |   |
| e |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| c |   |                                  |                  |   |   |
| a |   |                                  |                  |   |   |
| r |   |                                  |                  |   |   |
| e |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| b |   |                                  |                  |   |   |
| y |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| t |   |                                  |                  |   |   |
| h |   |                                  |                  |   |   |
| e |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| s |   |                                  |                  |   |   |
| u |   |                                  |                  |   |   |
| r |   |                                  |                  |   |   |
| g |   |                                  |                  |   |   |
| e |   |                                  |                  |   |   |
| o |   |                                  |                  |   |   |
| n |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| - |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| C |   |                                  |                  |   |   |
| o |   |                                  |                  |   |   |
| r |   |                                  |                  |   |   |
| r |   |                                  |                  |   |   |
| e |   |                                  |                  |   |   |
| c |   |                                  |                  |   |   |
| t |   |                                  |                  |   |   |
| i |   |                                  |                  |   |   |
| o |   |                                  |                  |   |   |
| n |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| o |   |                                  |                  |   |   |
| f |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| a |   |                                  |                  |   |   |
| m |   |                                  |                  |   |   |
| b |   |                                  |                  |   |   |
| l |   |                                  |                  |   |   |
| y |   |                                  |                  |   |   |
| o |   |                                  |                  |   |   |
| p |   |                                  |                  |   |   |
| i |   |                                  |                  |   |   |
| a |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| a |   |                                  |                  |   |   |
| n |   |                                  |                  |   |   |
| d |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| s |   |                                  |                  |   |   |
| t |   |                                  |                  |   |   |
| r |   |                                  |                  |   |   |
| a |   |                                  |                  |   |   |
| b |   |                                  |                  |   |   |
| i |   |                                  |                  |   |   |
| s |   |                                  |                  |   |   |
| m |   |                                  |                  |   |   |
| u |   |                                  |                  |   |   |
| s |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| - |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| E |   |                                  |                  |   |   |
| n |   |                                  |                  |   |   |
| d |   |                                  |                  |   |   |
| o |   |                                  |                  |   |   |
| s |   |                                  |                  |   |   |
| c |   |                                  |                  |   |   |
| o |   |                                  |                  |   |   |
| p |   |                                  |                  |   |   |
| y |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| p |   |                                  |                  |   |   |
| r |   |                                  |                  |   |   |
| o |   |                                  |                  |   |   |
| c |   |                                  |                  |   |   |
| e |   |                                  |                  |   |   |
| d |   |                                  |                  |   |   |
| u |   |                                  |                  |   |   |
| r |   |                                  |                  |   |   |
| e |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| - |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| B |   |                                  |                  |   |   |
| i |   |                                  |                  |   |   |
| o |   |                                  |                  |   |   |
| p |   |                                  |                  |   |   |
| s |   |                                  |                  |   |   |
| y |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| p |   |                                  |                  |   |   |
| r |   |                                  |                  |   |   |
| o |   |                                  |                  |   |   |
| c |   |                                  |                  |   |   |
| e |   |                                  |                  |   |   |
| d |   |                                  |                  |   |   |
| u |   |                                  |                  |   |   |
| r |   |                                  |                  |   |   |
| e |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| - |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| E |   |                                  |                  |   |   |
| l |   |                                  |                  |   |   |
| e |   |                                  |                  |   |   |
| c |   |                                  |                  |   |   |
| t |   |                                  |                  |   |   |
| r |   |                                  |                  |   |   |
| o |   |                                  |                  |   |   |
| c |   |                                  |                  |   |   |
| o |   |                                  |                  |   |   |
| n |   |                                  |                  |   |   |
| v |   |                                  |                  |   |   |
| u |   |                                  |                  |   |   |
| l |   |                                  |                  |   |   |
| s |   |                                  |                  |   |   |
| i |   |                                  |                  |   |   |
| v |   |                                  |                  |   |   |
| e |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   |                                  |                  |   |   |
| t |   |                                  |                  |   |   |
| h |   |                                  |                  |   |   |
| e |   |                                  |                  |   |   |
| r |   |                                  |                  |   |   |
| a |   |                                  |                  |   |   |
| p |   |                                  |                  |   |   |
| y |   |                                  |                  |   |   |
+---+---+----------------------------------+------------------+---+---+

Surgical procedures - Continued on next page.

+------------------------------------------+---------------------------+
| #                                        | ### **You pay**           |
| ## **Surgical procedures** *- Continued* |                           |
+------------------------------------------+---------------------------+
| -   Removal of tumors and cysts          | PPO: 15% of the Plan      |
|                                          | allowance for the primary |
| ```{=html}                               | procedure and 15% of      |
| <!-- -->                                 | one-half of the Plan      |
| ```                                      | allowance for the         |
| -   Correction of congenital anomalies   | secondary procedure(s)    |
|     (see Reconstructive surgery)         |                           |
|                                          | Non-PPO: 30% of the Plan  |
| -   Surgical treatment of morbid obesity | allowance for the primary |
|     \-- a condition in which an          | procedure and 30% of      |
|     individual weighs 100 pounds or 100% | one-half of the Plan      |
|     over his or her normal weight        | allowance for the         |
|     according to current underwriting    | secondary procedure(s);   |
|     standards; eligible members must be  | and any difference        |
|     age 18 or over *{Use this standard   | between our payment and   |
|     definition if you need to define it; | the billed amount         |
|     put your limits, if any, etc}*       |                           |
|                                          |                           |
| -   Insertion of internal prostethic     |                           |
|     devices. See 5(a) -- Orthopedic      |                           |
|     braces and prosthetic devices for    |                           |
|     device coverage information          |                           |
|                                          |                           |
| -   Voluntary sterilization, Norplant (a |                           |
|     surgically implanted contraceptive), |                           |
|     and intrauterine devices (IUDs)      |                           |
|                                          |                           |
| -   Treatment of burns                   |                           |
|                                          |                           |
| -   Assistant surgeons- we cover up to   |                           |
|     25% of our allowance for the         |                           |
|     surgeon\'s charge                    |                           |
+------------------------------------------+---------------------------+
| > When multiple or bilateral surgical    | PPO: 15% of the Plan      |
| > procedures performed during the same   | allowance for the primary |
| > operative session add time or          | procedure and 15% of      |
| > complexity to patient care, our        | one-half of the Plan      |
| > benefits are:                          | allowance for the         |
|                                          | secondary procedure(s)    |
| -   For the primary procedure:           |                           |
|                                          | Non-PPO: 30% of the Plan  |
| > PPO: 85% of the Plan allowance or      | allowance for the primary |
| >                                        | procedure and 30% of      |
| > Non-PPO: 70% of the reasonable and     | one-half of the Plan      |
| > customary charge                       | allowance for the         |
|                                          | secondary procedure(s);   |
| -   For the secondary procedure(s):      | and any difference        |
|                                          | between our payment and   |
| > PPO: 85% of one-half of the Plan       | the billed amount         |
| > allowance or                           |                           |
| >                                        |                           |
| > Non-PPO: 70% of one-half of the        |                           |
| > reasonable and customary charge        |                           |
| >                                        |                           |
| > Note: Multiple or bilateral surgical   |                           |
| > procedures performed through the same  |                           |
| > incision are "incidental" to the       |                           |
| > primary surgery. That is, the          |                           |
| > procedure would not add time or        |                           |
| > complexity to patient care. We do not  |                           |
| > pay extra for incidental procedures.   |                           |
| > *{describe this way if applies}*       |                           |
+------------------------------------------+---------------------------+
| > *Not covered:*                         | *All charges.*            |
|                                          |                           |
| -   *Reversal of voluntary               |                           |
|     sterilization*                       |                           |
|                                          |                           |
| -   *Services of a standby surgeon,      |                           |
|     except during angioplasty or other   |                           |
|     high risk procedures when we         |                           |
|     determine standbys are medically     |                           |
|     necessary*                           |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   *Routine treatment of conditions of  |                           |
|     the foot; see Foot care*             |                           |
+------------------------------------------+---------------------------+

+------------------------------------------+---------------------------+
| **Reconstructive surgery**               | ### **You pay**           |
+------------------------------------------+---------------------------+
| -   Surgery to correct a functional      | PPO: 15% of the Plan      |
|     defect                               | allowance                 |
|                                          |                           |
| -   Surgery to correct a condition       | Non-PPO: 30% of the Plan  |
|     caused by injury or illness if:      | allowance and any         |
|                                          | difference between our    |
| > the condition produced a major effect  | allowance and the billed  |
| > on the member's appearance and         | amount                    |
| >                                        |                           |
| > the condition can reasonably be        |                           |
| > expected to be corrected by such       |                           |
| > surgery *{use this standard            |                           |
| > description}*                          |                           |
|                                          |                           |
| -   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 deformaties; cleft lip; cleft    |                           |
|     palate; birth marks; and webbed      |                           |
|     fingers and toes. *{use this         |                           |
|     standard definition}*                |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   All stages of breast reconstruction  |                           |
|     surgery following a mastectomy, such |                           |
|     as:                                  |                           |
|                                          |                           |
| > surgery to produce a symmetrical       |                           |
| > appearance on the other breast;        |                           |
| >                                        |                           |
| > treatment of any physical              |                           |
| > complications, such as lymphedemas;    |                           |
| >                                        |                           |
| > breast prostheses; and surgical bras   |                           |
| > and replacements (see Prosthetic       |                           |
| > devices for coverage)                  |                           |
+------------------------------------------+---------------------------+
| > Note: Internal breast prostheses are   |                           |
| > paid as hospital benefits.             |                           |
| >                                        |                           |
| > Note: Women who undergo mastectomies   |                           |
| > may, at their option, have this        |                           |
| > procedure performed on an inpatient    |                           |
| > basis and remain in the hospital up to |                           |
| > 48 hours after the procedure.          |                           |
| > *{standard}*                           |                           |
+------------------------------------------+---------------------------+
| > *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 if repair is    |                           |
|     initiated within {insert negotiated  |                           |
|     limit, if any}*                      |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   *Surgeries related to sex            |                           |
|     transformation or sexual             |                           |
|     dysfunction*                         |                           |
+------------------------------------------+---------------------------+

+------------------------------------------+---------------------------+
| **Oral and maxillofacial surgery**       | ### **You pay**           |
+------------------------------------------+---------------------------+
| Oral surgical procedures, limited to:    | PPO: 15% of the Plan      |
|                                          | allowance                 |
| -   Reduction of fractures of the jaws   |                           |
|     or facial bones                      | Non-PPO: 30% of the Plan  |
|                                          | allowance and any         |
| -   Surgical correction of cleft lip,    | difference between our    |
|     cleft palate or severe functional    | allowance and the billed  |
|     malocclusion                         | amount                    |
|                                          |                           |
| -   Removal of stones from salivary      |                           |
|     ducts                                |                           |
|                                          |                           |
| -   Excision of leukoplakia or           |                           |
|     malignancies                         |                           |
|                                          |                           |
| -   Excision of cysts and incision of    |                           |
|     abscesses when done as independent   |                           |
|     procedures                           |                           |
|                                          |                           |
| -   Other surgical procedures that do    |                           |
|     not involve the teeth or their       |                           |
|     supporting structures                |                           |
+------------------------------------------+---------------------------+
| > *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)*         |                           |
+------------------------------------------+---------------------------+
| **Organ/tissue transplants**             | ###                       |
+------------------------------------------+---------------------------+
| > Limited to:                            | *{{Plan specific \-- for  |
|                                          | national transplant       |
| -   Cornea                               | program or other special  |
|                                          | programs, etc, refer back |
| -   Heart                                | to the page you explain   |
|                                          | it on.}*                  |
| -   Heart/lung                           |                           |
|                                          |                           |
| -   Kidney                               |                           |
|                                          |                           |
| -   Kidney/Pancreas                      |                           |
|                                          |                           |
| -   Liver                                |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   Lung: Single -- only for the         |                           |
|     following end-stage pulmonary        |                           |
|     diseases: primary fibrosis, primary  |                           |
|     pulmonary hypertension, or           |                           |
|     emphysema; Double -- only for        |                           |
|     patients with cystic fibrosis        |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   Pancreas                             |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   Allogeneic bone marrow transplants   |                           |
|     -- only for patients with acute      |                           |
|     leukemia, advanced Hodgkins disease  |                           |
|                                          |                           |
| > *{Insert ABMT benefits from 2000       |                           |
| > brochure}*                             |                           |
| >                                        |                           |
| > National Transplant Program (NTP) -    |                           |
| > *....{plan specific here}*             |                           |
| >                                        |                           |
| > Limited Benefits - *...{Plan           |                           |
| > specific}*                             |                           |
| >                                        |                           |
| > Treatment for breast cancer, multiple  |                           |
| > myeloma, and epithelial ovarian cancer |                           |
| > may be provided in an NCI- or          |                           |
| > NIH-approved clinical trial at a       |                           |
| > Plan-designated center of excellence   |                           |
| > and if approved by the Plan's medical  |                           |
| > director in accordance with the Plan's |                           |
| > protocols.                             |                           |
| >                                        |                           |
| > Note: We cover related medical and     |                           |
| > hospital expenses of the donor when we |                           |
| > cover the recipient.                   |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges*             |
|                                          |                           |
| -   *Donor screening tests and donor     |                           |
|     search expenses, except those        |                           |
|     performed for the actual donor*      |                           |
|                                          |                           |
| -   *Implants of artificial organs*      |                           |
|                                          |                           |
| -   *Transplants not listed as covered*  |                           |
+------------------------------------------+---------------------------+
| **Anesthesia**                           | ### **You pay**           |
+------------------------------------------+---------------------------+
| Professional services provided in --     | PPO: 15% of the Plan      |
|                                          | allowance (No deductible) |
| -   Hospital (inpatient)                 |                           |
|                                          | Non-PPO: 30% of the Plan  |
|                                          | allowance and any         |
|                                          | difference between our    |
|                                          | allowance and the billed  |
|                                          | amount (No deductible)    |
+------------------------------------------+---------------------------+
| Professional services provided in --     | PPO: 15% of the Plan      |
|                                          | allowance                 |
| -   Hospital outpatient department       |                           |
|                                          | Non-PPO: 30% of the Plan  |
| -   Skilled nursing facility             | allowance and any         |
|                                          | difference between our    |
| -   Ambulatory surgical center           | allowance and the billed  |
|                                          | amount                    |
| -   Office                               |                           |
|                                          | Note: If your PPO         |
|                                          | provider uses a non-PPO   |
|                                          | anesthesiologist, we will |
|                                          | pay non-PPO benefits for  |
|                                          | any anesthesia charges.   |
+------------------------------------------+---------------------------+

+---+---+----------------------------------+--------------------+---+---+
| * |   |                                  |                    |   |   |
| * |   |                                  |                    |   |   |
| S |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| c |   |                                  |                    |   |   |
| t |   |                                  |                    |   |   |
| i |   |                                  |                    |   |   |
| o |   |                                  |                    |   |   |
| n |   |                                  |                    |   |   |
| 5 |   |                                  |                    |   |   |
| ( |   |                                  |                    |   |   |
| c |   |                                  |                    |   |   |
| ) |   |                                  |                    |   |   |
| . |   |                                  |                    |   |   |
| S |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| r |   |                                  |                    |   |   |
| v |   |                                  |                    |   |   |
| i |   |                                  |                    |   |   |
| c |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| s |   |                                  |                    |   |   |
| p |   |                                  |                    |   |   |
| r |   |                                  |                    |   |   |
| o |   |                                  |                    |   |   |
| v |   |                                  |                    |   |   |
| i |   |                                  |                    |   |   |
| d |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| d |   |                                  |                    |   |   |
| b |   |                                  |                    |   |   |
| y |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| h |   |                                  |                    |   |   |
| o |   |                                  |                    |   |   |
| s |   |                                  |                    |   |   |
| p |   |                                  |                    |   |   |
| i |   |                                  |                    |   |   |
| t |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| l |   |                                  |                    |   |   |
| o |   |                                  |                    |   |   |
| r |   |                                  |                    |   |   |
| o |   |                                  |                    |   |   |
| t |   |                                  |                    |   |   |
| h |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| r |   |                                  |                    |   |   |
| f |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| c |   |                                  |                    |   |   |
| i |   |                                  |                    |   |   |
| l |   |                                  |                    |   |   |
| i |   |                                  |                    |   |   |
| t |   |                                  |                    |   |   |
| y |   |                                  |                    |   |   |
| , |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| n |   |                                  |                    |   |   |
| d |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| m |   |                                  |                    |   |   |
| b |   |                                  |                    |   |   |
| u |   |                                  |                    |   |   |
| l |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| n |   |                                  |                    |   |   |
| c |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| s |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| r |   |                                  |                    |   |   |
| v |   |                                  |                    |   |   |
| i |   |                                  |                    |   |   |
| c |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| s |   |                                  |                    |   |   |
| * |   |                                  |                    |   |   |
| * |   |                                  |                    |   |   |
+---+---+----------------------------------+--------------------+---+---+
|   | * | **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       |                    | * |   |
|   | M |     brochure and are payable     |                    | M |   |
|   | * |     only when we determine they  |                    | * |   |
|   | * |     are medically necessary.     |                    | * |   |
|   |   |                                  |                    |   |   |
|   | * | ```{=html}                       |                    | * |   |
|   | * | <!-- -->                         |                    | * |   |
|   | P | ```                              |                    | P |   |
|   | * | -   Unlike Sections (a) and (b), |                    | * |   |
|   | * |     in this section the calendar |                    | * |   |
|   |   |     year deductible applies to   |                    |   |   |
|   | * |     only a few benefits. In that |                    | * |   |
|   | * |     case, we added "(calendar    |                    | * |   |
|   | O |     year deductible applies)".   |                    | O |   |
|   | * |     ***[{Plan -- be sure to      |                    | * |   |
|   | * |     notice this is a different   |                    | * |   |
|   |   |     bullet}]{.underline}***      |                    |   |   |
|   | * |                                  |                    | * |   |
|   | * | -   Be sure to read Section 4,   |                    | * |   |
|   | R |     *Your costs for covered      |                    | R |   |
|   | * |     services* for valuable       |                    | * |   |
|   | * |     information about how cost   |                    | * |   |
|   |   |     sharing works, with special  |                    |   |   |
|   | * |     sections for members who are |                    | * |   |
|   | * |     age 65 or over. Also read    |                    | * |   |
|   | T |     Section 9 about coordinating |                    | T |   |
|   | * |     benefits with other          |                    | * |   |
|   | * |     coverage, including with     |                    | * |   |
|   |   |     Medicare.                    |                    |   |   |
|   | * |                                  |                    | * |   |
|   | * | ```{=html}                       |                    | * |   |
|   | A | <!-- -->                         |                    | A |   |
|   | * | ```                              |                    | * |   |
|   | * | -   The amounts listed below are |                    | * |   |
|   |   |     for the charges billed by    |                    |   |   |
|   | * |     the facility (i.e. hospital  |                    | * |   |
|   | * |     or surgical center) or       |                    | * |   |
|   | N |     ambulance service for your   |                    | N |   |
|   | * |     surgery or care. Any costs   |                    | * |   |
|   | * |     associated with the          |                    | * |   |
|   |   |     professional charge (i.e.    |                    |   |   |
|   | * |     physicians, etc.) are in     |                    | * |   |
|   | * |     Section 5(a) or (b).         |                    | * |   |
|   | T |                                  |                    | T |   |
|   | * | ```{=html}                       |                    | * |   |
|   | * | <!-- -->                         |                    | * |   |
|   |   | ```                              |                    |   |   |
|   |   | -   **YOU MUST GET               |                    |   |   |
|   |   |     PRECERTIFICATION OF HOSPITAL |                    |   |   |
|   |   |     STAYS; FAILURE TO DO SO WILL |                    |   |   |
|   |   |     RESULT IN A MINIMUM \$500    |                    |   |   |
|   |   |     PENALTY.** Please refer to   |                    |   |   |
|   |   |     the precertification         |                    |   |   |
|   |   |     information shown in Section |                    |   |   |
|   |   |     3 to be sure which services  |                    |   |   |
|   |   |     require precertification.    |                    |   |   |
+---+---+----------------------------------+--------------------+---+---+
| * |   |                                  | **You pay**        |   |   |
| * |   |                                  |                    |   |   |
| B |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| n |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| f |   |                                  |                    |   |   |
| i |   |                                  |                    |   |   |
| t |   |                                  |                    |   |   |
| D |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| s |   |                                  |                    |   |   |
| c |   |                                  |                    |   |   |
| r |   |                                  |                    |   |   |
| i |   |                                  |                    |   |   |
| p |   |                                  |                    |   |   |
| t |   |                                  |                    |   |   |
| i |   |                                  |                    |   |   |
| o |   |                                  |                    |   |   |
| n |   |                                  |                    |   |   |
| * |   |                                  |                    |   |   |
| * |   |                                  |                    |   |   |
+---+---+----------------------------------+--------------------+---+---+
| # |   |                                  |                    |   |   |
| # |   |                                  |                    |   |   |
| # |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| * |   |                                  |                    |   |   |
| * |   |                                  |                    |   |   |
| N |   |                                  |                    |   |   |
| O |   |                                  |                    |   |   |
| T |   |                                  |                    |   |   |
| E |   |                                  |                    |   |   |
| : |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| T |   |                                  |                    |   |   |
| h |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| c |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| l |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| n |   |                                  |                    |   |   |
| d |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| r |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| y |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| r |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| d |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| d |   |                                  |                    |   |   |
| u |   |                                  |                    |   |   |
| c |   |                                  |                    |   |   |
| t |   |                                  |                    |   |   |
| i |   |                                  |                    |   |   |
| b |   |                                  |                    |   |   |
| l |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| p |   |                                  |                    |   |   |
| p |   |                                  |                    |   |   |
| l |   |                                  |                    |   |   |
| i |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| s |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| O |   |                                  |                    |   |   |
| N |   |                                  |                    |   |   |
| L |   |                                  |                    |   |   |
| Y |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| w |   |                                  |                    |   |   |
| h |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| n |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| w |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| s |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| y |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| b |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| l |   |                                  |                    |   |   |
| o |   |                                  |                    |   |   |
| w |   |                                  |                    |   |   |
| : |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| " |   |                                  |                    |   |   |
| c |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| l |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| n |   |                                  |                    |   |   |
| d |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| r |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| y |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| r |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| d |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| d |   |                                  |                    |   |   |
| u |   |                                  |                    |   |   |
| c |   |                                  |                    |   |   |
| t |   |                                  |                    |   |   |
| i |   |                                  |                    |   |   |
| b |   |                                  |                    |   |   |
| l |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| p |   |                                  |                    |   |   |
| p |   |                                  |                    |   |   |
| l |   |                                  |                    |   |   |
| i |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| s |   |                                  |                    |   |   |
| " |   |                                  |                    |   |   |
| . |   |                                  |                    |   |   |
| * |   |                                  |                    |   |   |
| * |   |                                  |                    |   |   |
+---+---+----------------------------------+--------------------+---+---+
| # |   |                                  | ###                |   |   |
| # |   |                                  |                    |   |   |
| # |   |                                  |                    |   |   |
| # |   |                                  |                    |   |   |
| # |   |                                  |                    |   |   |
| # |   |                                  |                    |   |   |
| # |   |                                  |                    |   |   |
| # |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| I |   |                                  |                    |   |   |
| n |   |                                  |                    |   |   |
| p |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| t |   |                                  |                    |   |   |
| i |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| n |   |                                  |                    |   |   |
| t |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| h |   |                                  |                    |   |   |
| o |   |                                  |                    |   |   |
| s |   |                                  |                    |   |   |
| p |   |                                  |                    |   |   |
| i |   |                                  |                    |   |   |
| t |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| l |   |                                  |                    |   |   |
+---+---+----------------------------------+--------------------+---+---+
| > |   |                                  | > PPO: Nothing     |   |   |
|   |   |                                  | >                  |   |   |
| R |   |                                  | > Non-PPO: \$100   |   |   |
| o |   |                                  | > per admission    |   |   |
| o |   |                                  | > and 20% of the   |   |   |
| m |   |                                  | > covered charges  |   |   |
| > |   |                                  | >                  |   |   |
|   |   |                                  | > Note: If you use |   |   |
| a |   |                                  | > a PPO provider   |   |   |
| n |   |                                  | > and a PPO        |   |   |
| d |   |                                  | > facility, we may |   |   |
| > |   |                                  | > still pay        |   |   |
|   |   |                                  | > non-PPO benefits |   |   |
| b |   |                                  | > if you receive   |   |   |
| o |   |                                  | > treatment from a |   |   |
| a |   |                                  | > radiologist,     |   |   |
| r |   |                                  | > pathologist, or  |   |   |
| d |   |                                  | > anesthesiologist |   |   |
| , |   |                                  | > who is not a PPO |   |   |
| > |   |                                  | > provider.        |   |   |
|   |   |                                  | >                  |   |   |
| s |   |                                  | > PPO: Nothing     |   |   |
| u |   |                                  | >                  |   |   |
| c |   |                                  | > Non-PPO: 20% of  |   |   |
| h |   |                                  | > charges          |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| s |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| - |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| w |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| r |   |                                  |                    |   |   |
| d |   |                                  |                    |   |   |
| , |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| s |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| m |   |                                  |                    |   |   |
| i |   |                                  |                    |   |   |
| p |   |                                  |                    |   |   |
| r |   |                                  |                    |   |   |
| i |   |                                  |                    |   |   |
| v |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| t |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| , |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| o |   |                                  |                    |   |   |
| r |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| i |   |                                  |                    |   |   |
| n |   |                                  |                    |   |   |
| t |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| n |   |                                  |                    |   |   |
| s |   |                                  |                    |   |   |
| i |   |                                  |                    |   |   |
| v |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| c |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| r |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| c |   |                                  |                    |   |   |
| c |   |                                  |                    |   |   |
| o |   |                                  |                    |   |   |
| m |   |                                  |                    |   |   |
| m |   |                                  |                    |   |   |
| o |   |                                  |                    |   |   |
| d |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| t |   |                                  |                    |   |   |
| i |   |                                  |                    |   |   |
| o |   |                                  |                    |   |   |
| n |   |                                  |                    |   |   |
| s |   |                                  |                    |   |   |
| ; |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| - |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| g |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| n |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| r |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| l |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| n |   |                                  |                    |   |   |
| u |   |                                  |                    |   |   |
| r |   |                                  |                    |   |   |
| s |   |                                  |                    |   |   |
| i |   |                                  |                    |   |   |
| n |   |                                  |                    |   |   |
| g |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| c |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| r |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| ; |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| n |   |                                  |                    |   |   |
| d |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| - |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| m |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| l |   |                                  |                    |   |   |
| s |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| n |   |                                  |                    |   |   |
| d |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| s |   |                                  |                    |   |   |
| p |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| c |   |                                  |                    |   |   |
| i |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| l |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| d |   |                                  |                    |   |   |
| i |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| t |   |                                  |                    |   |   |
| s |   |                                  |                    |   |   |
| . |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| N |   |                                  |                    |   |   |
| O |   |                                  |                    |   |   |
| T |   |                                  |                    |   |   |
| E |   |                                  |                    |   |   |
| : |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| W |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| o |   |                                  |                    |   |   |
| n |   |                                  |                    |   |   |
| l |   |                                  |                    |   |   |
| y |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| c |   |                                  |                    |   |   |
| o |   |                                  |                    |   |   |
| v |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| r |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| p |   |                                  |                    |   |   |
| r |   |                                  |                    |   |   |
| i |   |                                  |                    |   |   |
| v |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| t |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| r |   |                                  |                    |   |   |
| o |   |                                  |                    |   |   |
| o |   |                                  |                    |   |   |
| m |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| w |   |                                  |                    |   |   |
| h |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| n |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| y |   |                                  |                    |   |   |
| o |   |                                  |                    |   |   |
| u |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| m |   |                                  |                    |   |   |
| u |   |                                  |                    |   |   |
| s |   |                                  |                    |   |   |
| t |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| b |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| i |   |                                  |                    |   |   |
| s |   |                                  |                    |   |   |
| o |   |                                  |                    |   |   |
| l |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| t |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| d |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| t |   |                                  |                    |   |   |
| o |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| p |   |                                  |                    |   |   |
| r |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| v |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| n |   |                                  |                    |   |   |
| t |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| c |   |                                  |                    |   |   |
| o |   |                                  |                    |   |   |
| n |   |                                  |                    |   |   |
| t |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| g |   |                                  |                    |   |   |
| i |   |                                  |                    |   |   |
| o |   |                                  |                    |   |   |
| n |   |                                  |                    |   |   |
| . |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| O |   |                                  |                    |   |   |
| t |   |                                  |                    |   |   |
| h |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| r |   |                                  |                    |   |   |
| w |   |                                  |                    |   |   |
| i |   |                                  |                    |   |   |
| s |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| , |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| w |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| w |   |                                  |                    |   |   |
| i |   |                                  |                    |   |   |
| l |   |                                  |                    |   |   |
| l |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| p |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| y |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| t |   |                                  |                    |   |   |
| h |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| h |   |                                  |                    |   |   |
| o |   |                                  |                    |   |   |
| s |   |                                  |                    |   |   |
| p |   |                                  |                    |   |   |
| i |   |                                  |                    |   |   |
| t |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| l |   |                                  |                    |   |   |
| ' |   |                                  |                    |   |   |
| s |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| v |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| r |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| g |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| c |   |                                  |                    |   |   |
| h |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| r |   |                                  |                    |   |   |
| g |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| f |   |                                  |                    |   |   |
| o |   |                                  |                    |   |   |
| r |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| s |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| m |   |                                  |                    |   |   |
| i |   |                                  |                    |   |   |
| p |   |                                  |                    |   |   |
| r |   |                                  |                    |   |   |
| i |   |                                  |                    |   |   |
| v |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| t |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| c |   |                                  |                    |   |   |
| c |   |                                  |                    |   |   |
| o |   |                                  |                    |   |   |
| m |   |                                  |                    |   |   |
| m |   |                                  |                    |   |   |
| o |   |                                  |                    |   |   |
| d |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| t |   |                                  |                    |   |   |
| i |   |                                  |                    |   |   |
| o |   |                                  |                    |   |   |
| n |   |                                  |                    |   |   |
| s |   |                                  |                    |   |   |
| . |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| I |   |                                  |                    |   |   |
| f |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| t |   |                                  |                    |   |   |
| h |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| h |   |                                  |                    |   |   |
| o |   |                                  |                    |   |   |
| s |   |                                  |                    |   |   |
| p |   |                                  |                    |   |   |
| i |   |                                  |                    |   |   |
| t |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| l |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| o |   |                                  |                    |   |   |
| n |   |                                  |                    |   |   |
| l |   |                                  |                    |   |   |
| y |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| h |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| s |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| p |   |                                  |                    |   |   |
| r |   |                                  |                    |   |   |
| i |   |                                  |                    |   |   |
| v |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| t |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| r |   |                                  |                    |   |   |
| o |   |                                  |                    |   |   |
| o |   |                                  |                    |   |   |
| m |   |                                  |                    |   |   |
| s |   |                                  |                    |   |   |
| , |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| w |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| b |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| s |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| o |   |                                  |                    |   |   |
| u |   |                                  |                    |   |   |
| r |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| p |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| y |   |                                  |                    |   |   |
| m |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| n |   |                                  |                    |   |   |
| t |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| o |   |                                  |                    |   |   |
| n |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| t |   |                                  |                    |   |   |
| h |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| v |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| r |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| g |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| s |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| m |   |                                  |                    |   |   |
| i |   |                                  |                    |   |   |
| p |   |                                  |                    |   |   |
| r |   |                                  |                    |   |   |
| i |   |                                  |                    |   |   |
| v |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| t |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| r |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| t |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| o |   |                                  |                    |   |   |
| f |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| t |   |                                  |                    |   |   |
| h |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| m |   |                                  |                    |   |   |
| o |   |                                  |                    |   |   |
| s |   |                                  |                    |   |   |
| t |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| c |   |                                  |                    |   |   |
| o |   |                                  |                    |   |   |
| m |   |                                  |                    |   |   |
| p |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| r |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| b |   |                                  |                    |   |   |
| l |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| h |   |                                  |                    |   |   |
| o |   |                                  |                    |   |   |
| s |   |                                  |                    |   |   |
| p |   |                                  |                    |   |   |
| i |   |                                  |                    |   |   |
| t |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| l |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| i |   |                                  |                    |   |   |
| n |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| t |   |                                  |                    |   |   |
| h |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| r |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| . |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| N |   |                                  |                    |   |   |
| O |   |                                  |                    |   |   |
| T |   |                                  |                    |   |   |
| E |   |                                  |                    |   |   |
| : |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| W |   |                                  |                    |   |   |
| h |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| n |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| t |   |                                  |                    |   |   |
| h |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| n |   |                                  |                    |   |   |
| o |   |                                  |                    |   |   |
| n |   |                                  |                    |   |   |
| - |   |                                  |                    |   |   |
| P |   |                                  |                    |   |   |
| P |   |                                  |                    |   |   |
| O |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| h |   |                                  |                    |   |   |
| o |   |                                  |                    |   |   |
| s |   |                                  |                    |   |   |
| p |   |                                  |                    |   |   |
| i |   |                                  |                    |   |   |
| t |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| l |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| b |   |                                  |                    |   |   |
| i |   |                                  |                    |   |   |
| l |   |                                  |                    |   |   |
| l |   |                                  |                    |   |   |
| s |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| f |   |                                  |                    |   |   |
| l |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| t |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| r |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| t |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| , |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| w |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| p |   |                                  |                    |   |   |
| r |   |                                  |                    |   |   |
| o |   |                                  |                    |   |   |
| r |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| t |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| t |   |                                  |                    |   |   |
| h |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| c |   |                                  |                    |   |   |
| h |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| r |   |                                  |                    |   |   |
| g |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| s |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| t |   |                                  |                    |   |   |
| o |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| d |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| t |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| r |   |                                  |                    |   |   |
| m |   |                                  |                    |   |   |
| i |   |                                  |                    |   |   |
| n |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| h |   |                                  |                    |   |   |
| o |   |                                  |                    |   |   |
| w |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| t |   |                                  |                    |   |   |
| o |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| p |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| y |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| t |   |                                  |                    |   |   |
| h |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| m |   |                                  |                    |   |   |
| , |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| s |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| f |   |                                  |                    |   |   |
| o |   |                                  |                    |   |   |
| l |   |                                  |                    |   |   |
| l |   |                                  |                    |   |   |
| o |   |                                  |                    |   |   |
| w |   |                                  |                    |   |   |
| s |   |                                  |                    |   |   |
| : |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| 3 |   |                                  |                    |   |   |
| 0 |   |                                  |                    |   |   |
| % |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| r |   |                                  |                    |   |   |
| o |   |                                  |                    |   |   |
| o |   |                                  |                    |   |   |
| m |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| n |   |                                  |                    |   |   |
| d |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| b |   |                                  |                    |   |   |
| o |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| r |   |                                  |                    |   |   |
| d |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| n |   |                                  |                    |   |   |
| d |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| 7 |   |                                  |                    |   |   |
| 0 |   |                                  |                    |   |   |
| % |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| o |   |                                  |                    |   |   |
| t |   |                                  |                    |   |   |
| h |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| r |   |                                  |                    |   |   |
| > |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
| c |   |                                  |                    |   |   |
| h |   |                                  |                    |   |   |
| a |   |                                  |                    |   |   |
| r |   |                                  |                    |   |   |
| g |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| s |   |                                  |                    |   |   |
| . |   |                                  |                    |   |   |
+---+---+----------------------------------+--------------------+---+---+

Inpatient hospital - Continued on next page.

+------------------------------------------+---------------------------+
| #                                        | ### **You pay**           |
| ####### Inpatient hospital *- Continued* |                           |
+------------------------------------------+---------------------------+
| #### Other                               | > (see above)             |
| hospital services and supplies, such as: |                           |
|                                          |                           |
| -   Operating, recovery, maternity, and  |                           |
|     other treatment rooms                |                           |
|                                          |                           |
| -   Prescribed drugs and medicines       |                           |
|                                          |                           |
| -   Diagnostic laboratory tests and      |                           |
|     X-rays                               |                           |
|                                          |                           |
| -   Blood or blood plasma, if not        |                           |
|     donated or replaced                  |                           |
|                                          |                           |
| -   Dressings, splints, casts, and       |                           |
|     sterile tray services                |                           |
|                                          |                           |
| -   Medical supplies and equipment,      |                           |
|     including oxygen                     |                           |
|                                          |                           |
| -   Anesthetics, including nurse         |                           |
|     anesthetist services                 |                           |
|                                          |                           |
| -   Take-home items                      |                           |
|                                          |                           |
| -   Medical supplies, appliances,        |                           |
|     medical equipment, and any covered   |                           |
|     items billed by a hospital for use   |                           |
|     at home (Note: calendar year         |                           |
|     deductible applies.)                 |                           |
|                                          |                           |
| > NOTE: We base payment on whether the   |                           |
| > facility or a health care professional |                           |
| > bills for the services or supplies.    |                           |
| > For example, when the hospital bills   |                           |
| > for its nurse anesthetists' services,  |                           |
| > we pay Hospital benefits and when the  |                           |
| > anesthesiologist bills, we pay Surgery |                           |
| > benefits.                              |                           |
+------------------------------------------+---------------------------+
| > *Not covered:*                         | > *All charges.*          |
|                                          |                           |
| -   *Any part of a hospital admission    |                           |
|     that is not medically necessary (see |                           |
|     definition), such as when you do not |                           |
|     need acute hospital inpatient        |                           |
|     (overnight) care, but could receive  |                           |
|     care in some other setting without   |                           |
|     adversely affecting your condition   |                           |
|     or the quality of your medical care. |                           |
|     Note: In this event, we pay benefits |                           |
|     for services and supplies other than |                           |
|     room and board and in-hospital       |                           |
|     physician care at the level they     |                           |
|     would have been covered if provided  |                           |
|     in an alternative setting*           |                           |
|                                          |                           |
| -   *Custodial care; see definition.*    |                           |
|                                          |                           |
| -   *Non-covered facilities, such as     |                           |
|     nursing homes, extended care         |                           |
|     facilities, schools, {Plan           |                           |
|     specific}*                           |                           |
|                                          |                           |
| -   *Personal comfort items, such as     |                           |
|     telephone, television, barber        |                           |
|     services, guest meals and beds*      |                           |
|                                          |                           |
| -   *Private nursing care*               |                           |
+------------------------------------------+---------------------------+
| #### **Outpatient                        | ###                       |
| hospital or ambulatory surgical center** |                           |
+------------------------------------------+---------------------------+
| -   Operating, recovery, and other       | > PPO: 15% of Plan        |
|     treatment rooms                      | > allowance               |
|                                          | >                         |
| #### Prescribed drugs and medicines      | > Non-PPO: 30% of the     |
|                                          | > Plan allowance and any  |
| -   Diagnostic laboratory tests, X-rays, | > difference between our  |
|     and pathology services               | > allowance and the       |
|                                          | > billed amount           |
| -   Administration of blood, blood       |                           |
|     plasma, and other biologicals        |                           |
|                                          |                           |
| -   Blood and blood plasma, if not       |                           |
|     donated or replaced                  |                           |
|                                          |                           |
| -   Pre-surgical testing                 |                           |
|                                          |                           |
| -   Dressings, casts, and sterile tray   |                           |
|     services                             |                           |
|                                          |                           |
| -   Medical supplies, including oxygen   |                           |
|                                          |                           |
| -   Anesthetics and anesthesia service   |                           |
|                                          |                           |
| > NOTE: -- We cover hospital services    |                           |
| > and supplies related to dental         |                           |
| > procedures when necessitated by a      |                           |
| > non-dental physical impairment. We do  |                           |
| > not cover the dental procedures.       |                           |
+------------------------------------------+---------------------------+
| # *Not covered:*                         | > *All charges.*          |
+------------------------------------------+---------------------------+

+------------------------------------------+---------------------------+
| ### **Extended care benefits/            | ### **You pay**           |
| Skilled nursing care facility benefits** |                           |
+------------------------------------------+---------------------------+
| > Skilled nursing facility (SNF): We     | > PPO: Nothing            |
| > cover semiprivate room, board,         | >                         |
| > services and supplies in a SNF for up  | > Non-PPO:                |
| > to 30 days per confinement when:       |                           |
|                                          | -   Room and board        |
| 1)  you are admitted directly from a     |     -Nothing              |
|     precertified hospital stay of at     |                           |
|     least 3 consecutive days; and        | -   Other charges- 20% of |
|                                          |     the Plan allowance    |
| 2)  you are admitted for the same        |     and any difference    |
|     condition as the hospital stay; and  |     between our allowance |
|                                          |     and the billed amount |
| 3)  your skilled nursing care is         |                           |
|     supervised by a physician and        |                           |
|     provided by an R.N., L.P.N., or      |                           |
|     L.V.N.; and                          |                           |
|                                          |                           |
| 4)  SNF care is medically appropriate.   |                           |
+------------------------------------------+---------------------------+
| > Extended care benefit: {insert         |                           |
| > benefit}                               |                           |
+------------------------------------------+---------------------------+
| > *{Plan \-- if extended care and        |                           |
| > skilled nursing are the same in your   |                           |
| > plan, only show one block and describe |                           |
| > your benefit.}*                        |                           |
+------------------------------------------+---------------------------+
| > *Not covered: Custodial care*          | > *All charges.*          |
+------------------------------------------+---------------------------+
| #### **Hospice care**                    | ###                       |
+------------------------------------------+---------------------------+
| > Definition: Hospice is a coordinated   | > PPO: 15% of Plan        |
| > program of maintenance and supportive  | > allowance until         |
| > care for the terminally ill provided   | > benefits stop at \$3000 |
| > by a medically supervised team under   | >                         |
| > the direction of a Plan-approved       | > Non-PPO: 30% of Plan    |
| > independent hospice administration.    | > allowance (and any      |
|                                          | > difference between our  |
| -   We pay \$3000 per lifetime for       | > allowance and the       |
|     inpatient and outpatient services.   | > billed amount) until    |
|                                          | > benefits stop at \$3000 |
+------------------------------------------+---------------------------+
| > *Not covered: Independent nursing,     | > *All charges.*          |
| > homemaker*                             |                           |
+------------------------------------------+---------------------------+
| ######## Ambulance                       | ###                       |
+------------------------------------------+---------------------------+
| -   Local professional ambulance service | > PPO: 15% of Plan        |
|     when medically appropriate           | > allowance               |
|                                          | >                         |
|                                          | > Non-PPO: 30% of Plan    |
|                                          | > allowance and any       |
|                                          | > difference between our  |
|                                          | > allowance and the       |
|                                          | > billed amount           |
+------------------------------------------+---------------------------+

+----+---+---------------------------------+-------------------+---+---+
| #  |   |                                 |                   |   |   |
| ## |   |                                 |                   |   |   |
| ## |   |                                 |                   |   |   |
|  S |   |                                 |                   |   |   |
| ec |   |                                 |                   |   |   |
| ti |   |                                 |                   |   |   |
| on |   |                                 |                   |   |   |
|  5 |   |                                 |                   |   |   |
|  ( |   |                                 |                   |   |   |
| d) |   |                                 |                   |   |   |
| .  |   |                                 |                   |   |   |
| Em |   |                                 |                   |   |   |
| er |   |                                 |                   |   |   |
| ge |   |                                 |                   |   |   |
| nc |   |                                 |                   |   |   |
| y  |   |                                 |                   |   |   |
| se |   |                                 |                   |   |   |
| rv |   |                                 |                   |   |   |
| ic |   |                                 |                   |   |   |
| es |   |                                 |                   |   |   |
| /a |   |                                 |                   |   |   |
| cc |   |                                 |                   |   |   |
| id |   |                                 |                   |   |   |
| en |   |                                 |                   |   |   |
| ts |   |                                 |                   |   |   |
+----+---+---------------------------------+-------------------+---+---+
| ## | * | **Here are some important       |                   | * |   |
| ## | * | things to keep in mind about    |                   | * |   |
| #  | I | these benefits:**               |                   | I |   |
|    | * |                                 |                   | * |   |
|    | * | -   Please remember that all    |                   | * |   |
|    |   |     benefits are subject to the |                   |   |   |
|    | * |     definitions, limitations,   |                   | * |   |
|    | * |     and exclusions in this      |                   | * |   |
|    | M |     brochure.                   |                   | M |   |
|    | * |                                 |                   | * |   |
|    | * | -   The calendar year           |                   | * |   |
|    |   |     deductible is: *{plan       |                   |   |   |
|    | * |     specific}* \$275 per person |                   | * |   |
|    | * |     (\$550 per family). The     |                   | * |   |
|    | P |     calendar year deductible    |                   | P |   |
|    | * |     applies to almost all       |                   | * |   |
|    | * |     benefits in this Section.   |                   | * |   |
|    |   |     We added "(No deductible)"  |                   |   |   |
|    | * |     to show when the calendar   |                   | * |   |
|    | * |     year deductible does not    |                   | * |   |
|    | O |     apply. *{If you want, you   |                   | O |   |
|    | * |     can say, "We added          |                   | * |   |
|    | * |     asterisks - \* - to show    |                   | * |   |
|    |   |     when the calendar year      |                   |   |   |
|    | * |     deductible does not         |                   | * |   |
|    | * |     apply."}*.                  |                   | * |   |
|    | R |                                 |                   | R |   |
|    | * | -   Be sure to read Section 4,  |                   | * |   |
|    | * |     *Your costs for covered     |                   | * |   |
|    |   |     services* for valuable      |                   |   |   |
|    | * |     information about how cost  |                   | * |   |
|    | * |     sharing works, with special |                   | * |   |
|    | T |     sections for members who    |                   | T |   |
|    | * |     are age 65 or over. Also    |                   | * |   |
|    | * |     read Section 9 about        |                   | * |   |
|    |   |     coordinating benefits with  |                   |   |   |
|    | * |     other coverage, including   |                   | * |   |
|    | * |     with Medicare.              |                   | * |   |
|    | A |                                 |                   | A |   |
|    | * | #####                           |                   | * |   |
|    | * |                                 |                   | * |   |
|    |   |                                 |                   |   |   |
|    | * |                                 |                   | * |   |
|    | * |                                 |                   | * |   |
|    | N |                                 |                   | N |   |
|    | * |                                 |                   | * |   |
|    | * |                                 |                   | * |   |
|    |   |                                 |                   |   |   |
|    | * |                                 |                   | * |   |
|    | * |                                 |                   | * |   |
|    | T |                                 |                   | T |   |
|    | * |                                 |                   | * |   |
|    | * |                                 |                   | * |   |
+----+---+---------------------------------+-------------------+---+---+
| ** |   |                                 |                   |   |   |
| ~~ |   |                                 |                   |   |   |
| Wh |   |                                 |                   |   |   |
| at |   |                                 |                   |   |   |
| is |   |                                 |                   |   |   |
| ac |   |                                 |                   |   |   |
| ci |   |                                 |                   |   |   |
| de |   |                                 |                   |   |   |
| nt |   |                                 |                   |   |   |
| al |   |                                 |                   |   |   |
| in |   |                                 |                   |   |   |
| ju |   |                                 |                   |   |   |
| ry |   |                                 |                   |   |   |
| /m |   |                                 |                   |   |   |
| ed |   |                                 |                   |   |   |
| ic |   |                                 |                   |   |   |
| al |   |                                 |                   |   |   |
| em |   |                                 |                   |   |   |
| er |   |                                 |                   |   |   |
| ge |   |                                 |                   |   |   |
| nc |   |                                 |                   |   |   |
| y~ |   |                                 |                   |   |   |
| ~? |   |                                 |                   |   |   |
| ** |   |                                 |                   |   |   |
| *{ |   |                                 |                   |   |   |
| ST |   |                                 |                   |   |   |
| ET |   |                                 |                   |   |   |
| f  |   |                                 |                   |   |   |
| or |   |                                 |                   |   |   |
| F  |   |                                 |                   |   |   |
| FS |   |                                 |                   |   |   |
| th |   |                                 |                   |   |   |
| at |   |                                 |                   |   |   |
| ha |   |                                 |                   |   |   |
| ve |   |                                 |                   |   |   |
| s  |   |                                 |                   |   |   |
| pe |   |                                 |                   |   |   |
| ci |   |                                 |                   |   |   |
| al |   |                                 |                   |   |   |
| be |   |                                 |                   |   |   |
| ne |   |                                 |                   |   |   |
| fi |   |                                 |                   |   |   |
| ts |   |                                 |                   |   |   |
| f  |   |                                 |                   |   |   |
| or |   |                                 |                   |   |   |
| m  |   |                                 |                   |   |   |
| ed |   |                                 |                   |   |   |
| ic |   |                                 |                   |   |   |
| al |   |                                 |                   |   |   |
| em |   |                                 |                   |   |   |
| er |   |                                 |                   |   |   |
| ge |   |                                 |                   |   |   |
| nc |   |                                 |                   |   |   |
| y. |   |                                 |                   |   |   |
| }* |   |                                 |                   |   |   |
|    |   |                                 |                   |   |   |
| ~  |   |                                 |                   |   |   |
| ~A |   |                                 |                   |   |   |
| m  |   |                                 |                   |   |   |
| ed |   |                                 |                   |   |   |
| ic |   |                                 |                   |   |   |
| al |   |                                 |                   |   |   |
| e  |   |                                 |                   |   |   |
| me |   |                                 |                   |   |   |
| rg |   |                                 |                   |   |   |
| en |   |                                 |                   |   |   |
| cy |   |                                 |                   |   |   |
| is |   |                                 |                   |   |   |
| t  |   |                                 |                   |   |   |
| he |   |                                 |                   |   |   |
| su |   |                                 |                   |   |   |
| dd |   |                                 |                   |   |   |
| en |   |                                 |                   |   |   |
| a  |   |                                 |                   |   |   |
| nd |   |                                 |                   |   |   |
| un |   |                                 |                   |   |   |
| ex |   |                                 |                   |   |   |
| pe |   |                                 |                   |   |   |
| ct |   |                                 |                   |   |   |
| ed |   |                                 |                   |   |   |
| o  |   |                                 |                   |   |   |
| ns |   |                                 |                   |   |   |
| et |   |                                 |                   |   |   |
| of |   |                                 |                   |   |   |
| a  |   |                                 |                   |   |   |
| c  |   |                                 |                   |   |   |
| on |   |                                 |                   |   |   |
| di |   |                                 |                   |   |   |
| ti |   |                                 |                   |   |   |
| on |   |                                 |                   |   |   |
| or |   |                                 |                   |   |   |
| an |   |                                 |                   |   |   |
| in |   |                                 |                   |   |   |
| ju |   |                                 |                   |   |   |
| ry |   |                                 |                   |   |   |
| th |   |                                 |                   |   |   |
| at |   |                                 |                   |   |   |
| y  |   |                                 |                   |   |   |
| ou |   |                                 |                   |   |   |
| b  |   |                                 |                   |   |   |
| el |   |                                 |                   |   |   |
| ie |   |                                 |                   |   |   |
| ve |   |                                 |                   |   |   |
| e  |   |                                 |                   |   |   |
| nd |   |                                 |                   |   |   |
| an |   |                                 |                   |   |   |
| ge |   |                                 |                   |   |   |
| rs |   |                                 |                   |   |   |
| yo |   |                                 |                   |   |   |
| ur |   |                                 |                   |   |   |
| li |   |                                 |                   |   |   |
| fe |   |                                 |                   |   |   |
| or |   |                                 |                   |   |   |
| c  |   |                                 |                   |   |   |
| ou |   |                                 |                   |   |   |
| ld |   |                                 |                   |   |   |
| re |   |                                 |                   |   |   |
| su |   |                                 |                   |   |   |
| lt |   |                                 |                   |   |   |
| in |   |                                 |                   |   |   |
| s  |   |                                 |                   |   |   |
| er |   |                                 |                   |   |   |
| io |   |                                 |                   |   |   |
| us |   |                                 |                   |   |   |
| in |   |                                 |                   |   |   |
| ju |   |                                 |                   |   |   |
| ry |   |                                 |                   |   |   |
| or |   |                                 |                   |   |   |
| d  |   |                                 |                   |   |   |
| is |   |                                 |                   |   |   |
| ab |   |                                 |                   |   |   |
| il |   |                                 |                   |   |   |
| it |   |                                 |                   |   |   |
| y, |   |                                 |                   |   |   |
| a  |   |                                 |                   |   |   |
| nd |   |                                 |                   |   |   |
| re |   |                                 |                   |   |   |
| qu |   |                                 |                   |   |   |
| ir |   |                                 |                   |   |   |
| es |   |                                 |                   |   |   |
| i  |   |                                 |                   |   |   |
| mm |   |                                 |                   |   |   |
| ed |   |                                 |                   |   |   |
| ia |   |                                 |                   |   |   |
| te |   |                                 |                   |   |   |
| m  |   |                                 |                   |   |   |
| ed |   |                                 |                   |   |   |
| ic |   |                                 |                   |   |   |
| al |   |                                 |                   |   |   |
| or |   |                                 |                   |   |   |
| su |   |                                 |                   |   |   |
| rg |   |                                 |                   |   |   |
| ic |   |                                 |                   |   |   |
| al |   |                                 |                   |   |   |
| c  |   |                                 |                   |   |   |
| ar |   |                                 |                   |   |   |
| e. |   |                                 |                   |   |   |
| So |   |                                 |                   |   |   |
| me |   |                                 |                   |   |   |
| pr |   |                                 |                   |   |   |
| ob |   |                                 |                   |   |   |
| le |   |                                 |                   |   |   |
| ms |   |                                 |                   |   |   |
| a  |   |                                 |                   |   |   |
| re |   |                                 |                   |   |   |
| e  |   |                                 |                   |   |   |
| me |   |                                 |                   |   |   |
| rg |   |                                 |                   |   |   |
| en |   |                                 |                   |   |   |
| ci |   |                                 |                   |   |   |
| es |   |                                 |                   |   |   |
| be |   |                                 |                   |   |   |
| ca |   |                                 |                   |   |   |
| us |   |                                 |                   |   |   |
| e, |   |                                 |                   |   |   |
| if |   |                                 |                   |   |   |
| n  |   |                                 |                   |   |   |
| ot |   |                                 |                   |   |   |
| t  |   |                                 |                   |   |   |
| re |   |                                 |                   |   |   |
| at |   |                                 |                   |   |   |
| ed |   |                                 |                   |   |   |
| p  |   |                                 |                   |   |   |
| ro |   |                                 |                   |   |   |
| mp |   |                                 |                   |   |   |
| tl |   |                                 |                   |   |   |
| y, |   |                                 |                   |   |   |
| th |   |                                 |                   |   |   |
| ey |   |                                 |                   |   |   |
| m  |   |                                 |                   |   |   |
| ig |   |                                 |                   |   |   |
| ht |   |                                 |                   |   |   |
| be |   |                                 |                   |   |   |
| co |   |                                 |                   |   |   |
| me |   |                                 |                   |   |   |
| mo |   |                                 |                   |   |   |
| re |   |                                 |                   |   |   |
| se |   |                                 |                   |   |   |
| ri |   |                                 |                   |   |   |
| ou |   |                                 |                   |   |   |
| s; |   |                                 |                   |   |   |
| ex |   |                                 |                   |   |   |
| am |   |                                 |                   |   |   |
| pl |   |                                 |                   |   |   |
| es |   |                                 |                   |   |   |
| i  |   |                                 |                   |   |   |
| nc |   |                                 |                   |   |   |
| lu |   |                                 |                   |   |   |
| de |   |                                 |                   |   |   |
| de |   |                                 |                   |   |   |
| ep |   |                                 |                   |   |   |
| cu |   |                                 |                   |   |   |
| ts |   |                                 |                   |   |   |
| a  |   |                                 |                   |   |   |
| nd |   |                                 |                   |   |   |
| br |   |                                 |                   |   |   |
| ok |   |                                 |                   |   |   |
| en |   |                                 |                   |   |   |
| bo |   |                                 |                   |   |   |
| ne |   |                                 |                   |   |   |
| s. |   |                                 |                   |   |   |
| Ot |   |                                 |                   |   |   |
| he |   |                                 |                   |   |   |
| rs |   |                                 |                   |   |   |
| a  |   |                                 |                   |   |   |
| re |   |                                 |                   |   |   |
| e  |   |                                 |                   |   |   |
| me |   |                                 |                   |   |   |
| rg |   |                                 |                   |   |   |
| en |   |                                 |                   |   |   |
| ci |   |                                 |                   |   |   |
| es |   |                                 |                   |   |   |
| b  |   |                                 |                   |   |   |
| ec |   |                                 |                   |   |   |
| au |   |                                 |                   |   |   |
| se |   |                                 |                   |   |   |
| th |   |                                 |                   |   |   |
| ey |   |                                 |                   |   |   |
| a  |   |                                 |                   |   |   |
| re |   |                                 |                   |   |   |
| p  |   |                                 |                   |   |   |
| ot |   |                                 |                   |   |   |
| en |   |                                 |                   |   |   |
| ti |   |                                 |                   |   |   |
| al |   |                                 |                   |   |   |
| ly |   |                                 |                   |   |   |
| l  |   |                                 |                   |   |   |
| if |   |                                 |                   |   |   |
| e- |   |                                 |                   |   |   |
| th |   |                                 |                   |   |   |
| re |   |                                 |                   |   |   |
| at |   |                                 |                   |   |   |
| en |   |                                 |                   |   |   |
| in |   |                                 |                   |   |   |
| g, |   |                                 |                   |   |   |
| su |   |                                 |                   |   |   |
| ch |   |                                 |                   |   |   |
| as |   |                                 |                   |   |   |
| h  |   |                                 |                   |   |   |
| ea |   |                                 |                   |   |   |
| rt |   |                                 |                   |   |   |
| at |   |                                 |                   |   |   |
| ta |   |                                 |                   |   |   |
| ck |   |                                 |                   |   |   |
| s, |   |                                 |                   |   |   |
| st |   |                                 |                   |   |   |
| ro |   |                                 |                   |   |   |
| ke |   |                                 |                   |   |   |
| s, |   |                                 |                   |   |   |
| p  |   |                                 |                   |   |   |
| oi |   |                                 |                   |   |   |
| so |   |                                 |                   |   |   |
| ni |   |                                 |                   |   |   |
| ng |   |                                 |                   |   |   |
| s, |   |                                 |                   |   |   |
| g  |   |                                 |                   |   |   |
| un |   |                                 |                   |   |   |
| sh |   |                                 |                   |   |   |
| ot |   |                                 |                   |   |   |
| w  |   |                                 |                   |   |   |
| ou |   |                                 |                   |   |   |
| nd |   |                                 |                   |   |   |
| s, |   |                                 |                   |   |   |
| or |   |                                 |                   |   |   |
| su |   |                                 |                   |   |   |
| dd |   |                                 |                   |   |   |
| en |   |                                 |                   |   |   |
| i  |   |                                 |                   |   |   |
| na |   |                                 |                   |   |   |
| bi |   |                                 |                   |   |   |
| li |   |                                 |                   |   |   |
| ty |   |                                 |                   |   |   |
| to |   |                                 |                   |   |   |
| br |   |                                 |                   |   |   |
| ea |   |                                 |                   |   |   |
| th |   |                                 |                   |   |   |
| e. |   |                                 |                   |   |   |
| T  |   |                                 |                   |   |   |
| he |   |                                 |                   |   |   |
| re |   |                                 |                   |   |   |
| a  |   |                                 |                   |   |   |
| re |   |                                 |                   |   |   |
| ma |   |                                 |                   |   |   |
| ny |   |                                 |                   |   |   |
| o  |   |                                 |                   |   |   |
| th |   |                                 |                   |   |   |
| er |   |                                 |                   |   |   |
| a  |   |                                 |                   |   |   |
| cu |   |                                 |                   |   |   |
| te |   |                                 |                   |   |   |
| co |   |                                 |                   |   |   |
| nd |   |                                 |                   |   |   |
| it |   |                                 |                   |   |   |
| io |   |                                 |                   |   |   |
| ns |   |                                 |                   |   |   |
| th |   |                                 |                   |   |   |
| at |   |                                 |                   |   |   |
| we |   |                                 |                   |   |   |
| m  |   |                                 |                   |   |   |
| ay |   |                                 |                   |   |   |
| d  |   |                                 |                   |   |   |
| et |   |                                 |                   |   |   |
| er |   |                                 |                   |   |   |
| mi |   |                                 |                   |   |   |
| ne |   |                                 |                   |   |   |
| a  |   |                                 |                   |   |   |
| re |   |                                 |                   |   |   |
| m  |   |                                 |                   |   |   |
| ed |   |                                 |                   |   |   |
| ic |   |                                 |                   |   |   |
| al |   |                                 |                   |   |   |
| e  |   |                                 |                   |   |   |
| me |   |                                 |                   |   |   |
| rg |   |                                 |                   |   |   |
| en |   |                                 |                   |   |   |
| ci |   |                                 |                   |   |   |
| es |   |                                 |                   |   |   |
| -- |   |                                 |                   |   |   |
| wh |   |                                 |                   |   |   |
| at |   |                                 |                   |   |   |
| th |   |                                 |                   |   |   |
| ey |   |                                 |                   |   |   |
| a  |   |                                 |                   |   |   |
| ll |   |                                 |                   |   |   |
| ha |   |                                 |                   |   |   |
| ve |   |                                 |                   |   |   |
| in |   |                                 |                   |   |   |
| co |   |                                 |                   |   |   |
| mm |   |                                 |                   |   |   |
| on |   |                                 |                   |   |   |
| is |   |                                 |                   |   |   |
| t  |   |                                 |                   |   |   |
| he |   |                                 |                   |   |   |
| ne |   |                                 |                   |   |   |
| ed |   |                                 |                   |   |   |
| f  |   |                                 |                   |   |   |
| or |   |                                 |                   |   |   |
| q  |   |                                 |                   |   |   |
| ui |   |                                 |                   |   |   |
| ck |   |                                 |                   |   |   |
| a  |   |                                 |                   |   |   |
| ct |   |                                 |                   |   |   |
| io |   |                                 |                   |   |   |
| n. |   |                                 |                   |   |   |
| ~~ |   |                                 |                   |   |   |
+----+---+---------------------------------+-------------------+---+---+
| ** |   |                                 |                   |   |   |
| Wh |   |                                 |                   |   |   |
| at |   |                                 |                   |   |   |
| is |   |                                 |                   |   |   |
| an |   |                                 |                   |   |   |
| ac |   |                                 |                   |   |   |
| ci |   |                                 |                   |   |   |
| de |   |                                 |                   |   |   |
| nt |   |                                 |                   |   |   |
| al |   |                                 |                   |   |   |
| i  |   |                                 |                   |   |   |
| nj |   |                                 |                   |   |   |
| ur |   |                                 |                   |   |   |
| y? |   |                                 |                   |   |   |
| ** |   |                                 |                   |   |   |
|    |   |                                 |                   |   |   |
| An |   |                                 |                   |   |   |
| ac |   |                                 |                   |   |   |
| ci |   |                                 |                   |   |   |
| de |   |                                 |                   |   |   |
| nt |   |                                 |                   |   |   |
| al |   |                                 |                   |   |   |
| in |   |                                 |                   |   |   |
| ju |   |                                 |                   |   |   |
| ry |   |                                 |                   |   |   |
| is |   |                                 |                   |   |   |
| a  |   |                                 |                   |   |   |
| bo |   |                                 |                   |   |   |
| di |   |                                 |                   |   |   |
| ly |   |                                 |                   |   |   |
| in |   |                                 |                   |   |   |
| ju |   |                                 |                   |   |   |
| ry |   |                                 |                   |   |   |
| s  |   |                                 |                   |   |   |
| us |   |                                 |                   |   |   |
| ta |   |                                 |                   |   |   |
| in |   |                                 |                   |   |   |
| ed |   |                                 |                   |   |   |
| so |   |                                 |                   |   |   |
| le |   |                                 |                   |   |   |
| ly |   |                                 |                   |   |   |
| t  |   |                                 |                   |   |   |
| hr |   |                                 |                   |   |   |
| ou |   |                                 |                   |   |   |
| gh |   |                                 |                   |   |   |
| vi |   |                                 |                   |   |   |
| ol |   |                                 |                   |   |   |
| en |   |                                 |                   |   |   |
| t, |   |                                 |                   |   |   |
| e  |   |                                 |                   |   |   |
| xt |   |                                 |                   |   |   |
| er |   |                                 |                   |   |   |
| na |   |                                 |                   |   |   |
| l, |   |                                 |                   |   |   |
| a  |   |                                 |                   |   |   |
| nd |   |                                 |                   |   |   |
| ac |   |                                 |                   |   |   |
| ci |   |                                 |                   |   |   |
| de |   |                                 |                   |   |   |
| nt |   |                                 |                   |   |   |
| al |   |                                 |                   |   |   |
| me |   |                                 |                   |   |   |
| an |   |                                 |                   |   |   |
| s, |   |                                 |                   |   |   |
| su |   |                                 |                   |   |   |
| ch |   |                                 |                   |   |   |
| as |   |                                 |                   |   |   |
| br |   |                                 |                   |   |   |
| ok |   |                                 |                   |   |   |
| en |   |                                 |                   |   |   |
| bo |   |                                 |                   |   |   |
| ne |   |                                 |                   |   |   |
| s, |   |                                 |                   |   |   |
| an |   |                                 |                   |   |   |
| im |   |                                 |                   |   |   |
| al |   |                                 |                   |   |   |
| bi |   |                                 |                   |   |   |
| te |   |                                 |                   |   |   |
| s, |   |                                 |                   |   |   |
| a  |   |                                 |                   |   |   |
| nd |   |                                 |                   |   |   |
| p  |   |                                 |                   |   |   |
| oi |   |                                 |                   |   |   |
| so |   |                                 |                   |   |   |
| ni |   |                                 |                   |   |   |
| ng |   |                                 |                   |   |   |
| s. |   |                                 |                   |   |   |
| We |   |                                 |                   |   |   |
| do |   |                                 |                   |   |   |
| n  |   |                                 |                   |   |   |
| ot |   |                                 |                   |   |   |
| c  |   |                                 |                   |   |   |
| ov |   |                                 |                   |   |   |
| er |   |                                 |                   |   |   |
| de |   |                                 |                   |   |   |
| nt |   |                                 |                   |   |   |
| al |   |                                 |                   |   |   |
| ca |   |                                 |                   |   |   |
| re |   |                                 |                   |   |   |
| f  |   |                                 |                   |   |   |
| or |   |                                 |                   |   |   |
| ac |   |                                 |                   |   |   |
| ci |   |                                 |                   |   |   |
| de |   |                                 |                   |   |   |
| nt |   |                                 |                   |   |   |
| al |   |                                 |                   |   |   |
| in |   |                                 |                   |   |   |
| ju |   |                                 |                   |   |   |
| ry |   |                                 |                   |   |   |
| *. |   |                                 |                   |   |   |
| {  |   |                                 |                   |   |   |
| Pl |   |                                 |                   |   |   |
| an |   |                                 |                   |   |   |
| sp |   |                                 |                   |   |   |
| ec |   |                                 |                   |   |   |
| if |   |                                 |                   |   |   |
| ic |   |                                 |                   |   |   |
| }* |   |                                 |                   |   |   |
+----+---+---------------------------------+-------------------+---+---+
| *  |   |                                 | **You pay**       |   |   |
| *B |   |                                 |                   |   |   |
| en |   |                                 | **After the       |   |   |
| ef |   |                                 | calendar year     |   |   |
| it |   |                                 | deductible...**   |   |   |
| D  |   |                                 |                   |   |   |
| es |   |                                 |                   |   |   |
| cr |   |                                 |                   |   |   |
| ip |   |                                 |                   |   |   |
| ti |   |                                 |                   |   |   |
| on |   |                                 |                   |   |   |
| ** |   |                                 |                   |   |   |
+----+---+---------------------------------+-------------------+---+---+
| ## |   |                                 |                   |   |   |
| #  |   |                                 |                   |   |   |
| ** |   |                                 |                   |   |   |
| NO |   |                                 |                   |   |   |
| TE |   |                                 |                   |   |   |
| :  |   |                                 |                   |   |   |
| Th |   |                                 |                   |   |   |
| e  |   |                                 |                   |   |   |
| ca |   |                                 |                   |   |   |
| le |   |                                 |                   |   |   |
| nd |   |                                 |                   |   |   |
| ar |   |                                 |                   |   |   |
|  y |   |                                 |                   |   |   |
| ea |   |                                 |                   |   |   |
| r  |   |                                 |                   |   |   |
| de |   |                                 |                   |   |   |
| du |   |                                 |                   |   |   |
| ct |   |                                 |                   |   |   |
| ib |   |                                 |                   |   |   |
| le |   |                                 |                   |   |   |
|  a |   |                                 |                   |   |   |
| pp |   |                                 |                   |   |   |
| li |   |                                 |                   |   |   |
| es |   |                                 |                   |   |   |
|  t |   |                                 |                   |   |   |
| o  |   |                                 |                   |   |   |
| al |   |                                 |                   |   |   |
| mo |   |                                 |                   |   |   |
| st |   |                                 |                   |   |   |
|  a |   |                                 |                   |   |   |
| ll |   |                                 |                   |   |   |
|  b |   |                                 |                   |   |   |
| en |   |                                 |                   |   |   |
| ef |   |                                 |                   |   |   |
| it |   |                                 |                   |   |   |
| s  |   |                                 |                   |   |   |
| in |   |                                 |                   |   |   |
|  t |   |                                 |                   |   |   |
| hi |   |                                 |                   |   |   |
| s  |   |                                 |                   |   |   |
| Se |   |                                 |                   |   |   |
| ct |   |                                 |                   |   |   |
| io |   |                                 |                   |   |   |
| n. |   |                                 |                   |   |   |
|  W |   |                                 |                   |   |   |
| e  |   |                                 |                   |   |   |
| sa |   |                                 |                   |   |   |
| y  |   |                                 |                   |   |   |
| "N |   |                                 |                   |   |   |
| o  |   |                                 |                   |   |   |
| de |   |                                 |                   |   |   |
| du |   |                                 |                   |   |   |
| ct |   |                                 |                   |   |   |
| ib |   |                                 |                   |   |   |
| le |   |                                 |                   |   |   |
| "  |   |                                 |                   |   |   |
| wh |   |                                 |                   |   |   |
| en |   |                                 |                   |   |   |
|  i |   |                                 |                   |   |   |
| t  |   |                                 |                   |   |   |
| do |   |                                 |                   |   |   |
| es |   |                                 |                   |   |   |
|  n |   |                                 |                   |   |   |
| ot |   |                                 |                   |   |   |
|  a |   |                                 |                   |   |   |
| pp |   |                                 |                   |   |   |
| ly |   |                                 |                   |   |   |
| .  |   |                                 |                   |   |   |
| *{ |   |                                 |                   |   |   |
| Or |   |                                 |                   |   |   |
| :  |   |                                 |                   |   |   |
| We |   |                                 |                   |   |   |
|  a |   |                                 |                   |   |   |
| dd |   |                                 |                   |   |   |
| ed |   |                                 |                   |   |   |
|  a |   |                                 |                   |   |   |
| n  |   |                                 |                   |   |   |
| as |   |                                 |                   |   |   |
| te |   |                                 |                   |   |   |
| ri |   |                                 |                   |   |   |
| sk |   |                                 |                   |   |   |
|  - |   |                                 |                   |   |   |
| \* |   |                                 |                   |   |   |
|  - |   |                                 |                   |   |   |
|  w |   |                                 |                   |   |   |
| he |   |                                 |                   |   |   |
| n  |   |                                 |                   |   |   |
| it |   |                                 |                   |   |   |
|  d |   |                                 |                   |   |   |
| oe |   |                                 |                   |   |   |
| s  |   |                                 |                   |   |   |
| no |   |                                 |                   |   |   |
| t  |   |                                 |                   |   |   |
| ap |   |                                 |                   |   |   |
| pl |   |                                 |                   |   |   |
| y. |   |                                 |                   |   |   |
| }* |   |                                 |                   |   |   |
| ** |   |                                 |                   |   |   |
+----+---+---------------------------------+-------------------+---+---+
| ## |   |                                 | ###               |   |   |
| ## |   |                                 |                   |   |   |
| ## |   |                                 |                   |   |   |
| ## |   |                                 |                   |   |   |
|  A |   |                                 |                   |   |   |
| cc |   |                                 |                   |   |   |
| id |   |                                 |                   |   |   |
| en |   |                                 |                   |   |   |
| ta |   |                                 |                   |   |   |
| l  |   |                                 |                   |   |   |
| in |   |                                 |                   |   |   |
| ju |   |                                 |                   |   |   |
| ry |   |                                 |                   |   |   |
+----+---+---------------------------------+-------------------+---+---+
| >  |   |                                 | > PPO: Nothing    |   |   |
| If |   |                                 | > (No deductible) |   |   |
| >  |   |                                 | >                 |   |   |
|  y |   |                                 | > Non-PPO: Only   |   |   |
| ou |   |                                 | > the difference  |   |   |
| >  |   |                                 | > between our     |   |   |
|  r |   |                                 | > allowance and   |   |   |
| ec |   |                                 | > the billed      |   |   |
| ei |   |                                 | > amount *{This   |   |   |
| ve |   |                                 | > example should  |   |   |
| >  |   |                                 | > work any time   |   |   |
| ca |   |                                 | > you pay 100% of |   |   |
| re |   |                                 | > your            |   |   |
| >  |   |                                 | > allowance}*     |   |   |
|  f |   |                                 |                   |   |   |
| or |   |                                 |                   |   |   |
| >  |   |                                 |                   |   |   |
| yo |   |                                 |                   |   |   |
| ur |   |                                 |                   |   |   |
| >  |   |                                 |                   |   |   |
| ac |   |                                 |                   |   |   |
| ci |   |                                 |                   |   |   |
| de |   |                                 |                   |   |   |
| nt |   |                                 |                   |   |   |
| al |   |                                 |                   |   |   |
| >  |   |                                 |                   |   |   |
| in |   |                                 |                   |   |   |
| ju |   |                                 |                   |   |   |
| ry |   |                                 |                   |   |   |
| >  |   |                                 |                   |   |   |
| wi |   |                                 |                   |   |   |
| th |   |                                 |                   |   |   |
| in |   |                                 |                   |   |   |
| >  |   |                                 |                   |   |   |
| 48 |   |                                 |                   |   |   |
| >  |   |                                 |                   |   |   |
| ho |   |                                 |                   |   |   |
| ur |   |                                 |                   |   |   |
| s, |   |                                 |                   |   |   |
| >  |   |                                 |                   |   |   |
| we |   |                                 |                   |   |   |
| >  |   |                                 |                   |   |   |
| co |   |                                 |                   |   |   |
| ve |   |                                 |                   |   |   |
| r: |   |                                 |                   |   |   |
|    |   |                                 |                   |   |   |
| -  |   |                                 |                   |   |   |
|    |   |                                 |                   |   |   |
| No |   |                                 |                   |   |   |
| n- |   |                                 |                   |   |   |
| su |   |                                 |                   |   |   |
| rg |   |                                 |                   |   |   |
| ic |   |                                 |                   |   |   |
| al |   |                                 |                   |   |   |
|    |   |                                 |                   |   |   |
|    |   |                                 |                   |   |   |
|  p |   |                                 |                   |   |   |
| hy |   |                                 |                   |   |   |
| si |   |                                 |                   |   |   |
| ci |   |                                 |                   |   |   |
| an |   |                                 |                   |   |   |
|    |   |                                 |                   |   |   |
|    |   |                                 |                   |   |   |
| se |   |                                 |                   |   |   |
| rv |   |                                 |                   |   |   |
| ic |   |                                 |                   |   |   |
| es |   |                                 |                   |   |   |
|    |   |                                 |                   |   |   |
|    |   |                                 |                   |   |   |
|  a |   |                                 |                   |   |   |
| nd |   |                                 |                   |   |   |
|    |   |                                 |                   |   |   |
|    |   |                                 |                   |   |   |
| su |   |                                 |                   |   |   |
| pp |   |                                 |                   |   |   |
| li |   |                                 |                   |   |   |
| es |   |                                 |                   |   |   |
|    |   |                                 |                   |   |   |
| -  |   |                                 |                   |   |   |
|    |   |                                 |                   |   |   |
|  R |   |                                 |                   |   |   |
| el |   |                                 |                   |   |   |
| at |   |                                 |                   |   |   |
| ed |   |                                 |                   |   |   |
|    |   |                                 |                   |   |   |
|    |   |                                 |                   |   |   |
| ou |   |                                 |                   |   |   |
| tp |   |                                 |                   |   |   |
| at |   |                                 |                   |   |   |
| ie |   |                                 |                   |   |   |
| nt |   |                                 |                   |   |   |
|    |   |                                 |                   |   |   |
|    |   |                                 |                   |   |   |
| ho |   |                                 |                   |   |   |
| sp |   |                                 |                   |   |   |
| it |   |                                 |                   |   |   |
| al |   |                                 |                   |   |   |
|    |   |                                 |                   |   |   |
|    |   |                                 |                   |   |   |
| se |   |                                 |                   |   |   |
| rv |   |                                 |                   |   |   |
| ic |   |                                 |                   |   |   |
| es |   |                                 |                   |   |   |
|    |   |                                 |                   |   |   |
| >  |   |                                 |                   |   |   |
|  N |   |                                 |                   |   |   |
| ot |   |                                 |                   |   |   |
| e: |   |                                 |                   |   |   |
| >  |   |                                 |                   |   |   |
| We |   |                                 |                   |   |   |
| >  |   |                                 |                   |   |   |
|  p |   |                                 |                   |   |   |
| ay |   |                                 |                   |   |   |
| >  |   |                                 |                   |   |   |
| Ho |   |                                 |                   |   |   |
| sp |   |                                 |                   |   |   |
| it |   |                                 |                   |   |   |
| al |   |                                 |                   |   |   |
| >  |   |                                 |                   |   |   |
| be |   |                                 |                   |   |   |
| ne |   |                                 |                   |   |   |
| fi |   |                                 |                   |   |   |
| ts |   |                                 |                   |   |   |
| >  |   |                                 |                   |   |   |
| if |   |                                 |                   |   |   |
| >  |   |                                 |                   |   |   |
|  y |   |                                 |                   |   |   |
| ou |   |                                 |                   |   |   |
| >  |   |                                 |                   |   |   |
|  a |   |                                 |                   |   |   |
| re |   |                                 |                   |   |   |
| >  |   |                                 |                   |   |   |
|  a |   |                                 |                   |   |   |
| dm |   |                                 |                   |   |   |
| it |   |                                 |                   |   |   |
| te |   |                                 |                   |   |   |
| d. |   |                                 |                   |   |   |
+----+---+---------------------------------+-------------------+---+---+

*Accidental injury \-- Continued on next page*

+------------------------------------------+---------------------------+
| ######## Accidental injury *(Continued)* | ### **You pay**           |
+------------------------------------------+---------------------------+
| > If you receive care for your           | > PPO: 15% of Plan        |
| > accidental injury after 48 hours, we   | > allowance               |
| > cover:                                 | >                         |
|                                          | > Non-PPO: 30% of Plan    |
| -   Non-surgical physician services and  | > allowance and any       |
|     supplies                             | > difference between our  |
|                                          | > allowance and the       |
| ```{=html}                               | > billed amount           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   Surgical care                        |                           |
|                                          |                           |
| > Note: We pay Hospital benefits if you  |                           |
| > are admitted.                          |                           |
+------------------------------------------+---------------------------+
| > **Medical emergency**                  | ###                       |
+------------------------------------------+---------------------------+
| > Outpatient medical or surgical         | > PPO: 15% of Plan        |
| > services and supplies                  | > allowance               |
|                                          | >                         |
|                                          | > Non-PPO: 30% of Plan    |
|                                          | > allowance and any       |
|                                          | > difference between our  |
|                                          | > allowance and the       |
|                                          | > billed amount           |
|                                          | >                         |
|                                          | > *{Plan \-- If you do    |
|                                          | > not have a special      |
|                                          | > benefit for medical     |
|                                          | > emergencies, describe   |
|                                          | > your regular benefits}* |
+------------------------------------------+---------------------------+
| > **Ambulance**                          | ###                       |
+------------------------------------------+---------------------------+
| > Professional ambulance service         | > PPO: 15% of Plan        |
| >                                        | > allowance               |
| > Note: See 5© for non-emergency         | >                         |
| > service.                               | > Non-PPO: 30% of Plan    |
|                                          | > allowance and any       |
|                                          | > difference between our  |
|                                          | > allowance and the       |
|                                          | > billed amount           |
+------------------------------------------+---------------------------+
| > *Not covered: air ambulance {{if       | > *All charges*           |
| > covered, show above}}*                 |                           |
+------------------------------------------+---------------------------+

{Plan - everything in 5(e) is standard\--edit to fit your benefits,
only}

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

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

+------------------------------------------+---------------------------+
| **Network Benefit**                      |                           |
+------------------------------------------+---------------------------+
| > **Here are some important things to    |                           |
| > keep in mind about these benefits:**   |                           |
| >                                        |                           |
| > Please remember that these benefits    |                           |
| > are subject to the definitions,        |                           |
| > limitations, and exclusions in this    |                           |
| > brochure and are payable only when we  |                           |
| > determine they are clinically          |                           |
| > appropriate to treat you condition.    |                           |
| >                                        |                           |
| > See page xx for Out-of-Network         |                           |
| > benefits.                              |                           |
| >                                        |                           |
| > Be sure to read Section 4, *Your costs |                           |
| > for covered services* for valuable     |                           |
| > information about how cost sharing     |                           |
| > works, with special sections for       |                           |
| > members who are age 65 or over. Also   |                           |
| > read Section 9 about coordinating      |                           |
| > benefits with other coverage,          |                           |
| > including with Medicare.               |                           |
+------------------------------------------+---------------------------+
| **Description**                          | **You Pay**               |
+------------------------------------------+---------------------------+
| ### **Network ment                       | ###                       |
| al health and substance abuse benefits** |                           |
+------------------------------------------+---------------------------+
| > We will cover services for the         | > Cost sharing and        |
| > treatment of mental health and         | > limitations for         |
| > substance abuse conditions recommended | > benefits that we cover  |
| > by a network provider contained in a   | > (for example, visit/day |
| > treatment plan that we approve.        | > limits, deductibles,    |
| >                                        | > coinsurance,            |
| > For example, this can include:         | > copayments, and         |
|                                          | > out-of-pocket maximums) |
| -   services by providers such as        | > for mental health and   |
|     psychiatrists, psychologists, or     | > substance abuse are     |
|     clinical social workers,             | > based on the cost       |
|                                          | > sharing and limits for  |
| -   any diagnostic tests that they       | > similar benefits under  |
|     order,                               | > our network medical,    |
|                                          | > hospital, prescription  |
| -   any facilities that they admit you   | > drug, diagnostic        |
|     to, or                               | > testing, and surgical   |
|                                          | > benefits.               |
| -   any drugs that are prescribe for     | >                         |
|     your condition.                      | > For example, the same   |
|                                          | > copayment or            |
| > In some cases, our network providers   | > coinsurance that        |
| > may refer you to community based       | > applies when you visit  |
| > programs if they are appropriate to    | > a specialist for a      |
| > treat your condition, such as          | > physical illness or     |
| > self-help groups or 12 step programs.  | > disease applies to a    |
|                                          | > visit to a mental       |
|                                          | > health or substance     |
|                                          | > abuse provider for a    |
|                                          | > therapy session.        |
|                                          | >                         |
|                                          | > You will pay the same   |
|                                          | > copayment or            |
|                                          | > coinsurance for a       |
|                                          | > prescription drug to    |
|                                          | > treat a mental health   |
|                                          | > or substance abuse      |
|                                          | > condition as you would  |
|                                          | > for a prescription to   |
|                                          | > treat a physical        |
|                                          | > illness or disease.     |
+------------------------------------------+---------------------------+
| ## Not c                                 | > *All charges.*          |
| overed in the network: The same exclusio |                           |
| ns contained in this brochure that apply |                           |
|  to other benefits apply to these mental |                           |
|  health and substance abuse benefits, un |                           |
| less the services are included in a trea |                           |
| tment plan that we approve. OPM\'s revie |                           |
| w of disputes about network treatment pl |                           |
| ans will be based on the treatment plan\ |                           |
| 's clinical appropriateness. OPM will ge |                           |
| nerally not order one clinically appropr |                           |
| iate treatment plan in favor of another. |                           |
+------------------------------------------+---------------------------+

*Network mental health and substance abuse benefits \-- Continued on
next page.*

  -----------------------------------------------------------------------
  **Network Benefit \-- *CONTINUED***

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

> **Preauthorization** To be eligible to receive these enhanced mental
> health and substance abuse benefits you must follow your treatment
> plan and all of our network authorization processes. These include:

-   *{insert network entry procedures, phone numbers, referral
    procedures, network restrictions, how to identify providers and
    obtain provider directories, inpatient and outpatient treatment plan
    approval procedures}*

## **Network deductibles and** {Insert Network deductible and out-of-pocket maximum policies}

## **out-of-pocket maximums** 

## 

*{About the special transitional benefit below: Your contract specialist
will work with you to decide which bullets listed below apply to your
plan. FFS plans that had no network mental health or substance abuse
providers in 2000 and are not reducing out-of-network benefits in 2001
can delete this section.)*

## 

## **Special transitional benefit** If a mental health or substance abuse professional provider is treating you under our plan as of January 1, 2001, you will be eligible for continued coverage with your provider for up to 90 days under the following conditions:

-   If your mental health or substance abuse professional provider with
    whom you are currently in treatment leaves the plan at our request
    for other than cause, or *{{add this bullet to HMO or POS brochures
    or a FFS plan that had network mental health and substance abuse
    providers in 2000}*

-   If changes to this plan\'s benefit structure for 2001 cause your
    out-of-pocket costs for your out-of-network provider to be greater
    than they were in contract year 2000. *{add this bullet to FFS or
    POS brochures only if the Plan had an increase in out-of-network
    member cost sharing}*

> If these conditions apply to you, *{or, If this condition applies to
> you,}* we will allow you reasonable time to transfer your care to a
> network mental health or substance abuse professional provider. During
> the transitional period, you may continue to see your treating
> provider and will not pay any more out-of-pocket than you did in the
> year 2000 for services. This transitional period will begin with our
> notice to you of the change in coverage. The transitional period will
> last for up to 90 days from the date you receive notice of the change.
> You may receive this notice prior to January 1, 2001, and the 90 day
> period begins with receipt of the notice.

## **Network limitation** We may limit your benefits if you do not follow your treatment plan.

**How to submit network claims** *{Insert claims process for in-Network
claims}*

+------------------------------------------+---------------------------+
| **Out-of-Network Benefit**               |                           |
+------------------------------------------+---------------------------+
| > **Here are some important things to    |                           |
| > keep in mind about these benefits:**   |                           |
| >                                        |                           |
| > Please remember that all benefits are  |                           |
| > subject to the definitions,            |                           |
| > limitations, and exclusions in this    |                           |
| > brochure and are payable only when we  |                           |
| > determine they are medically           |                           |
| > necessary.                             |                           |
| >                                        |                           |
| > See page xx for In-Network benefits.   |                           |
| >                                        |                           |
| > Be sure to read Section 4, *Your costs |                           |
| > for covered services* for valuable     |                           |
| > information about how cost sharing     |                           |
| > works, with special sections for       |                           |
| > members who are age 65 or over. Also   |                           |
| > read Section 9 about coordinating      |                           |
| > benefits with other coverage,          |                           |
| > including with Medicare.               |                           |
+------------------------------------------+---------------------------+
| **Description**                          | **You Pay**               |
+------------------------------------------+---------------------------+
| ### **Out-of-Network ment                |                           |
| al health and substance abuse benefits** |                           |
+------------------------------------------+---------------------------+
| > *{ insert your year 2000 mental health | > *(Insert year 2000 cost |
| > and substance abuse benefits}*         | > sharing)*               |
+------------------------------------------+---------------------------+
| ## Not covered                           | > *All charges.*          |
|  out-of-network: {Insert year 2000 menta |                           |
| l health and substance abuse exclusions} |                           |
+------------------------------------------+---------------------------+

Out-of-Network mental health and substance abuse benefits \-- Continued
on next page.

  -----------------------------------------------------------------------
  **Out-of-Network Benefit - *CONTINUED***

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

**Precertification** *{Insert precertification requirements}*

**Out-of-Network** *{Insert out-of-network out-of-pocket maximum
policy.}*

**Out-of-Pocket Maximums**

**How to submit**

**Out-of-Network claims** *{Insert process for submitting out-of-network
claims}*

+---+---+-------------------------------------------------------+---+---+
| * |   |                                                       |   |   |
| * |   |                                                       |   |   |
| S |   |                                                       |   |   |
| e |   |                                                       |   |   |
| c |   |                                                       |   |   |
| t |   |                                                       |   |   |
| i |   |                                                       |   |   |
| o |   |                                                       |   |   |
| n |   |                                                       |   |   |
| 5 |   |                                                       |   |   |
| ( |   |                                                       |   |   |
| f |   |                                                       |   |   |
| ) |   |                                                       |   |   |
| . |   |                                                       |   |   |
| P |   |                                                       |   |   |
| r |   |                                                       |   |   |
| e |   |                                                       |   |   |
| s |   |                                                       |   |   |
| c |   |                                                       |   |   |
| r |   |                                                       |   |   |
| i |   |                                                       |   |   |
| p |   |                                                       |   |   |
| t |   |                                                       |   |   |
| i |   |                                                       |   |   |
| o |   |                                                       |   |   |
| n |   |                                                       |   |   |
| d |   |                                                       |   |   |
| r |   |                                                       |   |   |
| u |   |                                                       |   |   |
| g |   |                                                       |   |   |
| b |   |                                                       |   |   |
| e |   |                                                       |   |   |
| n |   |                                                       |   |   |
| e |   |                                                       |   |   |
| f |   |                                                       |   |   |
| i |   |                                                       |   |   |
| t |   |                                                       |   |   |
| s |   |                                                       |   |   |
| * |   |                                                       |   |   |
| * |   |                                                       |   |   |
+---+---+-------------------------------------------------------+---+---+
|   | * | *{This block and all headers are standard; you add    | * |   |
|   | * | text}*                                                | * |   |
|   | I |                                                       | I |   |
|   | * | **Here are some important things to keep in mind      | * |   |
|   | * | about these benefits:**                               | * |   |
|   |   |                                                       |   |   |
|   | * | -   We cover prescribed drugs and medications, as     | * |   |
|   | * |     described in the chart beginning on the next      | * |   |
|   | M |     page.                                             | 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 |                                                       | P |   |
|   | * | ```{=html}                                            | * |   |
|   | * | <!-- -->                                              | * |   |
|   |   | ```                                                   |   |   |
|   | * | -   The calendar year deductible is: \$275 per person | * |   |
|   | * |     (\$550 per family). The calendar year deductible  | * |   |
|   | O |     applies to almost all benefits in this Section.   | O |   |
|   | * |     We added "No deductible" to show when the         | * |   |
|   | * |     calendar year deductible does not apply. *{If you | * |   |
|   |   |     want, you can say, "We added asterisks - \* - to  |   |   |
|   | * |     show when the calendar year deductible does not   | * |   |
|   | * |     apply."}*                                         | * |   |
|   | R |                                                       | R |   |
|   | * | ```{=html}                                            | * |   |
|   | * | <!-- -->                                              | * |   |
|   |   | ```                                                   |   |   |
|   | * | -   *{{If you have a prescription deductible,         | * |   |
|   | * |     describe it here; also describe any prior         | * |   |
|   | T |     authorization requirements.}}*                    | T |   |
|   | * |                                                       | * |   |
|   | * | ```{=html}                                            | * |   |
|   |   | <!-- -->                                              |   |   |
|   | * | ```                                                   | * |   |
|   | * | -   Be sure to read Section 4, *Your costs for        | * |   |
|   | A |     covered services* for valuable information about  | A |   |
|   | * |     how cost sharing works, with special sections for | * |   |
|   | * |     members who are age 65 or over. Also read Section | * |   |
|   |   |     9 about coordinating benefits with other          |   |   |
|   | * |     coverage, including with Medicare.                | * |   |
|   | * |                                                       | * |   |
|   | N |                                                       | N |   |
|   | * |                                                       | * |   |
|   | * |                                                       | * |   |
|   |   |                                                       |   |   |
|   | * |                                                       | * |   |
|   | * |                                                       | * |   |
|   | T |                                                       | T |   |
|   | * |                                                       | * |   |
|   | * |                                                       | * |   |
+---+---+-------------------------------------------------------+---+---+
|   | - |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | * |                                                       |   |   |
|   | * |                                                       |   |   |
|   | W |                                                       |   |   |
|   | h |                                                       |   |   |
|   | o |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | c |                                                       |   |   |
|   | a |                                                       |   |   |
|   | n |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | w |                                                       |   |   |
|   | r |                                                       |   |   |
|   | i |                                                       |   |   |
|   | t |                                                       |   |   |
|   | e |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | y |                                                       |   |   |
|   | o |                                                       |   |   |
|   | u |                                                       |   |   |
|   | r |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | p |                                                       |   |   |
|   | r |                                                       |   |   |
|   | e |                                                       |   |   |
|   | s |                                                       |   |   |
|   | c |                                                       |   |   |
|   | r |                                                       |   |   |
|   | i |                                                       |   |   |
|   | p |                                                       |   |   |
|   | t |                                                       |   |   |
|   | i |                                                       |   |   |
|   | o |                                                       |   |   |
|   | n |                                                       |   |   |
|   | . |                                                       |   |   |
|   | * |                                                       |   |   |
|   | * |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | A |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | l |                                                       |   |   |
|   | i |                                                       |   |   |
|   | c |                                                       |   |   |
|   | e |                                                       |   |   |
|   | n |                                                       |   |   |
|   | s |                                                       |   |   |
|   | e |                                                       |   |   |
|   | d |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | p |                                                       |   |   |
|   | h |                                                       |   |   |
|   | y |                                                       |   |   |
|   | s |                                                       |   |   |
|   | i |                                                       |   |   |
|   | c |                                                       |   |   |
|   | i |                                                       |   |   |
|   | a |                                                       |   |   |
|   | n |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | m |                                                       |   |   |
|   | u |                                                       |   |   |
|   | s |                                                       |   |   |
|   | t |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | w |                                                       |   |   |
|   | r |                                                       |   |   |
|   | i |                                                       |   |   |
|   | t |                                                       |   |   |
|   | e |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | t |                                                       |   |   |
|   | h |                                                       |   |   |
|   | e |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | p |                                                       |   |   |
|   | r |                                                       |   |   |
|   | e |                                                       |   |   |
|   | s |                                                       |   |   |
|   | c |                                                       |   |   |
|   | r |                                                       |   |   |
|   | i |                                                       |   |   |
|   | p |                                                       |   |   |
|   | t |                                                       |   |   |
|   | i |                                                       |   |   |
|   | o |                                                       |   |   |
|   | n |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | - |                                                       |   |   |
|   | - |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | o |                                                       |   |   |
|   | r |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | - |                                                       |   |   |
|   | - |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | A |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | p |                                                       |   |   |
|   | l |                                                       |   |   |
|   | a |                                                       |   |   |
|   | n |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | p |                                                       |   |   |
|   | h |                                                       |   |   |
|   | y |                                                       |   |   |
|   | s |                                                       |   |   |
|   | i |                                                       |   |   |
|   | c |                                                       |   |   |
|   | i |                                                       |   |   |
|   | a |                                                       |   |   |
|   | n |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | o |                                                       |   |   |
|   | r |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | l |                                                       |   |   |
|   | i |                                                       |   |   |
|   | c |                                                       |   |   |
|   | e |                                                       |   |   |
|   | n |                                                       |   |   |
|   | s |                                                       |   |   |
|   | e |                                                       |   |   |
|   | d |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | d |                                                       |   |   |
|   | e |                                                       |   |   |
|   | n |                                                       |   |   |
|   | t |                                                       |   |   |
|   | i |                                                       |   |   |
|   | s |                                                       |   |   |
|   | t |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | m |                                                       |   |   |
|   | u |                                                       |   |   |
|   | s |                                                       |   |   |
|   | t |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | w |                                                       |   |   |
|   | r |                                                       |   |   |
|   | i |                                                       |   |   |
|   | t |                                                       |   |   |
|   | e |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | t |                                                       |   |   |
|   | h |                                                       |   |   |
|   | e |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | p |                                                       |   |   |
|   | r |                                                       |   |   |
|   | e |                                                       |   |   |
|   | s |                                                       |   |   |
|   | c |                                                       |   |   |
|   | r |                                                       |   |   |
|   | i |                                                       |   |   |
|   | p |                                                       |   |   |
|   | t |                                                       |   |   |
|   | i |                                                       |   |   |
|   | o |                                                       |   |   |
|   | n |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | { |                                                       |   |   |
|   | * |                                                       |   |   |
|   | p |                                                       |   |   |
|   | l |                                                       |   |   |
|   | a |                                                       |   |   |
|   | n |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | s |                                                       |   |   |
|   | p |                                                       |   |   |
|   | e |                                                       |   |   |
|   | c |                                                       |   |   |
|   | i |                                                       |   |   |
|   | f |                                                       |   |   |
|   | i |                                                       |   |   |
|   | c |                                                       |   |   |
|   | } |                                                       |   |   |
|   | * |                                                       |   |   |
|   | . |                                                       |   |   |
|   |   |                                                       |   |   |
|   | ` |                                                       |   |   |
|   | ` |                                                       |   |   |
|   | ` |                                                       |   |   |
|   | { |                                                       |   |   |
|   | = |                                                       |   |   |
|   | h |                                                       |   |   |
|   | t |                                                       |   |   |
|   | m |                                                       |   |   |
|   | l |                                                       |   |   |
|   | } |                                                       |   |   |
|   | < |                                                       |   |   |
|   | ! |                                                       |   |   |
|   | - |                                                       |   |   |
|   | - |                                                       |   |   |
|   |   |                                                       |   |   |
|   | - |                                                       |   |   |
|   | - |                                                       |   |   |
|   | > |                                                       |   |   |
|   | ` |                                                       |   |   |
|   | ` |                                                       |   |   |
|   | ` |                                                       |   |   |
|   | - |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | * |                                                       |   |   |
|   | * |                                                       |   |   |
|   | W |                                                       |   |   |
|   | h |                                                       |   |   |
|   | e |                                                       |   |   |
|   | r |                                                       |   |   |
|   | e |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | y |                                                       |   |   |
|   | o |                                                       |   |   |
|   | u |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | c |                                                       |   |   |
|   | a |                                                       |   |   |
|   | n |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | o |                                                       |   |   |
|   | b |                                                       |   |   |
|   | t |                                                       |   |   |
|   | a |                                                       |   |   |
|   | i |                                                       |   |   |
|   | n |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | t |                                                       |   |   |
|   | h |                                                       |   |   |
|   | e |                                                       |   |   |
|   | m |                                                       |   |   |
|   | . |                                                       |   |   |
|   | * |                                                       |   |   |
|   | * |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | Y |                                                       |   |   |
|   | o |                                                       |   |   |
|   | u |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | m |                                                       |   |   |
|   | a |                                                       |   |   |
|   | y |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | f |                                                       |   |   |
|   | i |                                                       |   |   |
|   | l |                                                       |   |   |
|   | l |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | t |                                                       |   |   |
|   | h |                                                       |   |   |
|   | e |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | p |                                                       |   |   |
|   | r |                                                       |   |   |
|   | e |                                                       |   |   |
|   | s |                                                       |   |   |
|   | c |                                                       |   |   |
|   | r |                                                       |   |   |
|   | i |                                                       |   |   |
|   | p |                                                       |   |   |
|   | t |                                                       |   |   |
|   | i |                                                       |   |   |
|   | o |                                                       |   |   |
|   | n |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | a |                                                       |   |   |
|   | t |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | a |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | x |                                                       |   |   |
|   | x |                                                       |   |   |
|   | x |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | p |                                                       |   |   |
|   | h |                                                       |   |   |
|   | a |                                                       |   |   |
|   | r |                                                       |   |   |
|   | m |                                                       |   |   |
|   | a |                                                       |   |   |
|   | c |                                                       |   |   |
|   | y |                                                       |   |   |
|   | , |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | a |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | n |                                                       |   |   |
|   | o |                                                       |   |   |
|   | n |                                                       |   |   |
|   | - |                                                       |   |   |
|   | n |                                                       |   |   |
|   | e |                                                       |   |   |
|   | t |                                                       |   |   |
|   | w |                                                       |   |   |
|   | o |                                                       |   |   |
|   | r |                                                       |   |   |
|   | k |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | p |                                                       |   |   |
|   | h |                                                       |   |   |
|   | a |                                                       |   |   |
|   | r |                                                       |   |   |
|   | m |                                                       |   |   |
|   | a |                                                       |   |   |
|   | c |                                                       |   |   |
|   | y |                                                       |   |   |
|   | , |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | o |                                                       |   |   |
|   | r |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | b |                                                       |   |   |
|   | y |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | m |                                                       |   |   |
|   | a |                                                       |   |   |
|   | i |                                                       |   |   |
|   | l |                                                       |   |   |
|   | . |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | W |                                                       |   |   |
|   | e |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | p |                                                       |   |   |
|   | a |                                                       |   |   |
|   | y |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | a |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | h |                                                       |   |   |
|   | i |                                                       |   |   |
|   | g |                                                       |   |   |
|   | h |                                                       |   |   |
|   | e |                                                       |   |   |
|   | r |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | l |                                                       |   |   |
|   | e |                                                       |   |   |
|   | v |                                                       |   |   |
|   | e |                                                       |   |   |
|   | l |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | o |                                                       |   |   |
|   | f |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | b |                                                       |   |   |
|   | e |                                                       |   |   |
|   | n |                                                       |   |   |
|   | e |                                                       |   |   |
|   | f |                                                       |   |   |
|   | i |                                                       |   |   |
|   | t |                                                       |   |   |
|   | s |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | w |                                                       |   |   |
|   | h |                                                       |   |   |
|   | e |                                                       |   |   |
|   | n |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | y |                                                       |   |   |
|   | o |                                                       |   |   |
|   | u |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | u |                                                       |   |   |
|   | s |                                                       |   |   |
|   | e |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | a |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | n |                                                       |   |   |
|   | e |                                                       |   |   |
|   | t |                                                       |   |   |
|   | w |                                                       |   |   |
|   | o |                                                       |   |   |
|   | r |                                                       |   |   |
|   | k |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | p |                                                       |   |   |
|   | h |                                                       |   |   |
|   | a |                                                       |   |   |
|   | r |                                                       |   |   |
|   | m |                                                       |   |   |
|   | a |                                                       |   |   |
|   | c |                                                       |   |   |
|   | y |                                                       |   |   |
|   | . |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | - |                                                       |   |   |
|   | - |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | o |                                                       |   |   |
|   | r |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | - |                                                       |   |   |
|   | - |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | Y |                                                       |   |   |
|   | o |                                                       |   |   |
|   | u |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | m |                                                       |   |   |
|   | u |                                                       |   |   |
|   | s |                                                       |   |   |
|   | t |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | f |                                                       |   |   |
|   | i |                                                       |   |   |
|   | l |                                                       |   |   |
|   | l |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | t |                                                       |   |   |
|   | h |                                                       |   |   |
|   | e |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | p |                                                       |   |   |
|   | r |                                                       |   |   |
|   | e |                                                       |   |   |
|   | s |                                                       |   |   |
|   | c |                                                       |   |   |
|   | r |                                                       |   |   |
|   | i |                                                       |   |   |
|   | p |                                                       |   |   |
|   | t |                                                       |   |   |
|   | i |                                                       |   |   |
|   | o |                                                       |   |   |
|   | n |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | a |                                                       |   |   |
|   | t |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | a |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | p |                                                       |   |   |
|   | l |                                                       |   |   |
|   | a |                                                       |   |   |
|   | n |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | p |                                                       |   |   |
|   | h |                                                       |   |   |
|   | a |                                                       |   |   |
|   | r |                                                       |   |   |
|   | m |                                                       |   |   |
|   | a |                                                       |   |   |
|   | c |                                                       |   |   |
|   | y |                                                       |   |   |
|   | , |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | o |                                                       |   |   |
|   | r |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | b |                                                       |   |   |
|   | y |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | m |                                                       |   |   |
|   | a |                                                       |   |   |
|   | i |                                                       |   |   |
|   | l |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | f |                                                       |   |   |
|   | o |                                                       |   |   |
|   | r |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | a |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | m |                                                       |   |   |
|   | a |                                                       |   |   |
|   | i |                                                       |   |   |
|   | n |                                                       |   |   |
|   | t |                                                       |   |   |
|   | e |                                                       |   |   |
|   | n |                                                       |   |   |
|   | a |                                                       |   |   |
|   | n |                                                       |   |   |
|   | c |                                                       |   |   |
|   | e |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | m |                                                       |   |   |
|   | e |                                                       |   |   |
|   | d |                                                       |   |   |
|   | i |                                                       |   |   |
|   | c |                                                       |   |   |
|   | a |                                                       |   |   |
|   | t |                                                       |   |   |
|   | i |                                                       |   |   |
|   | o |                                                       |   |   |
|   | n |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | * |                                                       |   |   |
|   | { |                                                       |   |   |
|   | P |                                                       |   |   |
|   | l |                                                       |   |   |
|   | a |                                                       |   |   |
|   | n |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | s |                                                       |   |   |
|   | p |                                                       |   |   |
|   | e |                                                       |   |   |
|   | c |                                                       |   |   |
|   | i |                                                       |   |   |
|   | f |                                                       |   |   |
|   | i |                                                       |   |   |
|   | c |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | \ |                                                       |   |   |
|   | - |                                                       |   |   |
|   | - |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | a |                                                       |   |   |
|   | n |                                                       |   |   |
|   | y |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | t |                                                       |   |   |
|   | i |                                                       |   |   |
|   | m |                                                       |   |   |
|   | e |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | y |                                                       |   |   |
|   | o |                                                       |   |   |
|   | u |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | h |                                                       |   |   |
|   | a |                                                       |   |   |
|   | v |                                                       |   |   |
|   | e |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | d |                                                       |   |   |
|   | i |                                                       |   |   |
|   | f |                                                       |   |   |
|   | f |                                                       |   |   |
|   | e |                                                       |   |   |
|   | r |                                                       |   |   |
|   | e |                                                       |   |   |
|   | n |                                                       |   |   |
|   | t |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | r |                                                       |   |   |
|   | u |                                                       |   |   |
|   | l |                                                       |   |   |
|   | e |                                                       |   |   |
|   | s |                                                       |   |   |
|   | / |                                                       |   |   |
|   | b |                                                       |   |   |
|   | e |                                                       |   |   |
|   | n |                                                       |   |   |
|   | e |                                                       |   |   |
|   | f |                                                       |   |   |
|   | i |                                                       |   |   |
|   | t |                                                       |   |   |
|   | s |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | f |                                                       |   |   |
|   | o |                                                       |   |   |
|   | r |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | m |                                                       |   |   |
|   | a |                                                       |   |   |
|   | i |                                                       |   |   |
|   | l |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | o |                                                       |   |   |
|   | r |                                                       |   |   |
|   | d |                                                       |   |   |
|   | e |                                                       |   |   |
|   | r |                                                       |   |   |
|   | , |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | p |                                                       |   |   |
|   | h |                                                       |   |   |
|   | a |                                                       |   |   |
|   | r |                                                       |   |   |
|   | m |                                                       |   |   |
|   | a |                                                       |   |   |
|   | c |                                                       |   |   |
|   | y |                                                       |   |   |
|   | , |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | e |                                                       |   |   |
|   | t |                                                       |   |   |
|   | c |                                                       |   |   |
|   | . |                                                       |   |   |
|   | , |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | b |                                                       |   |   |
|   | r |                                                       |   |   |
|   | e |                                                       |   |   |
|   | a |                                                       |   |   |
|   | k |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | t |                                                       |   |   |
|   | h |                                                       |   |   |
|   | e |                                                       |   |   |
|   | m |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | o |                                                       |   |   |
|   | u |                                                       |   |   |
|   | t |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | i |                                                       |   |   |
|   | n |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | b |                                                       |   |   |
|   | u |                                                       |   |   |
|   | l |                                                       |   |   |
|   | l |                                                       |   |   |
|   | e |                                                       |   |   |
|   | t |                                                       |   |   |
|   | s |                                                       |   |   |
|   | . |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | F |                                                       |   |   |
|   | o |                                                       |   |   |
|   | r |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | e |                                                       |   |   |
|   | a |                                                       |   |   |
|   | c |                                                       |   |   |
|   | h |                                                       |   |   |
|   | , |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | d |                                                       |   |   |
|   | e |                                                       |   |   |
|   | s |                                                       |   |   |
|   | c |                                                       |   |   |
|   | r |                                                       |   |   |
|   | i |                                                       |   |   |
|   | b |                                                       |   |   |
|   | e |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | i |                                                       |   |   |
|   | s |                                                       |   |   |
|   | s |                                                       |   |   |
|   | u |                                                       |   |   |
|   | e |                                                       |   |   |
|   | s |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | t |                                                       |   |   |
|   | h |                                                       |   |   |
|   | a |                                                       |   |   |
|   | t |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | a |                                                       |   |   |
|   | r |                                                       |   |   |
|   | e |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | p |                                                       |   |   |
|   | r |                                                       |   |   |
|   | o |                                                       |   |   |
|   | b |                                                       |   |   |
|   | l |                                                       |   |   |
|   | e |                                                       |   |   |
|   | m |                                                       |   |   |
|   | a |                                                       |   |   |
|   | t |                                                       |   |   |
|   | i |                                                       |   |   |
|   | c |                                                       |   |   |
|   | , |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | e |                                                       |   |   |
|   | . |                                                       |   |   |
|   | g |                                                       |   |   |
|   | . |                                                       |   |   |
|   | , |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | i |                                                       |   |   |
|   | f |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | y |                                                       |   |   |
|   | o |                                                       |   |   |
|   | u |                                                       |   |   |
|   | r |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | m |                                                       |   |   |
|   | a |                                                       |   |   |
|   | i |                                                       |   |   |
|   | l |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | o |                                                       |   |   |
|   | r |                                                       |   |   |
|   | d |                                                       |   |   |
|   | e |                                                       |   |   |
|   | r |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | f |                                                       |   |   |
|   | i |                                                       |   |   |
|   | r |                                                       |   |   |
|   | m |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | d |                                                       |   |   |
|   | o |                                                       |   |   |
|   | e |                                                       |   |   |
|   | s |                                                       |   |   |
|   | n |                                                       |   |   |
|   | \ |                                                       |   |   |
|   | ' |                                                       |   |   |
|   | t |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | c |                                                       |   |   |
|   | o |                                                       |   |   |
|   | v |                                                       |   |   |
|   | e |                                                       |   |   |
|   | r |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | a |                                                       |   |   |
|   | l |                                                       |   |   |
|   | l |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | d |                                                       |   |   |
|   | r |                                                       |   |   |
|   | u |                                                       |   |   |
|   | g |                                                       |   |   |
|   | s |                                                       |   |   |
|   | } |                                                       |   |   |
|   | . |                                                       |   |   |
|   | * |                                                       |   |   |
|   |   |                                                       |   |   |
|   | ` |                                                       |   |   |
|   | ` |                                                       |   |   |
|   | ` |                                                       |   |   |
|   | { |                                                       |   |   |
|   | = |                                                       |   |   |
|   | h |                                                       |   |   |
|   | t |                                                       |   |   |
|   | m |                                                       |   |   |
|   | l |                                                       |   |   |
|   | } |                                                       |   |   |
|   | < |                                                       |   |   |
|   | ! |                                                       |   |   |
|   | - |                                                       |   |   |
|   | - |                                                       |   |   |
|   |   |                                                       |   |   |
|   | - |                                                       |   |   |
|   | - |                                                       |   |   |
|   | > |                                                       |   |   |
|   | ` |                                                       |   |   |
|   | ` |                                                       |   |   |
|   | ` |                                                       |   |   |
|   | - |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | * |                                                       |   |   |
|   | * |                                                       |   |   |
|   | W |                                                       |   |   |
|   | e |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | u |                                                       |   |   |
|   | s |                                                       |   |   |
|   | e |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | a |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | f |                                                       |   |   |
|   | o |                                                       |   |   |
|   | r |                                                       |   |   |
|   | m |                                                       |   |   |
|   | u |                                                       |   |   |
|   | l |                                                       |   |   |
|   | a |                                                       |   |   |
|   | r |                                                       |   |   |
|   | y |                                                       |   |   |
|   | . |                                                       |   |   |
|   | * |                                                       |   |   |
|   | * |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | * |                                                       |   |   |
|   | { |                                                       |   |   |
|   | P |                                                       |   |   |
|   | l |                                                       |   |   |
|   | a |                                                       |   |   |
|   | n |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | s |                                                       |   |   |
|   | p |                                                       |   |   |
|   | e |                                                       |   |   |
|   | c |                                                       |   |   |
|   | i |                                                       |   |   |
|   | f |                                                       |   |   |
|   | i |                                                       |   |   |
|   | c |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | \ |                                                       |   |   |
|   | - |                                                       |   |   |
|   | - |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | m |                                                       |   |   |
|   | a |                                                       |   |   |
|   | k |                                                       |   |   |
|   | e |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | i |                                                       |   |   |
|   | t |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | v |                                                       |   |   |
|   | e |                                                       |   |   |
|   | r |                                                       |   |   |
|   | y |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | c |                                                       |   |   |
|   | l |                                                       |   |   |
|   | e |                                                       |   |   |
|   | a |                                                       |   |   |
|   | r |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | i |                                                       |   |   |
|   | f |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | y |                                                       |   |   |
|   | o |                                                       |   |   |
|   | u |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | u |                                                       |   |   |
|   | s |                                                       |   |   |
|   | e |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | a |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | f |                                                       |   |   |
|   | o |                                                       |   |   |
|   | r |                                                       |   |   |
|   | m |                                                       |   |   |
|   | u |                                                       |   |   |
|   | l |                                                       |   |   |
|   | a |                                                       |   |   |
|   | r |                                                       |   |   |
|   | y |                                                       |   |   |
|   | . |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | I |                                                       |   |   |
|   | n |                                                       |   |   |
|   | c |                                                       |   |   |
|   | l |                                                       |   |   |
|   | u |                                                       |   |   |
|   | d |                                                       |   |   |
|   | e |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | a |                                                       |   |   |
|   | n |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | e |                                                       |   |   |
|   | x |                                                       |   |   |
|   | p |                                                       |   |   |
|   | l |                                                       |   |   |
|   | a |                                                       |   |   |
|   | n |                                                       |   |   |
|   | a |                                                       |   |   |
|   | t |                                                       |   |   |
|   | i |                                                       |   |   |
|   | o |                                                       |   |   |
|   | n |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | o |                                                       |   |   |
|   | f |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | j |                                                       |   |   |
|   | u |                                                       |   |   |
|   | s |                                                       |   |   |
|   | t |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | e |                                                       |   |   |
|   | x |                                                       |   |   |
|   | a |                                                       |   |   |
|   | c |                                                       |   |   |
|   | t |                                                       |   |   |
|   | l |                                                       |   |   |
|   | y |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | w |                                                       |   |   |
|   | h |                                                       |   |   |
|   | a |                                                       |   |   |
|   | t |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | a |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | f |                                                       |   |   |
|   | o |                                                       |   |   |
|   | r |                                                       |   |   |
|   | m |                                                       |   |   |
|   | u |                                                       |   |   |
|   | l |                                                       |   |   |
|   | a |                                                       |   |   |
|   | r |                                                       |   |   |
|   | y |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | i |                                                       |   |   |
|   | s |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | a |                                                       |   |   |
|   | n |                                                       |   |   |
|   | d |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | w |                                                       |   |   |
|   | h |                                                       |   |   |
|   | a |                                                       |   |   |
|   | t |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | h |                                                       |   |   |
|   | a |                                                       |   |   |
|   | p |                                                       |   |   |
|   | p |                                                       |   |   |
|   | e |                                                       |   |   |
|   | n |                                                       |   |   |
|   | s |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | i |                                                       |   |   |
|   | f |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | t |                                                       |   |   |
|   | h |                                                       |   |   |
|   | e |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | p |                                                       |   |   |
|   | r |                                                       |   |   |
|   | o |                                                       |   |   |
|   | v |                                                       |   |   |
|   | i |                                                       |   |   |
|   | d |                                                       |   |   |
|   | e |                                                       |   |   |
|   | r |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | p |                                                       |   |   |
|   | r |                                                       |   |   |
|   | e |                                                       |   |   |
|   | s |                                                       |   |   |
|   | c |                                                       |   |   |
|   | r |                                                       |   |   |
|   | i |                                                       |   |   |
|   | b |                                                       |   |   |
|   | e |                                                       |   |   |
|   | s |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | s |                                                       |   |   |
|   | o |                                                       |   |   |
|   | m |                                                       |   |   |
|   | e |                                                       |   |   |
|   | t |                                                       |   |   |
|   | h |                                                       |   |   |
|   | i |                                                       |   |   |
|   | n |                                                       |   |   |
|   | g |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | t |                                                       |   |   |
|   | h |                                                       |   |   |
|   | a |                                                       |   |   |
|   | t |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | i |                                                       |   |   |
|   | s |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | n |                                                       |   |   |
|   | o |                                                       |   |   |
|   | t |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | o |                                                       |   |   |
|   | n |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | t |                                                       |   |   |
|   | h |                                                       |   |   |
|   | e |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | f |                                                       |   |   |
|   | o |                                                       |   |   |
|   | r |                                                       |   |   |
|   | m |                                                       |   |   |
|   | u |                                                       |   |   |
|   | l |                                                       |   |   |
|   | a |                                                       |   |   |
|   | r |                                                       |   |   |
|   | y |                                                       |   |   |
|   | . |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | I |                                                       |   |   |
|   | f |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | y |                                                       |   |   |
|   | o |                                                       |   |   |
|   | u |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | d |                                                       |   |   |
|   | o |                                                       |   |   |
|   | n |                                                       |   |   |
|   | \ |                                                       |   |   |
|   | ' |                                                       |   |   |
|   | t |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | u |                                                       |   |   |
|   | s |                                                       |   |   |
|   | e |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | a |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | f |                                                       |   |   |
|   | o |                                                       |   |   |
|   | r |                                                       |   |   |
|   | m |                                                       |   |   |
|   | u |                                                       |   |   |
|   | l |                                                       |   |   |
|   | a |                                                       |   |   |
|   | r |                                                       |   |   |
|   | y |                                                       |   |   |
|   | , |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | d |                                                       |   |   |
|   | o |                                                       |   |   |
|   | n |                                                       |   |   |
|   | \ |                                                       |   |   |
|   | ' |                                                       |   |   |
|   | t |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | a |                                                       |   |   |
|   | d |                                                       |   |   |
|   | d |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | t |                                                       |   |   |
|   | h |                                                       |   |   |
|   | i |                                                       |   |   |
|   | s |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | p |                                                       |   |   |
|   | a |                                                       |   |   |
|   | r |                                                       |   |   |
|   | a |                                                       |   |   |
|   | g |                                                       |   |   |
|   | r |                                                       |   |   |
|   | a |                                                       |   |   |
|   | p |                                                       |   |   |
|   | h |                                                       |   |   |
|   | } |                                                       |   |   |
|   | } |                                                       |   |   |
|   | * |                                                       |   |   |
|   |   |                                                       |   |   |
|   | ` |                                                       |   |   |
|   | ` |                                                       |   |   |
|   | ` |                                                       |   |   |
|   | { |                                                       |   |   |
|   | = |                                                       |   |   |
|   | h |                                                       |   |   |
|   | t |                                                       |   |   |
|   | m |                                                       |   |   |
|   | l |                                                       |   |   |
|   | } |                                                       |   |   |
|   | < |                                                       |   |   |
|   | ! |                                                       |   |   |
|   | - |                                                       |   |   |
|   | - |                                                       |   |   |
|   |   |                                                       |   |   |
|   | - |                                                       |   |   |
|   | - |                                                       |   |   |
|   | > |                                                       |   |   |
|   | ` |                                                       |   |   |
|   | ` |                                                       |   |   |
|   | ` |                                                       |   |   |
|   | - |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | * |                                                       |   |   |
|   | * |                                                       |   |   |
|   | T |                                                       |   |   |
|   | h |                                                       |   |   |
|   | e |                                                       |   |   |
|   | s |                                                       |   |   |
|   | e |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | a |                                                       |   |   |
|   | r |                                                       |   |   |
|   | e |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | t |                                                       |   |   |
|   | h |                                                       |   |   |
|   | e |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | d |                                                       |   |   |
|   | i |                                                       |   |   |
|   | s |                                                       |   |   |
|   | p |                                                       |   |   |
|   | e |                                                       |   |   |
|   | n |                                                       |   |   |
|   | s |                                                       |   |   |
|   | i |                                                       |   |   |
|   | n |                                                       |   |   |
|   | g |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | l |                                                       |   |   |
|   | i |                                                       |   |   |
|   | m |                                                       |   |   |
|   | i |                                                       |   |   |
|   | t |                                                       |   |   |
|   | a |                                                       |   |   |
|   | t |                                                       |   |   |
|   | i |                                                       |   |   |
|   | o |                                                       |   |   |
|   | n |                                                       |   |   |
|   | s |                                                       |   |   |
|   | . |                                                       |   |   |
|   | * |                                                       |   |   |
|   | * |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | * |                                                       |   |   |
|   | { |                                                       |   |   |
|   | P |                                                       |   |   |
|   | l |                                                       |   |   |
|   | a |                                                       |   |   |
|   | n |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | s |                                                       |   |   |
|   | p |                                                       |   |   |
|   | e |                                                       |   |   |
|   | c |                                                       |   |   |
|   | i |                                                       |   |   |
|   | f |                                                       |   |   |
|   | i |                                                       |   |   |
|   | c |                                                       |   |   |
|   | . |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | P |                                                       |   |   |
|   | l |                                                       |   |   |
|   | e |                                                       |   |   |
|   | a |                                                       |   |   |
|   | s |                                                       |   |   |
|   | e |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | i |                                                       |   |   |
|   | n |                                                       |   |   |
|   | c |                                                       |   |   |
|   | l |                                                       |   |   |
|   | u |                                                       |   |   |
|   | d |                                                       |   |   |
|   | e |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | i |                                                       |   |   |
|   | n |                                                       |   |   |
|   | f |                                                       |   |   |
|   | o |                                                       |   |   |
|   | r |                                                       |   |   |
|   | m |                                                       |   |   |
|   | a |                                                       |   |   |
|   | t |                                                       |   |   |
|   | i |                                                       |   |   |
|   | o |                                                       |   |   |
|   | n |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | o |                                                       |   |   |
|   | n |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | d |                                                       |   |   |
|   | a |                                                       |   |   |
|   | y |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | l |                                                       |   |   |
|   | i |                                                       |   |   |
|   | m |                                                       |   |   |
|   | i |                                                       |   |   |
|   | t |                                                       |   |   |
|   | a |                                                       |   |   |
|   | t |                                                       |   |   |
|   | i |                                                       |   |   |
|   | o |                                                       |   |   |
|   | n |                                                       |   |   |
|   | s |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | f |                                                       |   |   |
|   | o |                                                       |   |   |
|   | r |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | b |                                                       |   |   |
|   | o |                                                       |   |   |
|   | t |                                                       |   |   |
|   | h |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | r |                                                       |   |   |
|   | e |                                                       |   |   |
|   | t |                                                       |   |   |
|   | a |                                                       |   |   |
|   | i |                                                       |   |   |
|   | l |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | a |                                                       |   |   |
|   | n |                                                       |   |   |
|   | d |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | m |                                                       |   |   |
|   | a |                                                       |   |   |
|   | i |                                                       |   |   |
|   | l |                                                       |   |   |
|   | - |                                                       |   |   |
|   | o |                                                       |   |   |
|   | r |                                                       |   |   |
|   | d |                                                       |   |   |
|   | e |                                                       |   |   |
|   | r |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | a |                                                       |   |   |
|   | n |                                                       |   |   |
|   | d |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | p |                                                       |   |   |
|   | r |                                                       |   |   |
|   | i |                                                       |   |   |
|   | o |                                                       |   |   |
|   | r |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | a |                                                       |   |   |
|   | p |                                                       |   |   |
|   | p |                                                       |   |   |
|   | r |                                                       |   |   |
|   | o |                                                       |   |   |
|   | v |                                                       |   |   |
|   | a |                                                       |   |   |
|   | l |                                                       |   |   |
|   | s |                                                       |   |   |
|   | , |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | c |                                                       |   |   |
|   | o |                                                       |   |   |
|   | p |                                                       |   |   |
|   | a |                                                       |   |   |
|   | y |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | d |                                                       |   |   |
|   | i |                                                       |   |   |
|   | f |                                                       |   |   |
|   | f |                                                       |   |   |
|   | e |                                                       |   |   |
|   | r |                                                       |   |   |
|   | e |                                                       |   |   |
|   | n |                                                       |   |   |
|   | c |                                                       |   |   |
|   | e |                                                       |   |   |
|   | s |                                                       |   |   |
|   | , |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | e |                                                       |   |   |
|   | t |                                                       |   |   |
|   | c |                                                       |   |   |
|   | . |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | A |                                                       |   |   |
|   | l |                                                       |   |   |
|   | s |                                                       |   |   |
|   | o |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | e |                                                       |   |   |
|   | x |                                                       |   |   |
|   | p |                                                       |   |   |
|   | l |                                                       |   |   |
|   | a |                                                       |   |   |
|   | i |                                                       |   |   |
|   | n |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | t |                                                       |   |   |
|   | h |                                                       |   |   |
|   | a |                                                       |   |   |
|   | t |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | n |                                                       |   |   |
|   | o |                                                       |   |   |
|   | t |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | e |                                                       |   |   |
|   | v |                                                       |   |   |
|   | e |                                                       |   |   |
|   | r |                                                       |   |   |
|   | y |                                                       |   |   |
|   | t |                                                       |   |   |
|   | h |                                                       |   |   |
|   | i |                                                       |   |   |
|   | n |                                                       |   |   |
|   | g |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | i |                                                       |   |   |
|   | s |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | a |                                                       |   |   |
|   | v |                                                       |   |   |
|   | a |                                                       |   |   |
|   | i |                                                       |   |   |
|   | l |                                                       |   |   |
|   | a |                                                       |   |   |
|   | b |                                                       |   |   |
|   | l |                                                       |   |   |
|   | e |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | v |                                                       |   |   |
|   | i |                                                       |   |   |
|   | a |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | m |                                                       |   |   |
|   | a |                                                       |   |   |
|   | i |                                                       |   |   |
|   | l |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | o |                                                       |   |   |
|   | r |                                                       |   |   |
|   | d |                                                       |   |   |
|   | e |                                                       |   |   |
|   | r |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | \ |                                                       |   |   |
|   | - |                                                       |   |   |
|   | - |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | a |                                                       |   |   |
|   | n |                                                       |   |   |
|   | d |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | e |                                                       |   |   |
|   | x |                                                       |   |   |
|   | p |                                                       |   |   |
|   | l |                                                       |   |   |
|   | a |                                                       |   |   |
|   | i |                                                       |   |   |
|   | n |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | w |                                                       |   |   |
|   | h |                                                       |   |   |
|   | y |                                                       |   |   |
|   | . |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | S |                                                       |   |   |
|   | h |                                                       |   |   |
|   | o |                                                       |   |   |
|   | w |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | i |                                                       |   |   |
|   | f |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | y |                                                       |   |   |
|   | o |                                                       |   |   |
|   | u |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | f |                                                       |   |   |
|   | o |                                                       |   |   |
|   | l |                                                       |   |   |
|   | l |                                                       |   |   |
|   | o |                                                       |   |   |
|   | w |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | F |                                                       |   |   |
|   | D |                                                       |   |   |
|   | A |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | d |                                                       |   |   |
|   | i |                                                       |   |   |
|   | s |                                                       |   |   |
|   | p |                                                       |   |   |
|   | e |                                                       |   |   |
|   | n |                                                       |   |   |
|   | s |                                                       |   |   |
|   | i |                                                       |   |   |
|   | n |                                                       |   |   |
|   | g |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | g |                                                       |   |   |
|   | u |                                                       |   |   |
|   | i |                                                       |   |   |
|   | d |                                                       |   |   |
|   | e |                                                       |   |   |
|   | l |                                                       |   |   |
|   | i |                                                       |   |   |
|   | n |                                                       |   |   |
|   | e |                                                       |   |   |
|   | s |                                                       |   |   |
|   | . |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | S |                                                       |   |   |
|   | h |                                                       |   |   |
|   | o |                                                       |   |   |
|   | w |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | w |                                                       |   |   |
|   | h |                                                       |   |   |
|   | a |                                                       |   |   |
|   | t |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | w |                                                       |   |   |
|   | i |                                                       |   |   |
|   | l |                                                       |   |   |
|   | l |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | h |                                                       |   |   |
|   | a |                                                       |   |   |
|   | p |                                                       |   |   |
|   | p |                                                       |   |   |
|   | e |                                                       |   |   |
|   | n |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | i |                                                       |   |   |
|   | f |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | t |                                                       |   |   |
|   | h |                                                       |   |   |
|   | e |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | m |                                                       |   |   |
|   | e |                                                       |   |   |
|   | m |                                                       |   |   |
|   | b |                                                       |   |   |
|   | e |                                                       |   |   |
|   | r |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | s |                                                       |   |   |
|   | e |                                                       |   |   |
|   | n |                                                       |   |   |
|   | d |                                                       |   |   |
|   | s |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | i |                                                       |   |   |
|   | n |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | a |                                                       |   |   |
|   | n |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | o |                                                       |   |   |
|   | r |                                                       |   |   |
|   | d |                                                       |   |   |
|   | e |                                                       |   |   |
|   | r |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | t |                                                       |   |   |
|   | o |                                                       |   |   |
|   | o |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | s |                                                       |   |   |
|   | o |                                                       |   |   |
|   | o |                                                       |   |   |
|   | n |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | a |                                                       |   |   |
|   | f |                                                       |   |   |
|   | t |                                                       |   |   |
|   | e |                                                       |   |   |
|   | r |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | t |                                                       |   |   |
|   | h |                                                       |   |   |
|   | e |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | l |                                                       |   |   |
|   | a |                                                       |   |   |
|   | s |                                                       |   |   |
|   | t |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | o |                                                       |   |   |
|   | n |                                                       |   |   |
|   | e |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | w |                                                       |   |   |
|   | a |                                                       |   |   |
|   | s |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | f |                                                       |   |   |
|   | i |                                                       |   |   |
|   | l |                                                       |   |   |
|   | l |                                                       |   |   |
|   | e |                                                       |   |   |
|   | d |                                                       |   |   |
|   | . |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | D |                                                       |   |   |
|   | e |                                                       |   |   |
|   | s |                                                       |   |   |
|   | c |                                                       |   |   |
|   | r |                                                       |   |   |
|   | i |                                                       |   |   |
|   | b |                                                       |   |   |
|   | e |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | i |                                                       |   |   |
|   | f |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | m |                                                       |   |   |
|   | u |                                                       |   |   |
|   | l |                                                       |   |   |
|   | t |                                                       |   |   |
|   | i |                                                       |   |   |
|   | p |                                                       |   |   |
|   | l |                                                       |   |   |
|   | e |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | c |                                                       |   |   |
|   | o |                                                       |   |   |
|   | p |                                                       |   |   |
|   | a |                                                       |   |   |
|   | y |                                                       |   |   |
|   | s |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | f |                                                       |   |   |
|   | o |                                                       |   |   |
|   | r |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | s |                                                       |   |   |
|   | a |                                                       |   |   |
|   | m |                                                       |   |   |
|   | e |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | p |                                                       |   |   |
|   | r |                                                       |   |   |
|   | e |                                                       |   |   |
|   | s |                                                       |   |   |
|   | c |                                                       |   |   |
|   | r |                                                       |   |   |
|   | i |                                                       |   |   |
|   | p |                                                       |   |   |
|   | t |                                                       |   |   |
|   | i |                                                       |   |   |
|   | o |                                                       |   |   |
|   | n |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | \ |                                                       |   |   |
|   | - |                                                       |   |   |
|   | - |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | e |                                                       |   |   |
|   | x |                                                       |   |   |
|   | p |                                                       |   |   |
|   | l |                                                       |   |   |
|   | a |                                                       |   |   |
|   | i |                                                       |   |   |
|   | n |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | w |                                                       |   |   |
|   | e |                                                       |   |   |
|   | l |                                                       |   |   |
|   | l |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | t |                                                       |   |   |
|   | h |                                                       |   |   |
|   | a |                                                       |   |   |
|   | t |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | m |                                                       |   |   |
|   | e |                                                       |   |   |
|   | m |                                                       |   |   |
|   | b |                                                       |   |   |
|   | e |                                                       |   |   |
|   | r |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | p |                                                       |   |   |
|   | a |                                                       |   |   |
|   | y |                                                       |   |   |
|   | s |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | f |                                                       |   |   |
|   | o |                                                       |   |   |
|   | r |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | e |                                                       |   |   |
|   | a |                                                       |   |   |
|   | c |                                                       |   |   |
|   | h |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | o |                                                       |   |   |
|   | n |                                                       |   |   |
|   | e |                                                       |   |   |
|   | . |                                                       |   |   |
|   | } |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | { |                                                       |   |   |
|   | B |                                                       |   |   |
|   | e |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | s |                                                       |   |   |
|   | u |                                                       |   |   |
|   | r |                                                       |   |   |
|   | e |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | t |                                                       |   |   |
|   | o |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | s |                                                       |   |   |
|   | h |                                                       |   |   |
|   | o |                                                       |   |   |
|   | w |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | t |                                                       |   |   |
|   | h |                                                       |   |   |
|   | a |                                                       |   |   |
|   | t |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | i |                                                       |   |   |
|   | f |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | t |                                                       |   |   |
|   | h |                                                       |   |   |
|   | e |                                                       |   |   |
|   | r |                                                       |   |   |
|   | e |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | i |                                                       |   |   |
|   | s |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | n |                                                       |   |   |
|   | o |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | g |                                                       |   |   |
|   | e |                                                       |   |   |
|   | n |                                                       |   |   |
|   | e |                                                       |   |   |
|   | r |                                                       |   |   |
|   | i |                                                       |   |   |
|   | c |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | e |                                                       |   |   |
|   | q |                                                       |   |   |
|   | u |                                                       |   |   |
|   | i |                                                       |   |   |
|   | v |                                                       |   |   |
|   | a |                                                       |   |   |
|   | l |                                                       |   |   |
|   | e |                                                       |   |   |
|   | n |                                                       |   |   |
|   | t |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | a |                                                       |   |   |
|   | v |                                                       |   |   |
|   | a |                                                       |   |   |
|   | i |                                                       |   |   |
|   | l |                                                       |   |   |
|   | a |                                                       |   |   |
|   | b |                                                       |   |   |
|   | l |                                                       |   |   |
|   | e |                                                       |   |   |
|   | , |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | m |                                                       |   |   |
|   | e |                                                       |   |   |
|   | m |                                                       |   |   |
|   | b |                                                       |   |   |
|   | e |                                                       |   |   |
|   | r |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | w |                                                       |   |   |
|   | i |                                                       |   |   |
|   | l |                                                       |   |   |
|   | l |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | s |                                                       |   |   |
|   | t |                                                       |   |   |
|   | i |                                                       |   |   |
|   | l |                                                       |   |   |
|   | l |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | h |                                                       |   |   |
|   | a |                                                       |   |   |
|   | v |                                                       |   |   |
|   | e |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | t |                                                       |   |   |
|   | o |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | p |                                                       |   |   |
|   | a |                                                       |   |   |
|   | y |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | t |                                                       |   |   |
|   | h |                                                       |   |   |
|   | e |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | b |                                                       |   |   |
|   | r |                                                       |   |   |
|   | a |                                                       |   |   |
|   | n |                                                       |   |   |
|   | d |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | n |                                                       |   |   |
|   | a |                                                       |   |   |
|   | m |                                                       |   |   |
|   | e |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | c |                                                       |   |   |
|   | o |                                                       |   |   |
|   | p |                                                       |   |   |
|   | a |                                                       |   |   |
|   | y |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | \ |                                                       |   |   |
|   | - |                                                       |   |   |
|   | - |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | i |                                                       |   |   |
|   | f |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | t |                                                       |   |   |
|   | h |                                                       |   |   |
|   | a |                                                       |   |   |
|   | t |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | i |                                                       |   |   |
|   | s |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | t |                                                       |   |   |
|   | h |                                                       |   |   |
|   | e |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | c |                                                       |   |   |
|   | a |                                                       |   |   |
|   | s |                                                       |   |   |
|   | e |                                                       |   |   |
|   | ; |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | i |                                                       |   |   |
|   | f |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | i |                                                       |   |   |
|   | t |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | i |                                                       |   |   |
|   | s |                                                       |   |   |
|   | n |                                                       |   |   |
|   | \ |                                                       |   |   |
|   | ' |                                                       |   |   |
|   | t |                                                       |   |   |
|   | , |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | e |                                                       |   |   |
|   | x |                                                       |   |   |
|   | p |                                                       |   |   |
|   | l |                                                       |   |   |
|   | a |                                                       |   |   |
|   | i |                                                       |   |   |
|   | n |                                                       |   |   |
|   | } |                                                       |   |   |
|   | * |                                                       |   |   |
|   | * |                                                       |   |   |
|   | * |                                                       |   |   |
|   | W |                                                       |   |   |
|   | h |                                                       |   |   |
|   | e |                                                       |   |   |
|   | n |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | y |                                                       |   |   |
|   | o |                                                       |   |   |
|   | u |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | h |                                                       |   |   |
|   | a |                                                       |   |   |
|   | v |                                                       |   |   |
|   | e |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | t |                                                       |   |   |
|   | o |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | f |                                                       |   |   |
|   | i |                                                       |   |   |
|   | l |                                                       |   |   |
|   | e |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | a |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | c |                                                       |   |   |
|   | l |                                                       |   |   |
|   | a |                                                       |   |   |
|   | i |                                                       |   |   |
|   | m |                                                       |   |   |
|   | . |                                                       |   |   |
|   | * |                                                       |   |   |
|   | * |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | * |                                                       |   |   |
|   | { |                                                       |   |   |
|   | P |                                                       |   |   |
|   | l |                                                       |   |   |
|   | a |                                                       |   |   |
|   | n |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   |   |                                                       |   |   |
|   | s |                                                       |   |   |
|   | p |                                                       |   |   |
|   | e |                                                       |   |   |
|   | c |                                                       |   |   |
|   | i |                                                       |   |   |
|   | f |                                                       |   |   |
|   | i |                                                       |   |   |
|   | c |                                                       |   |   |
|   | } |                                                       |   |   |
|   | . |                                                       |   |   |
|   | * |                                                       |   |   |
+---+---+-------------------------------------------------------+---+---+

*Prescription drug benefits begin on next page.*

+------------------------------------------+---------------------------+
| **Benefit Description**                  | **You Pay**               |
|                                          |                           |
|                                          | **After the calendar year |
|                                          | deductible...**           |
+------------------------------------------+---------------------------+
| ### **NOTE: The calendar year ded        |                           |
| uctible applies to almost all benefits i |                           |
| n this Section. We say "No deductible" w |                           |
| hen it does not apply.** *{or: We added  |                           |
| asterisks -\*- when it does not apply.}* |                           |
+------------------------------------------+---------------------------+
| #                                        | ###                       |
| ####### Covered medications and supplies |                           |
+------------------------------------------+---------------------------+
| > Each new enrollee will receive a       | -   Network Retail: \$5   |
| > description of our prescription drug   |     generic/\$10 brand    |
| > program, a combined prescription       |     name                  |
| > drug/Plan identification card, a mail  |                           |
| > order form/patient profile and a       | -   Network Retail        |
| > preaddressed reply envelope.           |     Medicare: \$1         |
| >                                        |     generic/\$2 brand (No |
| > You may purchase the following         |     deductible)           |
| > medications and supplies prescribed by |                           |
| > a physician from either a pharmacy or  | -   Non-Network Retail:   |
| > by mail:                               |     40% of cost           |
|                                          |                           |
| -   *Plan specific -- based on what a    | -   Non-Network Retail    |
|     plan lists in 2000 under "what is    |     Medicare: 40% of cost |
|     covered"*                            |     (No deductible)       |
|                                          |                           |
| ```{=html}                               | -   Network Mail Order:   |
| <!-- -->                                 |     \$12 generic/\$25     |
| ```                                      |     brand                 |
| -   Drugs and medicines (including those |                           |
|     administered during a non-covered    | -   Network Mail Order    |
|     admission or in a non-covered        |     Medicare: \$2         |
|     facility) that by Federal law of the |     generic/\$4 brand (No |
|     United States require a physician's  |     deductible)           |
|     prescription for their purchase,     |                           |
|     except as excluded below             | > Note: If there is no    |
|                                          | > generic equivalent      |
| -   Insulin                              | > available, you will     |
|                                          | > still have to pay the   |
| -   Needles and syringes for the         | > brand name copay.       |
|     administration of covered            |                           |
|     medications                          |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   Contraceptive drugs and devices      |                           |
|                                          |                           |
| > Here are some things to keep in mind   |                           |
| > about our prescription drug program:   |                           |
|                                          |                           |
| -   A generic equivalent will be         |                           |
|     dispensed if it is available, unless |                           |
|     your physician specifically requires |                           |
|     a name brand. If you receive a name  |                           |
|     brand drug when a Federally-approved |                           |
|     generic drug is available, and your  |                           |
|     physician has not specified          |                           |
|     \"dispense as written\" for the name |                           |
|     brand drug, you have to pay the      |                           |
|     difference in cost between the name  |                           |
|     brand drug and the generic.          |                           |
|                                          |                           |
| > We administer an open formulary. If    |                           |
| > your physician believes a name brand   |                           |
| > product is necessary or there is no    |                           |
| > generic available, your physician may  |                           |
| > prescribe a name brand drug from a     |                           |
| > formulary list. This list of name      |                           |
| > brand drugs is a preferred list of     |                           |
| > drugs that we selected to meet patient |                           |
| > needs at a lower cost. To order a      |                           |
| > prescription drug brochure, call xxx.  |                           |
+------------------------------------------+---------------------------+
| > *Not covered:*                         | > *All Charges*           |
|                                          |                           |
| -   *Drugs and supplies for cosmetic     |                           |
|     purposes*                            |                           |
|                                          |                           |
| -   *Vitamins, nutrients and food        |                           |
|     supplements even if a physician      |                           |
|     prescribes or administers them*      |                           |
|                                          |                           |
| -   *Nonprescription medicines*          |                           |
+------------------------------------------+---------------------------+

+-----------------------------------------------------------------------+
| > Section 5 (g). Special features                                     |
+=======================================================================+
+-----------------------------------------------------------------------+

+--------------------------+--------------------------------------------+
| > **Special features**   | > **Description**                          |
+--------------------------+--------------------------------------------+
| > **Flexible benefits    | > Under the flexible benefits option, we   |
| > 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.                               |
|                          |                                            |
|                          | > ***{This benefit description is          |
|                          | > standard}***                             |
+--------------------------+--------------------------------------------+
| > **24 hour nurse line** | > For any of your health concerns, 24      |
|                          | > hours a day, 7 days a week, you may call |
|                          | > 1-800-622-6252 and talk with a           |
|                          | > registered nurse who will discuss        |
|                          | > treatment options and answer your health |
|                          | > questions.                               |
+--------------------------+--------------------------------------------+
| > **Services for deaf    |                                            |
| > and hearing impaired** |                                            |
+--------------------------+--------------------------------------------+
| > **Reciprocity          |                                            |
| > benefit**              |                                            |
+--------------------------+--------------------------------------------+
| > **High risk            |                                            |
| > pregnancies**          |                                            |
+--------------------------+--------------------------------------------+
| > **Centers of           |                                            |
| > excellence for         |                                            |
| > transplants/heart      |                                            |
| > surgery/etc**          |                                            |
+--------------------------+--------------------------------------------+
| > **Travel benefit/      |                                            |
| > services overseas**    |                                            |
+--------------------------+--------------------------------------------+

+-----+---+-------------------------------+----------------+----+----+
| > S |   |                               |                |    |    |
| ect |   |                               |                |    |    |
| ion |   |                               |                |    |    |
| > 5 |   |                               |                |    |    |
| > ( |   |                               |                |    |    |
| h). |   |                               |                |    |    |
| >   |   |                               |                |    |    |
| Den |   |                               |                |    |    |
| tal |   |                               |                |    |    |
| >   |   |                               |                |    |    |
|  be |   |                               |                |    |    |
| nef |   |                               |                |    |    |
| its |   |                               |                |    |    |
+=====+===+===============================+================+====+====+
|     | * | **Here are some important     |                | *  |    |
|     | * | things to keep in mind about  |                | *I |    |
|     | I | these benefits:**             |                | ** |    |
|     | * |                               |                |    |    |
|     | * | -   Please remember that all  |                | *  |    |
|     |   |     benefits are subject to   |                | *M |    |
|     | * |     the definitions,          |                | ** |    |
|     | * |     limitations, and          |                |    |    |
|     | M |     exclusions in this        |                | *  |    |
|     | * |     brochure and are payable  |                | *P |    |
|     | * |     only when we determine    |                | ** |    |
|     |   |     they are medically        |                |    |    |
|     | * |     necessary.                |                | *  |    |
|     | * |                               |                | *O |    |
|     | P | -   The calendar year         |                | ** |    |
|     | * |     deductible is: *{plan     |                |    |    |
|     | * |     specific}* \$275 per      |                | *  |    |
|     |   |     person (\$550 per         |                | *R |    |
|     | * |     family). The calendar     |                | ** |    |
|     | * |     year deductible applies   |                |    |    |
|     | O |     to almost all benefits in |                | *  |    |
|     | * |     this Section. We added    |                | *T |    |
|     | * |     "(No deductible)" to show |                | ** |    |
|     |   |     when the calendar year    |                |    |    |
|     | * |     deductible does not       |                | *  |    |
|     | * |     apply. *{If you want, you |                | *A |    |
|     | R |     can say, "We added        |                | ** |    |
|     | * |     asterisks - \* - to show  |                |    |    |
|     | * |     when the calendar year    |                | *  |    |
|     |   |     deductible does not       |                | *N |    |
|     | * |     apply."}*. *{If HMO -- if |                | ** |    |
|     | * |     you don't have            |                |    |    |
|     | T |     deductible, remove this   |                | *  |    |
|     | * |     check mark or say "We     |                | *T |    |
|     | * |     have no calendar year     |                | ** |    |
|     |   |     deductible.}*             |                |    |    |
|     | * |                               |                |    |    |
|     | * | -   Be sure to read Section   |                |    |    |
|     | A |     4, *Your costs for        |                |    |    |
|     | * |     covered services* for     |                |    |    |
|     | * |     valuable information      |                |    |    |
|     |   |     about how cost sharing    |                |    |    |
|     | * |     works, with special       |                |    |    |
|     | * |     sections for members who  |                |    |    |
|     | N |     are age 65 or over. Also  |                |    |    |
|     | * |     read Section 9 about      |                |    |    |
|     | * |     coordinating benefits     |                |    |    |
|     |   |     with other coverage,      |                |    |    |
|     | * |     including with Medicare.  |                |    |    |
|     | * |                               |                |    |    |
|     | T | ```{=html}                    |                |    |    |
|     | * | <!-- -->                      |                |    |    |
|     | * | ```                           |                |    |    |
|     |   | -   Note: We cover            |                |    |    |
|     |   |     hospitalization for       |                |    |    |
|     |   |     dental procedures only    |                |    |    |
|     |   |     when a non-dental         |                |    |    |
|     |   |     physical impairment       |                |    |    |
|     |   |     exists which makes        |                |    |    |
|     |   |     hospitalization necessary |                |    |    |
|     |   |     to safeguard the health   |                |    |    |
|     |   |     of the patient. We do not |                |    |    |
|     |   |     cover the dental          |                |    |    |
|     |   |     procedure.                |                |    |    |
+-----+---+-------------------------------+----------------+----+----+
| ### |   |                               |                |    |    |
|  ** |   |                               |                |    |    |
| Acc |   |                               |                |    |    |
| ide |   |                               |                |    |    |
| nta |   |                               |                |    |    |
| l i |   |                               |                |    |    |
| nju |   |                               |                |    |    |
| ry  |   |                               |                |    |    |
| ben |   |                               |                |    |    |
| efi |   |                               |                |    |    |
| t** |   |                               |                |    |    |
+-----+---+-------------------------------+----------------+----+----+
| >   |   |                               |                |    |    |
|  We |   |                               |                |    |    |
| >   |   |                               |                |    |    |
|  co |   |                               |                |    |    |
| ver |   |                               |                |    |    |
| >   |   |                               |                |    |    |
|  re |   |                               |                |    |    |
| sto |   |                               |                |    |    |
| rat |   |                               |                |    |    |
| ive |   |                               |                |    |    |
| >   |   |                               |                |    |    |
|  se |   |                               |                |    |    |
| rvi |   |                               |                |    |    |
| ces |   |                               |                |    |    |
| >   |   |                               |                |    |    |
| and |   |                               |                |    |    |
| >   |   |                               |                |    |    |
|  su |   |                               |                |    |    |
| ppl |   |                               |                |    |    |
| ies |   |                               |                |    |    |
| >   |   |                               |                |    |    |
| nec |   |                               |                |    |    |
| ess |   |                               |                |    |    |
| ary |   |                               |                |    |    |
| >   |   |                               |                |    |    |
|  to |   |                               |                |    |    |
| >   |   |                               |                |    |    |
|  pr |   |                               |                |    |    |
| omp |   |                               |                |    |    |
| tly |   |                               |                |    |    |
| >   |   |                               |                |    |    |
| rep |   |                               |                |    |    |
| air |   |                               |                |    |    |
| > ( |   |                               |                |    |    |
| but |   |                               |                |    |    |
| >   |   |                               |                |    |    |
| not |   |                               |                |    |    |
| >   |   |                               |                |    |    |
|  re |   |                               |                |    |    |
| pla |   |                               |                |    |    |
| ce) |   |                               |                |    |    |
| >   |   |                               |                |    |    |
|  so |   |                               |                |    |    |
| und |   |                               |                |    |    |
| > n |   |                               |                |    |    |
| atu |   |                               |                |    |    |
| ral |   |                               |                |    |    |
| >   |   |                               |                |    |    |
| tee |   |                               |                |    |    |
| th. |   |                               |                |    |    |
| >   |   |                               |                |    |    |
| The |   |                               |                |    |    |
| > n |   |                               |                |    |    |
| eed |   |                               |                |    |    |
| >   |   |                               |                |    |    |
| for |   |                               |                |    |    |
| >   |   |                               |                |    |    |
|  th |   |                               |                |    |    |
| ese |   |                               |                |    |    |
| >   |   |                               |                |    |    |
|  se |   |                               |                |    |    |
| rvi |   |                               |                |    |    |
| ces |   |                               |                |    |    |
| > m |   |                               |                |    |    |
| ust |   |                               |                |    |    |
| >   |   |                               |                |    |    |
| res |   |                               |                |    |    |
| ult |   |                               |                |    |    |
| > f |   |                               |                |    |    |
| rom |   |                               |                |    |    |
| >   |   |                               |                |    |    |
|  an |   |                               |                |    |    |
| > a |   |                               |                |    |    |
| cci |   |                               |                |    |    |
| den |   |                               |                |    |    |
| tal |   |                               |                |    |    |
| > i |   |                               |                |    |    |
| nju |   |                               |                |    |    |
| ry. |   |                               |                |    |    |
| >   |   |                               |                |    |    |
| You |   |                               |                |    |    |
| >   |   |                               |                |    |    |
| pay |   |                               |                |    |    |
| >   |   |                               |                |    |    |
| \_\ |   |                               |                |    |    |
| _\_ |   |                               |                |    |    |
| \_\ |   |                               |                |    |    |
| _\_ |   |                               |                |    |    |
| \_\ |   |                               |                |    |    |
| _\_ |   |                               |                |    |    |
| \_\ |   |                               |                |    |    |
| _\_ |   |                               |                |    |    |
| \_\ |   |                               |                |    |    |
| _\_ |   |                               |                |    |    |
+-----+---+-------------------------------+----------------+----+----+
| >   |   |                               |                |    |    |
|  ** |   |                               |                |    |    |
| Den |   |                               |                |    |    |
| tal |   |                               |                |    |    |
| > b |   |                               |                |    |    |
| ene |   |                               |                |    |    |
| fit |   |                               |                |    |    |
| s** |   |                               |                |    |    |
+-----+---+-------------------------------+----------------+----+----+
| >   |   |                               |                |    |    |
|  We |   |                               |                |    |    |
| > h |   |                               |                |    |    |
| ave |   |                               |                |    |    |
| >   |   |                               |                |    |    |
|  no |   |                               |                |    |    |
| >   |   |                               |                |    |    |
|  ot |   |                               |                |    |    |
| her |   |                               |                |    |    |
| >   |   |                               |                |    |    |
| den |   |                               |                |    |    |
| tal |   |                               |                |    |    |
| >   |   |                               |                |    |    |
| ben |   |                               |                |    |    |
| efi |   |                               |                |    |    |
| ts. |   |                               |                |    |    |
+-----+---+-------------------------------+----------------+----+----+

***{{Or, if you have dental benefits and you have a fee scheduled use
this format/table:}}***

+------------------+-------------------------------+-------------------+
| **Dental         |                               |                   |
| benefits**       |                               |                   |
+------------------+-------------------------------+-------------------+
| ### **Service**  | ### **W                       | **You pay**       |
|                  | e pay (scheduled allowance)** |                   |
+------------------+-------------------------------+-------------------+
| > Office visits  | > \$\_\_\_ per                | > All charges in  |
| >                | >                             | > excess of the   |
| > *{List         | > \$\_\_\_ per                | > scheduled       |
| > services you   |                               | > amounts listed  |
| > cover}*        |                               | > to the left     |
+------------------+-------------------------------+-------------------+

***{{If you have dental HMO benefits use this format/table:}}***

+------------------------------------------+---------------------------+
| **Dental benefits**                      |                           |
+------------------------------------------+---------------------------+
| ### **Service**                          | **You pay**               |
+------------------------------------------+---------------------------+
| > *{list services you cover}*            | > \$xxx                   |
+------------------------------------------+---------------------------+

  -----------------------------------------------------------------------
  **Section 5 (i). Point-of-Service benefits**

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

*{Describe your point-of-service benefits. If you don\'t have any, or
don\'t describe them here, remove this section and renumber the next
section to 5(I). Be sure to add all that apply of the IMPORTANT bullets
at the start of the section.}*