+------------+---------------------------------------------------------+
| !          | ####### Blue Cross^®^ and Blue Shield^®^                |
| [](media/i |                                                         |
| mage1.jpeg | ####### Service Benefit Plan                            |
| ){width="1 |                                                         |
| .097222222 |                                                         |
| 2222223in" |                                                         |
| height="0. |                                                         |
| 5486111111 |                                                         |
| 111112in"} |                                                         |
+------------+---------------------------------------------------------+

####### [**http://www.fepblue.org**](http://www.planAddress.org/)

**2004**

**A fee-for-service plan**

![](media/image2.png){width="1.5in" height="1.6in"} **organization**

> **Sponsored and administered by:** The Blue Cross and Blue Shield
> Association and participating Blue Cross and Blue Shield Plans
>
> **Who may enroll in this Plan:** All Federal employees and annuitants
> who are eligible to enroll in the FEHB

+-----------------------------------------------------------------------+
| > **Enrollment codes for this Plan:**                                 |
| >                                                                     |
| > **104 Standard Option - Self Only**                                 |
| >                                                                     |
| > **105 Standard Option - Self and Family**                           |
| >                                                                     |
| > **111 Basic Option - Self Only**                                    |
| >                                                                     |
| > **112 Basic Option - Self and Family**                              |
+-----------------------------------------------------------------------+

![](media/image3.png){width="1.4722222222222223in"
height="1.2222222222222223in"}

> This Plan has Case Management accreditation from URAC (also known as
> the American Accreditation HealthCare Commission). See the 2004 FEHB
> Guide for more information on accreditation.

#  RI 71-005

![](media/image5.png){width="4.84375in" height="1.1354166666666667in"}

Dear Federal Employees Health Benefits Program Participant:

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

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

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

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

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

> Sincerely,
>
> ![](media/image6.png){width="2.5833333333333335in"
> height="0.7291666666666666in"}
>
> Kay Coles James
>
> Director

![](media/image7.png){width="1.195138888888889in"
height="1.0354166666666667in"}
![](media/image8.png){width="1.1715277777777777in"
height="0.9208333333333333in"}

# Notice of the United States Office of Personnel Management\'s

# Privacy Practices

### This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

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

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

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

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

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

-   Where required by law.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

-   Get a separate paper copy of this notice.

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

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

Privacy Complaints

United States Office of Personnel Management

P.O. Box 707

Washington, DC 20004-0707

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

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

+-----------------------------------------------------------------------+
| ## Table of Contents                                                  |
+-----------------------------------------------------------------------+

Introduction 4

Plain Language 4

Stop Health Care Fraud! 5

Preventing medical mistakes 6

Section 1. Facts about this fee-for-service Plan 7

Section 2. How we change for 2004 9

Section 3. How you receive benefits 10

Identification cards 10

Where you get covered care 10

-   Covered professional providers 10

-   Covered facility providers 11

What you must do to get covered care 12

How to get approval for . . . 13

-   Your hospital stay (precertification) 13

-   Other services 14

Section 4. Your costs for covered services 16

-   Copayments 16

-   Deductible 16

-   Coinsurance 16

-   Waivers 17

-   Differences between our allowance and the bill 17

Your catastrophic protection out-of-pocket maximum 19

When Government facilities bill us 20

If we overpay you 20

When you are age 65 or over and you do **not** have Medicare 21

When you have Medicare 22

Should I enroll in Medicare? 22

Section 5. Benefits 23

Overview 23

(a) Medical services and supplies provided by physicians and other
    health care professionals 24

(b) Surgical and anesthesia services provided by physicians and other
    health care professionals 45

(c) Services provided by a hospital or other facility, and ambulance
    services 57

(d) Emergency services/accidents 67

(e) Mental health and substance abuse benefits 72

(f) Prescription drug benefits 79

(g) Special features 87

-   Flexible benefits option 87

```{=html}
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-   Online customer and claims service 87

-   24-hour nurse line 87

-   Services for the deaf and hearing impaired 87

-   Travel benefit/services overseas 87

-   Health support programs 87

-   Healthy Families Program 87

(h) Dental benefits 88

(i) Services, drugs, and supplies provided overseas 94

(j) Non-FEHB benefits available to Plan members 96

Section 6. General exclusions -- things we don\'t cover 97

Section 7. Filing a claim for covered services 98

Section 8. The disputed claims process 101

Section 9. Coordinating benefits with other coverage 103

-   When you have other health coverage 103

```{=html}
<!-- -->
```
-   What is Medicare? 103

```{=html}
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```
-   Medicare + Choice 107

-   TRICARE and CHAMPVA 108

-   Workers\' Compensation 108

-   Medicaid 108

-   When other Government agencies are responsible for your care 108

-   When others are responsible for injuries 109

Section 10. Definitions of terms we use in this brochure 110

Section 11. FEHB facts 115

Coverage information 115

-   No pre-existing condition limitation 115

-   Where you can get information about enrolling in the FEHB Program
    115

-   Types of coverage available for you and your family 115

-   Children\'s Equity Act 115

-   When benefits and premiums start 116

```{=html}
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```
-   Your medical and claims records are confidential 116

```{=html}
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```
-   When you retire 116

When you lose benefits 116

-   When FEHB coverage ends 116

-   Spouse equity coverage 117

-   Temporary Continuation of Coverage (TCC) 117

-   Converting to individual coverage 117

-   Getting a Certificate of Group Health Plan Coverage 117

Two new Federal Programs complement FEHB benefits 118

The Federal Flexible Spending Account Program -- *FSAFEDS* 118

The Federal Long Term Care Insurance Program 121

Index 122

Summary of Standard Option benefits 123

Summary of Basic Option benefits 124

Rates Back cover

+-----------------------------------------------------------------------+
| ### Introduction                                                      |
+-----------------------------------------------------------------------+

This brochure describes the benefits of the **Blue Cross and Blue Shield
Service Benefit Plan** under our contract (CS 1039) with the United
States Office of Personnel Management, as authorized by the Federal
Employees Health Benefits law. This Plan is underwritten by
participating Blue Cross and Blue Shield Plans (Local Plans) that
administer this Plan on behalf of the Blue Cross and Blue Shield
Association (the Carrier). The address for the Blue Cross and Blue
Shield Service Benefit Plan administrative offices is:

**Blue Cross and Blue Shield Service Benefit Plan**

1310 G Street, NW, Suite 900

Washington, DC 20005

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

If you are enrolled in this Plan, you are entitled to the benefits
described in this brochure. If you are enrolled in Self and Family
coverage, each eligible family member is also entitled to these
benefits. You do not have a right to benefits that were available before
January 1, 2004, unless those benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefit
changes are effective January 1, 2004, and changes are summarized on
page 9. Rates are shown on the back cover of this brochure.

+-----------------------------------------------------------------------+
| ### Plain Language                                                    |
+-----------------------------------------------------------------------+

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

> • Except for necessary technical terms, we use common words. For
> instance, \"you\" means the enrollee or family member; \"we\" means
> the Blue Cross and Blue Shield Service Benefit Plan.

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

```{=html}
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```
-   Our brochure and other FEHB plans\' brochures have the same format
    and similar descriptions to help you compare plans.

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

  -----------------------------------------------------------------------
  Stop Health Care Fraud!

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

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

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

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

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

```{=html}
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```
-   Let only the appropriate medical professionals review your medical
    record or recommend services.

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

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

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

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

```{=html}
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```
-   Call the provider and ask for an explanation. There may be an error.

-   If the provider does not resolve the matter, call us at
    1-800-FEP-8440 and explain the situation.

-   If we do not resolve the issue:

```{=html}
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```
-   Do not maintain as a family member on your policy:

```{=html}
<!-- -->
```
-   Your former spouse after a divorce decree or annulment is final
    (even if a court order stipulates otherwise); or

```{=html}
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```
-   Your child over age 22 (unless he/she is disabled and incapable of
    self support).

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

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

  -----------------------------------------------------------------------
  Preventing medical mistakes

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

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

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

-   Ask questions and make sure you understand the answers.

-   Choose a doctor with whom you feel comfortable talking.

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

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

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

-   Tell them about any drug allergies you have.

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

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

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

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

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

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

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

-   Call your doctor and ask for your results.

-   Ask what the results mean for your care.

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

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

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

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

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

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

-   Ask your surgeon:

    Exactly what will you be doing?

    About how long will it take?

    What will happen after surgery?

    How can I expect to feel during recovery?

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

    Want more information on patient safety?

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

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

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

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

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

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

+-----------------------------------------------------------------------+
| ### Section 1. Facts about this fee-for-service Plan                  |
+-----------------------------------------------------------------------+

This Plan is a fee-for-service (FFS) plan. You can choose your own
physicians, hospitals, and other health care providers.

We reimburse you or your provider for your covered services, usually
based on a percentage of the amount we allow. The type and extent of
covered services, and the amount we allow, may be different from other
plans. Read brochures carefully.

**We also have a Preferred Provider Organization (PPO):**

Our fee-for-service plan offers services through a PPO. When you use our
PPO (Preferred) providers, you will receive covered services at a
reduced cost. Your Local Plan (or, for retail pharmacies, AdvancePCS) is
solely responsible for the selection of PPO providers in your area.
Contact your Local Plan for the names of PPO (Preferred) providers and
to verify their continued participation. You can also go to our Web
page, which you can reach through the FEHB Web site,
[www.opm.gov/insure](http://www.opm.gov/insure). Contact your Local Plan
to request a PPO directory.

**Under Standard Option,** PPO (Preferred) benefits apply only when you
use a PPO (Preferred) provider. PPO networks may be more extensive in
some areas than in others. We cannot guarantee the availability of every
specialty in all areas. If no PPO (Preferred) provider is available, or
you do not use a PPO (Preferred) provider, non-PPO (Non-preferred)
benefits apply.

**Under Basic Option, you must use Preferred providers in order to
receive benefits**. See page 12 for the exceptions to this requirement.

How we pay professional and facility providers:

We pay benefits when we receive a claim for covered services. Each Local
Plan contracts with hospitals and other health care facilities,
physicians, and other health care professionals in its service area, and
is responsible for processing and paying claims for services you receive
within that area. Many, but not all, of these contracted providers are
in our PPO (Preferred) network.

-   **PPO providers.** PPO (Preferred) providers have agreed to accept a
    specific negotiated amount as payment in full for covered services
    provided to you. **We refer to PPO facility and professional
    providers as \"Preferred.\"** They will generally bill the Local
    Plan directly, who will then pay them directly. You do not file a
    claim. Your out-of-pocket costs are generally less when you receive
    covered services from Preferred providers, and are limited to your
    coinsurance or copayments (and, under **Standard Option** only, the
    applicable deductible).

```{=html}
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```
-   **Participating providers.** Some Local Plans also contract with
    other providers that are not in our Preferred network. **If they are
    professionals, we refer to them as \"Participating\" providers. If
    they are facilities, we refer to them as \"Member\" facilities.**
    They have agreed to accept a different negotiated amount than our
    Preferred providers as payment in full. They will also generally
    file your claims for you. They have agreed not to bill you for more
    than your applicable deductible, and coinsurance or copayments, for
    covered services. We pay them directly, but at our Non-preferred
    benefit levels. Your out-of-pocket costs will be greater than if you
    use Preferred providers.

> ***Note:*** Not all areas have Participating providers and/or Member
> facilities. To verify the status of a provider, please contact the
> Local Plan where the services will be performed.

-   **Non-participating providers.** Providers who are not Preferred or
    Participating providers do not have contracts with us, and may or
    may not accept our allowance. **We refer to them as
    \"Non-participating providers\" generally, although if they are
    facilities we refer to them as \"Non-member facilities.\"** When you
    use Non-participating providers, you may have to file your claim
    with us. We will then pay our benefits to you, and you must pay the
    provider.

> You must pay any difference between the amount Non-participating
> providers charge and our allowance, in addition to any applicable
> coinsurance amounts, copayment amounts, amounts applied to your
> calendar year deductible, and amounts for noncovered services.
> **Important: Under Standard Option, your out-of-pocket costs may be
> substantially higher when you use Non-participating providers than
> when you use Preferred or Participating providers.** Under Basic
> Option, you must use Preferred providers to receive benefits. See page
> 12 for the exceptions to this requirement.

***Note:*** In Local Plan areas, Preferred providers and Participating
providers who contract with us will accept 100% of the Plan allowance as
payment in full for covered services. As a result, you are only
responsible for applicable coinsurance or copayments (and, under
**Standard Option** only, the applicable deductible), for covered
services, and any charges for noncovered services.

**Your Rights**

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

-   Care management, including medical practice guidelines;

-   Disease management programs; and

-   How we determine if procedures are experimental or investigational.

If you want more information about us, call or write to us. Our
telephone number and address are shown on the back of your Service
Benefit Plan ID card. You may also visit our Web site at
[www.fepblue.org](http://www.fepblue.org/).

+-----------------------------------------------------------------------+
| ### Section 2. How we change for 2004                                 |
+-----------------------------------------------------------------------+

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

# Program-wide changes

-   We added information regarding two new Federal Programs that
    complement FEHB benefits, the Federal Flexible Spending Account
    Program − *FSAFEDS* and the Federal Long Term Care Insurance
    Program. See page 118.

-   We added information regarding preventing medical mistakes. See page
    6.

-   We added information regarding enrolling in Medicare. See page 22.

-   We revised the Medicare Primary Payer Chart. See page 106.

Changes to this Plan

-   Under Standard Option, your share of the non-Postal premium will
    increase by 7.1% for Self Only or 7.3% for Self and Family.

-   Under Basic Option, your share of the non-Postal premium will
    increase by 8.6% for Self Only or 8.2% for Self and Family.

```{=html}
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```
-   Under Standard Option, we now provide benefits in full for
    outpatient pharmacotherapy (medication management) you receive from
    Preferred providers after you pay a \$15 copayment. Previously, we
    paid benefits for outpatient pharmacotherapy given by Preferred
    providers at 90% of our allowance after your Standard Option
    calendar year deductible had been met. \[See Sections 5(a) and
    5(e).\]

-   Under Standard Option, we now provide benefits in full for
    anesthesia and assistant surgeon services you receive from Preferred
    providers as part of your covered maternity care. Previously, we
    paid benefits for these services when performed by Preferred
    providers at 90% of our allowance after your Standard Option
    calendar year deductible had been met. \[See Section 5(a).\]

```{=html}
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```
-   Under Standard Option, we now provide benefits for emergency
    admissions to Non-member facilities at 100% of the Plan allowance
    after the patient\'s \$300 per admission copayment. Previously,
    benefits were provided at 70% of the Plan allowance after the \$300
    per admission copayment. \[See Section 5(c).\]

```{=html}
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```
-   Under Standard Option, we now provide benefits for covered ambulance
    transport services not related to accidental injury at 90% of the
    Plan allowance, not subject to the calendar year deductible.
    Previously, benefits were subject to the calendar year deductible
    and were paid at either 90% or 75% of the Plan allowance, depending
    on the contracting status of the ambulance provider. You remain
    responsible for any difference between our allowance and the billed
    amount when you use Non-participating/Non-member ambulance
    providers. \[See Sections 5(c) and 5(d).\]

```{=html}
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```
-   Under Standard Option, office visits made to your primary/family
    doctor for the diagnosis or treatment of a mental health or
    substance abuse condition (not including therapy) no longer count as
    a visit toward the requirement to obtain an approved treatment plan
    from your therapist prior to your ninth outpatient therapy visit
    (the treatment plan requirement). Previously, we counted visits to
    your primary/family doctor toward the treatment plan requirement.

-   Under Standard Option, we no longer require prior approval for
    partial hospitalization or intensive outpatient treatment provided
    by Non-preferred providers. \[See Section 3.\]

```{=html}
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```
-   Under Basic Option, we now provide benefits in full for covered
    preventive care that your children receive from Preferred providers.
    Previously, members paid a \$20 or \$30 copayment for this type of
    care. \[See Section 5(a).\]

```{=html}
<!-- -->
```
-   We now provide benefits for bone density tests when performed for
    screening purposes. \[See Section 5(a).\]

```{=html}
<!-- -->
```
-   We now provide Maternity care benefits for tocolytic therapy and
    related services when provided and billed by a home infusion therapy
    company or a home health care agency. \[See Section 5(a).\]

```{=html}
<!-- -->
```
-   We now provide benefits for covered services performed by physician
    assistants. \[See Section 3.\]

```{=html}
<!-- -->
```
-   We now provide benefits for autologous bone marrow or peripheral
    blood stem cell transplants performed in specific, comparative
    trials funded by the National Institutes of Health (NIH) for
    systemic sclerosis, systemic lupus erythematosus, and multiple
    sclerosis. \[See Section 5(b).\]

-   All members must contact us at the customer service number listed on
    the back of their ID card before obtaining services at Blue Quality
    Centers for Transplant (BQCT). This requirement applies even if you
    have Medicare Part A or another group health insurance policy as
    your primary payer. \[See Section 3.\]

```{=html}
<!-- -->
```
-   We changed a number of the procedure codes for covered dental
    services to reflect changes made by the American Dental Association
    (ADA). \[See Section 5(h).\]

```{=html}
<!-- -->
```
-   We changed the address for FEP Enrollment Services. \[See Section
    3.\]

-   We changed the address for filing overseas claims. \[See Section
    5(i).\]

```{=html}
<!-- -->
```
-   We no longer provide benefits for acupuncture performed by a
    physical therapist.

  -----------------------------------------------------------------------
  Section 3. How you receive benefits
  -----------------------------------------------------------------------

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

+------------------+---------------------------------------------------+
| ##### Iden       | We will send you an identification (ID) card when |
| tification cards | you enroll. You should carry your ID card with    |
|                  | you at all times. You will need it whenever you   |
|                  | receive services from a covered provider, or fill |
|                  | a prescription through a Preferred retail or      |
|                  | internet pharmacy. Until you receive your ID      |
|                  | card, use your copy of the Health Benefits        |
|                  | Election Form, SF-2809, your health benefits      |
|                  | enrollment confirmation letter (for annuitants),  |
|                  | or your Employee Express confirmation letter.     |
+------------------+---------------------------------------------------+
|                  |                                                   |
+------------------+---------------------------------------------------+
|                  | If you do not receive your ID card within 30 days |
|                  | after the effective date of your enrollment, or   |
|                  | if you need replacement cards, call the Local     |
|                  | Plan serving the area where you reside and ask    |
|                  | them to assist you, or write to us directly at:   |
|                  | FEP Enrollment Services, 840 First Street, NE,    |
|                  | Washington, DC 20065. You may also request        |
|                  | replacement cards through our Web site,           |
|                  | [www.fepblue.org]{.underline}.                    |
+------------------+---------------------------------------------------+
|                  |                                                   |
+------------------+---------------------------------------------------+
| **Where you get  | **Under Standard Option,** you can get care from  |
| covered care**   | any \"covered professional provider\" or          |
|                  | \"covered facility provider.\" How much we pay -- |
|                  | and you pay -- depends on the type of covered     |
|                  | provider you use. If you use our Preferred,       |
|                  | Participating, or Member providers, you will pay  |
|                  | less.                                             |
+------------------+---------------------------------------------------+
|                  |                                                   |
+------------------+---------------------------------------------------+
|                  | **Under Basic Option,** you **must** use those    |
|                  | \"covered professional providers\" or \"covered   |
|                  | facility providers\" that are **Preferred         |
|                  | providers** for Basic Option in order to receive  |
|                  | benefits. Please refer to page 12 for the         |
|                  | exceptions to this requirement. Refer to page 7   |
|                  | for more information about Preferred providers.   |
+------------------+---------------------------------------------------+
|                  |                                                   |
+------------------+---------------------------------------------------+
|                  | For Basic Option, the term \"primary care         |
|                  | provider\" includes family practitioners, general |
|                  | practitioners, medical internists, pediatricians, |
|                  | obstetricians/gynecologists, and physician        |
|                  | assistants.                                       |
+------------------+---------------------------------------------------+
|                  |                                                   |
+------------------+---------------------------------------------------+
| -   **Covered    | **We consider the following to be covered         |
|     professional | professionals when they perform services within   |
|     providers**  | the scope of their license or certification:**    |
+------------------+---------------------------------------------------+
|                  |                                                   |
+------------------+---------------------------------------------------+
|                  | **Physicians --** Doctors of medicine (M.D.);     |
|                  | osteopathy (D.O.); dental surgery (D.D.S.);       |
|                  | medical dentistry (D.M.D.); podiatric medicine    |
|                  | (D.P.M.); and optometry (O.D.).                   |
+------------------+---------------------------------------------------+
|                  |                                                   |
+------------------+---------------------------------------------------+
|                  | **Other Covered Health Care Professionals --**    |
|                  | Professionals who provide additional covered      |
|                  | services and meet the state\'s applicable         |
|                  | licensing or certification requirements and the   |
|                  | requirements of the Local Plan. Other covered     |
|                  | health care professionals include:                |
+------------------+---------------------------------------------------+
|                  |                                                   |
+------------------+---------------------------------------------------+
|                  | -   **Audiologist --** A professional who, if the |
|                  |     state requires it, is licensed, certified, or |
|                  |     registered as an audiologist where the        |
|                  |     services are performed.                       |
+------------------+---------------------------------------------------+
|                  | -   **Clinical Psychologist --** A psychologist   |
|                  |     who (1) is licensed or certified in the state |
|                  |     where the services are performed; (2) has a   |
|                  |     doctoral degree in psychology (or an allied   |
|                  |     degree if, in the individual state, the       |
|                  |     academic licensing/certification requirement  |
|                  |     for clinical psychologist is met by an allied |
|                  |     degree) or is approved by the Local Plan;     |
|                  |     and (3) has met the clinical psychological    |
|                  |     experience requirements of the individual     |
|                  |     State Licensing Board.                        |
+------------------+---------------------------------------------------+
|                  | -   **Clinical Social Worker --** A social worker |
|                  |     who (1) has a master\'s or doctoral degree in |
|                  |     social work; (2) has at least two years of    |
|                  |     clinical social work practice; and (3) if the |
|                  |     state requires it, is licensed, certified, or |
|                  |     registered as a social worker where the       |
|                  |     services are performed.                       |
+------------------+---------------------------------------------------+
|                  | -   **Diabetic educator --** A professional who,  |
|                  |     if the state requires it, is licensed,        |
|                  |     certified, or registered as a diabetic        |
|                  |     educator where the services are performed.    |
+------------------+---------------------------------------------------+
|                  | -   **Dietician --** A professional who, if the   |
|                  |     state requires it, is licensed, certified, or |
|                  |     registered as a dietician where the services  |
|                  |     are performed.                                |
+------------------+---------------------------------------------------+
|                  | -   **Independent Laboratory --** A laboratory    |
|                  |     that is licensed under state law or, where no |
|                  |     licensing requirement exists, that is         |
|                  |     approved by the Local Plan.                   |
+------------------+---------------------------------------------------+
|                  | -   **Nurse Midwife --** A person who is          |
|                  |     certified by the American College of Nurse    |
|                  |     Midwives or, if the state requires it, is     |
|                  |     licensed or certified as a nurse midwife.     |
+------------------+---------------------------------------------------+
|                  | -   **Nurse Practitioner/Clinical Specialist --** |
|                  |     A person who (1) has an active R.N. license   |
|                  |     in the United States; (2) has a baccalaureate |
|                  |     or higher degree in nursing; and (3) if the   |
|                  |     state requires it, is licensed or certified   |
|                  |     as a nurse practitioner or clinical nurse     |
|                  |     specialist.                                   |
+------------------+---------------------------------------------------+
|                  | -   **Nursing School Administered Clinic --** A   |
|                  |     clinic that (1) is licensed or certified in   |
|                  |     the state where services are performed;       |
|                  |     and (2) provides ambulatory care in an        |
|                  |     outpatient setting -- primarily in rural or   |
|                  |     inner-city areas where there is a shortage of |
|                  |     physicians. Services billed for by these      |
|                  |     clinics are considered outpatient \"office\"  |
|                  |     services rather than facility charges.        |
+------------------+---------------------------------------------------+
|                  | -   **Nutritionist --** A professional who, if    |
|                  |     the state requires it, is licensed,           |
|                  |     certified, or registered as a nutritionist    |
|                  |     where the services are performed.             |
+------------------+---------------------------------------------------+
|                  | -   **Physical, Speech, and Occupational          |
|                  |     Therapist --** A professional who is licensed |
|                  |     where the services are performed or meets the |
|                  |     requirements of the Local Plan to provide     |
|                  |     physical, speech, or occupational therapy     |
|                  |     services.                                     |
+------------------+---------------------------------------------------+
|                  | -   **Physician Assistant** **--** A person who   |
|                  |     is nationally certified by the National       |
|                  |     Commission on Certification of Physician      |
|                  |     Assistants in conjunction with the National   |
|                  |     Board of Medical Examiners or, if the state   |
|                  |     requires it, is licensed, certified, or       |
|                  |     registered as a physician assistant where the |
|                  |     services are performed.                       |
+------------------+---------------------------------------------------+
|                  | -   **Other professional providers** specifically |
|                  |     shown in the benefit descriptions in Section  |
|                  |     5.                                            |
+------------------+---------------------------------------------------+
|                  |                                                   |
+------------------+---------------------------------------------------+
|                  | **Medically underserved areas.** In states that   |
|                  | OPM determines are \"medically underserved\":     |
+------------------+---------------------------------------------------+
|                  |                                                   |
+------------------+---------------------------------------------------+
|                  | > **Under Standard Option,** we cover any         |
|                  | > licensed medical practitioner for any covered   |
|                  | > service performed within the scope of that      |
|                  | > license.                                        |
+------------------+---------------------------------------------------+
|                  |                                                   |
+------------------+---------------------------------------------------+
|                  | > **Under Basic Option,** we cover any licensed   |
|                  | > medical practitioner who is **Preferred** for   |
|                  | > any covered service performed within the scope  |
|                  | > of that license.                                |
+------------------+---------------------------------------------------+
|                  |                                                   |
+------------------+---------------------------------------------------+
|                  | For 2004, the states are: Alabama, Idaho,         |
|                  | Kentucky, Louisiana, Maine, Mississippi,          |
|                  | Missouri, Montana, New Mexico, North Dakota,      |
|                  | South Carolina, South Dakota, Texas, Utah, West   |
|                  | Virginia, and Wyoming.                            |
+------------------+---------------------------------------------------+
|                  |                                                   |
+------------------+---------------------------------------------------+
| -   **Covered    | **Covered facilities include those listed below,  |
|     facility     | when they meet the state\'s applicable licensing  |
|     providers**  | or certification requirements.**                  |
+------------------+---------------------------------------------------+
|                  |                                                   |
+------------------+---------------------------------------------------+
|                  | -   **Hospital --** An institution, or a distinct |
|                  |     portion of an institution, that:              |
+------------------+---------------------------------------------------+
|                  |                                                   |
+------------------+---------------------------------------------------+
|                  | (1) Primarily provides diagnostic and therapeutic |
|                  |     facilities for surgical and medical           |
|                  |     diagnoses, treatment, and care of injured and |
|                  |     sick persons provided or supervised by a      |
|                  |     staff of licensed doctors of medicine (M.D.)  |
|                  |     or licensed doctors of osteopathy (D.O.), for |
|                  |     compensation from its patients, on an         |
|                  |     inpatient or outpatient basis;                |
+------------------+---------------------------------------------------+
|                  | (2) Continuously provides 24-hour-a-day           |
|                  |     professional registered nursing (R.N.)        |
|                  |     services; and                                 |
+------------------+---------------------------------------------------+
|                  | (3) Is not, other than incidentally, an extended  |
|                  |     care facility; a nursing home; a place for    |
|                  |     rest; an institution for exceptional          |
|                  |     children, the aged, drug addicts, or          |
|                  |     alcoholics; or a custodial or domiciliary     |
|                  |     institution having as its primary purpose the |
|                  |     furnishing of food, shelter, training, or     |
|                  |     non-medical personal services.                |
+------------------+---------------------------------------------------+
|                  |                                                   |
+------------------+---------------------------------------------------+
|                  | > ***Note:*** We consider college infirmaries to  |
|                  | > be Non-member hospitals. In addition, we may,   |
|                  | > at our discretion, recognize any institution    |
|                  | > located outside the 50 states and the District  |
|                  | > of Columbia as a Non-member hospital.           |
+------------------+---------------------------------------------------+
|                  |                                                   |
+------------------+---------------------------------------------------+
|                  | -   **Freestanding Ambulatory Facility --** A     |
|                  |     freestanding facility, such as an ambulatory  |
|                  |     surgical center, freestanding surgi-center,   |
|                  |     freestanding dialysis center, or freestanding |
|                  |     ambulatory medical facility, that:            |
+------------------+---------------------------------------------------+
|                  |                                                   |
+------------------+---------------------------------------------------+
|                  | (1) Provides services in an outpatient setting;   |
+------------------+---------------------------------------------------+
|                  | (2) Contains permanent amenities and equipment    |
|                  |     primarily for the purpose of performing       |
|                  |     medical, surgical, and/or renal dialysis      |
|                  |     procedures;                                   |
+------------------+---------------------------------------------------+
|                  | (3) Provides treatment performed or supervised by |
|                  |     doctors and/or nurses, and may include other  |
|                  |     professional services performed at the        |
|                  |     facility; and                                 |
+------------------+---------------------------------------------------+
|                  | (4) Is not, other than incidentally, an office or |
|                  |     clinic for the private practice of a doctor   |
|                  |     or other professional.                        |
+------------------+---------------------------------------------------+
|                  |                                                   |
+------------------+---------------------------------------------------+
|                  | > ***Note:*** We may, at our discretion,          |
|                  | > recognize any other similar facilities, such as |
|                  | > birthing centers, as freestanding ambulatory    |
|                  | > facilities.                                     |
+------------------+---------------------------------------------------+
|                  |                                                   |
+------------------+---------------------------------------------------+

+------------------+---------------------------------------------------+
|                  | -   **Blue Quality Centers for Transplant (BQCT)  |
|                  |     --**                                          |
+------------------+---------------------------------------------------+
|                  |                                                   |
+------------------+---------------------------------------------------+
|                  | In addition to Preferred transplant facilities,   |
|                  | you have access to the Blue Quality Centers for   |
|                  | Transplant (BQCT), a centers of excellence        |
|                  | program. BQCT institutions are selected based on  |
|                  | their ability to meet defined clinical quality    |
|                  | criteria that are unique for each type of         |
|                  | transplant. BQCT negotiates a payment for         |
|                  | transplant services performed during the          |
|                  | transplant period (see page 114 for the           |
|                  | definition of \"transplant period\").             |
+------------------+---------------------------------------------------+
|                  |                                                   |
+------------------+---------------------------------------------------+
|                  | Members who choose to use a BQCT facility for a   |
|                  | covered transplant only pay the \$100 per         |
|                  | admission copayment under Standard Option, or the |
|                  | \$100 per day copayment (\$500 maximum) under     |
|                  | Basic Option, for the transplant period. Members  |
|                  | are not responsible for additional costs for      |
|                  | included professional services. Regular Preferred |
|                  | benefits (subject to the regular cost-sharing     |
|                  | levels for facility and professional services)    |
|                  | are paid for pre- and post-transplant services    |
|                  | performed in BQCT facilities before and after the |
|                  | transplant period.                                |
+------------------+---------------------------------------------------+
|                  |                                                   |
+------------------+---------------------------------------------------+
|                  | BQCT institutions are available for seven types   |
|                  | of transplants: heart; heart-lung; single or      |
|                  | bilateral lung; liver; pancreas; simultaneous     |
|                  | pancreas-kidney; and autologous or allogeneic     |
|                  | bone marrow (see pages 53 through 55 for          |
|                  | limitations).                                     |
+------------------+---------------------------------------------------+
|                  |                                                   |
+------------------+---------------------------------------------------+
|                  | **All members (including those who have Medicare  |
|                  | Part A or another group health insurance policy   |
|                  | as their primary payer) must contact us at the    |
|                  | customer service number listed on the back of     |
|                  | their ID card before obtaining services.** We     |
|                  | will refer you to the designated Plan transplant  |
|                  | coordinator for information about BQCT and        |
|                  | approved facilities, and assistance in arranging  |
|                  | for your transplant at a BQCT facility.           |
+------------------+---------------------------------------------------+
|                  |                                                   |
+------------------+---------------------------------------------------+
|                  | -   **Cancer Research Facility --** A facility    |
|                  |     that is:                                      |
+------------------+---------------------------------------------------+
|                  |                                                   |
+------------------+---------------------------------------------------+
|                  | (1) A National Cooperative Cancer Study Group     |
|                  |     institution that is funded by the National    |
|                  |     Cancer Institute (NCI) and has been approved  |
|                  |     by a Cooperative Group as a bone marrow       |
|                  |     transplant center;                            |
+------------------+---------------------------------------------------+
|                  | (2) An NCI-designated Cancer Center; or           |
+------------------+---------------------------------------------------+
|                  | (3) An institution that has a peer-reviewed grant |
|                  |     funded by the National Cancer Institute (NCI) |
|                  |     or National Institutes of Health (NIH) to     |
|                  |     study allogeneic or autologous bone marrow    |
|                  |     transplants and blood stem cell transplant    |
|                  |     support.                                      |
+------------------+---------------------------------------------------+
|                  |                                                   |
+------------------+---------------------------------------------------+
|                  | -   **Other facilities** specifically listed in   |
|                  |     the benefits descriptions in Section 5(c).    |
+------------------+---------------------------------------------------+
|                  |                                                   |
+------------------+---------------------------------------------------+
| **What you must  | **Under Standard Option,** you can go to any      |
| do to**          | covered provider you want, but in some            |
|                  | circumstances, we must approve your care in       |
| **get covered    | advance.                                          |
| care**           |                                                   |
+------------------+---------------------------------------------------+
|                  | **Under Basic Option,** you **must** use          |
|                  | **Preferred** providers in order to receive       |
|                  | benefits, except under the special situations     |
|                  | listed below. In addition, we must approve        |
|                  | certain types of care in advance. Please refer to |
|                  | Section 4, *Your costs for covered services*, for |
|                  | related benefits information.                     |
+------------------+---------------------------------------------------+
|                  |                                                   |
+------------------+---------------------------------------------------+
|                  | (1) Medical emergency or accidental injury care   |
|                  |     in a hospital emergency room and related      |
|                  |     ambulance transport as described in Section   |
|                  |     5(d), *Emergency services/accidents*;         |
+------------------+---------------------------------------------------+
|                  | (2) Professional care provided at Preferred       |
|                  |     facilities by Non-preferred radiologists,     |
|                  |     anesthesiologists, certified registered nurse |
|                  |     anesthetists (CRNAs), pathologists, emergency |
|                  |     room physicians, and assistant surgeons;      |
+------------------+---------------------------------------------------+
|                  | (3) Laboratory and pathology services, X-rays,    |
|                  |     and diagnostic tests billed by Non-preferred  |
|                  |     laboratories, radiologists, and outpatient    |
|                  |     facilities;                                   |
+------------------+---------------------------------------------------+
|                  | (4) Services of assistant surgeons;               |
+------------------+---------------------------------------------------+
|                  | (5) Special provider access situations (contact   |
|                  |     your Local Plan for more information);        |
+------------------+---------------------------------------------------+
|                  | > or                                              |
+------------------+---------------------------------------------------+
|                  | (6) Care received outside the United States and   |
|                  |     Puerto Rico.                                  |
+------------------+---------------------------------------------------+
|                  |                                                   |
+------------------+---------------------------------------------------+
|                  | Unless otherwise noted in Section 5, when         |
|                  | services of Non-preferred providers are covered   |
|                  | in a special exception, benefits will be provided |
|                  | based on the Plan allowance. You are responsible  |
|                  | for the applicable coinsurance or copayment, and  |
|                  | may also be responsible for any difference        |
|                  | between our allowance and the billed amount.      |
+------------------+---------------------------------------------------+
|                  |                                                   |
+------------------+---------------------------------------------------+

+------------------+---------------------------------------------------+---+
| **Transitional   | **Specialty care:** If you have a chronic or      |   |
| care:**          | disabling condition and                           |   |
+------------------+---------------------------------------------------+---+
|                  |                                                   |   |
+------------------+---------------------------------------------------+---+
|                  | -   lose access to your specialist because we     |   |
|                  |     drop out of the Federal Employees Health      |   |
|                  |     Benefits (FEHB) Program and you enroll in     |   |
|                  |     another FEHB plan, or                         |   |
+------------------+---------------------------------------------------+---+
|                  |                                                   |   |
+------------------+---------------------------------------------------+---+
|                  | -   lose access to your Preferred specialist      |   |
|                  |     because we terminate our contract with your   |   |
|                  |     specialist for other than cause,              |   |
+------------------+---------------------------------------------------+---+
|                  |                                                   |   |
+------------------+---------------------------------------------------+---+
|                  | you may be able to continue seeing your           |   |
|                  | specialist and receiving any Preferred benefits   |   |
|                  | for up to 90 days after you receive notice of the |   |
|                  | change. Contact us or, if we drop out of the      |   |
|                  | Program, contact your new plan.                   |   |
+------------------+---------------------------------------------------+---+
|                  |                                                   |   |
+------------------+---------------------------------------------------+---+
|                  | If you are in the second or third trimester of    |   |
|                  | pregnancy and you lose access to your specialist  |   |
|                  | based on the above circumstances, you can         |   |
|                  | continue to see your specialist and any Preferred |   |
|                  | benefits will continue until the end of your      |   |
|                  | postpartum care, even if it is beyond the 90      |   |
|                  | days.                                             |   |
+------------------+---------------------------------------------------+---+
|                  |                                                   |   |
+------------------+---------------------------------------------------+---+
| > **Hospital     | We pay for covered services from the effective    |   |
| > care:**        | date of your enrollment. However, if you are in   |   |
|                  | the hospital when your enrollment in our Plan     |   |
|                  | begins, call us immediately. If you have not yet  |   |
|                  | received your Service Benefit Plan ID card, you   |   |
|                  | can contact your Local Plan at the telephone      |   |
|                  | number listed in your local telephone directory.  |   |
|                  | If you already have your new Service Benefit Plan |   |
|                  | ID card, call us at the number on the back of the |   |
|                  | card. If you are new to the FEHB Program, we will |   |
|                  | reimburse you for your covered expenses while in  |   |
|                  | the hospital.                                     |   |
+------------------+---------------------------------------------------+---+
|                  |                                                   |   |
+------------------+---------------------------------------------------+---+
|                  | However, if you changed from another FEHB plan to |   |
|                  | us, your former plan will pay for the hospital    |   |
|                  | stay until:                                       |   |
+------------------+---------------------------------------------------+---+
|                  |                                                   |   |
+------------------+---------------------------------------------------+---+
|                  | -   You are discharged, not merely moved to an    |   |
|                  |     alternative care center; or                   |   |
+------------------+---------------------------------------------------+---+
|                  |                                                   |   |
+------------------+---------------------------------------------------+---+
|                  | -   The day your benefits from your former plan   |   |
|                  |     run out; or                                   |   |
+------------------+---------------------------------------------------+---+
|                  |                                                   |   |
+------------------+---------------------------------------------------+---+
|                  | -   The 92^nd^ day after you become a member of   |   |
|                  |     this Plan, whichever happens first.           |   |
+------------------+---------------------------------------------------+---+
| #                | #                                                 |   |
+------------------+---------------------------------------------------+---+
|                  | These provisions apply only to the benefits of    |   |
|                  | the hospitalized person. If your plan terminates  |   |
|                  | participation in the FEHB in whole or in part, or |   |
|                  | if OPM orders an enrollment change, this          |   |
|                  | continuation of coverage provision does not       |   |
|                  | apply. In such case, the hospitalized family      |   |
|                  | member\'s benefits under the new plan begin on    |   |
|                  | the effective date of enrollment.                 |   |
+------------------+---------------------------------------------------+---+
|                  |                                                   |   |
+------------------+---------------------------------------------------+---+
| **How to get     |                                                   |   |
| approval for . . |                                                   |   |
| .**              |                                                   |   |
+------------------+---------------------------------------------------+---+
|                  |                                                   |   |
+------------------+---------------------------------------------------+---+
| -   **Your       | **Precertification** is the process by which --   |   |
|     hospital     | prior to your inpatient hospital admission -- we  |   |
|     stay**       | evaluate the medical necessity of your proposed   |   |
|                  | stay and the number of days required to treat     |   |
|                  | your condition. Unless we are misled by the       |   |
|                  | information given to us, we will not change our   |   |
|                  | decision on medical necessity.                    |   |
+------------------+---------------------------------------------------+---+
|                  |                                                   |   |
+------------------+---------------------------------------------------+---+
|                  | In most cases, your physician or hospital will    |   |
|                  | take care of precertification. Because you are    |   |
|                  | still responsible for ensuring that we are asked  |   |
|                  | to precertify your care, you should always ask    |   |
|                  | your physician or hospital whether they have      |   |
|                  | contacted us.                                     |   |
+------------------+---------------------------------------------------+---+
|                  |                                                   |   |
+------------------+---------------------------------------------------+---+
| **Warning:**     | We will reduce our benefits for the inpatient     |   |
|                  | hospital stay by \$500 if no one contacts us for  |   |
|                  | precertification. If the stay is not medically    |   |
|                  | necessary, we will not pay any benefits.          |   |
+------------------+---------------------------------------------------+---+
|                  |                                                   |   |
+------------------+---------------------------------------------------+---+
| > **How to       | -   You, your representative, your doctor, or     |   |
| > precertify an  |     your hospital must call us at the telephone   |   |
| > admission:**   |     number listed on the back of your Service     |   |
|                  |     Benefit Plan ID card any time prior to        |   |
|                  |     admission.                                    |   |
+------------------+---------------------------------------------------+---+
|                  |                                                   |   |
+------------------+---------------------------------------------------+---+
|                  | -   If you have an **emergency admission** due to |   |
|                  |     a condition that you reasonably believe puts  |   |
|                  |     your life in danger or could cause serious    |   |
|                  |     damage to bodily function, you, your          |   |
|                  |     representative, your doctor, or your hospital |   |
|                  |     must telephone us within two business days    |   |
|                  |     following the day of the emergency admission, |   |
|                  |     even if you have been discharged from the     |   |
|                  |     hospital.                                     |   |
+------------------+---------------------------------------------------+---+
|                  |                                                   |   |
+------------------+---------------------------------------------------+---+
|                  | -   Provide the following information:            |   |
+------------------+---------------------------------------------------+---+
|                  |                                                   |   |
+------------------+---------------------------------------------------+---+
|                  | -   Enrollee\'s name and Plan identification      |   |
|                  |     number;                                       |   |
+------------------+---------------------------------------------------+---+
|                  |                                                   |   |
+------------------+---------------------------------------------------+---+
|                  | -   Patient\'s name, birth date, and phone        |   |
|                  |     number;                                       |   |
+------------------+---------------------------------------------------+---+
|                  | -   Reason for hospitalization, proposed          |   |
|                  |     treatment, or surgery;                        |   |
+------------------+---------------------------------------------------+---+
|                  |                                                   |   |
+------------------+---------------------------------------------------+---+
|                  | -   Name and phone number of admitting doctor;    |   |
+------------------+---------------------------------------------------+---+
|                  |                                                   |   |
+------------------+---------------------------------------------------+---+
|                  | -   Name of hospital or facility; and             |   |
+------------------+---------------------------------------------------+---+
|                  |                                                   |   |
+------------------+---------------------------------------------------+---+
|                  | -   Number of planned days of confinement.        |   |
+------------------+---------------------------------------------------+---+
|                  |                                                   |   |
+------------------+---------------------------------------------------+---+
|                  | -   We will then tell the doctor and/or hospital  |   |
|                  |     the number of approved inpatient days and we  |   |
|                  |     will send written confirmation of our         |   |
|                  |     decision to you, your doctor, and the         |   |
|                  |     hospital.                                     |   |
+------------------+---------------------------------------------------+---+
|                  |                                                   |   |
+------------------+---------------------------------------------------+---+
| **Maternity      | You do not need to precertify a maternity         |   |
| care**           | admission for a routine delivery. However, if     |   |
|                  | your medical condition requires you to stay more  |   |
|                  | than 48 hours after a vaginal delivery or 96      |   |
|                  | hours after a cesarean section, then your         |   |
|                  | physician or the hospital must contact us for     |   |
|                  | precertification of additional days. Further, if  |   |
|                  | your baby stays after you are discharged, then    |   |
|                  | your physician or the hospital must contact us    |   |
|                  | for precertification of additional days for your  |   |
|                  | baby.                                             |   |
+------------------+---------------------------------------------------+---+
|                  |                                                   |   |
+------------------+---------------------------------------------------+---+
| > **If your      | If your hospital stay -- including for maternity  |   |
| > hospital       | care -- needs to be extended, you, your           |   |
| > stay**         | representative, your doctor, or the hospital must |   |
| >                | ask us to approve the additional days.            |   |
| > **needs to be  |                                                   |   |
| > extended:**    |                                                   |   |
+------------------+---------------------------------------------------+---+
|                  |                                                   |   |
+------------------+---------------------------------------------------+---+
| > **What happens | -   If no one contacted us, we will decide        |   |
| > when you do    |     whether the hospital stay was medically       |   |
| > not follow the |     necessary.                                    |   |
| >                |                                                   |   |
| precertification |                                                   |   |
| > rules**        |                                                   |   |
+------------------+---------------------------------------------------+---+
|                  |                                                   |   |
+------------------+---------------------------------------------------+---+
|                  | -   If we determine that the stay was medically   |   |
|                  |     necessary, we will pay the inpatient charges, |   |
|                  |     less the \$500 penalty. \[See Section 5(c)    |   |
|                  |     for payment information.\]                    |   |
+------------------+---------------------------------------------------+---+
|                  |                                                   |   |
+------------------+---------------------------------------------------+---+
|                  |                                                   |   |
+------------------+---------------------------------------------------+---+
|                  | -   If we determine that it was not medically     |   |
|                  |     necessary for you to be an inpatient, we will |   |
|                  |     not pay inpatient hospital benefits. We will  |   |
|                  |     only pay for any covered medical supplies and |   |
|                  |     services that are otherwise payable on an     |   |
|                  |     outpatient basis.                             |   |
+------------------+---------------------------------------------------+---+
|                  |                                                   |   |
+------------------+---------------------------------------------------+---+
|                  | -   If we denied the precertification request, we |   |
|                  |     will not pay inpatient hospital benefits or   |   |
|                  |     inpatient physician care benefits. We will    |   |
|                  |     only pay for any covered medical supplies and |   |
|                  |     services that are otherwise payable on an     |   |
|                  |     outpatient basis.                             |   |
+------------------+---------------------------------------------------+---+
|                  |                                                   |   |
+------------------+---------------------------------------------------+---+
|                  | -   When we precertified the admission but you    |   |
|                  |     remained in the hospital beyond the number of |   |
|                  |     days we approved and you did not get the      |   |
|                  |     additional days precertified, then:           |   |
+------------------+---------------------------------------------------+---+
|                  |                                                   |   |
+------------------+---------------------------------------------------+---+
|                  | -   for the part of the admission that was        |   |
|                  |     medically necessary, we will pay inpatient    |   |
|                  |     benefits, but                                 |   |
+------------------+---------------------------------------------------+---+
|                  |                                                   |   |
+------------------+---------------------------------------------------+---+
|                  | -   for the part of the admission that was not    |   |
|                  |     medically necessary, we will pay only medical |   |
|                  |     services and supplies otherwise payable on an |   |
|                  |     outpatient basis and we will not pay          |   |
|                  |     inpatient benefits.                           |   |
+------------------+---------------------------------------------------+---+
|                  |                                                   |   |
+------------------+---------------------------------------------------+---+
| **Exceptions:**  | You do not need precertification in these cases:  |   |
+------------------+---------------------------------------------------+---+
|                  |                                                   |   |
+------------------+---------------------------------------------------+---+
|                  | -   You are admitted to a hospital outside the    |   |
|                  |     United States.                                |   |
+------------------+---------------------------------------------------+---+
|                  |                                                   |   |
+------------------+---------------------------------------------------+---+
|                  | -   You have another group health insurance       |   |
|                  |     policy that is the primary payer for the      |   |
|                  |     hospital stay. (See page 12 for special       |   |
|                  |     instructions regarding admissions to BQCT     |   |
|                  |     institutions.)                                |   |
+------------------+---------------------------------------------------+---+
|                  |                                                   |   |
+------------------+---------------------------------------------------+---+
|                  | -   Your Medicare Part A is the primary payer for |   |
|                  |     the hospital stay. (See page 12 for special   |   |
|                  |     instructions regarding admissions to BQCT     |   |
|                  |     institutions.)                                |   |
+------------------+---------------------------------------------------+---+
|                  |                                                   |   |
+------------------+---------------------------------------------------+---+
|                  | > ***Note:*** If you exhaust your Medicare        |   |
|                  | > hospital benefits and do not want to use your   |   |
|                  | > Medicare lifetime reserve days, then we will    |   |
|                  | > become the primary payer and you **do** need    |   |
|                  | > precertification.                               |   |
+------------------+---------------------------------------------------+---+
|                  |                                                   |   |
+------------------+---------------------------------------------------+---+
| -   **Other      | **These services require prior approval under     |   |
|     services**   | both Standard and Basic Option:**                 |   |
+------------------+---------------------------------------------------+---+
|                  |                                                   |   |
+------------------+---------------------------------------------------+---+
|                  | -   **Home hospice care --** Contact us at the    |   |
|                  |     customer service number listed on the back of |   |
|                  |     your ID card before obtaining services. We    |   |
|                  |     will request the medical evidence we need to  |   |
|                  |     make our coverage determination and advise    |   |
|                  |     you which home hospice care agencies we have  |   |
|                  |     approved.                                     |   |
+------------------+---------------------------------------------------+---+
|                  |                                                   |   |
+------------------+---------------------------------------------------+---+
|                  | -   **Partial hospitalization or intensive        |   |
|                  |     outpatient treatment for mental               |   |
|                  |     health/substance abuse --** Contact us at the |   |
|                  |     mental health and substance abuse number      |   |
|                  |     listed on the back of your ID card before     |   |
|                  |     obtaining services for intensive outpatient   |   |
|                  |     treatment or partial hospitalization from     |   |
|                  |     Preferred providers. We will request the      |   |
|                  |     medical evidence we need to make our coverage |   |
|                  |     determination. We will also consider the      |   |
|                  |     necessary duration of either of these         |   |
|                  |     services.                                     |   |
+------------------+---------------------------------------------------+---+
|                  |                                                   |   |
+------------------+---------------------------------------------------+---+
|                  | -   **Organ/tissue transplants --** Contact us at |   |
|                  |     the customer service number listed on the     |   |
|                  |     back of your ID card before obtaining         |   |
|                  |     services. We will request the medical         |   |
|                  |     evidence we need to make our coverage         |   |
|                  |     determination. We will consider whether the   |   |
|                  |     facility is approved for the procedure and    |   |
|                  |     whether you meet the facility\'s criteria.    |   |
+------------------+---------------------------------------------------+---+
|                  |                                                   |   |
+------------------+---------------------------------------------------+---+
|                  | -   **Clinical trials for certain organ/tissue    |   |
|                  |     transplants --** Contact our Clinical Trials  |   |
|                  |     Information Unit at 1-800-225-2268 for        |   |
|                  |     information or to request prior approval      |   |
|                  |     before obtaining services. We will request    |   |
|                  |     the medical evidence we need to make our      |   |
|                  |     coverage determination. Use this number       |   |
|                  |     **only** for prior approval of clinical       |   |
|                  |     trials for bone marrow and peripheral blood   |   |
|                  |     stem cell transplant support procedures for   |   |
|                  |     those conditions shown on pages 54 and 55 as  |   |
|                  |     covered only in clinical trials.              |   |
+------------------+---------------------------------------------------+---+
|                  |                                                   |   |
+------------------+---------------------------------------------------+---+
|                  | -   **Prescription drugs --** Certain             |   |
|                  |     prescription drugs require prior approval.    |   |
|                  |     Contact our Retail Pharmacy Program at        |   |
|                  |     1-800-624-5060 (TDD: 1-800-624-5077 for the   |   |
|                  |     hearing impaired) to request prior approval,  |   |
|                  |     or to obtain an updated list of prescription  |   |
|                  |     drugs that require prior approval. We will    |   |
|                  |     request the information we need to make our   |   |
|                  |     coverage determination. You must periodically |   |
|                  |     renew prior approval for certain drugs. See   |   |
|                  |     page 85 for more about our prescription drug  |   |
|                  |     prior approval program, which is part of our  |   |
|                  |     Patient Safety and Quality Monitoring (PSQM)  |   |
|                  |     program.                                      |   |
+------------------+---------------------------------------------------+---+
|                  |                                                   |   |
+------------------+---------------------------------------------------+---+
|                  | ***Note:*** Benefits for drugs to aid smoking     |   |
|                  | cessation that require a prescription by Federal  |   |
|                  | law are limited to one course of treatment per    |   |
|                  | calendar year. Prior approval is required before  |   |
|                  | benefits will be provided for additional          |   |
|                  | medication. To obtain approval, the physician     |   |
|                  | must certify the patient is participating in a    |   |
|                  | smoking cessation program that provides clinical  |   |
|                  | treatment, including counseling and behavioral    |   |
|                  | therapies.                                        |   |
+------------------+---------------------------------------------------+---+
|                  |                                                   |   |
+------------------+---------------------------------------------------+---+
|                  | ***Note:*** Until we approve them, you must pay   |   |
|                  | for these drugs in full when you purchase them -- |   |
|                  | even if you purchase them at a Preferred retail   |   |
|                  | pharmacy or through an internet pharmacy -- and   |   |
|                  | submit the expense(s) to us on a claim form.      |   |
|                  | Preferred pharmacies will not file these claims   |   |
|                  | for you.                                          |   |
+------------------+---------------------------------------------------+---+
|                  |                                                   |   |
+------------------+---------------------------------------------------+---+
|                  | Under **Standard Option**, members may use our    |   |
|                  | Mail Service Prescription Drug Program to fill    |   |
|                  | their prescriptions. However, the Mail Service    |   |
|                  | Prescription Drug Program also will not fill your |   |
|                  | prescription until you have obtained prior        |   |
|                  | approval. Medco Health Solutions, Inc., the       |   |
|                  | administrator of the Mail Service Prescription    |   |
|                  | Drug Program, will hold your prescription for you |   |
|                  | up to thirty days. If prior approval is not       |   |
|                  | obtained within 30 days, your prescription will   |   |
|                  | be returned to you along with a Prior Approval    |   |
|                  | Request Form and a letter explaining the prior    |   |
|                  | approval procedures.                              |   |
+------------------+---------------------------------------------------+---+
|                  |                                                   |   |
+------------------+---------------------------------------------------+---+
|                  | The Mail Service Prescription Drug Program is not |   |
|                  | available under **Basic Option**.                 |   |
+------------------+---------------------------------------------------+---+
|                  |                                                   |   |
+------------------+---------------------------------------------------+---+
|                  | **In addition to the types of care listed above,  |   |
|                  | these services also require prior approval under  |   |
|                  | Basic Option:**                                   |   |
+------------------+---------------------------------------------------+---+
|                  |                                                   |   |
+------------------+---------------------------------------------------+---+
|                  | -   **Outpatient mental health and substance      |   |
|                  |     abuse treatment -- You must call us** at the  |   |
|                  |     number listed on the back of your ID card for |   |
|                  |     mental health and substance abuse **before    |   |
|                  |     receiving any outpatient professional or      |   |
|                  |     facility care**. We will then provide you     |   |
|                  |     with the names and phone numbers of several   |   |
|                  |     Preferred providers to choose from and tell   |   |
|                  |     you how many visits we are initially          |   |
|                  |     approving.                                    |   |
+------------------+---------------------------------------------------+---+

<table>
<colgroup>
<col style="width: 7%" />
<col style="width: 18%" />
<col style="width: 7%" />
<col style="width: 0%" />
<col style="width: 9%" />
<col style="width: 16%" />
<col style="width: 19%" />
<col style="width: 0%" />
<col style="width: 19%" />
<col style="width: 1%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="10"><strong>Section 4. Your costs for covered
services</strong></td>
</tr>
<tr class="even">
<td colspan="10"></td>
</tr>
<tr class="odd">
<td colspan="10">This is what you will pay out-of-pocket for your
covered care:</td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="7"></td>
</tr>
<tr class="odd">
<td colspan="3"><ul>
<li><p><strong>Copayments</strong></p></li>
</ul></td>
<td colspan="7">A copayment is a fixed amount of money you pay to the
provider, facility, pharmacy, etc., when you receive certain
services.</td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="7"></td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="7">Example: If you have Standard Option when you see your
Preferred physician, you pay a copayment of $15 for the office visit and
we then pay the remainder of the amount billed for the office visit.
(You may have to pay separately for other services you receive while in
the physician's office.) When you go into a Preferred hospital, you pay
a copayment of $100 per admission. We then pay the remainder of the
hospital bill for the covered services you receive.</td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="7"></td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="7">Copayments do not apply to services and supplies that
are subject to a deductible and/or coinsurance amount.</td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="7"></td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="7"><em><strong>Note:</strong></em> If the billed amount (or
the Plan allowance that providers we contract with have agreed to accept
as payment in full) is less than your copayment, you pay the lower
amount.</td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="7"></td>
</tr>
<tr class="odd">
<td colspan="3"><ul>
<li><p><strong>Deductible</strong></p></li>
</ul></td>
<td colspan="7">A deductible is a fixed amount of covered expenses you
must incur for certain covered services and supplies before we start
paying benefits for them. Copayments and coinsurance amounts do not
count toward your deductible. When a covered service or supply is
subject to a deductible, only the Plan allowance for the service or
supply that you then pay counts toward meeting your deductible.</td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="7"></td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="7"><strong>Under Standard Option,</strong> the calendar
year deductible is $250 per person. Under a family enrollment, the
calendar year deductible for each family member is satisfied and
benefits are payable for all family members when the combined covered
expenses of the family reach $500.</td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="7"></td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="7"><em><strong>Note:</strong></em> If the billed amount (or
the Plan allowance that providers we contract with have agreed to accept
as payment in full) is less than the remaining portion of your
deductible, you pay the lower amount.</td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="7"></td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="7">Example: If the billed amount is $100, the provider has
an agreement with us to accept $80, and you have not paid any amount
toward meeting your Standard Option calendar year deductible, you must
pay $80. We will apply $80 to your deductible. We will begin paying
benefits once the remaining portion of your Standard Option calendar
year deductible ($170) has been satisfied.</td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="7"></td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="7"><em><strong>Note:</strong></em> If you change plans
during Open Season and the effective date of your new plan is after
January 1 of the next year, you do not have to start a new deductible
under your old plan between January 1 and the effective date of your new
plan. If you change plans at another time during the year, you must
begin a new deductible under your new plan.</td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="7"></td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="7"><strong>Under Basic Option,</strong> there is <strong>no
calendar year deductible</strong>.</td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="7"></td>
</tr>
<tr class="odd">
<td colspan="3"><ul>
<li><p><strong>Coinsurance</strong></p></li>
</ul></td>
<td colspan="7">Coinsurance is the percentage of the Plan allowance that
you must pay for your care. Your coinsurance is based on the Plan
allowance, or billed amount, whichever is less. <strong>Under Standard
Option only,</strong> coinsurance does not begin until you meet your
deductible.</td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="7"></td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="7">Example: You pay 10% of the Plan allowance under
Standard Option for durable medical equipment obtained from a Preferred
provider, after meeting your $250 calendar year deductible.</td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="7"></td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="7"><strong><em>Note:</em> If your provider routinely
waives</strong> (does not require you to pay) your applicable deductible
(under Standard Option only), coinsurance, or copayments, the provider
is misstating the fee and may be violating the law. In this case, when
we calculate our share, we will reduce the provider's fee by the amount
waived.</td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="7">Example: If your physician ordinarily charges $100 for a
service but routinely waives your 25% Standard Option coinsurance, the
actual charge is $75. We will pay $56.25 (75% of the actual charge of
$75).</td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="7"></td>
</tr>
<tr class="even">
<td colspan="3"><ul>
<li><p><strong>Waivers</strong></p></li>
</ul></td>
<td colspan="7">In some instances, a Preferred, Participating, or Member
provider may ask you to sign a "waiver" prior to receiving care. This
waiver may state that you accept responsibility for the total charge for
any care that is not covered by your health plan. If you sign such a
waiver, whether you are responsible for the total charge depends on the
content of the contracts that the Local Plan has with its providers. If
you are asked to sign this type of waiver, please be aware that, if
benefits are denied for the services, you could be legally liable for
the related expenses. If you would like more information about waivers,
please contact us at the customer service number on the back of your ID
card.</td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="7"></td>
</tr>
<tr class="even">
<td colspan="3"><ul>
<li><p><strong>Differences between our allowance and the
bill</strong></p></li>
</ul></td>
<td colspan="7">Our <strong>"Plan allowance"</strong> is the amount we
use to calculate our payment for certain types of covered services.
Fee-for-service plans arrive at their allowances in different ways, so
allowances vary. For information about how we determine our Plan
allowance, see the definition of Plan allowance in Section 10.</td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="7"></td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="7">Often, the provider's bill is more than a
fee-for-service plan's allowance. Whether or not you have to pay the
difference between our allowance and the bill will depend on the type of
provider you use. In this Plan, we have the following types of
providers:</td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="7"></td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="7"><ul>
<li><p><strong>Preferred providers.</strong> These types of providers
have agreements with the Local Plan to limit what they bill our members.
Because of that, when you use a Preferred provider, your share of the
provider's bill for covered care is limited.</p></li>
</ul></td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="7"></td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="7"><blockquote>
<p><strong>Under Standard Option,</strong> your share consists only of
your deductible and coinsurance or copayment. Here is an example about
coinsurance: You see a Preferred physician who charges $150, but our
allowance is $100. If you have met your deductible, you are only
responsible for your coinsurance. That is, under Standard Option, you
pay just 10% of our $100 allowance ($10). Because of the agreement, your
Preferred physician will not bill you for the $50 difference between our
allowance and his/her bill.</p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="7"></td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="7"><blockquote>
<p><strong>Under Basic Option,</strong> your share consists only of your
copayment or coinsurance amount, since there is no calendar year
deductible. Here is an example involving a copayment: You see a
Preferred physician who charges $150 for covered services subject to a
$20 copayment. Even though our allowance may be $100, you still pay just
the $20 copayment. Because of the agreement, your Preferred physician
will not bill you for the $130 difference between your copayment and
his/her bill.</p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="7"></td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="7"><blockquote>
<p><strong>Remember, under Basic Option, you must use Preferred
providers in order to receive benefits.</strong> See page 12 for the
exceptions to this requirement.</p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="7"></td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="7"><ul>
<li><p><strong>Participating providers.</strong> These types of
<strong>Non-preferred</strong> <strong>providers</strong> have
agreements with the Local Plan to limit what they bill our
<strong>Standard</strong> <strong>Option</strong> members.</p></li>
</ul></td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="7"></td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="7"><blockquote>
<p><strong>Under Standard Option,</strong> when you use a Participating
provider, your share of covered charges consists only of your deductible
and coinsurance or copayment. Here is an example: You see a
Participating physician who charges $150, but the Plan allowance is
$100. If you have met your deductible, you are only responsible for your
coinsurance. That is, under Standard Option, you pay just 25% of our
$100 allowance ($25). Because of the agreement, your Participating
physician will not bill you for the $50 difference between our allowance
and his/her bill.</p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="7"></td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="7"><blockquote>
<p><strong>Under Basic Option, there are no benefits for care performed
by Participating providers; you pay all charges.</strong> See page 12
for the exceptions to this requirement.</p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="7"></td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="7"><ul>
<li><p><strong>Non-participating</strong> <strong>providers.</strong>
These <strong>Non-preferred providers</strong> have no agreement to
limit what they will bill you.</p></li>
</ul></td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="7"></td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="7"><blockquote>
<p><strong>Under Standard Option,</strong> when you use a
Non-participating provider, you will pay your deductible and coinsurance
– <strong>plus</strong> any difference between our allowance and the
charges on the bill. For example, you see a Non-participating physician
who charges $150. The Plan allowance is again $100, and you have met
your deductible. You are responsible for your coinsurance, so you pay
25% of the $100 Plan allowance or $25. Plus, because there is no
agreement between the Non-participating physician and us, the physician
can bill you for the $50 difference between our allowance and his/her
bill.</p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="7"></td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="7"><blockquote>
<p><strong>Under Basic Option, there are no benefits for care performed
by Non-participating providers; you pay all charges.</strong> See page
12 for the exceptions to this requirement.</p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="7"></td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="7">The following table illustrates examples of how much you
have to pay out-of-pocket for services from a Preferred physician, a
Participating physician, and a Non-participating physician. The table
uses our example of a service for which the physician charges $150 and
the Plan allowance is $100. For Standard Option, the table shows the
amount you pay if you have met your calendar year deductible.</td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="7"></td>
</tr>
<tr class="even">
<td></td>
<td><strong>EXAMPLE</strong></td>
<td colspan="3"><p><strong>Preferred physician</strong></p>
<p><strong>Standard Option</strong></p></td>
<td><p><strong>Preferred physician</strong></p>
<p><strong>Basic Option</strong></p></td>
<td colspan="2"><p><strong>Participating physician</strong></p>
<p><strong>(Standard Option*)</strong></p></td>
<td><p><strong>Non-participating physician</strong></p>
<p><strong>(Standard Option*)</strong></p></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td>Physician's charge</td>
<td colspan="3">$150</td>
<td>$150</td>
<td colspan="2">$150</td>
<td>$150</td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td>Our allowance</td>
<td colspan="3">We set it at: 100</td>
<td>We set it at: 100</td>
<td>We set it at: 100</td>
<td colspan="2">We set it at: 100</td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td>We pay</td>
<td colspan="3">90% of our allowance: 90</td>
<td><p>Our allowance</p>
<p>less copay: 80</p></td>
<td><p>75% of our</p>
<p>allowance: 75</p></td>
<td colspan="2"><p>75% of our</p>
<p>allowance: 75</p></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td><p>You owe:</p>
<p>Coinsurance</p></td>
<td colspan="3">10% of our allowance: 10</td>
<td>Not applicable</td>
<td colspan="2"><p>25% of our</p>
<p>allowance: 25</p></td>
<td><p>25% of our</p>
<p>allowance: 25</p></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td><p>You owe:</p>
<p>Copayment</p></td>
<td colspan="3">Not applicable</td>
<td>20</td>
<td colspan="2">Not applicable</td>
<td>Not applicable</td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td>+Difference up to charge?</td>
<td colspan="3">No: 0</td>
<td>No: 0</td>
<td colspan="2">No: 0</td>
<td>Yes: 50</td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td><strong>TOTAL YOU PAY</strong></td>
<td colspan="3">$10</td>
<td>$20</td>
<td colspan="2">$25</td>
<td>$75</td>
<td></td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="7"></td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="7"><strong>*Under Basic Option, there are no benefits for
care performed by Participating and Non-participating physicians. You
must use Preferred providers in order to receive benefits.</strong> See
page 12 for the exceptions to this requirement.</td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="7"></td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="7"><em><strong>Note:</strong></em> Under Standard Option,
had you not met any of your deductible in the above examples, only our
allowance ($100), which you would pay in full, would count toward your
deductible.</td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="7"></td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="7"><ul>
<li><p><strong>Overseas providers.</strong> We pay overseas claims at
Preferred benefit levels, using an Overseas Fee Schedule as our Plan
allowance. Most overseas professional providers are under no obligation
to accept our allowance, and you must pay any difference between our
payment and the provider's bill. For facility care you receive overseas,
we provide benefits in full after you pay the applicable copayment or
coinsurance (and, under Standard Option, any deductible amount that may
apply). See Section 5(i) for more information about our overseas
benefits.</p></li>
</ul></td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="7"></td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="7"><ul>
<li><p><strong>Dental care. Under Standard Option,</strong> we pay
scheduled amounts for routine dental services and you pay any balance.
<strong>Under Basic Option,</strong> you pay $20 for any covered
evaluation and we pay the balance for covered services. See Section 5(h)
for a listing of covered dental services and additional payment
information.</p></li>
</ul></td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="7"></td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="7"><ul>
<li><p><strong>Hospital care.</strong> You pay the coinsurance or
copayment amounts listed in Section 5(c). <strong>Under Standard
Option,</strong> you must meet your deductible before we begin providing
benefits for certain hospital-billed services. <strong>Under Basic
Option,</strong> you must use <strong>Preferred</strong> facilities in
order to receive benefits. See page 12 for the exceptions to this
requirement.</p></li>
</ul></td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="6"></td>
</tr>
<tr class="odd">
<td colspan="4"><p><strong>Your catastrophic protection</strong></p>
<p><strong>out-of-pocket maximum for deductibles, coinsurance, and
copayments</strong></p></td>
<td colspan="6">If the total amount of out-of-pocket expenses in a
calendar year for you and your covered family members for deductibles
(Standard Option only), coinsurance, and copayments (other than those
listed below) exceeds $6,000 under Standard Option, or $5,000 under
Basic Option, then you and any covered family members will not have to
continue paying them for the remainder of the calendar year.</td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="6"></td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td colspan="6"><strong>Standard Option Preferred maximum:</strong> If
the total amount of these out-of-pocket expenses from using Preferred
providers for you and your covered family members exceeds $4,000 in a
calendar year under Standard Option, then you and any covered family
members will not have to pay these expenses for the remainder of the
calendar year when you continue to use Preferred providers. You will,
however, have to pay them when you use Non-preferred providers, until
your out-of-pocket expenses (for the services of both Preferred and
Non-preferred providers) reach $6,000 under Standard Option, as shown
above.</td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="6"></td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td colspan="6"><strong>Basic Option maximum:</strong> If the total
amount of these out-of-pocket expenses from using Preferred providers
for you and your covered family members exceeds $5,000 in a calendar
year under Basic Option, then you and any covered family members will
not have to pay these expenses for the remainder of the calendar
year.</td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="6"></td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td colspan="6"><strong>The following expenses are not included</strong>
under this feature. These expenses do not count toward your catastrophic
protection out-of-pocket maximum, and you must continue to pay them even
after your expenses exceed the limits described above.</td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="6"></td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td colspan="6"><ul>
<li><p>The difference between the Plan allowance and the billed amount.
See pages 17-19;</p></li>
</ul></td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="6"><ul>
<li><p>Expenses for services, drugs, and supplies in excess of our
maximum benefit limitations;</p></li>
</ul></td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td colspan="6"><ul>
<li><p>Under Standard Option, your 30% coinsurance for inpatient care in
a Non-member hospital;</p></li>
</ul></td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="6"><ul>
<li><p>Under Standard Option, your 25% coinsurance for outpatient care
by a Non-member facility;</p></li>
</ul></td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td colspan="6"><ul>
<li><p>Your expenses for mental conditions and substance abuse care by a
Non-preferred professional or facility provider;</p></li>
</ul></td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="6"><ul>
<li><p>Your expenses for dental services in excess of our fee schedule
payments under Standard Option. See Section 5(h);</p></li>
</ul></td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td colspan="6"><ul>
<li><p>The $500 penalty for failing to obtain precertification, and any
other amounts you pay because we reduce benefits for not complying with
our cost containment requirements;</p></li>
</ul></td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="6"><ul>
<li><p>Under Basic Option, coinsurance you pay for non-formulary
brand-name drugs; and</p></li>
</ul></td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td colspan="6"><ul>
<li><p>Under Basic Option, your expenses for care received from
Participating/Non-participating professional providers or
Member/Non-member facilities, except for coinsurance and copayments you
pay in those special situations where we do pay for care provided by
Non-preferred providers. Please see page 12 for the exceptions to the
requirement to use Preferred providers.</p></li>
</ul></td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="6"></td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td colspan="6"><blockquote>
<p><em><strong>Note:</strong></em> If you change to another plan during
Open Season, we will continue to provide benefits between January 1 and
the effective date of your new plan.</p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="6"></td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td colspan="6"><ul>
<li><p>If you had already paid the out-of-pocket maximum, we will
continue to provide benefits as described on this page until the
effective date of your new plan.</p></li>
</ul></td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="6"><ul>
<li><p>If you had not yet paid the out-of-pocket maximum, we will apply
any expenses you incur in January (before the effective date of your new
plan) to our prior year's out-of-pocket maximum. Once you reach the
maximum, you don't need to pay our deductibles, copayments, or
coinsurance amounts (except as shown on this page) from that point until
the effective date of your new plan.</p></li>
</ul></td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td colspan="6"></td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="6"><em><strong>Note:</strong></em> Because benefit changes
are effective January 1, we will apply our next year's benefits to any
expenses you incur in January.</td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td colspan="6"></td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="6"><em><strong>Note:</strong></em> If you change options in
this Plan during the year, we will credit the amounts already
accumulated toward the catastrophic protection out-of-pocket limit of
your old option to the catastrophic protection out-of-pocket limit of
your new option. If you change from Self Only to Self and Family, or
vice versa, during the calendar year, please call us about your
out-of-pocket accumulations and how they carry over.</td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td colspan="6"></td>
</tr>
<tr class="even">
<td colspan="4"><p><strong>When Government facilities</strong></p>
<p><strong>bill us</strong></p></td>
<td colspan="6">Facilities of the Department of Veterans Affairs, the
Department of Defense, and the Indian Health Service are entitled to
seek reimbursement from us for certain services and supplies they
provide to you or a family member. They may not seek more than their
governing laws allow.</td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td colspan="6"></td>
</tr>
<tr class="even">
<td colspan="4"><strong>If we overpay you</strong></td>
<td colspan="6">We will make diligent efforts to recover benefit
payments we made in error but in good faith. We may reduce subsequent
benefit payments to offset overpayments.</td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td colspan="6"></td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="6"><em><strong>Note:</strong></em> We will generally first
seek recovery from the provider if we paid the provider directly, or
from the person (covered family member, guardian, custodial parent,
etc.) to whom we sent our payment.</td>
</tr>
</tbody>
</table>

**When you are age 65 or over and you do not have Medicare**

Under the FEHB law, we must limit our payments for **inpatient hospital
care** and for **physician care** to those benefits you would be
entitled to if you had Medicare. And, your physician and hospital must
follow Medicare rules and cannot bill you for more than they could bill
you if you had Medicare. You and the FEHB benefit from these payment
limits. Outpatient hospital care is not covered by this law; regular
Plan benefits apply. The following chart has more information about the
limits.

+---+-------------------------+---------+------------------------------+---+
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| . |                         |         |                              |   |
+---+-------------------------+---------+------------------------------+---+
|   | # If your physician ... | Then    |                              |   |
|   |                         | you are |                              |   |
|   |                         | resp    |                              |   |
|   |                         | onsible |                              |   |
|   |                         | for ... |                              |   |
+---+-------------------------+---------+------------------------------+---+
|   | Participates with       | S       | your deductibles,            |   |
|   | Medicare or accepts     | tandard | coinsurance, and copayments  |   |
|   | Medicare assignment for | Option: |                              |   |
|   | the claim and is in our |         |                              |   |
|   | Preferred network       |         |                              |   |
+---+-------------------------+---------+------------------------------+---+
|   |                         | Basic   | your copayments and          |   |
|   |                         | Option: | coinsurance                  |   |
+---+-------------------------+---------+------------------------------+---+
|   | Participates with       | S       | your deductibles,            |   |
|   | Medicare or accepts     | tandard | coinsurance, and copayments, |   |
|   | Medicare assignment and | Option: | and any balance up to the    |   |
|   | is **not** in our       |         | Medicare approved amount     |   |
|   | Preferred network       |         |                              |   |
+---+-------------------------+---------+------------------------------+---+
|   |                         | Basic   | all charges                  |   |
|   |                         | Option: |                              |   |
+---+-------------------------+---------+------------------------------+---+
|   | Does not participate    | S       | your deductibles,            |   |
|   | with Medicare, and is   | tandard | coinsurance, and copayments, |   |
|   | in our Preferred        | Option: | and any balance up to 115%   |   |
|   | network                 |         | of the Medicare approved     |   |
|   |                         |         | amount                       |   |
+---+-------------------------+---------+------------------------------+---+
|   |                         | Basic   | your copayments and          |   |
|   |                         | Option: | coinsurance                  |   |
+---+-------------------------+---------+------------------------------+---+
|   |                         |         | ***Note:*** In many cases,   |   |
|   |                         |         | your payment will be less    |   |
|   |                         |         | because of our Preferred     |   |
|   |                         |         | agreements. Contact your     |   |
|   |                         |         | Local Plan for information   |   |
|   |                         |         | about what your specific     |   |
|   |                         |         | Preferred provider can       |   |
|   |                         |         | collect from you.            |   |
+---+-------------------------+---------+------------------------------+---+
|   | Does not participate    | S       | your deductibles,            |   |
|   | with Medicare and is    | tandard | coinsurance, copayments, and |   |
|   | **not** in our          | Option: | any balance up to 115% of    |   |
|   | Preferred network       |         | the Medicare approved amount |   |
+---+-------------------------+---------+------------------------------+---+
|   |                         | Basic   | all charges                  |   |
|   |                         | Option: |                              |   |
+---+-------------------------+---------+------------------------------+---+
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| . |                         |         |                              |   |
+---+-------------------------+---------+------------------------------+---+

+----------------------+-----------------------------------------------+
| **When you have      | We limit our payment to an amount that        |
| the**                | supplements the benefits that Medicare would  |
|                      | pay under Medicare Part A (Hospital           |
| **Original Medicare  | Insurance) and Medicare Part B (Medical       |
| Plan**               | Insurance), regardless of whether Medicare    |
|                      | pays.                                         |
| **(Part A, Part B,   |                                               |
| or both)**           |                                               |
+----------------------+-----------------------------------------------+
|                      | ***Note:*** We pay our regular benefits for   |
|                      | emergency services to a facility provider,    |
|                      | such as a hospital, that does not participate |
|                      | with Medicare and is not reimbursed by        |
|                      | Medicare.                                     |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | If you are covered by Medicare Part B and it  |
|                      | is primary, your out-of-pocket costs for      |
|                      | services that both Medicare Part B and we     |
|                      | cover depend on whether your physician        |
|                      | accepts Medicare assignment for the claim.    |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | -   If your physician accepts Medicare        |
|                      |     assignment, then you pay nothing for      |
|                      |     covered charges (see note below for Basic |
|                      |     Option).                                  |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | -   If your physician does not accept         |
|                      |     Medicare assignment, then you pay the     |
|                      |     difference between the \"limiting         |
|                      |     charge\" or the physician\'s charge       |
|                      |     (whichever is less) and our payment       |
|                      |     combined with Medicare\'s payment (see    |
|                      |     note below for Basic Option).             |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | ***Note:* Under Basic Option,** you must see  |
|                      | **Preferred** providers in order to receive   |
|                      | benefits. See page 12 for the exceptions to   |
|                      | this requirement.                             |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | It\'s important to know that a physician who  |
|                      | does not accept Medicare assignment may not   |
|                      | bill you for more than 115% of the amount     |
|                      | Medicare bases its payment on, called the     |
|                      | \"limiting charge.\" The Medicare Summary     |
|                      | Notice (MSN) form that you receive from       |
|                      | Medicare will have more information about the |
|                      | limiting charge. If your physician tries to   |
|                      | collect more than allowed by law, ask the     |
|                      | physician to reduce the charges. If the       |
|                      | physician does not, report the physician to   |
|                      | your Medicare carrier who sent you the MSN    |
|                      | form. Call us if you need further assistance. |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
| **Should I enroll in | The decision to enroll in Medicare is yours.  |
| Medicare?**          | We encourage you to apply for Medicare        |
|                      | benefits 3 months before you turn age 65.     |
|                      | It\'s easy. Just call the Social Security     |
|                      | Administration toll-free number               |
|                      | 1-800-772-1213 to set up an appointment to    |
|                      | apply. If you do not apply for one or both    |
|                      | Parts of Medicare, you can still be covered   |
|                      | under the FEHB Program.                       |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | If you can get premium-free Part A coverage,  |
|                      | we advise you to enroll in it. Most Federal   |
|                      | employees and annuitants are entitled to      |
|                      | Medicare Part A at age 65 **without cost.**   |
|                      | Medicare Part A covers hospital stays,        |
|                      | skilled nursing facility care, and other      |
|                      | expenses. When you don\'t have to pay         |
|                      | premiums for Medicare Part A, it makes good   |
|                      | sense to obtain the coverage. It can reduce   |
|                      | your out-of-pocket expenses as well as costs  |
|                      | to the FEHB, which can help keep FEHB         |
|                      | premiums down.                                |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | Medicare Part B covers doctors\' services and |
|                      | outpatient hospital care. Everyone is charged |
|                      | a premium for Medicare Part B coverage. The   |
|                      | Social Security Administration can provide    |
|                      | you with premium and benefit information.     |
|                      | Review the information and decide if it makes |
|                      | sense for you to buy Medicare Part B          |
|                      | coverage.                                     |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | **Please see Section 9, *Coordinating         |
|                      | benefits with other coverage*, for more       |
|                      | information about how we coordinate benefits  |
|                      | with Medicare.**                              |
+----------------------+-----------------------------------------------+

+-----------------------------------------------------------------------+
| ## Section 5. Benefits -- OVERVIEW                                    |
|                                                                       |
| ##### *(See page 9 for how our b                                      |
| enefits changed this year and pages 123-124 for a benefits summary.)* |
+-----------------------------------------------------------------------+

**Note:** This benefits section is divided into subsections. Please read
the important things you should keep in mind at the beginning of each
subsection. Also read the General exclusions in Section 6; they apply to
the benefits in the following subsections. To obtain claim forms, claims
filing advice, or more information about our benefits, contact us at the
customer service telephone number on the back of your Service Benefit
Plan ID card or at our Web site at [www.fepblue.org]().

(a) Medical services and supplies provided by physicians and other
    health care professionals 24-44

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

(b) Surgical and anesthesia services provided by physicians and other
    health care professionals 45-56

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

(c) Services provided by a hospital or other facility, and ambulance
    services 57-66

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

(d) Emergency services/Accidents 67-71

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

(e) Mental health and substance abuse benefits 72-78

(f) Prescription drug benefits 79-86

(g) Special features 87

-   Flexible benefits option

-   Online customer and claims service

-   24-hour nurse line

-   Services for the deaf and hearing impaired

-   Travel benefit/services overseas

-   Health support programs

-   Healthy Families Program

(h) Dental benefits 88-93

(i) Services, drugs, and supplies provided overseas 94-95

(j) Non-FEHB benefits available to Plan members 96

*SUMMARY OF BENEFITS* 123-124

+---+---+-----------------------+-------------------+-------------+---+---+
| # |   |                       |                   |             |   |   |
| # |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| 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 |   |                       |                   |             |   |   |
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|   |   |                       |                   |             |   |   |
| p |   |                       |                   |             |   |   |
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| 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    |                   |             | * |   |
|   | I | > you should keep in  |                   |             | I |   |
|   | * | > mind about these    |                   |             | * |   |
|   | * | > benefits:**         |                   |             | * |   |
|   |   |                       |                   |             |   |   |
|   | * | -   Please remember   |                   |             | * |   |
|   | * |     that all benefits |                   |             | * |   |
|   | M |     are subject to    |                   |             | M |   |
|   | * |     the definitions,  |                   |             | * |   |
|   | * |     limitations, and  |                   |             | * |   |
|   |   |     exclusions in     |                   |             |   |   |
|   | * |     this brochure and |                   |             | * |   |
|   | * |     are payable only  |                   |             | * |   |
|   | P |     when we determine |                   |             | P |   |
|   | * |     they are          |                   |             | * |   |
|   | * |     medically         |                   |             | * |   |
|   |   |     necessary.        |                   |             |   |   |
|   | * |                       |                   |             | * |   |
|   | * | -   **Under Standard  |                   |             | * |   |
|   | O |     Option,** the     |                   |             | O |   |
|   | * |     calendar year     |                   |             | * |   |
|   | * |     deductible is     |                   |             | * |   |
|   |   |     \$250 per person  |                   |             |   |   |
|   | * |     (\$500 per        |                   |             | * |   |
|   | * |     family). The      |                   |             | * |   |
|   | R |     calendar year     |                   |             | R |   |
|   | * |     deductible        |                   |             | * |   |
|   | * |     applies to almost |                   |             | * |   |
|   |   |     all benefits in   |                   |             |   |   |
|   | * |     this Section. We  |                   |             | * |   |
|   | * |     added \"(No       |                   |             | * |   |
|   | T |     deductible)\" to  |                   |             | T |   |
|   | * |     show when the     |                   |             | * |   |
|   | * |     calendar year     |                   |             | * |   |
|   |   |     deductible does   |                   |             |   |   |
|   | * |     not apply.        |                   |             | * |   |
|   | * |                       |                   |             | * |   |
|   | A | -   **Under Basic     |                   |             | A |   |
|   | * |     Option,** there   |                   |             | * |   |
|   | * |     is **no calendar  |                   |             | * |   |
|   |   |     year              |                   |             |   |   |
|   | * |     deductible.**     |                   |             | * |   |
|   | * |                       |                   |             | * |   |
|   | N | -   **Under Basic     |                   |             | N |   |
|   | * |     Option,** **you   |                   |             | * |   |
|   | * |     must use          |                   |             | * |   |
|   |   |     Preferred         |                   |             |   |   |
|   | * |     providers in      |                   |             | * |   |
|   | * |     order to receive  |                   |             | * |   |
|   | T |     benefits. See     |                   |             | T |   |
|   | * |     page 12 for the   |                   |             | * |   |
|   | * |     exceptions to     |                   |             | * |   |
|   |   |     this              |                   |             |   |   |
|   |   |     requirement.**    |                   |             |   |   |
|   |   |                       |                   |             |   |   |
|   |   | -   Please refer to   |                   |             |   |   |
|   |   |     Section 3, *How   |                   |             |   |   |
|   |   |     you receive       |                   |             |   |   |
|   |   |     benefits*, for a  |                   |             |   |   |
|   |   |     list of providers |                   |             |   |   |
|   |   |     we consider to be |                   |             |   |   |
|   |   |     primary care      |                   |             |   |   |
|   |   |     providers (under  |                   |             |   |   |
|   |   |     Basic Option) and |                   |             |   |   |
|   |   |     other health care |                   |             |   |   |
|   |   |     professionals.    |                   |             |   |   |
|   |   |                       |                   |             |   |   |
|   |   | ```{=html}            |                   |             |   |   |
|   |   | <!-- -->              |                   |             |   |   |
|   |   | ```                   |                   |             |   |   |
|   |   | -   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         |                   |             |   |   |
|   |   |     Medicare.         |                   |             |   |   |
|   |   |                       |                   |             |   |   |
|   |   | ```{=html}            |                   |             |   |   |
|   |   | <!-- -->              |                   |             |   |   |
|   |   | ```                   |                   |             |   |   |
|   |   | -   We base payment   |                   |             |   |   |
|   |   |     on whether a      |                   |             |   |   |
|   |   |     facility or a     |                   |             |   |   |
|   |   |     health care       |                   |             |   |   |
|   |   |     professional      |                   |             |   |   |
|   |   |     bills for the     |                   |             |   |   |
|   |   |     services or       |                   |             |   |   |
|   |   |     supplies. You     |                   |             |   |   |
|   |   |     will find that    |                   |             |   |   |
|   |   |     some benefits are |                   |             |   |   |
|   |   |     listed in more    |                   |             |   |   |
|   |   |     than one section  |                   |             |   |   |
|   |   |     of the brochure.  |                   |             |   |   |
|   |   |     This is because   |                   |             |   |   |
|   |   |     how they are paid |                   |             |   |   |
|   |   |     depends on what   |                   |             |   |   |
|   |   |     type of provider  |                   |             |   |   |
|   |   |     bills for the     |                   |             |   |   |
|   |   |     service. For      |                   |             |   |   |
|   |   |     example, physical |                   |             |   |   |
|   |   |     therapy is paid   |                   |             |   |   |
|   |   |     differently       |                   |             |   |   |
|   |   |     depending on      |                   |             |   |   |
|   |   |     whether it is     |                   |             |   |   |
|   |   |     billed by an      |                   |             |   |   |
|   |   |     inpatient         |                   |             |   |   |
|   |   |     facility, a       |                   |             |   |   |
|   |   |     doctor, a         |                   |             |   |   |
|   |   |     physical          |                   |             |   |   |
|   |   |     therapist, or an  |                   |             |   |   |
|   |   |     outpatient        |                   |             |   |   |
|   |   |     facility.         |                   |             |   |   |
|   |   |                       |                   |             |   |   |
|   |   | -   The amounts       |                   |             |   |   |
|   |   |     listed below are  |                   |             |   |   |
|   |   |     for the charges   |                   |             |   |   |
|   |   |     billed by a       |                   |             |   |   |
|   |   |     physician or      |                   |             |   |   |
|   |   |     other health care |                   |             |   |   |
|   |   |     professional for  |                   |             |   |   |
|   |   |     your medical      |                   |             |   |   |
|   |   |     care. Look in     |                   |             |   |   |
|   |   |     Section 5(c) for  |                   |             |   |   |
|   |   |     charges           |                   |             |   |   |
|   |   |     associated with   |                   |             |   |   |
|   |   |     the facility      |                   |             |   |   |
|   |   |     (i.e.*,* hospital |                   |             |   |   |
|   |   |     or other          |                   |             |   |   |
|   |   |     outpatient        |                   |             |   |   |
|   |   |     facility, etc.).  |                   |             |   |   |
|   |   |                       |                   |             |   |   |
|   |   | ```{=html}            |                   |             |   |   |
|   |   | <!-- -->              |                   |             |   |   |
|   |   | ```                   |                   |             |   |   |
|   |   | -   PPO benefits      |                   |             |   |   |
|   |   |     apply only when   |                   |             |   |   |
|   |   |     you use a PPO     |                   |             |   |   |
|   |   |     provider. When no |                   |             |   |   |
|   |   |     PPO provider is   |                   |             |   |   |
|   |   |     available,        |                   |             |   |   |
|   |   |     non-PPO benefits  |                   |             |   |   |
|   |   |     apply.            |                   |             |   |   |
+---+---+-----------------------+-------------------+-------------+---+---+
| * |   |                       | **You Pay**       |             |   |   |
| * |   |                       |                   |             |   |   |
| B |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| n |   |                       |                   |             |   |   |
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| f |   |                       |                   |             |   |   |
| i |   |                       |                   |             |   |   |
| t |   |                       |                   |             |   |   |
| D |   |                       |                   |             |   |   |
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| s |   |                       |                   |             |   |   |
| c |   |                       |                   |             |   |   |
| r |   |                       |                   |             |   |   |
| i |   |                       |                   |             |   |   |
| p |   |                       |                   |             |   |   |
| t |   |                       |                   |             |   |   |
| i |   |                       |                   |             |   |   |
| o |   |                       |                   |             |   |   |
| n |   |                       |                   |             |   |   |
| * |   |                       |                   |             |   |   |
| * |   |                       |                   |             |   |   |
+---+---+-----------------------+-------------------+-------------+---+---+
| # |   |                       |                   |             |   |   |
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+---+---+-----------------------+-------------------+-------------+---+---+
| # |   |                       | ### You Pay       | ###         |   |   |
| # |   |                       | − Standard Option | You Pay − B |   |   |
| # |   |                       |                   | asic Option |   |   |
|   |   |                       |                   |             |   |   |
| D |   |                       |                   |             |   |   |
| i |   |                       |                   |             |   |   |
| a |   |                       |                   |             |   |   |
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| n |   |                       |                   |             |   |   |
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| c |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| a |   |                       |                   |             |   |   |
| n |   |                       |                   |             |   |   |
| d |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| t |   |                       |                   |             |   |   |
| r |   |                       |                   |             |   |   |
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| a |   |                       |                   |             |   |   |
| t |   |                       |                   |             |   |   |
| m |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| n |   |                       |                   |             |   |   |
| t |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| s |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| r |   |                       |                   |             |   |   |
| v |   |                       |                   |             |   |   |
| i |   |                       |                   |             |   |   |
| c |   |                       |                   |             |   |   |
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| s |   |                       |                   |             |   |   |
+---+---+-----------------------+-------------------+-------------+---+---+
| > |   |                       | > Preferred: \$15 | > Preferred |   |   |
|   |   |                       | > copayment for   | > primary   |   |   |
| P |   |                       | > the office      | > care      |   |   |
| r |   |                       | > visit charge    | > provider  |   |   |
| o |   |                       | > (No deductible) | > or other  |   |   |
| f |   |                       | >                 | > health    |   |   |
| e |   |                       | > Participating:  | > care      |   |   |
| s |   |                       | > 25% of the Plan | > pr        |   |   |
| s |   |                       | > allowance       | ofessional: |   |   |
| i |   |                       | >                 | > \$20      |   |   |
| o |   |                       | > N               | > copayment |   |   |
| n |   |                       | on-participating: | > per visit |   |   |
| a |   |                       | > 25% of the Plan | >           |   |   |
| l |   |                       | > allowance, plus | > Preferred |   |   |
| > |   |                       | > any difference  | >           |   |   |
|   |   |                       | > between our     | specialist: |   |   |
| s |   |                       | > allowance and   | > \$30      |   |   |
| e |   |                       | > the billed      | > copayment |   |   |
| r |   |                       | > amount          | > per visit |   |   |
| v |   |                       |                   | >           |   |   |
| i |   |                       |                   | >           |   |   |
| c |   |                       |                   | ***Note:*** |   |   |
| e |   |                       |                   | > You pay   |   |   |
| s |   |                       |                   | > 30% of    |   |   |
| > |   |                       |                   | > the Plan  |   |   |
|   |   |                       |                   | > allowance |   |   |
| o |   |                       |                   | > for drugs |   |   |
| f |   |                       |                   | > and       |   |   |
| > |   |                       |                   | > supplies. |   |   |
|   |   |                       |                   | >           |   |   |
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| y |   |                       |                   | ing/Non-par |   |   |
| s |   |                       |                   | ticipating: |   |   |
| i |   |                       |                   | > You pay   |   |   |
| c |   |                       |                   | > all       |   |   |
| i |   |                       |                   | > charges   |   |   |
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|   |   |                       |                   |             |   |   |
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|   |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| d |   |                       |                   |             |   |   |
| r |   |                       |                   |             |   |   |
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| g |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| c |   |                       |                   |             |   |   |
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| r |   |                       |                   |             |   |   |
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| \ |   |                       |                   |             |   |   |
| ] |   |                       |                   |             |   |   |
+---+---+-----------------------+-------------------+-------------+---+---+

Diagnostic and treatment services − *continued on next page*

+-----------------------------+-------------------+-------------------+
| # Note: The calenda         |                   |                   |
| r year deductible applies t |                   |                   |
| o almost all Standard Optio |                   |                   |
| n benefits in this Section. |                   |                   |
|                             |                   |                   |
| #                           |                   |                   |
|  We say \"(No deductible)\" |                   |                   |
|  when the Standard Option d |                   |                   |
| eductible does *not* apply. |                   |                   |
|                             |                   |                   |
| **There is no calendar year |                   |                   |
| deductible under Basic      |                   |                   |
| Option.**                   |                   |                   |
+-----------------------------+-------------------+-------------------+
| **Diagnostic and treatment  | ### You Pay       | ### You P         |
| services**                  | − Standard Option | ay − Basic Option |
|                             |                   |                   |
| *(continued)*               |                   |                   |
+-----------------------------+-------------------+-------------------+
| > Outpatient professional   | > Preferred: 10%  | > Preferred       |
| > services:                 | > of the Plan     | > primary care    |
|                             | > allowance       | > provider or     |
| -   Neurological testing    | >                 | > other health    |
|                             | > Participating:  | > care            |
|                             | > 25% of the Plan | > professional:   |
|                             | > allowance       | > \$20 copayment  |
|                             | >                 | > per visit       |
|                             | > N               | >                 |
|                             | on-participating: | > Preferred       |
|                             | > 25% of the Plan | > specialist:     |
|                             | > allowance, plus | > \$30 copayment  |
|                             | > any difference  | > per visit       |
|                             | > between our     | >                 |
|                             | > allowance and   | > ***Note:*** You |
|                             | > the billed      | > pay 30% of the  |
|                             | > amount          | > Plan allowance  |
|                             |                   | > for drugs and   |
|                             |                   | > supplies.       |
|                             |                   | >                 |
|                             |                   | > Participating/N |
|                             |                   | on-participating: |
|                             |                   | > You pay all     |
|                             |                   | > charges         |
+-----------------------------+-------------------+-------------------+
| > Inpatient professional    | > Preferred: 10%  | > Preferred:      |
| > services:                 | > of the Plan     | > Nothing         |
|                             | > allowance       | >                 |
| -   During a hospital stay  | >                 | > Participating/N |
|                             | > Participating:  | on-participating: |
| -   Services for            | > 25% of the Plan | > You pay all     |
|     nonsurgical procedures  | > allowance       | > charges         |
|     when ordered, provided, | >                 | >                 |
|     and billed by a         | > N               | > ***Note:*** We  |
|     physician during a      | on-participating: | > provide         |
|     covered inpatient       | > 25% of the Plan | > benefits at     |
|     hospital admission      | > allowance, plus | > 100% of the     |
|                             | > any difference  | > Plan allowance  |
| ```{=html}                  | > between our     | > for services    |
| <!-- -->                    | > allowance and   | > provided in     |
| ```                         | > the billed      | > Preferred       |
| -   Medical care by the     | > amount          | > facilities by   |
|     attending physician     | >                 | > Non-preferred   |
|     (the physician who is   | > ***Note:*** We  | > radiologists,   |
|     primarily responsible   | > provide         | > a               |
|     for your care when you  | > benefits at 90% | nesthesiologists, |
|     are hospitalized) on    | > of the Plan     | > certified       |
|     days we pay inpatient   | > allowance for   | > registered      |
|     hospital benefits       | > services        | > nurse           |
|                             | > provided in     | > anesthetists    |
| > ***Note:*** A consulting  | > Preferred       | > (CRNAs),        |
| > physician employed by the | > facilities by   | > pathologists,   |
| > hospital is not the       | > Non-preferred   | > emergency room  |
| > attending physician.      | > radiologists,   | > physicians, and |
|                             | > a               | > assistant       |
| -   Consultations when      | nesthesiologists, | > surgeons. You   |
|     requested by the        | > certified       | > are responsible |
|     attending physician     | > registered      | > for any         |
|                             | > nurse           | > difference      |
| ```{=html}                  | > anesthetists    | > between our     |
| <!-- -->                    | > (CRNAs),        | > allowance and   |
| ```                         | > pathologists,   | > the billed      |
| -   Concurrent care --      | > and emergency   | > amount.         |
|     hospital inpatient care | > room            |                   |
|     by a physician other    | > physicians. You |                   |
|     than the attending      | > are responsible |                   |
|     physician for a         | > for any         |                   |
|     condition not related   | > difference      |                   |
|     to your primary         | > between our     |                   |
|     diagnosis, or because   | > allowance and   |                   |
|     the medical complexity  | > the billed      |                   |
|     of your condition       | > amount.         |                   |
|     requires this           |                   |                   |
|     additional medical care |                   |                   |
|                             |                   |                   |
| -   Physical therapy by a   |                   |                   |
|     physician other than    |                   |                   |
|     the attending physician |                   |                   |
|                             |                   |                   |
| -   Initial examination of  |                   |                   |
|     a newborn needing       |                   |                   |
|     definitive treatment    |                   |                   |
|     when covered under a    |                   |                   |
|     family enrollment       |                   |                   |
|                             |                   |                   |
| -   Pharmacotherapy \[see   |                   |                   |
|     Section 5(c) for        |                   |                   |
|     prescription drug       |                   |                   |
|     coverage\]              |                   |                   |
|                             |                   |                   |
| -   Neurological testing    |                   |                   |
|                             |                   |                   |
| -   Second surgical opinion |                   |                   |
+-----------------------------+-------------------+-------------------+

Diagnostic and treatment services − *continued on next page*

+-----------------------------+-------------------+-------------------+
| # Note: The calenda         |                   |                   |
| r year deductible applies t |                   |                   |
| o almost all Standard Optio |                   |                   |
| n benefits in this Section. |                   |                   |
|                             |                   |                   |
| #                           |                   |                   |
|  We say \"(No deductible)\" |                   |                   |
|  when the Standard Option d |                   |                   |
| eductible does *not* apply. |                   |                   |
|                             |                   |                   |
| **There is no calendar year |                   |                   |
| deductible under Basic      |                   |                   |
| Option.**                   |                   |                   |
+-----------------------------+-------------------+-------------------+
| ### Diagnostic and treat    | ### You Pay       | **You Pay − Basic |
| ment services *(continued)* | − Standard Option | Option**          |
+-----------------------------+-------------------+-------------------+
| > *Not covered:*            | > *All charges*   | > *All charges*   |
|                             |                   |                   |
| -   *Routine services       |                   |                   |
|     except for those        |                   |                   |
|     Preventive care         |                   |                   |
|     services described      |                   |                   |
|     below, on pages*        |                   |                   |
|                             |                   |                   |
| *27-30, and page 45*        |                   |                   |
|                             |                   |                   |
| -   *Inpatient private duty |                   |                   |
|     nursing*                |                   |                   |
|                             |                   |                   |
| -   *Standby physicians*    |                   |                   |
|                             |                   |                   |
| -   *Routine radiological   |                   |                   |
|     and staff consultations |                   |                   |
|     required by hospital    |                   |                   |
|     rules and regulations*  |                   |                   |
|                             |                   |                   |
| ```{=html}                  |                   |                   |
| <!-- -->                    |                   |                   |
| ```                         |                   |                   |
| -   *Inpatient physician    |                   |                   |
|     care when your hospital |                   |                   |
|     admission or portion of |                   |                   |
|     an admission is not     |                   |                   |
|     covered \[see Section   |                   |                   |
|     5(c)\]*                 |                   |                   |
|                             |                   |                   |
| > ***Note:** If we          |                   |                   |
| > determine that a hospital |                   |                   |
| > admission is not covered, |                   |                   |
| > we will not provide       |                   |                   |
| > benefits for inpatient    |                   |                   |
| > room and board or         |                   |                   |
| > inpatient physician care. |                   |                   |
| > However, we will provide  |                   |                   |
| > benefits for covered      |                   |                   |
| > services or supplies      |                   |                   |
| > other than room and board |                   |                   |
| > and inpatient physician   |                   |                   |
| > care at the level that we |                   |                   |
| > would have paid if they   |                   |                   |
| > had been provided in some |                   |                   |
| > other setting.*           |                   |                   |
+-----------------------------+-------------------+-------------------+
| # Lab, X-ray,               |                   |                   |
|  and other diagnostic tests |                   |                   |
+-----------------------------+-------------------+-------------------+
| > Diagnostic tests          | > Preferred: 10%  | > Preferred       |
| > provided, or ordered and  | > of the Plan     | > primary care    |
| > billed by a physician,    | > allowance       | > provider or     |
| > such as:                  | >                 | > other health    |
|                             | > Participating:  | > care            |
| -   Blood tests             | > 25% of the Plan | > professional:   |
|                             | > allowance       | > \$20 copayment  |
| ```{=html}                  | >                 | > per visit       |
| <!-- -->                    | > N               | >                 |
| ```                         | on-participating: | > Preferred       |
| -   Bone density tests --   | > 25% of the Plan | > specialist:     |
|     screening or diagnostic | > allowance, plus | > \$30 copayment  |
|                             | > any difference  | > per visit       |
| ```{=html}                  | > between our     | >                 |
| <!-- -->                    | > allowance and   | > ***Note:*** You |
| ```                         | > the billed      | > pay 30% of the  |
| -   CT scans/MRIs           | > amount          | > Plan allowance  |
|                             | >                 | > for drugs and   |
| ```{=html}                  | > ***Note:*** If  | > supplies.       |
| <!-- -->                    | > your Preferred  | >                 |
| ```                         | > provider uses a | > Participating/N |
| -   EKGs and EEGs           | > Non-preferred   | on-participating: |
|                             | > laboratory or   | > You pay all     |
| -   Laboratory tests        | > radiologist, we | > charges         |
|                             | > will pay        | >                 |
| ```{=html}                  | > Non-preferred   | > ***Note:*** For |
| <!-- -->                    | > benefits for    | > services billed |
| ```                         | > any laboratory  | > by              |
| -   Pathology services      | > and X-ray       | > Participating   |
|                             | > charges.        | > and             |
| ```{=html}                  |                   | >                 |
| <!-- -->                    |                   | Non-participating |
| ```                         |                   | > laboratories or |
| -   Ultrasounds             |                   | > radiologists,   |
|                             |                   | > you pay a       |
| -   Urinalysis              |                   | > separate \$20   |
|                             |                   | > copayment, plus |
| -   X-rays                  |                   | > any difference  |
|                             |                   | > between our     |
| > Laboratory and pathology  |                   | > allowance and   |
| > services billed by an     |                   | > the billed      |
| > independent laboratory    |                   | > amount.         |
| >                           |                   |                   |
| > ***Note:*** See Section   |                   |                   |
| > 5(c) for services billed  |                   |                   |
| > for by a facility, such   |                   |                   |
| > as the outpatient         |                   |                   |
| > department of a hospital. |                   |                   |
+-----------------------------+-------------------+-------------------+

Lab, X-ray, and other diagnostic tests − *continued on next page*

+-----------------------------+-------------------+-------------------+
| # Note: The calenda         |                   |                   |
| r year deductible applies t |                   |                   |
| o almost all Standard Optio |                   |                   |
| n benefits in this Section. |                   |                   |
|                             |                   |                   |
| #                           |                   |                   |
|  We say \"(No deductible)\" |                   |                   |
|  when the Standard Option d |                   |                   |
| eductible does *not* apply. |                   |                   |
|                             |                   |                   |
| **There is no calendar year |                   |                   |
| deductible under Basic      |                   |                   |
| Option.**                   |                   |                   |
+-----------------------------+-------------------+-------------------+
| # Lab, X-ray, and other dia | ### You Pay       | **You Pay − Basic |
| gnostic tests *(continued)* | − Standard Option | Option**          |
+-----------------------------+-------------------+-------------------+
| > Other diagnostic tests    | > Preferred: \$15 | > Preferred       |
| > provided, or ordered and  | > copayment for   | > primary care    |
| > billed by a physician,    | > associated      | > provider or     |
| > such as:                  | > office visits   | > other health    |
|                             | > (No             | > care            |
| -   Fecal occult blood      | > deductible);    | > professional:   |
|     tests                   | > nothing for     | > \$20 copayment  |
|                             | > services or     | > per visit       |
| -   Non-routine mammograms  | > tests           | >                 |
|                             | >                 | > Preferred       |
| -   Non-routine Pap tests   | > Participating:  | > specialist:     |
|                             | > 25% of the Plan | > \$30 copayment  |
| -   Prostate Specific       | > allowance       | > per visit       |
|     Antigen (PSA) tests     | >                 | >                 |
|                             | > N               | > ***Note:*** You |
| -   Sigmoidoscopies         | on-participating: | > pay 30% of the  |
|                             | > 25% of the Plan | > Plan allowance  |
| > ***Note:*** See Section   | > allowance, plus | > for drugs and   |
| > 5(c) for services billed  | > any difference  | > supplies.       |
| > for by a facility, such   | > between our     | >                 |
| > as the outpatient         | > allowance and   | > Participating/N |
| > department of a hospital. | > the billed      | on-participating: |
|                             | > amount          | > You pay all     |
|                             | >                 | > charges         |
|                             | > ***Note:*** If  | >                 |
|                             | > your Preferred  | > ***Note:*** For |
|                             | > provider uses a | > services billed |
|                             | > Non-preferred   | > by              |
|                             | > laboratory or   | > Participating   |
|                             | > radiologist, we | > and             |
|                             | > will pay        | >                 |
|                             | > Non-preferred   | Non-participating |
|                             | > benefits for    | > laboratories or |
|                             | > any laboratory  | > radiologists,   |
|                             | > and X-ray       | > you pay a       |
|                             | > charges.        | > separate \$20   |
|                             |                   | > copayment, plus |
|                             |                   | > any difference  |
|                             |                   | > between our     |
|                             |                   | > allowance and   |
|                             |                   | > the billed      |
|                             |                   | > amount.         |
+-----------------------------+-------------------+-------------------+
| #                           | ###               |                   |
| #### Preventive care, adult |                   |                   |
+-----------------------------+-------------------+-------------------+
| > Home and office visits    | > Preferred: \$15 | > Preferred       |
| > for routine (screening)   | > copayment for   | > primary care    |
| > physical examinations     | > the examination | > provider or     |
| >                           | > (No             | > other health    |
| > **Under Standard          | > deductible);    | > care            |
| > Option,** benefits are    | > nothing for     | > professional:   |
| > limited to the following  | > services or     | > \$20 copayment  |
| > services when performed   | > tests           | > per visit       |
| > as part of a routine      | >                 | >                 |
| > physical examination:     | > ***Note:*** We  | > Preferred       |
|                             | > cover one       | > specialist:     |
| -   History and risk        | > routine         | > \$30 copayment  |
|     assessment              | > physical        | > per visit       |
|                             | > examination     | >                 |
| ```{=html}                  | > every three     | > ***Note:*** You |
| <!-- -->                    | > calendar years  | > pay 30% of the  |
| ```                         | > for members     | > Plan allowance  |
| -   Chest X-ray             | > under age 65    | > for drugs and   |
|                             | > and one each    | > supplies.       |
| ```{=html}                  | > calendar year   | >                 |
| <!-- -->                    | > for members age | > Participating/N |
| ```                         | > 65 and older.   | on-participating: |
| -   EKG                     | >                 | > You pay all     |
|                             | > ***Note:*** We  | > charges         |
| ```{=html}                  | > provide         | >                 |
| <!-- -->                    | > benefits for    | > ***Note:*** For |
| ```                         | > adult routine   | > services billed |
| -   Urinalysis              | > physical        | > by              |
|                             | > examinations    | > Participating   |
| ```{=html}                  | > only when you   | > and             |
| <!-- -->                    | > receive these   | >                 |
| ```                         | > services from a | Non-participating |
| -   Basic or comprehensive  | > **Preferred     | > laboratories or |
|     metabolic panel test    | > provider**.     | > radiologists,   |
|                             | >                 | > you pay a       |
| ```{=html}                  | > Participating:  | > separate \$20   |
| <!-- -->                    | >                 | > copayment, plus |
| ```                         | > You pay all     | > any difference  |
| -   CBC                     | > charges         | > between our     |
|                             | >                 | > allowance and   |
| ```{=html}                  | > N               | > the billed      |
| <!-- -->                    | on-participating: | > amount.         |
| ```                         | >                 | >                 |
| -   Fasting lipoprotein     | > You pay all     | > ***Note:*** See |
|     profile (total          | > charges         | > Section 5(c)    |
|     cholesterol, LDL, HDL,  | >                 | > for our payment |
|     and triglycerides) when | > ***Note:***     | > levels for      |
|     performed by a          | > When billed by  | > these services  |
|     Preferred provider or   | > a facility,     | > when billed for |
|     any independent         | > such as the     | > by a facility,  |
|     laboratory              | > outpatient      | > such as the     |
|                             | > department of a | > outpatient      |
| > ***Note:*** The benefits  | > hospital, we    | > department of a |
| > listed above do not apply | > provide         | > hospital.       |
| > to children up to age 22. | > benefits as     |                   |
| > (See benefits under       | > shown here,     |                   |
| > *Preventive care,*        | > according to    |                   |
| > *children*, this          | > the contracting |                   |
| > section.)                 | > status of the   |                   |
|                             | > facility.       |                   |
| -   Chlamydial infection    |                   |                   |
|     test                    |                   |                   |
|                             |                   |                   |
| > **Under Basic Option,**   |                   |                   |
| > benefits are provided for |                   |                   |
| > all of the services       |                   |                   |
| > listed above and for      |                   |                   |
| > other appropriate         |                   |                   |
| > screening tests and       |                   |                   |
| > services.                 |                   |                   |
+-----------------------------+-------------------+-------------------+

Preventive care, adult -- *continued on next page*

+-----------------------------+-------------------+-------------------+
| # Note: The calenda         |                   |                   |
| r year deductible applies t |                   |                   |
| o almost all Standard Optio |                   |                   |
| n benefits in this Section. |                   |                   |
|                             |                   |                   |
| #                           |                   |                   |
|  We say \"(No deductible)\" |                   |                   |
|  when the Standard Option d |                   |                   |
| eductible does *not* apply. |                   |                   |
|                             |                   |                   |
| **There is no calendar year |                   |                   |
| deductible under Basic      |                   |                   |
| Option.**                   |                   |                   |
+-----------------------------+-------------------+-------------------+
| ##### Preventiv             | ### You Pay       | **You Pay − Basic |
| e care, adult *(continued)* | − Standard Option | Option**          |
+-----------------------------+-------------------+-------------------+
| > Cancer screening          | > Preferred: \$15 | > Preferred       |
|                             | > copayment for   | > primary care    |
| -   Colorectal cancer       | > associated      | > provider or     |
|     screening, including:   | > office visits   | > other health    |
|                             | > (No             | > care            |
| ```{=html}                  | > deductible);    | > professional:   |
| <!-- -->                    | > nothing for     | > \$20 copayment  |
| ```                         | > services or     | > per visit       |
| -   Fecal occult blood test | > tests           | >                 |
|                             | >                 | > Preferred       |
| -   Sigmoidoscopy           | > ***Note:*** We  | > specialist:     |
|                             | > provide         | > \$30 copayment  |
| -   Double contrast barium  | > benefits in     | > per visit       |
|     enema                   | > full for        | >                 |
|                             | > preventive      | > ***Note:*** You |
| ```{=html}                  | > (screening)     | > pay 30% of the  |
| <!-- -->                    | > tests and       | > Plan allowance  |
| ```                         | > immunizations   | > for drugs and   |
| -   Prostate cancer         | > only when you   | > supplies.       |
|     screening -- Prostate   | > receive these   | >                 |
|     Specific Antigen (PSA)  | > services from a | > Participating/N |
|     test                    | > **Preferred     | on-participating: |
|                             | > provider** on   | > You pay all     |
| ```{=html}                  | > an outpatient   | > charges         |
| <!-- -->                    | > basis. If these | >                 |
| ```                         | > services are    | > ***Note:*** For |
| -   Cervical cancer         | > billed          | > services billed |
|     screening               | > separately from | > by              |
|                             | > the routine     | > Participating   |
| ```{=html}                  | > physical        | > and             |
| <!-- -->                    | > examination,    | >                 |
| ```                         | > you may be      | Non-participating |
| -   Breast cancer screening | > responsible for | > laboratories or |
|     (routine mammograms)    | > paying an       | > radiologists,   |
|                             | > additional      | > you pay a       |
|                             | > copayment for   | > separate \$20   |
|                             | > each office     | > copayment, plus |
|                             | > visit billed.   | > any difference  |
|                             | >                 | > between our     |
|                             | > Participating:  | > allowance and   |
|                             | > 25% of the Plan | > the billed      |
|                             | > allowance       | > amount.         |
|                             | >                 | >                 |
|                             | > N               | > ***Note:*** See |
|                             | on-participating: | > Section 5(c)    |
|                             | > 25% of the Plan | > for our payment |
|                             | > allowance, plus | > levels for      |
|                             | > any difference  | > these services  |
|                             | > between our     | > when billed for |
|                             | > allowance and   | > by a facility,  |
|                             | > the billed      | > such as the     |
|                             | > amount          | > outpatient      |
|                             | >                 | > department of a |
|                             | > ***Note:***     | > hospital.       |
|                             | > When billed by  |                   |
|                             | > a facility,     |                   |
|                             | > such as the     |                   |
|                             | > outpatient      |                   |
|                             | > department of a |                   |
|                             | > hospital, we    |                   |
|                             | > provide         |                   |
|                             | > benefits as     |                   |
|                             | > shown here,     |                   |
|                             | > according to    |                   |
|                             | > the contracting |                   |
|                             | > status of the   |                   |
|                             | > facility.       |                   |
+-----------------------------+-------------------+-------------------+

Preventive care, adult -- *continued on next page*

+-----------------------------+-------------------+-------------------+
| # Note: The calenda         |                   |                   |
| r year deductible applies t |                   |                   |
| o almost all Standard Optio |                   |                   |
| n benefits in this Section. |                   |                   |
|                             |                   |                   |
| #                           |                   |                   |
|  We say \"(No deductible)\" |                   |                   |
|  when the Standard Option d |                   |                   |
| eductible does *not* apply. |                   |                   |
|                             |                   |                   |
| **There is no calendar year |                   |                   |
| deductible under Basic      |                   |                   |
| Option.**                   |                   |                   |
+-----------------------------+-------------------+-------------------+
| ##### Preventiv             | ### You Pay       | **You Pay − Basic |
| e care, adult *(continued)* | − Standard Option | Option**          |
+-----------------------------+-------------------+-------------------+
| > Cancer screening          | > ***Note:*** If  | > See page 28     |
| > *(continued)*             | > you go to a     |                   |
|                             | > Participating   |                   |
|                             | > or              |                   |
|                             | >                 |                   |
|                             | Non-participating |                   |
|                             | > provider for    |                   |
|                             | > these services, |                   |
|                             | > the following   |                   |
|                             | > limits apply:   |                   |
|                             |                   |                   |
|                             | -   Fecal occult  |                   |
|                             |     blood test -- |                   |
|                             |     one annually  |                   |
|                             |     starting at   |                   |
|                             |     age 40        |                   |
|                             |                   |                   |
|                             | -   Sigmoidoscopy |                   |
|                             |     -- one every  |                   |
|                             |     five years    |                   |
|                             |     starting at   |                   |
|                             |     age 50        |                   |
|                             |                   |                   |
|                             | -   Double        |                   |
|                             |     contrast      |                   |
|                             |     barium enema  |                   |
|                             |     -- one every  |                   |
|                             |     five years    |                   |
|                             |     starting at   |                   |
|                             |     age 50        |                   |
|                             |                   |                   |
|                             | -   Prostate      |                   |
|                             |     Specific      |                   |
|                             |     Antigen (PSA) |                   |
|                             |     test -- one   |                   |
|                             |     annually for  |                   |
|                             |     males age 40  |                   |
|                             |     and older     |                   |
|                             |                   |                   |
|                             | -   Cervical      |                   |
|                             |     cancer        |                   |
|                             |     screening --  |                   |
|                             |     one routine   |                   |
|                             |     Pap test      |                   |
|                             |     annually for  |                   |
|                             |     females of    |                   |
|                             |     any age       |                   |
|                             |                   |                   |
|                             | -   Breast cancer |                   |
|                             |     screening --  |                   |
|                             |     routine       |                   |
|                             |     mammograms    |                   |
|                             |     for females   |                   |
|                             |     age 35 and    |                   |
|                             |     older, as     |                   |
|                             |     follows:      |                   |
|                             |                   |                   |
|                             | ```{=html}        |                   |
|                             | <!-- -->          |                   |
|                             | ```               |                   |
|                             | -   From age 35   |                   |
|                             |     through 39,   |                   |
|                             |     one during    |                   |
|                             |     this          |                   |
|                             |     five-year     |                   |
|                             |     period        |                   |
|                             |                   |                   |
|                             | ```{=html}        |                   |
|                             | <!-- -->          |                   |
|                             | ```               |                   |
|                             | -   From age 40   |                   |
|                             |     through 64,   |                   |
|                             |     one annually  |                   |
|                             |                   |                   |
|                             | ```{=html}        |                   |
|                             | <!-- -->          |                   |
|                             | ```               |                   |
|                             | -   At age 65 and |                   |
|                             |     older, one    |                   |
|                             |     every two     |                   |
|                             |     consecutive   |                   |
|                             |     calendar      |                   |
|                             |     years         |                   |
|                             |                   |                   |
|                             | > ***Note:***     |                   |
|                             | > When billed by  |                   |
|                             | > a facility,     |                   |
|                             | > such as the     |                   |
|                             | > outpatient      |                   |
|                             | > department of a |                   |
|                             | > hospital, we    |                   |
|                             | > provide         |                   |
|                             | > benefits as     |                   |
|                             | > shown here,     |                   |
|                             | > according to    |                   |
|                             | > the contracting |                   |
|                             | > status of the   |                   |
|                             | > facility.       |                   |
+-----------------------------+-------------------+-------------------+

Preventive care, adult -- *continued on next page*

+-----------------------------+-------------------+-------------------+
| # Note: The calenda         |                   |                   |
| r year deductible applies t |                   |                   |
| o almost all Standard Optio |                   |                   |
| n benefits in this Section. |                   |                   |
|                             |                   |                   |
| #                           |                   |                   |
|  We say \"(No deductible)\" |                   |                   |
|  when the Standard Option d |                   |                   |
| eductible does *not* apply. |                   |                   |
|                             |                   |                   |
| **There is no calendar year |                   |                   |
| deductible under Basic      |                   |                   |
| Option.**                   |                   |                   |
+-----------------------------+-------------------+-------------------+
| ##### Preventiv             | ### You Pay       | **You Pay − Basic |
| e care, adult *(continued)* | − Standard Option | Option**          |
+-----------------------------+-------------------+-------------------+
| > Routine immunizations     | > Preferred: \$15 | > Preferred       |
| > without regard to age,    | > copayment for   | > primary care    |
| > limited to:               | > associated      | > provider or     |
|                             | > office visits   | > other health    |
| -   Hepatitis immunizations | > (No             | > care            |
|     (Types A and B) for     | > deductible);    | > professional:   |
|     patients with increased | > nothing for     | > \$20 copayment  |
|     risk or family history  | > immunizations   | > for associated  |
|                             | >                 | > office visits;  |
| ```{=html}                  | > Participating:  | > nothing for     |
| <!-- -->                    | > 25% of the Plan | > immunizations   |
| ```                         | > allowance       | >                 |
| -   Influenza and           | >                 | > Preferred       |
|     pneumococcal vaccines,  | > N               | > specialist:     |
|     annually                | on-participating: | > \$30 copayment  |
|                             | > 25% of the Plan | > for associated  |
| -   Lyme disease vaccine    | > allowance, plus | > office visits;  |
|                             | > any difference  | > nothing for     |
| -   Tetanus-diphtheria (Td) | > between our     | > immunizations   |
|     booster -- once every   | > allowance and   | >                 |
|     10 years                | > the billed      | > Participating/N |
|                             | > amount          | on-participating: |
|                             |                   | > You pay all     |
|                             |                   | > charges         |
+-----------------------------+-------------------+-------------------+
| > *Not covered: Office      | > *All charges*   | > *All charges*   |
| > visit charges associated  |                   |                   |
| > with preventive services  |                   |                   |
| > and routine immunizations |                   |                   |
| > performed by              |                   |                   |
| > Participating and         |                   |                   |
| > Non-participating         |                   |                   |
| > providers*                |                   |                   |
+-----------------------------+-------------------+-------------------+
| ####                        | #########         | #########         |
| # Preventive care, children |                   |                   |
+-----------------------------+-------------------+-------------------+
| > We provide benefits for   | > Preferred:      | > Preferred       |
| > the following services:   | > Nothing (No     | > primary care    |
|                             | > deductible)     | > provider or     |
| -   All healthy newborn     | >                 | > other health    |
|     visits including        | > Participating:  | > care            |
|     routine screening       | > Nothing (No     | > professional:   |
|     (inpatient or           | > deductible)     | > Nothing         |
|     outpatient)             | >                 | >                 |
|                             | > N               | > Preferred       |
| ```{=html}                  | on-participating: | > specialist:     |
| <!-- -->                    | > Nothing (No     | > Nothing         |
| ```                         | > deductible) up  | >                 |
| -   The following routine   | > to the Plan     | > Participating/N |
|     services as recommended | > allowance. You  | on-participating: |
|     by the American Academy | > are responsible | > You pay all     |
|     of Pediatrics for       | > only for any    | > charges         |
|     children up to the age  | > difference      | >                 |
|     of 22, including        | > between our     | > ***Note:*** For |
|     children living,        | > allowance and   | > services billed |
|     traveling, or adopted   | > the billed      | > by              |
|     from outside the United | > amount.         | > Participating   |
|     States:                 | >                 | > and             |
|                             | > ***Note:***     | >                 |
| ```{=html}                  | > When billed by  | Non-participating |
| <!-- -->                    | > a facility,     | > laboratories or |
| ```                         | > such as the     | > radiologists,   |
| -   Routine physical        | > outpatient      | > you pay any     |
|     examinations            | > department of a | > difference      |
|                             | > hospital, we    | > between our     |
| -   Routine hearing tests   | > provide         | > allowance and   |
|                             | > benefits as     | > the billed      |
| -   Laboratory tests        | > shown here,     | > amount.         |
|                             | > according to    | >                 |
| -   Immunizations           | > the contracting | > ***Note:***     |
|                             | > status of the   | > When billed by  |
| -   Related office visits   | > facility.       | > a facility,     |
|                             |                   | > such as the     |
|                             |                   | > outpatient      |
|                             |                   | > department of a |
|                             |                   | > hospital, we    |
|                             |                   | > provide         |
|                             |                   | > benefits as     |
|                             |                   | > shown here,     |
|                             |                   | > according to    |
|                             |                   | > the contracting |
|                             |                   | > status of the   |
|                             |                   | > facility.       |
+-----------------------------+-------------------+-------------------+

+-----------------------------+-------------------+-------------------+
| # Note: The calenda         |                   |                   |
| r year deductible applies t |                   |                   |
| o almost all Standard Optio |                   |                   |
| n benefits in this Section. |                   |                   |
|                             |                   |                   |
| #                           |                   |                   |
|  We say \"(No deductible)\" |                   |                   |
|  when the Standard Option d |                   |                   |
| eductible does *not* apply. |                   |                   |
|                             |                   |                   |
| **There is no calendar year |                   |                   |
| deductible under Basic      |                   |                   |
| Option.**                   |                   |                   |
+-----------------------------+-------------------+-------------------+
| ######## Maternity care     | ### You Pay       | **You Pay − Basic |
|                             | − Standard Option | Option**          |
+-----------------------------+-------------------+-------------------+
| > Complete maternity        | > Preferred:      | > Preferred:      |
| > (obstetrical) care        | > Nothing (No     | > \$100 copayment |
| > including related         | > deductible)     | > for the         |
| > conditions resulting in   | >                 | > delivery;       |
| > childbirth or miscarriage | > ***Note:*** For | > nothing for     |
| > when provided, or ordered | > facility care   | > prenatal and    |
| > and billed by a physician | > related to      | > postpartum care |
| > or nurse midwife, such    | > maternity,      | >                 |
| > as:                       | > including care  | > ***Note:*** For |
|                             | > at birthing     | > facility care   |
| -   Prenatal care           | > facilities, we  | > related to      |
|     (including laboratory   | > waive the per   | > maternity,      |
|     and diagnostic tests)   | > admission       | > including care  |
|                             | > copayment and   | > at birthing     |
| -   Tocolytic therapy and   | > pay for covered | > facilities, see |
|     related services (when  | > services in     | > Section 5(c).   |
|     provided and billed by  | > full when you   | >                 |
|     a home infusion therapy | > use Preferred   | > Participating/N |
|     company or a home       | > providers.      | on-participating: |
|     health care agency)     | >                 | > You pay all     |
|                             | > Participating:  | > charges         |
| > ***Note:*** Benefits are  | > 25% of the Plan | >                 |
| > not provided for oral     | > allowance       | > ***Note:*** For |
| > tocolytic agents.         | >                 | > services billed |
| > Benefits for home nursing | > N               | > by              |
| > visits related to covered | on-participating: | > Participating   |
| > tocolytic therapy are     | > 25% of the Plan | > and             |
| > subject to the visit      | > allowance, plus | >                 |
| > limitations described on  | > any difference  | Non-participating |
| > page 42.                  | > between our     | > laboratories    |
|                             | > allowance and   | > and             |
| -   Delivery                | > the billed      | > radiologists,   |
|                             | > amount          | > you are         |
| -   Postpartum care         |                   | > responsible     |
|                             |                   | > only for any    |
| ```{=html}                  |                   | > difference      |
| <!-- -->                    |                   | > between our     |
| ```                         |                   | > allowance and   |
| -   Assistant               |                   | > the billed      |
|     surgeons/surgical       |                   | > amount.         |
|     assistance by a         |                   |                   |
|     physician if required   |                   |                   |
|     because of the          |                   |                   |
|     complexity of the       |                   |                   |
|     delivery                |                   |                   |
|                             |                   |                   |
| -   Anesthesia (including   |                   |                   |
|     acupuncture) when       |                   |                   |
|     requested by the        |                   |                   |
|     attending physician and |                   |                   |
|     performed by a          |                   |                   |
|     certified registered    |                   |                   |
|     nurse anesthetist       |                   |                   |
|     (CRNA) or a physician   |                   |                   |
|     other than the          |                   |                   |
|     operating physician     |                   |                   |
|     (surgeon) or the        |                   |                   |
|     assistant               |                   |                   |
+-----------------------------+-------------------+-------------------+

Maternity care -- *continued on next page*

+-----------------------------+-------------------+-------------------+
| # Note: The calenda         |                   |                   |
| r year deductible applies t |                   |                   |
| o almost all Standard Optio |                   |                   |
| n benefits in this Section. |                   |                   |
|                             |                   |                   |
| #                           |                   |                   |
|  We say \"(No deductible)\" |                   |                   |
|  when the Standard Option d |                   |                   |
| eductible does *not* apply. |                   |                   |
|                             |                   |                   |
| **There is no calendar year |                   |                   |
| deductible under Basic      |                   |                   |
| Option.**                   |                   |                   |
+-----------------------------+-------------------+-------------------+
| ######## M                  | ### You Pay       | **You Pay − Basic |
| aternity care *(continued)* | − Standard Option | Option**          |
+-----------------------------+-------------------+-------------------+
| > ***Note:*** Here are some | #                 | #                 |
| > things to keep in mind:   |                   |                   |
|                             |                   |                   |
| -   You do not need to      |                   |                   |
|     precertify your normal  |                   |                   |
|     delivery; see page 14   |                   |                   |
|     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, your           |                   |                   |
|     representative, your    |                   |                   |
|     doctor, or your         |                   |                   |
|     hospital must           |                   |                   |
|     precertify the extended |                   |                   |
|     stay. See Section 3 for |                   |                   |
|     information on          |                   |                   |
|     requesting additional   |                   |                   |
|     days.                   |                   |                   |
|                             |                   |                   |
| ```{=html}                  |                   |                   |
| <!-- -->                    |                   |                   |
| ```                         |                   |                   |
| -   We cover routine        |                   |                   |
|     nursery care of the     |                   |                   |
|     newborn child during    |                   |                   |
|     the covered portion of  |                   |                   |
|     the mother\'s maternity |                   |                   |
|     stay, or if the child   |                   |                   |
|     is covered under the    |                   |                   |
|     father\'s Self and      |                   |                   |
|     Family enrollment.      |                   |                   |
|                             |                   |                   |
| > ***Note:*** When a        |                   |                   |
| > newborn requires          |                   |                   |
| > definitive treatment      |                   |                   |
| > including incubation      |                   |                   |
| > charges by reason of      |                   |                   |
| > prematurity or evaluation |                   |                   |
| > for medical or surgical   |                   |                   |
| > reasons during or after   |                   |                   |
| > the mother\'s             |                   |                   |
| > confinement, the newborn  |                   |                   |
| > is considered a patient   |                   |                   |
| > in his or her own right.  |                   |                   |
| >                           |                   |                   |
| > ***Note:*** Expenses of   |                   |                   |
| > the newborn are eligible  |                   |                   |
| > for benefits only if the  |                   |                   |
| > child is covered by a     |                   |                   |
| > Self and Family           |                   |                   |
| > enrollment. For services  |                   |                   |
| > such as circumcision,     |                   |                   |
| > regular medical or        |                   |                   |
| > surgical benefits apply   |                   |                   |
| > rather than maternity     |                   |                   |
| > benefits.                 |                   |                   |
| >                           |                   |                   |
| > ***Note:*** See page 46   |                   |                   |
| > for our payment levels    |                   |                   |
| > for circumcision.         |                   |                   |
+-----------------------------+-------------------+-------------------+
| > *Not covered: Procedures, | > *All charges*   | > *All charges*   |
| > services, drugs, and      |                   |                   |
| > supplies related to       |                   |                   |
| > abortions except when the |                   |                   |
| > life of the mother would  |                   |                   |
| > be endangered if the      |                   |                   |
| > fetus were carried to     |                   |                   |
| > term or when the          |                   |                   |
| > pregnancy is the result   |                   |                   |
| > of an act of rape or      |                   |                   |
| > incest*                   |                   |                   |
+-----------------------------+-------------------+-------------------+

+-----------------------------+-------------------+-------------------+
| # Note: The calenda         |                   |                   |
| r year deductible applies t |                   |                   |
| o almost all Standard Optio |                   |                   |
| n benefits in this Section. |                   |                   |
|                             |                   |                   |
| #                           |                   |                   |
|  We say \"(No deductible)\" |                   |                   |
|  when the Standard Option d |                   |                   |
| eductible does *not* apply. |                   |                   |
|                             |                   |                   |
| **There is no calendar year |                   |                   |
| deductible under Basic      |                   |                   |
| Option.**                   |                   |                   |
+-----------------------------+-------------------+-------------------+
| ######## Family planning    | ### You Pay       | **You Pay − Basic |
|                             | − Standard Option | Option**          |
+-----------------------------+-------------------+-------------------+
| > A range of voluntary      | > Preferred: 10%  | > Preferred       |
| > family planning services, | > of the Plan     | > primary care    |
| > limited to:               | > allowance       | > provider or     |
|                             | >                 | > other health    |
| -   Depo-Provera            | > Participating:  | > care            |
|                             | > 25% of the Plan | > professional:   |
| -   Diaphragms and          | > allowance       | > \$20 copayment  |
|     contraceptive rings     | >                 | > per visit       |
|                             | > N               | >                 |
| -   Intrauterine devices    | on-participating: | > Preferred       |
|     (IUDs)                  | > 25% of the Plan | > specialist:     |
|                             | > allowance, plus | > \$30 copayment  |
| -   Implantable             | > any difference  | > per visit       |
|     contraceptives          | > between our     | >                 |
|                             | > allowance and   | > ***Note:*** You |
| -   Oral and transdermal    | > the billed      | > pay \$100 for   |
|     contraceptives          | > amount          | > related         |
|                             |                   | > surgical        |
| -   Voluntary sterilization |                   | > procedures. See |
|     \[see Surgical          |                   | > Section 5(b)    |
|     procedures in Section   |                   | > for our         |
|     5(b)\]                  |                   | > coverage for    |
|                             |                   | > related         |
| > ***Note:*** See Section   |                   | > surgical        |
| > 5(f) for prescription     |                   | > procedures.     |
| > drug coverage.            |                   | >                 |
|                             |                   | > ***Note:*** You |
|                             |                   | > pay 30% of the  |
|                             |                   | > Plan allowance  |
|                             |                   | > for drugs and   |
|                             |                   | > supplies.       |
|                             |                   | >                 |
|                             |                   | > Participating/N |
|                             |                   | on-participating: |
|                             |                   | > You pay all     |
|                             |                   | > charges         |
+-----------------------------+-------------------+-------------------+
| > *Not covered:*            | > *All charges*   | > *All charges*   |
|                             |                   |                   |
| -   *Reversal of voluntary  |                   |                   |
|     surgical sterilization* |                   |                   |
|                             |                   |                   |
| -   *Contraceptive devices  |                   |                   |
|     not described above*    |                   |                   |
+-----------------------------+-------------------+-------------------+
| ##                          | #########         | #########         |
| ###### Infertility services |                   |                   |
+-----------------------------+-------------------+-------------------+
| > Diagnosis and treatment   | > Preferred: 10%  | > Preferred       |
| > of infertility, except as | > of the Plan     | > primary care    |
| > shown in *Not Covered*    | > allowance       | > provider or     |
| >                           | >                 | > other health    |
| > ***Note:*** See Section   | > Participating:  | > care            |
| > 5(f) for prescription     | > 25% of the Plan | > professional:   |
| > drug coverage.            | > allowance       | > \$20 copayment  |
|                             | >                 | > per visit       |
|                             | > N               | >                 |
|                             | on-participating: | > Preferred       |
|                             | > 25% of the Plan | > specialist:     |
|                             | > allowance, plus | > \$30 copayment  |
|                             | > any difference  | > per visit       |
|                             | > between our     | >                 |
|                             | > allowance and   | > ***Note:*** You |
|                             | > the billed      | > pay 30% of the  |
|                             | > amount          | > Plan allowance  |
|                             |                   | > for drugs and   |
|                             |                   | > supplies.       |
|                             |                   | >                 |
|                             |                   | > Participating/N |
|                             |                   | on-participating: |
|                             |                   | > You pay all     |
|                             |                   | > charges         |
|                             |                   | >                 |
|                             |                   | > ***Note:*** For |
|                             |                   | > services billed |
|                             |                   | > by              |
|                             |                   | > Participating   |
|                             |                   | > and             |
|                             |                   | >                 |
|                             |                   | Non-participating |
|                             |                   | > laboratories or |
|                             |                   | > radiologists,   |
|                             |                   | > you pay a       |
|                             |                   | > separate \$20   |
|                             |                   | > copayment, plus |
|                             |                   | > any difference  |
|                             |                   | > between our     |
|                             |                   | > allowance and   |
|                             |                   | > the billed      |
|                             |                   | > amount.         |
+-----------------------------+-------------------+-------------------+

Infertility services -- *continued on next page*

+-----------------------------+-------------------+-------------------+
| # Note: The calenda         |                   |                   |
| r year deductible applies t |                   |                   |
| o almost all Standard Optio |                   |                   |
| n benefits in this Section. |                   |                   |
|                             |                   |                   |
| #                           |                   |                   |
|  We say \"(No deductible)\" |                   |                   |
|  when the Standard Option d |                   |                   |
| eductible does *not* apply. |                   |                   |
|                             |                   |                   |
| **There is no calendar year |                   |                   |
| deductible under Basic      |                   |                   |
| Option.**                   |                   |                   |
+-----------------------------+-------------------+-------------------+
| ######## Inferti            | ### You Pay       | **You Pay − Basic |
| lity services *(continued)* | − Standard Option | Option**          |
+-----------------------------+-------------------+-------------------+
| > *Not covered:*            | > *All charges*   | > *All charges*   |
|                             |                   |                   |
| -   *Assisted reproductive  |                   |                   |
|     technology (ART)        |                   |                   |
|     procedures, such as:*   |                   |                   |
|                             |                   |                   |
| ```{=html}                  |                   |                   |
| <!-- -->                    |                   |                   |
| ```                         |                   |                   |
| -   *artificial             |                   |                   |
|     insemination (AI)*      |                   |                   |
|                             |                   |                   |
| -   *in vitro fertilization |                   |                   |
|     (IVF)*                  |                   |                   |
|                             |                   |                   |
| -   *embryo transfer and    |                   |                   |
|     Gamete Intrafallopian   |                   |                   |
|     Transfer (GIFT)*        |                   |                   |
|                             |                   |                   |
| -   *intravaginal           |                   |                   |
|     insemination (IVI)*     |                   |                   |
|                             |                   |                   |
| -   *intracervical          |                   |                   |
|     insemination (ICI)*     |                   |                   |
|                             |                   |                   |
| -   *intrauterine           |                   |                   |
|     insemination (IUI)*     |                   |                   |
|                             |                   |                   |
| ```{=html}                  |                   |                   |
| <!-- -->                    |                   |                   |
| ```                         |                   |                   |
| -   *Services and supplies  |                   |                   |
|     related to ART          |                   |                   |
|     procedures, such as     |                   |                   |
|     sperm banking*          |                   |                   |
+-----------------------------+-------------------+-------------------+
| **Allergy care**            | #########         | #########         |
+-----------------------------+-------------------+-------------------+
| -   Testing and treatment,  | > Preferred: 10%  | > Preferred       |
|     including materials     | > of the Plan     | > primary care    |
|     (such as allergy serum) | > allowance       | > provider or     |
|                             | >                 | > other health    |
| -   Allergy injections      | > Participating:  | > care            |
|                             | > 25% of the Plan | > professional:   |
|                             | > allowance       | > \$20 copayment  |
|                             | >                 | > per visit;      |
|                             | > N               | > nothing for     |
|                             | on-participating: | > injections      |
|                             | > 25% of the Plan | >                 |
|                             | > allowance, plus | > Preferred       |
|                             | > any difference  | > specialist:     |
|                             | > between our     | > \$30 copayment  |
|                             | > allowance and   | > per visit;      |
|                             | > the billed      | > nothing for     |
|                             | > amount          | > injections      |
|                             |                   | >                 |
|                             |                   | > Participating/N |
|                             |                   | on-participating: |
|                             |                   | > You pay all     |
|                             |                   | > charges         |
|                             |                   | >                 |
|                             |                   | > ***Note:*** For |
|                             |                   | > services billed |
|                             |                   | > by              |
|                             |                   | > Participating   |
|                             |                   | > and             |
|                             |                   | >                 |
|                             |                   | Non-participating |
|                             |                   | > laboratories or |
|                             |                   | > radiologists,   |
|                             |                   | > you pay a       |
|                             |                   | > separate \$20   |
|                             |                   | > copayment, plus |
|                             |                   | > any difference  |
|                             |                   | > between our     |
|                             |                   | > allowance and   |
|                             |                   | > the billed      |
|                             |                   | > amount.         |
+-----------------------------+-------------------+-------------------+
| > *Not covered: Provocative | > *All charges*   | > *All charges*   |
| > food testing and          |                   |                   |
| > sublingual allergy        |                   |                   |
| > desensitization*          |                   |                   |
+-----------------------------+-------------------+-------------------+

+-----------------------------+-------------------+-------------------+
| # Note: The calenda         |                   |                   |
| r year deductible applies t |                   |                   |
| o almost all Standard Optio |                   |                   |
| n benefits in this Section. |                   |                   |
|                             |                   |                   |
| #                           |                   |                   |
|  We say \"(No deductible)\" |                   |                   |
|  when the Standard Option d |                   |                   |
| eductible does *not* apply. |                   |                   |
|                             |                   |                   |
| **There is no calendar year |                   |                   |
| deductible under Basic      |                   |                   |
| Option.**                   |                   |                   |
+-----------------------------+-------------------+-------------------+
| #                           | ### You Pay       | **You Pay − Basic |
| ####### Treatment therapies | − Standard Option | Option**          |
+-----------------------------+-------------------+-------------------+
| > Outpatient treatment      | > Preferred: 10%  | > Preferred       |
| > therapies:                | > of the Plan     | > primary care    |
|                             | > allowance       | > provider or     |
| -   Chemotherapy and        | >                 | > other health    |
|     radiation therapy       | > Participating:  | > care            |
|                             | > 25% of the Plan | > professional:   |
| > ***Note:*** We cover high | > allowance       | > \$20 copayment  |
| > dose chemotherapy and/or  | >                 | > per visit       |
| > radiation therapy in      | > N               | >                 |
| > connection with bone      | on-participating: | > Preferred       |
| > marrow transplants, and   | > 25% of the Plan | > specialist:     |
| > drugs or medications to   | > allowance, plus | > \$30 copayment  |
| > stimulate or mobilize     | > any difference  | > per visit       |
| > stem cells for transplant | > between our     | >                 |
| > procedures, only for      | > allowance and   | > ***Note:*** You |
| > those conditions listed   | > the billed      | > pay 30% of the  |
| > as covered under          | > amount          | > Plan allowance  |
| > Organ/tissue transplants  |                   | > for drugs and   |
| > in Section 5(b). See      |                   | > supplies.       |
| > also, *Other services*    |                   | >                 |
| > under *How to get         |                   | > Participating/N |
| > approval for . . .* in    |                   | on-participating: |
| > Section 3 (page 14).      |                   | > You pay all     |
|                             |                   | > charges         |
| -   Renal dialysis --       |                   |                   |
|     Hemodialysis and        |                   |                   |
|     peritoneal dialysis     |                   |                   |
|                             |                   |                   |
| ```{=html}                  |                   |                   |
| <!-- -->                    |                   |                   |
| ```                         |                   |                   |
| -   Intravenous             |                   |                   |
|     (IV)/infusion therapy   |                   |                   |
|     -- Home IV or infusion  |                   |                   |
|     therapy                 |                   |                   |
|                             |                   |                   |
| > ***Note:*** Home nursing  |                   |                   |
| > visits associated with    |                   |                   |
| > Home IV/infusion therapy  |                   |                   |
| > are covered as shown      |                   |                   |
| > under Home health         |                   |                   |
| > services on page 42.      |                   |                   |
|                             |                   |                   |
| -   Outpatient cardiac      |                   |                   |
|     rehabilitation          |                   |                   |
|                             |                   |                   |
| > ***Note:*** See Section   |                   |                   |
| > 5(c) for our payment      |                   |                   |
| > levels for treatment      |                   |                   |
| > therapies billed for by   |                   |                   |
| > the outpatient department |                   |                   |
| > of a hospital.            |                   |                   |
+-----------------------------+-------------------+-------------------+
| Inpatient treatment         | > Preferred: 10%  | > Preferred:      |
| therapies:                  | > of the Plan     | > Nothing         |
|                             | > allowance       | >                 |
| -   Chemotherapy and        | >                 | > Participating/N |
|     radiation therapy       | > Participating:  | on-participating: |
|                             | > 25% of the Plan | > You pay all     |
| > ***Note:*** We cover high | > allowance       | > charges         |
| > dose chemotherapy and/or  | >                 | >                 |
| > radiation therapy in      | > N               | > ***Note:*** We  |
| > connection with bone      | on-participating: | > provide         |
| > marrow transplants, and   | > 25% of the Plan | > benefits at     |
| > drugs or medications to   | > allowance, plus | > 100% of the     |
| > stimulate or mobilize     | > any difference  | > Plan allowance  |
| > stem cells for transplant | > between our     | > for services    |
| > procedures, only for      | > allowance and   | > provided in     |
| > those conditions listed   | > the billed      | > Preferred       |
| > as covered under          | > amount          | > facilities by   |
| > Organ/tissue transplants  | >                 | > Non-preferred   |
| > in Section 5(b). See      | > ***Note:*** We  | > radiologists,   |
| > also, *Other services*    | > provide         | > a               |
| > under *How to get         | > benefits at 90% | nesthesiologists, |
| > approval for . . .* in    | > of the Plan     | > certified       |
| > Section 3 (page 14).      | > allowance for   | > registered      |
|                             | > services        | > nurse           |
| -   Renal dialysis --       | > provided in     | > anesthetists    |
|     Hemodialysis and        | > Preferred       | > (CRNAs),        |
|     peritoneal dialysis     | > facilities by   | > pathologists,   |
|                             | > Non-preferred   | > emergency room  |
| ```{=html}                  | > radiologists,   | > physicians, and |
| <!-- -->                    | > a               | > assistant       |
| ```                         | nesthesiologists, | > surgeons. You   |
| -   Pharmacotherapy \[see   | > certified       | > are responsible |
|     Section 5(f) for        | > registered      | > for any         |
|     prescription drug       | > nurse           | > difference      |
|     coverage\]              | > anesthetists    | > between our     |
|                             | > (CRNAs),        | > allowance and   |
|                             | > pathologists,   | > the billed      |
|                             | > and emergency   | > amount.         |
|                             | > room            |                   |
|                             | > physicians. You |                   |
|                             | > are responsible |                   |
|                             | > for any         |                   |
|                             | > difference      |                   |
|                             | > between our     |                   |
|                             | > allowance and   |                   |
|                             | > the billed      |                   |
|                             | > amount.         |                   |
+-----------------------------+-------------------+-------------------+

+-----------------------------+-------------------+-------------------+
| # Note: The calenda         |                   |                   |
| r year deductible applies t |                   |                   |
| o almost all Standard Optio |                   |                   |
| n benefits in this Section. |                   |                   |
|                             |                   |                   |
| #                           |                   |                   |
|  We say \"(No deductible)\" |                   |                   |
|  when the Standard Option d |                   |                   |
| eductible does *not* apply. |                   |                   |
|                             |                   |                   |
| **There is no calendar year |                   |                   |
| deductible under Basic      |                   |                   |
| Option.**                   |                   |                   |
+-----------------------------+-------------------+-------------------+
| **Physical therapy**        | ### You Pay       | **You Pay − Basic |
|                             | − Standard Option | Option**          |
+-----------------------------+-------------------+-------------------+
| -   Physical therapy when   | > Preferred: 10%  | > Preferred       |
|     performed by a physical | > of the Plan     | > primary care    |
|     therapist or physician  | > allowance       | > provider or     |
|                             | >                 | > other health    |
| -   Acupuncture when        | > Participating:  | > care            |
|     provided by a physician | > 25% of the Plan | > professional:   |
|                             | > allowance       | > \$20 copayment  |
| > ***Note:*** See Section   | >                 | > per visit       |
| > 5(c) for our payment      | > N               | >                 |
| > levels for physical       | on-participating: | > Preferred       |
| > therapy performed in and  | > 25% of the Plan | > specialist:     |
| > billed by the outpatient  | > allowance, plus | > \$30 copayment  |
| > department of a hospital. | > any difference  | > per visit       |
| >                           | > between our     | >                 |
| > ***Note:*** When billed   | > allowance and   | > ***Note:*** You |
| > by a skilled nursing      | > the billed      | > pay 30% of the  |
| > facility, nursing home,   | > amount          | > Plan allowance  |
| > or extended care          | >                 | > for drugs and   |
| > facility, we pay benefits | > ***Note:***     | > supplies.       |
| > as shown here for         | > Benefits are    | >                 |
| > professional care,        | > limited to 50   | > ***Note:***     |
| > according to the          | > visits per      | > Benefits are    |
| > contracting status of the | > person, per     | > limited to 50   |
| > therapist.                | > calendar year.  | > visits per      |
|                             | >                 | > person, per     |
|                             | > ***Note:***     | > calendar year   |
|                             | > Visits that you | > for physical,   |
|                             | > pay for while   | > occupational,   |
|                             | > meeting your    | > or speech       |
|                             | > calendar year   | > therapy, or a   |
|                             | > deductible      | > combination of  |
|                             | > count toward    | > all three.      |
|                             | > the limit cited | >                 |
|                             | > above.          | > Participating/N |
|                             |                   | on-participating: |
|                             |                   | > You pay all     |
|                             |                   | > charges         |
+-----------------------------+-------------------+-------------------+
| > *Not covered:*            | > *All charges*   | > *All charges*   |
|                             |                   |                   |
| -   *Recreational or        |                   |                   |
|     educational therapy,    |                   |                   |
|     and any related         |                   |                   |
|     diagnostic testing      |                   |                   |
|     except as provided by a |                   |                   |
|     hospital as part of a   |                   |                   |
|     covered inpatient stay* |                   |                   |
|                             |                   |                   |
| ```{=html}                  |                   |                   |
| <!-- -->                    |                   |                   |
| ```                         |                   |                   |
| -   *Maintenance or         |                   |                   |
|     palliative              |                   |                   |
|     rehabilitative therapy* |                   |                   |
|                             |                   |                   |
| -   *Exercise programs*     |                   |                   |
|                             |                   |                   |
| -   *Hippotherapy (exercise |                   |                   |
|     on horseback)*          |                   |                   |
+-----------------------------+-------------------+-------------------+

+-----------------------------+-------------------+-------------------+
| # Note: The calenda         |                   |                   |
| r year deductible applies t |                   |                   |
| o almost all Standard Optio |                   |                   |
| n benefits in this Section. |                   |                   |
|                             |                   |                   |
| #                           |                   |                   |
|  We say \"(No deductible)\" |                   |                   |
|  when the Standard Option d |                   |                   |
| eductible does *not* apply. |                   |                   |
|                             |                   |                   |
| **There is no calendar year |                   |                   |
| deductible under Basic      |                   |                   |
| Option.**                   |                   |                   |
+-----------------------------+-------------------+-------------------+
| **Occupational and speech   | ### You Pay       | **You Pay − Basic |
| therapies**                 | − Standard Option | Option**          |
+-----------------------------+-------------------+-------------------+
| > Occupational and speech   | > Preferred: 10%  | > Preferred       |
| > therapy when performed by | > of the Plan     | > primary care    |
| > an occupational           | > allowance       | > provider or     |
| > therapist, speech         | >                 | > other health    |
| > therapist, or physician   | > Participating:  | > care            |
| >                           | > 25% of the Plan | > professional:   |
| > ***Note:*** See Section   | > allowance       | > \$20 copayment  |
| > 5(c) for our payment      | >                 | > per visit       |
| > levels for occupational   | > N               | >                 |
| > and speech therapy        | on-participating: | > Preferred       |
| > performed in and billed   | > 25% of the Plan | > specialist:     |
| > by the outpatient         | > allowance, plus | > \$30 copayment  |
| > department of a hospital. | > any difference  | > per visit       |
| >                           | > between our     | >                 |
| > ***Note:*** When billed   | > allowance and   | > ***Note:*** You |
| > by a skilled nursing      | > the billed      | > pay 30% of the  |
| > facility, nursing home,   | > amount          | > Plan allowance  |
| > or extended care          | >                 | > for drugs and   |
| > facility, we pay benefits | > ***Note:***     | > supplies.       |
| > as shown here for         | > Benefits are    | >                 |
| > professional care,        | > limited to 25   | > ***Note:***     |
| > according to the          | > visits per      | > Benefits are    |
| > contracting status of the | > person, per     | > limited to 50   |
| > therapist.                | > calendar year   | > visits per      |
|                             | > for             | > person, per     |
|                             | > occupational    | > calendar year   |
|                             | > therapy or      | > for physical,   |
|                             | > speech therapy, | > occupational,   |
|                             | > or a            | > or speech       |
|                             | > combination of  | > therapy, or a   |
|                             | > both.           | > combination of  |
|                             | >                 | > all three.      |
|                             | > ***Note:***     | >                 |
|                             | > Visits that you | > Participating/N |
|                             | > pay for while   | on-participating: |
|                             | > meeting your    | > You pay all     |
|                             | > calendar year   | > charges         |
|                             | > deductible      |                   |
|                             | > count toward    |                   |
|                             | > the limit cited |                   |
|                             | > above.          |                   |
+-----------------------------+-------------------+-------------------+
| > *Not covered:*            | > *All charges*   | > *All charges*   |
|                             |                   |                   |
| -   *Recreational or        |                   |                   |
|     educational therapy,    |                   |                   |
|     and any related         |                   |                   |
|     diagnostic testing      |                   |                   |
|     except as provided by a |                   |                   |
|     hospital as part of a   |                   |                   |
|     covered inpatient stay* |                   |                   |
|                             |                   |                   |
| ```{=html}                  |                   |                   |
| <!-- -->                    |                   |                   |
| ```                         |                   |                   |
| -   *Maintenance or         |                   |                   |
|     palliative              |                   |                   |
|     rehabilitative therapy* |                   |                   |
|                             |                   |                   |
| -   *Exercise programs*     |                   |                   |
+-----------------------------+-------------------+-------------------+

+-----------------------------+-------------------+-------------------+
| # Note: The calenda         |                   |                   |
| r year deductible applies t |                   |                   |
| o almost all Standard Optio |                   |                   |
| n benefits in this Section. |                   |                   |
|                             |                   |                   |
| #                           |                   |                   |
|  We say \"(No deductible)\" |                   |                   |
|  when the Standard Option d |                   |                   |
| eductible does *not* apply. |                   |                   |
|                             |                   |                   |
| **There is no calendar year |                   |                   |
| deductible under Basic      |                   |                   |
| Option.**                   |                   |                   |
+-----------------------------+-------------------+-------------------+
| **Hearing services          | ### You Pay       | ### You P         |
| (testing, treatment, and    | − Standard Option | ay − Basic Option |
| supplies)**                 |                   |                   |
+-----------------------------+-------------------+-------------------+
| > Hearing tests related to  | > Preferred: 10%  | > Preferred       |
| > illness or injury         | > of the Plan     | > primary care    |
|                             | > allowance       | > provider or     |
|                             | >                 | > other health    |
|                             | > Participating:  | > care            |
|                             | > 25% of the Plan | > professional:   |
|                             | > allowance       | > \$20 copayment  |
|                             | >                 | > per visit       |
|                             | > N               | >                 |
|                             | on-participating: | > Preferred       |
|                             | > 25% of the Plan | > specialist:     |
|                             | > allowance, plus | > \$30 copayment  |
|                             | > any difference  | > per visit       |
|                             | > between our     | >                 |
|                             | > allowance and   | > ***Note:*** You |
|                             | > the billed      | > pay 30% of the  |
|                             | > amount          | > Plan allowance  |
|                             |                   | > for drugs and   |
|                             |                   | > supplies.       |
|                             |                   | >                 |
|                             |                   | > Participating/N |
|                             |                   | on-participating: |
|                             |                   | > You pay all     |
|                             |                   | > charges         |
+-----------------------------+-------------------+-------------------+
| > *Not covered:*            | > *All charges*   | > *All charges*   |
|                             |                   |                   |
| -   *Routine hearing tests  |                   |                   |
|     (except as indicated    |                   |                   |
|     under Preventive care,  |                   |                   |
|     children)*              |                   |                   |
|                             |                   |                   |
| -   *Hearing aids           |                   |                   |
|     (including implanted    |                   |                   |
|     bone conduction hearing |                   |                   |
|     aids)*                  |                   |                   |
|                             |                   |                   |
| ```{=html}                  |                   |                   |
| <!-- -->                    |                   |                   |
| ```                         |                   |                   |
| -   *Testing and            |                   |                   |
|     examinations for the    |                   |                   |
|     prescribing or fitting  |                   |                   |
|     of hearing aids*        |                   |                   |
+-----------------------------+-------------------+-------------------+
| **Vision services (testing, | #########         | #########         |
| treatment, and supplies)**  |                   |                   |
+-----------------------------+-------------------+-------------------+
| -   One pair of eyeglasses, | > Preferred: 10%  | > Preferred: 30%  |
|     replacement lenses, or  | > of the Plan     | > of the Plan     |
|     contact lenses to       | > allowance       | > allowance       |
|     correct an impairment   | >                 | >                 |
|     directly caused by a    | > Participating:  | > Participating/N |
|     single instance of      | > 25% of the Plan | on-participating: |
|     accidental ocular       | > allowance       | > You pay all     |
|     injury or intraocular   | >                 | > charges         |
|     surgery                 | > N               |                   |
|                             | on-participating: |                   |
| > ***Note:*** This benefit  | > 25% of the Plan |                   |
| > may also be used to       | > allowance, plus |                   |
| > obtain one pair of        | > any difference  |                   |
| > eyeglasses, replacement   | > between our     |                   |
| > lenses, or contact lenses | > allowance and   |                   |
| > prescribed in lieu of     | > the billed      |                   |
| > surgery when the          | > amount          |                   |
| > condition can be          |                   |                   |
| > corrected by surgery, but |                   |                   |
| > surgery is precluded      |                   |                   |
| > because of age or medical |                   |                   |
| > condition.                |                   |                   |
+-----------------------------+-------------------+-------------------+
| -   Eye examinations        | > Preferred: 10%  | > Preferred       |
|     related to a specific   | > of the Plan     | > primary care    |
|     medical condition       | > allowance       | > provider or     |
|                             | >                 | > other health    |
| -   Nonsurgical treatment   | > Participating:  | > care            |
|     for amblyopia and       | > 25% of the Plan | > professional:   |
|     strabismus, for         | > allowance       | > \$20 copayment  |
|     children from birth     | >                 | > per visit       |
|     through age 12          | > N               | >                 |
|                             | on-participating: | > Preferred       |
| > ***Note:*** See Section   | > 25% of the Plan | > specialist:     |
| > 5(b), *Surgical           | > allowance, plus | > \$30 copayment  |
| > procedures*, for coverage | > any difference  | > per visit       |
| > for surgical treatment of | > between our     | >                 |
| > amblyopia and strabismus. | > allowance and   | > ***Note:*** You |
|                             | > the billed      | > pay 30% of the  |
|                             | > amount          | > Plan allowance  |
|                             |                   | > for drugs and   |
|                             |                   | > supplies.       |
|                             |                   | >                 |
|                             |                   | > Participating/N |
|                             |                   | on-participating: |
|                             |                   | > You pay all     |
|                             |                   | > charges         |
+-----------------------------+-------------------+-------------------+

*Vision services (testing, treatment, and supplies) -- continued on next
page*

+-----------------------------+-------------------+-------------------+
| # Note: The calenda         |                   |                   |
| r year deductible applies t |                   |                   |
| o almost all Standard Optio |                   |                   |
| n benefits in this Section. |                   |                   |
|                             |                   |                   |
| #                           |                   |                   |
|  We say \"(No deductible)\" |                   |                   |
|  when the Standard Option d |                   |                   |
| eductible does *not* apply. |                   |                   |
|                             |                   |                   |
| **There is no calendar year |                   |                   |
| deductible under Basic      |                   |                   |
| Option.**                   |                   |                   |
+-----------------------------+-------------------+-------------------+
| **Vision services (testing, | ### You Pay       | ### You P         |
| treatment, and supplies)**  | − Standard Option | ay − Basic Option |
| *(continued)*               |                   |                   |
+-----------------------------+-------------------+-------------------+
| > *Not covered:*            | > *All charges*   | > *All charges*   |
|                             |                   |                   |
| -   *Eyeglasses, contact    |                   |                   |
|     lenses, routine eye     |                   |                   |
|     examinations, or vision |                   |                   |
|     testing for the         |                   |                   |
|     prescribing or fitting  |                   |                   |
|     of eyeglasses or        |                   |                   |
|     contact lenses, except  |                   |                   |
|     as described on page    |                   |                   |
|     38*                     |                   |                   |
|                             |                   |                   |
| -   *Eye exercises, visual  |                   |                   |
|     training, or            |                   |                   |
|     orthoptics, except for  |                   |                   |
|     nonsurgical treatment   |                   |                   |
|     of amblyopia and        |                   |                   |
|     strabismus as described |                   |                   |
|     on page 38*             |                   |                   |
|                             |                   |                   |
| -   *LASIK, radial          |                   |                   |
|     keratotomy, and other   |                   |                   |
|     refractive services*    |                   |                   |
+-----------------------------+-------------------+-------------------+
| ######## Foot care          | #########         |                   |
+-----------------------------+-------------------+-------------------+
| > Routine foot care when    | > Preferred: \$15 | > Preferred       |
| > you are under active      | > copayment for   | > primary care    |
| > treatment for a metabolic | > the office      | > provider or     |
| > or peripheral vascular    | > visit (No       | > other health    |
| > disease, such as diabetes | > deductible);    | > care            |
| >                           | > 10% of the Plan | > professional:   |
| > ***Note:*** See           | > allowance for   | > \$20 copayment  |
| > orthopedic and prosthetic | > all other       | > per visit       |
| > devices for information   | > services        | >                 |
| > on podiatric shoe         | > (deductible     | > Preferred       |
| > inserts.                  | > applies)        | > specialist:     |
| >                           | >                 | > \$30 copayment  |
| > ***Note:*** See Section   | > Participating:  | > per visit       |
| > 5(b) for our coverage for | > 25% of the Plan | >                 |
| > surgical procedures.      | > allowance       | > ***Note:*** You |
|                             | >                 | > pay 30% of the  |
|                             | > N               | > Plan allowance  |
|                             | on-participating: | > for drugs and   |
|                             | > 25% of the Plan | > supplies.       |
|                             | > allowance, plus | >                 |
|                             | > any difference  | > Participating/N |
|                             | > between our     | on-participating: |
|                             | > allowance and   | > You pay all     |
|                             | > the billed      | > charges         |
|                             | > amount          |                   |
+-----------------------------+-------------------+-------------------+
| > *Not covered: Routine     | > *All charges*   | > *All charges*   |
| > foot care, such as        |                   |                   |
| > 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*                    |                   |                   |
+-----------------------------+-------------------+-------------------+

+-----------------------------+-------------------+-------------------+
| # Note: The calenda         |                   |                   |
| r year deductible applies t |                   |                   |
| o almost all Standard Optio |                   |                   |
| n benefits in this Section. |                   |                   |
|                             |                   |                   |
| #                           |                   |                   |
|  We say \"(No deductible)\" |                   |                   |
|  when the Standard Option d |                   |                   |
| eductible does *not* apply. |                   |                   |
|                             |                   |                   |
| **There is no calendar year |                   |                   |
| deductible under Basic      |                   |                   |
| Option.**                   |                   |                   |
+-----------------------------+-------------------+-------------------+
| **Orthopedic and prosthetic | ### You Pay       | **You Pay − Basic |
| devices**                   | − Standard Option | Option**          |
+-----------------------------+-------------------+-------------------+
| > Orthopedic braces and     | > Preferred: 10%  | > Preferred: 30%  |
| > prosthetic appliances     | > of the Plan     | > of the Plan     |
| > such as:                  | > allowance       | > allowance       |
|                             | >                 | >                 |
| -   Artificial limbs and    | > Participating:  | > Participating/N |
|     eyes                    | > 25% of the Plan | on-participating: |
|                             | > allowance       | > You pay all     |
| ```{=html}                  | >                 | > charges         |
| <!-- -->                    | > N               |                   |
| ```                         | on-participating: |                   |
| -   Functional foot         | > 25% of the Plan |                   |
|     orthotics when          | > allowance, plus |                   |
|     prescribed by a         | > any difference  |                   |
|     physician               | > between our     |                   |
|                             | > allowance and   |                   |
| ```{=html}                  | > the billed      |                   |
| <!-- -->                    | > amount          |                   |
| ```                         |                   |                   |
| -   Rigid devices attached  |                   |                   |
|     to the foot or a brace, |                   |                   |
|     or placed in a shoe     |                   |                   |
|                             |                   |                   |
| ```{=html}                  |                   |                   |
| <!-- -->                    |                   |                   |
| ```                         |                   |                   |
| -   Replacement, repair,    |                   |                   |
|     and adjustment of       |                   |                   |
|     covered devices         |                   |                   |
|                             |                   |                   |
| ```{=html}                  |                   |                   |
| <!-- -->                    |                   |                   |
| ```                         |                   |                   |
| -   Following a mastectomy, |                   |                   |
|     breast prostheses and   |                   |                   |
|     surgical bras,          |                   |                   |
|     including necessary     |                   |                   |
|     replacements            |                   |                   |
|                             |                   |                   |
| > ***Note:*** A             |                   |                   |
| > **prosthetic appliance**  |                   |                   |
| > is a device that is       |                   |                   |
| > surgically inserted or    |                   |                   |
| > physically attached to    |                   |                   |
| > the body to restore a     |                   |                   |
| > bodily function or        |                   |                   |
| > replace a physical        |                   |                   |
| > portion of the body.      |                   |                   |
| >                           |                   |                   |
| > We provide hospital       |                   |                   |
| > benefits for internal     |                   |                   |
| > prosthetic devices, such  |                   |                   |
| > as artificial joints,     |                   |                   |
| > pacemakers, cochlear      |                   |                   |
| > implants, and surgically  |                   |                   |
| > implanted breast implants |                   |                   |
| > following mastectomy; see |                   |                   |
| > Section 5(c) for payment  |                   |                   |
| > information. Insertion of |                   |                   |
| > the device is paid as     |                   |                   |
| > surgery; see Section      |                   |                   |
| > 5(b).                     |                   |                   |
+-----------------------------+-------------------+-------------------+
| > *Not covered:*            | > *All charges*   | > *All charges*   |
|                             |                   |                   |
| -   *Shoes and              |                   |                   |
|     over-the-counter        |                   |                   |
|     orthotics*              |                   |                   |
|                             |                   |                   |
| -   *Arch supports*         |                   |                   |
|                             |                   |                   |
| -   *Heel pads and heel     |                   |                   |
|     cups*                   |                   |                   |
|                             |                   |                   |
| -   *Penile implants*       |                   |                   |
|                             |                   |                   |
| -   *Wigs* *(including      |                   |                   |
|     cranial prostheses)*    |                   |                   |
|                             |                   |                   |
| -   *Implanted bone         |                   |                   |
|     conduction hearing      |                   |                   |
|     aids*                   |                   |                   |
+-----------------------------+-------------------+-------------------+

+-----------------------------+-------------------+-------------------+
| # Note: The calenda         |                   |                   |
| r year deductible applies t |                   |                   |
| o almost all Standard Optio |                   |                   |
| n benefits in this Section. |                   |                   |
|                             |                   |                   |
| #                           |                   |                   |
|  We say \"(No deductible)\" |                   |                   |
|  when the Standard Option d |                   |                   |
| eductible does *not* apply. |                   |                   |
|                             |                   |                   |
| **There is no calendar year |                   |                   |
| deductible under Basic      |                   |                   |
| Option.**                   |                   |                   |
+-----------------------------+-------------------+-------------------+
| ######## Dura               | ### You Pay       | ### You P         |
| ble medical equipment (DME) | − Standard Option | ay − Basic Option |
+-----------------------------+-------------------+-------------------+
| > Durable medical equipment | > Preferred: 10%  | > Preferred: 30%  |
| > (DME) is equipment and    | > of the Plan     | > of the Plan     |
| > supplies that:            | > allowance       | > allowance       |
|                             | >                 | >                 |
| 1.  Are prescribed by your  | > Participating:  | > Participating/N |
|     attending physician     | > 25% of the Plan | on-participating: |
|     (i.e., the physician    | > allowance       | > You pay all     |
|     who is treating your    | >                 | > charges         |
|     illness or injury);     | > N               |                   |
|                             | on-participating: |                   |
| 2.  Are medically           | > 25% of the Plan |                   |
|     necessary;              | > allowance, plus |                   |
|                             | > any difference  |                   |
| 3.  Are primarily and       | > between our     |                   |
|     customarily used only   | > allowance and   |                   |
|     for a medical purpose;  | > the billed      |                   |
|                             | > amount          |                   |
| 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. Under  |                   |                   |
| > this benefit, we cover:   |                   |                   |
|                             |                   |                   |
| -   Home dialysis equipment |                   |                   |
|                             |                   |                   |
| -   Oxygen equipment        |                   |                   |
|                             |                   |                   |
| ```{=html}                  |                   |                   |
| <!-- -->                    |                   |                   |
| ```                         |                   |                   |
| -   Hospital beds           |                   |                   |
|                             |                   |                   |
| -   Wheelchairs             |                   |                   |
|                             |                   |                   |
| -   Crutches                |                   |                   |
|                             |                   |                   |
| -   Walkers                 |                   |                   |
|                             |                   |                   |
| -   Other items that we     |                   |                   |
|     determine to be DME,    |                   |                   |
|     such as compression     |                   |                   |
|     stockings               |                   |                   |
|                             |                   |                   |
| > ***Note:*** We cover DME  |                   |                   |
| > at Preferred benefit      |                   |                   |
| > levels only when you use  |                   |                   |
| > a Preferred DME provider. |                   |                   |
| > Preferred physicians,     |                   |                   |
| > facilities, and           |                   |                   |
| > pharmacies are not        |                   |                   |
| > necessarily Preferred DME |                   |                   |
| > providers.                |                   |                   |
| >                           |                   |                   |
| > ***Note:*** See Section   |                   |                   |
| > 5(c) for our coverage of  |                   |                   |
| > DME provided and billed   |                   |                   |
| > by a facility.            |                   |                   |
+-----------------------------+-------------------+-------------------+
| > *Not covered:*            | > *All charges*   | > *All charges*   |
|                             |                   |                   |
| -   *Exercise and bathroom  |                   |                   |
|     equipment*              |                   |                   |
|                             |                   |                   |
| -   *Lifts, such as seat,   |                   |                   |
|     chair, or van lifts*    |                   |                   |
|                             |                   |                   |
| -   *Car seats*             |                   |                   |
|                             |                   |                   |
| -   *Air conditioners,      |                   |                   |
|     humidifiers,            |                   |                   |
|     dehumidifiers, and      |                   |                   |
|     purifiers*              |                   |                   |
|                             |                   |                   |
| -   *Breast pumps*          |                   |                   |
|                             |                   |                   |
| -   *Computer               |                   |                   |
|     equipment/devices such  |                   |                   |
|     as \"story boards\" or  |                   |                   |
|     other communication     |                   |                   |
|     aids to assist          |                   |                   |
|     communication-impaired  |                   |                   |
|     individuals*            |                   |                   |
|                             |                   |                   |
| ```{=html}                  |                   |                   |
| <!-- -->                    |                   |                   |
| ```                         |                   |                   |
| -   *Equipment for cosmetic |                   |                   |
|     purposes*               |                   |                   |
+-----------------------------+-------------------+-------------------+

+-----------------------------+-------------------+-------------------+
| # Note: The calenda         |                   |                   |
| r year deductible applies t |                   |                   |
| o almost all Standard Optio |                   |                   |
| n benefits in this Section. |                   |                   |
|                             |                   |                   |
| #                           |                   |                   |
|  We say \"(No deductible)\" |                   |                   |
|  when the Standard Option d |                   |                   |
| eductible does *not* apply. |                   |                   |
|                             |                   |                   |
| **There is no calendar year |                   |                   |
| deductible under Basic      |                   |                   |
| Option.**                   |                   |                   |
+-----------------------------+-------------------+-------------------+
| ######## Medical supplies   | ### You Pay       | ### You P         |
|                             | − Standard Option | ay − Basic Option |
+-----------------------------+-------------------+-------------------+
| -   Medical foods for       | > Preferred: 10%  | > Preferred: 30%  |
|     children with inborn    | > of the Plan     | > of the Plan     |
|     errors of amino acid    | > allowance       | > allowance       |
|     metabolism              | >                 | >                 |
|                             | > Participating:  | > Participating/N |
| -   Medical foods and       | > 25% of the Plan | on-participating: |
|     nutritional supplements | > allowance       | > You pay all     |
|     when administered by    | >                 | > charges         |
|     catheter or nasogastric | > N               |                   |
|     tubes                   | on-participating: |                   |
|                             | > 25% of the Plan |                   |
| -   Ostomy and catheter     | > allowance, plus |                   |
|     supplies                | > any difference  |                   |
|                             | > between our     |                   |
| -   Oxygen, regardless of   | > allowance and   |                   |
|     the provider            | > the billed      |                   |
|                             | > amount          |                   |
| -   Blood and blood plasma  |                   |                   |
|     except when donated or  |                   |                   |
|     replaced, and blood     |                   |                   |
|     plasma expanders        |                   |                   |
|                             |                   |                   |
| > ***Note:*** We cover      |                   |                   |
| > medical supplies at       |                   |                   |
| > Preferred benefit levels  |                   |                   |
| > only when you use a       |                   |                   |
| > Preferred medical supply  |                   |                   |
| > provider. Preferred       |                   |                   |
| > physicians, facilities,   |                   |                   |
| > and pharmacies are not    |                   |                   |
| > necessarily Preferred     |                   |                   |
| > medical supply providers. |                   |                   |
+-----------------------------+-------------------+-------------------+
| ##                          | #########         | #########         |
| ###### Home health services |                   |                   |
+-----------------------------+-------------------+-------------------+
| > Home nursing care for two | > Preferred: 10%  | > Preferred: \$20 |
| > (2) hours per day, up to  | > of the Plan     | > copayment per   |
| > 25 visits per calendar    | > allowance       | > visit           |
| > year, when:               | >                 | >                 |
|                             | > Participating:  | > Participating/N |
| -   A registered nurse      | > 25% of the Plan | on-participating: |
|     (R.N.) or licensed      | > allowance       | > You pay all     |
|     practical nurse         | >                 | > charges         |
|     (L.P.N.) provides the   | > N               |                   |
|     services; and           | on-participating: |                   |
|                             | > 25% of the Plan |                   |
| -   A physician orders the  | > allowance, plus |                   |
|     care                    | > any difference  |                   |
|                             | > between our     |                   |
|                             | > allowance and   |                   |
|                             | > the billed      |                   |
|                             | > amount          |                   |
|                             | >                 |                   |
|                             | > ***Note:***     |                   |
|                             | > Visits that you |                   |
|                             | > pay for while   |                   |
|                             | > meeting your    |                   |
|                             | > calendar year   |                   |
|                             | > deductible      |                   |
|                             | > count toward    |                   |
|                             | > the annual      |                   |
|                             | > visit limit.    |                   |
+-----------------------------+-------------------+-------------------+
| > *Not covered:*            | > *All charges*   | > *All charges*   |
|                             |                   |                   |
| -   *Nursing care requested |                   |                   |
|     by, or for the          |                   |                   |
|     convenience of, the     |                   |                   |
|     patient or the          |                   |                   |
|     patient\'s family*      |                   |                   |
|                             |                   |                   |
| ```{=html}                  |                   |                   |
| <!-- -->                    |                   |                   |
| ```                         |                   |                   |
| -   *Services primarily for |                   |                   |
|     bathing, feeding,       |                   |                   |
|     exercising, moving the  |                   |                   |
|     patient, homemaking,    |                   |                   |
|     giving medication, or   |                   |                   |
|     acting as a companion   |                   |                   |
|     or sitter*              |                   |                   |
+-----------------------------+-------------------+-------------------+

+-----------------------------+-------------------+-------------------+
| # Note: The calenda         |                   |                   |
| r year deductible applies t |                   |                   |
| o almost all Standard Optio |                   |                   |
| n benefits in this Section. |                   |                   |
|                             |                   |                   |
| #                           |                   |                   |
|  We say \"(No deductible)\" |                   |                   |
|  when the Standard Option d |                   |                   |
| eductible does *not* apply. |                   |                   |
|                             |                   |                   |
| **There is no calendar year |                   |                   |
| deductible under Basic      |                   |                   |
| Option.**                   |                   |                   |
+-----------------------------+-------------------+-------------------+
| # Chiropractic              | ### You Pay       | ### You P         |
|                             | − Standard Option | ay − Basic Option |
+-----------------------------+-------------------+-------------------+
| -   Initial office visit    | > *All charges*   | > Preferred: \$20 |
|                             | >                 | > copayment per   |
| -   Spinal manipulations    | > ***Note:***     | > visit, up to 20 |
|                             | > Benefits may be | > manipulations   |
| -   Initial set of X-rays   | > available for   | > per calendar    |
|                             | > covered         | > year            |
|                             | > services you    | >                 |
|                             | > receive from    | > Participating/N |
|                             | > chiropractors   | on-participating: |
|                             | > in medically    | > You pay all     |
|                             | > underserved     | > charges         |
|                             | > areas. See page |                   |
|                             | > 11 for          |                   |
|                             | > additional      |                   |
|                             | > information.    |                   |
+-----------------------------+-------------------+-------------------+
| ####                        |                   | #########         |
| #### Alternative treatments |                   |                   |
+-----------------------------+-------------------+-------------------+
| > Acupuncture -- when       | > Preferred: 10%  | > Preferred       |
| > performed and billed by a | > of the Plan     | > primary care    |
| > physician for:            | > allowance       | > provider or     |
|                             | >                 | > other health    |
| -   pain relief, and        | > Participating:  | > care            |
|                             | > 25% of the Plan | > professional:   |
| -   as a modality of        | > allowance       | > \$20 copayment  |
|     physical therapy        | >                 | > per visit       |
|                             | > N               | >                 |
| > ***Note:*** See page 36   | on-participating: | > Preferred       |
| > for limitations.          | > 25% of the Plan | > specialist:     |
| >                           | > allowance, plus | > \$30 copayment  |
| > ***Note:*** We may also   | > any difference  | > per visit       |
| > cover services of certain | > between our     | >                 |
| > alternative treatment     | > allowance and   | > ***Note:*** You |
| > providers in medically    | > the billed      | > pay 30% of the  |
| > underserved areas. See    | > amount          | > Plan allowance  |
| > page 11 for additional    |                   | > for drugs and   |
| > information.              |                   | > supplies.       |
|                             |                   | >                 |
|                             |                   | > Participating/N |
|                             |                   | on-participating: |
|                             |                   | > You pay all     |
|                             |                   | > charges         |
+-----------------------------+-------------------+-------------------+
| > *Not covered:*            | > *All charges*   | > *All charges*   |
|                             |                   |                   |
| -   *Services you receive   |                   |                   |
|     from noncovered         |                   |                   |
|     providers such as:*     |                   |                   |
|                             |                   |                   |
| ```{=html}                  |                   |                   |
| <!-- -->                    |                   |                   |
| ```                         |                   |                   |
| -   *naturopaths*           |                   |                   |
|                             |                   |                   |
| -   *hypnotherapists*       |                   |                   |
|                             |                   |                   |
| ```{=html}                  |                   |                   |
| <!-- -->                    |                   |                   |
| ```                         |                   |                   |
| -   *Biofeedback (or other  |                   |                   |
|     > forms of self-care or |                   |                   |
|     > self-help training)*  |                   |                   |
+-----------------------------+-------------------+-------------------+

+-----------------------------+-------------------+-------------------+
| # Note: The calenda         |                   |                   |
| r year deductible applies t |                   |                   |
| o almost all Standard Optio |                   |                   |
| n benefits in this Section. |                   |                   |
|                             |                   |                   |
| #                           |                   |                   |
|  We say \"(No deductible)\" |                   |                   |
|  when the Standard Option d |                   |                   |
| eductible does *not* apply. |                   |                   |
|                             |                   |                   |
| **There is no calendar year |                   |                   |
| deductible under Basic      |                   |                   |
| Option.**                   |                   |                   |
+-----------------------------+-------------------+-------------------+
| #### **Educati              | ### You Pay       | ### You P         |
| onal classes and programs** | − Standard Option | ay − Basic Option |
+-----------------------------+-------------------+-------------------+
| -   Smoking cessation       | > Preferred: \$15 | > Preferred       |
|                             | > copayment for   | > primary care    |
| > ***Note:*** See Section   | > the office      | > provider or     |
| > 5(e) for our coverage of  | > visit charge    | > other health    |
| > individual and group      | > (No             | > care            |
| > psychotherapy for smoking | > deductible);    | > professional:   |
| > cessation and Section     | > 10% of the Plan | > \$20 copayment  |
| > 5(f) for our coverage of  | > allowance for   | > per visit       |
| > smoking cessation drugs.  | > all other       | >                 |
|                             | > services        | > Preferred       |
|                             | > (deductible     | > specialist:     |
|                             | > applies)        | > \$30 copayment  |
|                             | >                 | > per visit       |
|                             | > Participating:  | >                 |
|                             | > 25% of the Plan | > Participating/N |
|                             | > allowance       | on-participating: |
|                             | >                 | > You pay all     |
|                             | > N               | > charges         |
|                             | on-participating: |                   |
|                             | > 25% of the Plan |                   |
|                             | > allowance, plus |                   |
|                             | > any difference  |                   |
|                             | > between our     |                   |
|                             | > allowance and   |                   |
|                             | > the billed      |                   |
|                             | > amount          |                   |
+-----------------------------+-------------------+-------------------+
| -   Diabetic education when | > Preferred: 10%  | > Preferred       |
|     billed by a covered     | > of the Plan     | > primary care    |
|     provider                | > allowance       | > provider or     |
|                             | >                 | > other health    |
| > ***Note:*** We cover      | > Participating:  | > care            |
| > diabetic educators,       | > 25% of the Plan | > professional:   |
| > dieticians, and           | > allowance       | > \$20 copayment  |
| > nutritionists who bill    | >                 | > per visit       |
| > independently only as     | > N               | >                 |
| > part of a covered         | on-participating: | > Preferred       |
| > diabetic education        | > 25% of the Plan | > specialist:     |
| > program.                  | > allowance, plus | > \$30 copayment  |
|                             | > any difference  | > per visit       |
|                             | > between our     | >                 |
|                             | > allowance and   | > Participating/N |
|                             | > the billed      | on-participating: |
|                             | > amount          | > You pay all     |
|                             |                   | > charges         |
+-----------------------------+-------------------+-------------------+
| > *Not covered:*            | > *All charges*   | > *All charges*   |
|                             |                   |                   |
| -   *Marital, family,       |                   |                   |
|     educational, or other   |                   |                   |
|     counseling or training  |                   |                   |
|     services when performed |                   |                   |
|     as part of an           |                   |                   |
|     educational class or    |                   |                   |
|     program*                |                   |                   |
|                             |                   |                   |
| -   *Premenstrual syndrome  |                   |                   |
|     (PMS), lactation,       |                   |                   |
|     headache, eating        |                   |                   |
|     disorder, and other     |                   |                   |
|     educational clinics*    |                   |                   |
|                             |                   |                   |
| -   *Recreational or        |                   |                   |
|     educational therapy,    |                   |                   |
|     and any related         |                   |                   |
|     diagnostic testing      |                   |                   |
|     except as provided by a |                   |                   |
|     hospital as part of a   |                   |                   |
|     covered inpatient stay* |                   |                   |
|                             |                   |                   |
| -   *Services performed or  |                   |                   |
|     billed by a school or   |                   |                   |
|     halfway house or a      |                   |                   |
|     member of its staff*    |                   |                   |
+-----------------------------+-------------------+-------------------+

+---+---+-----------------------+-------------------+-------------+---+---+
| # |   |                       |                   |             |   |   |
| # |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| 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 |   |                       |                   |             |   |   |
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| 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    |                   |             | * |   |
|   | I | > you should keep in  |                   |             | I |   |
|   | * | > mind about these    |                   |             | * |   |
|   | * | > benefits:**         |                   |             | * |   |
|   |   |                       |                   |             |   |   |
|   | * | -   Please remember   |                   |             | * |   |
|   | * |     that all benefits |                   |             | * |   |
|   | M |     are subject to    |                   |             | M |   |
|   | * |     the definitions,  |                   |             | * |   |
|   | * |     limitations, and  |                   |             | * |   |
|   |   |     exclusions in     |                   |             |   |   |
|   | * |     this brochure and |                   |             | * |   |
|   | * |     are payable only  |                   |             | * |   |
|   | P |     when we determine |                   |             | P |   |
|   | * |     they are          |                   |             | * |   |
|   | * |     medically         |                   |             | * |   |
|   |   |     necessary.        |                   |             |   |   |
|   | * |                       |                   |             | * |   |
|   | * | -   **Under Standard  |                   |             | * |   |
|   | O |     Option,** the     |                   |             | O |   |
|   | * |     calendar year     |                   |             | * |   |
|   | * |     deductible is     |                   |             | * |   |
|   |   |     \$250 per person  |                   |             |   |   |
|   | * |     (\$500 per        |                   |             | * |   |
|   | * |     family). The      |                   |             | * |   |
|   | R |     calendar year     |                   |             | R |   |
|   | * |     deductible        |                   |             | * |   |
|   | * |     applies to almost |                   |             | * |   |
|   |   |     all **Standard    |                   |             |   |   |
|   | * |     Option** benefits |                   |             | * |   |
|   | * |     in this Section.  |                   |             | * |   |
|   | T |     We say \"(No      |                   |             | T |   |
|   | * |     deductible)\" to  |                   |             | * |   |
|   | * |     show when the     |                   |             | * |   |
|   |   |     calendar year     |                   |             |   |   |
|   | * |     deductible does   |                   |             | * |   |
|   | * |     not apply.        |                   |             | * |   |
|   | A |                       |                   |             | A |   |
|   | * | -   **Under Basic     |                   |             | * |   |
|   | * |     Option,** there   |                   |             | * |   |
|   |   |     is **no calendar  |                   |             |   |   |
|   | * |     year              |                   |             | * |   |
|   | * |     deductible**.     |                   |             | * |   |
|   | N |                       |                   |             | N |   |
|   | * | -   **Under Basic     |                   |             | * |   |
|   | * |     Option,** **you   |                   |             | * |   |
|   |   |     must use          |                   |             |   |   |
|   | * |     Preferred         |                   |             | * |   |
|   | * |     providers in      |                   |             | * |   |
|   | T |     order to receive  |                   |             | T |   |
|   | * |     benefits. See     |                   |             | * |   |
|   | * |     page 12 for the   |                   |             | * |   |
|   |   |     exceptions to     |                   |             |   |   |
|   |   |     this              |                   |             |   |   |
|   |   |     requirement.**    |                   |             |   |   |
|   |   |                       |                   |             |   |   |
|   |   | ```{=html}            |                   |             |   |   |
|   |   | <!-- -->              |                   |             |   |   |
|   |   | ```                   |                   |             |   |   |
|   |   | -   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         |                   |             |   |   |
|   |   |     Medicare.         |                   |             |   |   |
|   |   |                       |                   |             |   |   |
|   |   | ```{=html}            |                   |             |   |   |
|   |   | <!-- -->              |                   |             |   |   |
|   |   | ```                   |                   |             |   |   |
|   |   | -   We base payment   |                   |             |   |   |
|   |   |     on whether a      |                   |             |   |   |
|   |   |     facility or a     |                   |             |   |   |
|   |   |     health care       |                   |             |   |   |
|   |   |     professional      |                   |             |   |   |
|   |   |     bills for the     |                   |             |   |   |
|   |   |     services or       |                   |             |   |   |
|   |   |     supplies. You     |                   |             |   |   |
|   |   |     will find that    |                   |             |   |   |
|   |   |     some benefits are |                   |             |   |   |
|   |   |     listed in more    |                   |             |   |   |
|   |   |     than one section  |                   |             |   |   |
|   |   |     of the brochure.  |                   |             |   |   |
|   |   |     This is because   |                   |             |   |   |
|   |   |     how they are paid |                   |             |   |   |
|   |   |     depends on what   |                   |             |   |   |
|   |   |     type of provider  |                   |             |   |   |
|   |   |     bills for the     |                   |             |   |   |
|   |   |     service.          |                   |             |   |   |
|   |   |                       |                   |             |   |   |
|   |   | -   The amounts       |                   |             |   |   |
|   |   |     listed below are  |                   |             |   |   |
|   |   |     for the charges   |                   |             |   |   |
|   |   |     billed by a       |                   |             |   |   |
|   |   |     physician or      |                   |             |   |   |
|   |   |     other health care |                   |             |   |   |
|   |   |     professional for  |                   |             |   |   |
|   |   |     your surgical     |                   |             |   |   |
|   |   |     care. Look in     |                   |             |   |   |
|   |   |     Section 5(c) for  |                   |             |   |   |
|   |   |     charges           |                   |             |   |   |
|   |   |     associated with   |                   |             |   |   |
|   |   |     the facility      |                   |             |   |   |
|   |   |     (i.e.*,*          |                   |             |   |   |
|   |   |     hospital,         |                   |             |   |   |
|   |   |     surgical center,  |                   |             |   |   |
|   |   |     etc.).            |                   |             |   |   |
|   |   |                       |                   |             |   |   |
|   |   | -   **YOU MUST GET    |                   |             |   |   |
|   |   |     PRIOR APPROVAL    |                   |             |   |   |
|   |   |     for all organ     |                   |             |   |   |
|   |   |     transplant        |                   |             |   |   |
|   |   |     surgical          |                   |             |   |   |
|   |   |     procedures        |                   |             |   |   |
|   |   |     (except kidney    |                   |             |   |   |
|   |   |     and cornea        |                   |             |   |   |
|   |   |     transplants);**   |                   |             |   |   |
|   |   |     and if your       |                   |             |   |   |
|   |   |     surgical          |                   |             |   |   |
|   |   |     procedure         |                   |             |   |   |
|   |   |     requires an       |                   |             |   |   |
|   |   |     inpatient         |                   |             |   |   |
|   |   |     admission, **YOU  |                   |             |   |   |
|   |   |     MUST GET          |                   |             |   |   |
|   |   |     PRECERTIFICATION. |                   |             |   |   |
|   |   |     Please refer to   |                   |             |   |   |
|   |   |     the prior         |                   |             |   |   |
|   |   |     approval and      |                   |             |   |   |
|   |   |     precertification  |                   |             |   |   |
|   |   |     information shown |                   |             |   |   |
|   |   |     in Section 3 to   |                   |             |   |   |
|   |   |     be sure which     |                   |             |   |   |
|   |   |     services require  |                   |             |   |   |
|   |   |     prior approval or |                   |             |   |   |
|   |   |                       |                   |             |   |   |
|   |   |   precertification.** |                   |             |   |   |
|   |   |                       |                   |             |   |   |
|   |   | ```{=html}            |                   |             |   |   |
|   |   | <!-- -->              |                   |             |   |   |
|   |   | ```                   |                   |             |   |   |
|   |   | -   PPO benefits      |                   |             |   |   |
|   |   |     apply only when   |                   |             |   |   |
|   |   |     you use a PPO     |                   |             |   |   |
|   |   |     provider. When no |                   |             |   |   |
|   |   |     PPO provider is   |                   |             |   |   |
|   |   |     available,        |                   |             |   |   |
|   |   |     non-PPO benefits  |                   |             |   |   |
|   |   |     apply.            |                   |             |   |   |
+---+---+-----------------------+-------------------+-------------+---+---+
| * |   |                       | **You Pay**       |             |   |   |
| * |   |                       |                   |             |   |   |
| B |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| n |   |                       |                   |             |   |   |
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| f |   |                       |                   |             |   |   |
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| t |   |                       |                   |             |   |   |
| D |   |                       |                   |             |   |   |
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| n |   |                       |                   |             |   |   |
| * |   |                       |                   |             |   |   |
| * |   |                       |                   |             |   |   |
+---+---+-----------------------+-------------------+-------------+---+---+
| # |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
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+---+---+-----------------------+-------------------+-------------+---+---+
| * |   |                       | ### You Pay       | ###         |   |   |
| * |   |                       | − Standard Option | You Pay − B |   |   |
| S |   |                       |                   | asic Option |   |   |
| u |   |                       |                   |             |   |   |
| r |   |                       |                   |             |   |   |
| g |   |                       |                   |             |   |   |
| i |   |                       |                   |             |   |   |
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| d |   |                       |                   |             |   |   |
| u |   |                       |                   |             |   |   |
| r |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| s |   |                       |                   |             |   |   |
| * |   |                       |                   |             |   |   |
| * |   |                       |                   |             |   |   |
+---+---+-----------------------+-------------------+-------------+---+---+
| > |   |                       | > Preferred: 10%  | >           |   |   |
|   |   |                       | > of the Plan     |  Preferred: |   |   |
| A |   |                       | > allowance       | > \$100     |   |   |
| > |   |                       | >                 | > copayment |   |   |
|   |   |                       | > Participating:  | > per       |   |   |
| c |   |                       | > 25% of the Plan | >           |   |   |
| o |   |                       | > allowance       |  performing |   |   |
| m |   |                       | >                 | > surgeon   |   |   |
| p |   |                       | > N               | >           |   |   |
| r |   |                       | on-participating: | >           |   |   |
| e |   |                       | > 25% of the Plan | ***Note:*** |   |   |
| h |   |                       | > allowance, plus | > If you    |   |   |
| e |   |                       | > any difference  | > receive   |   |   |
| n |   |                       | > between our     | > the       |   |   |
| s |   |                       | > allowance and   | > services  |   |   |
| i |   |                       | > the billed      | > of a      |   |   |
| v |   |                       | > amount          | >           |   |   |
| e |   |                       |                   | co-surgeon, |   |   |
| > |   |                       |                   | > you pay a |   |   |
|   |   |                       |                   | > second    |   |   |
| r |   |                       |                   | > \$100     |   |   |
| a |   |                       |                   | > copayment |   |   |
| n |   |                       |                   | > for those |   |   |
| g |   |                       |                   | > services. |   |   |
| e |   |                       |                   | > No        |   |   |
| > |   |                       |                   | >           |   |   |
|   |   |                       |                   |  additional |   |   |
| o |   |                       |                   | > copayment |   |   |
| f |   |                       |                   | > applies   |   |   |
| > |   |                       |                   | > to the    |   |   |
|   |   |                       |                   | > services  |   |   |
| s |   |                       |                   | > of        |   |   |
| e |   |                       |                   | > assistant |   |   |
| r |   |                       |                   | > surgeons. |   |   |
| v |   |                       |                   | >           |   |   |
| i |   |                       |                   | >           |   |   |
| c |   |                       |                   |  Participat |   |   |
| e |   |                       |                   | ing/Non-par |   |   |
| s |   |                       |                   | ticipating: |   |   |
| > |   |                       |                   | > You pay   |   |   |
|   |   |                       |                   | > all       |   |   |
| p |   |                       |                   | > charges   |   |   |
| r |   |                       |                   |             |   |   |
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| d |   |                       |                   |             |   |   |
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|   |   |                       |                   |             |   |   |
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|   |   |                       |                   |             |   |   |
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|   |   |                       |                   |             |   |   |
| p |   |                       |                   |             |   |   |
| r |   |                       |                   |             |   |   |
| o |   |                       |                   |             |   |   |
| c |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| d |   |                       |                   |             |   |   |
| u |   |                       |                   |             |   |   |
| r |   |                       |                   |             |   |   |
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| ` |   |                       |                   |             |   |   |
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| { |   |                       |                   |             |   |   |
| = |   |                       |                   |             |   |   |
| h |   |                       |                   |             |   |   |
| t |   |                       |                   |             |   |   |
| m |   |                       |                   |             |   |   |
| l |   |                       |                   |             |   |   |
| } |   |                       |                   |             |   |   |
| < |   |                       |                   |             |   |   |
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| = |   |                       |                   |             |   |   |
| h |   |                       |                   |             |   |   |
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| m |   |                       |                   |             |   |   |
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| n |   |                       |                   |             |   |   |
| d |   |                       |                   |             |   |   |
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|   |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
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+---+---+-----------------------+-------------------+-------------+---+---+

Surgical procedures -- *continued on next page*

+-----------------------------+-------------------+-------------------+
| # Note: The calenda         |                   |                   |
| r year deductible applies t |                   |                   |
| o almost all Standard Optio |                   |                   |
| n benefits in this Section. |                   |                   |
|                             |                   |                   |
| #                           |                   |                   |
|  We say \"(No deductible)\" |                   |                   |
|  when the Standard Option d |                   |                   |
| eductible does *not* apply. |                   |                   |
|                             |                   |                   |
| **There is no calendar year |                   |                   |
| deductible under Basic      |                   |                   |
| Option.**                   |                   |                   |
+-----------------------------+-------------------+-------------------+
| ### Surgic                  | ### You Pay       | **You Pay − Basic |
| al procedures *(continued)* | − Standard Option | Option**          |
+-----------------------------+-------------------+-------------------+
| -   Correction of           | > Preferred: 10%  | > Preferred:      |
|     congenital anomalies    | > of the Plan     | > \$100 copayment |
|     (see Reconstructive     | > allowance       | > per performing  |
|     surgery on page 47)     | >                 | > surgeon         |
|                             | > Participating:  | >                 |
| ```{=html}                  | > 25% of the Plan | > ***Note:*** If  |
| <!-- -->                    | > allowance       | > you receive the |
| ```                         | >                 | > services of a   |
| -   Treatment of burns      | > N               | > co-surgeon, you |
|                             | on-participating: | > pay a second    |
| -   Circumcision of newborn | > 25% of the Plan | > \$100 copayment |
|                             | > allowance, plus | > for those       |
| -   Insertion of internal   | > any difference  | > services. No    |
|     prosthetic devices. See | > between our     | > additional      |
|     Section 5(a) --         | > allowance and   | > copayment       |
|     Orthopedic and          | > the billed      | > applies to the  |
|     prosthetic devices, and | > amount          | > services of     |
|     Section 5(c) -- Other   | >                 | > assistant       |
|     hospital services and   | > ***Note:*** We  | > surgeons.       |
|     supplies -- for our     | > provide         | >                 |
|     coverage for the        | > benefits at 90% | > Participating/N |
|     device.                 | > of the Plan     | on-participating: |
|                             | > allowance for   | > You pay all     |
| -   Voluntary sterilization | > services        | > charges         |
|     (e.g., Tubal ligation,  | > provided in     | >                 |
|     Vasectomy)              | > Preferred       | > ***Note:*** We  |
|                             | > facilities by   | > provide         |
| -   Assistant               | > Non-preferred   | > benefits at     |
|     surgeons/surgical       | > radiologists,   | > 100% of the     |
|     assistance by a         | > a               | > Plan allowance  |
|     physician if required   | nesthesiologists, | > for services    |
|     because of the          | > certified       | > provided in     |
|     complexity of the       | > registered      | > Preferred       |
|     surgical procedures     | > nurse           | > facilities by   |
|                             | > anesthetists    | > Non-preferred   |
| -   Gastric bypass surgery  | > (CRNAs),        | > radiologists,   |
|     or gastric stapling     | > pathologists,   | > a               |
|     procedures for morbid   | > and emergency   | nesthesiologists, |
|     obesity -- a condition  | > room            | > certified       |
|     in which an individual  | > physicians. You | > registered      |
|     weighs 100 pounds over, | > are responsible | > nurse           |
|     or 100% over, his or    | > for any         | > anesthetists    |
|     her normal weight       | > difference      | > (CRNAs),        |
|     according to current    | > between our     | > pathologists,   |
|     underwriting standards; | > allowance and   | > emergency room  |
|     eligible members must   | > the billed      | > physicians, and |
|     be age 18 or over       | > amount.         | > assistant       |
|                             |                   | > surgeons        |
| > ***Note:*** When multiple |                   | > (including      |
| > surgical procedures that  |                   | > assistant       |
| > add time or complexity to |                   | > surgeons in a   |
| > patient care are          |                   | > physician\'s    |
| > performed during the same |                   | > office). You    |
| > operative session, the    |                   | > are responsible |
| > Local Plan determines our |                   | > for any         |
| > allowance for the         |                   | > difference      |
| > combination of multiple,  |                   | > between our     |
| > bilateral, or incidental  |                   | > allowance and   |
| > surgical procedures.      |                   | > the billed      |
| > Generally, we will allow  |                   | > amount.         |
| > a reduced amount for      |                   |                   |
| > procedures other than the |                   |                   |
| > primary procedure.        |                   |                   |
| >                           |                   |                   |
| > ***Note:*** We do not pay |                   |                   |
| > extra for \"incidental\"  |                   |                   |
| > procedures (those that do |                   |                   |
| > not add time or           |                   |                   |
| > complexity to patient     |                   |                   |
| > care).                    |                   |                   |
| >                           |                   |                   |
| > ***Note:*** When unusual  |                   |                   |
| > circumstances require the |                   |                   |
| > removal of casts or       |                   |                   |
| > sutures by a physician    |                   |                   |
| > other than the one who    |                   |                   |
| > applied them, the Local   |                   |                   |
| > Plan may determine that a |                   |                   |
| > separate allowance is     |                   |                   |
| > payable.                  |                   |                   |
+-----------------------------+-------------------+-------------------+
| > *Not covered:*            | > *All charges*   | > *All charges*   |
|                             |                   |                   |
| -   *Reversal of voluntary  |                   |                   |
|     sterilization*          |                   |                   |
|                             |                   |                   |
| -   *Services of a standby  |                   |                   |
|     physician*              |                   |                   |
|                             |                   |                   |
| -   *Routine surgical       |                   |                   |
|     treatment of conditions |                   |                   |
|     of the foot \[see       |                   |                   |
|     Section 5(a) -- Foot    |                   |                   |
|     care\]*                 |                   |                   |
|                             |                   |                   |
| -   *Cosmetic surgery*      |                   |                   |
|                             |                   |                   |
| ```{=html}                  |                   |                   |
| <!-- -->                    |                   |                   |
| ```                         |                   |                   |
| -   *LASIK, radial          |                   |                   |
|     keratotomy, and other   |                   |                   |
|     refractive surgery*     |                   |                   |
+-----------------------------+-------------------+-------------------+

+-----------------------------+-------------------+-------------------+
| # Note: The calenda         |                   |                   |
| r year deductible applies t |                   |                   |
| o almost all Standard Optio |                   |                   |
| n benefits in this Section. |                   |                   |
|                             |                   |                   |
| #                           |                   |                   |
|  We say \"(No deductible)\" |                   |                   |
|  when the Standard Option d |                   |                   |
| eductible does *not* apply. |                   |                   |
|                             |                   |                   |
| **There is no calendar year |                   |                   |
| deductible under Basic      |                   |                   |
| Option.**                   |                   |                   |
+-----------------------------+-------------------+-------------------+
| ##                          | ### You Pay       | **You Pay − Basic |
| ### Reconstructive surgery  | − Standard Option | Option**          |
+-----------------------------+-------------------+-------------------+
| -   Surgery to correct a    | > Preferred: 10%  | > Preferred:      |
|     functional defect       | > of the Plan     | > \$100 copayment |
|                             | > allowance       | > per performing  |
| ```{=html}                  | >                 | > surgeon         |
| <!-- -->                    | > Participating:  | >                 |
| ```                         | > 25% of the Plan | > ***Note:*** If  |
| -   Surgery to correct a    | > allowance       | > you receive the |
|     congenital anomaly -- a | >                 | > services of a   |
|     condition that existed  | > N               | > co-surgeon, you |
|     at or from birth and is | on-participating: | > pay a second    |
|     a significant deviation | > 25% of the Plan | > \$100 copayment |
|     from the common form or | > allowance, plus | > for those       |
|     norm. Examples of       | > any difference  | > services. No    |
|     congenital anomalies    | > between our     | > additional      |
|     are: protruding ear     | > allowance and   | > copayment       |
|     deformities; cleft lip; | > the billed      | > applies to the  |
|     cleft palate; birth     | > amount          | > services of     |
|     marks; and webbed       | >                 | > assistant       |
|     fingers and toes.       | > ***Note:*** We  | > surgeons.       |
|                             | > provide         | >                 |
| > ***Note:*** Congenital    | > benefits at 90% | > Participating/N |
| > anomalies do not include  | > of the Plan     | on-participating: |
| > conditions related to the | > allowance for   | > You pay all     |
| > teeth or intra-oral       | > services        | > charges         |
| > structures supporting the | > provided in     | >                 |
| > teeth.                    | > Preferred       | > ***Note:*** We  |
|                             | > facilities by   | > provide         |
| -   Treatment to restore    | > Non-preferred   | > benefits at     |
|     the mouth to a          | > radiologists,   | > 100% of the     |
|     pre-cancer state        | > a               | > Plan allowance  |
|                             | nesthesiologists, | > for services    |
| ```{=html}                  | > certified       | > provided in     |
| <!-- -->                    | > registered      | > Preferred       |
| ```                         | > nurse           | > facilities by   |
| -   All stages of breast    | > anesthetists    | > Non-preferred   |
|     reconstruction surgery  | > (CRNAs),        | > radiologists,   |
|     following a mastectomy, | > pathologists,   | > a               |
|     such as:                | > and emergency   | nesthesiologists, |
|                             | > room            | > certified       |
| ```{=html}                  | > physicians. You | > registered      |
| <!-- -->                    | > are responsible | > nurse           |
| ```                         | > for any         | > anesthetists    |
| -   surgery to produce a    | > difference      | > (CRNAs),        |
|     symmetrical appearance  | > between our     | > pathologists,   |
|     of the patient\'s       | > allowance and   | > emergency room  |
|     breasts                 | > the billed      | > physicians, and |
|                             | > amount.         | > assistant       |
| -   treatment of any        |                   | > surgeons        |
|     physical complications, |                   | > (including      |
|     such as lymphedemas     |                   | > assistant       |
|                             |                   | > surgeons in a   |
| > ***Note:*** Internal      |                   | > physician\'s    |
| > breast prostheses are     |                   | > office). You    |
| > paid as orthopedic and    |                   | > are responsible |
| > prosthetic devices \[see  |                   | > for any         |
| > Section 5(a)\]. See       |                   | > difference      |
| > Section 5(c) when billed  |                   | > between our     |
| > by a facility.            |                   | > allowance and   |
| >                           |                   | > the billed      |
| > ***Note:*** If you need a |                   | > amount.         |
| > mastectomy, you may       |                   |                   |
| > choose to have the        |                   |                   |
| > procedure performed on an |                   |                   |
| > inpatient basis and       |                   |                   |
| > remain in the hospital up |                   |                   |
| > to 48 hours after the     |                   |                   |
| > procedure.                |                   |                   |
+-----------------------------+-------------------+-------------------+
| > *Not covered:*            | > *All charges*   | > *All charges*   |
|                             |                   |                   |
| -   *Cosmetic surgery --    |                   |                   |
|     any operative procedure |                   |                   |
|     or any portion of a     |                   |                   |
|     procedure performed     |                   |                   |
|     primarily to improve    |                   |                   |
|     physical appearance     |                   |                   |
|     through change in       |                   |                   |
|     bodily form -- unless   |                   |                   |
|     required for a          |                   |                   |
|     congenital anomaly or   |                   |                   |
|     to restore or correct a |                   |                   |
|     part of the body that   |                   |                   |
|     has been altered as a   |                   |                   |
|     result of accidental    |                   |                   |
|     injury, disease, or     |                   |                   |
|     surgery (does not       |                   |                   |
|     include anomalies       |                   |                   |
|     related to the teeth or |                   |                   |
|     structures supporting   |                   |                   |
|     the teeth)*             |                   |                   |
|                             |                   |                   |
| ```{=html}                  |                   |                   |
| <!-- -->                    |                   |                   |
| ```                         |                   |                   |
| -   *Surgeries related to   |                   |                   |
|     sex transformation,     |                   |                   |
|     sexual dysfunction, or  |                   |                   |
|     sexual inadequacy*      |                   |                   |
+-----------------------------+-------------------+-------------------+

+-----------------------------+-------------------+-------------------+
| # Note: The calenda         |                   |                   |
| r year deductible applies t |                   |                   |
| o almost all Standard Optio |                   |                   |
| n benefits in this Section. |                   |                   |
|                             |                   |                   |
| #                           |                   |                   |
|  We say \"(No deductible)\" |                   |                   |
|  when the Standard Option d |                   |                   |
| eductible does *not* apply. |                   |                   |
|                             |                   |                   |
| **There is no calendar year |                   |                   |
| deductible under Basic      |                   |                   |
| Option.**                   |                   |                   |
+-----------------------------+-------------------+-------------------+
| ##### Oral                  | ### You Pay       | ### You P         |
|  and maxillofacial surgery  | − Standard Option | ay − Basic Option |
+-----------------------------+-------------------+-------------------+
| > Oral surgical procedures, | > Preferred: 10%  | > Preferred:      |
| > limited to:               | > of the Plan     | > \$100 copayment |
|                             | > allowance       | > per performing  |
| -   Excision of tumors and  | >                 | > surgeon         |
|     cysts of the jaws,      | > Participating:  | >                 |
|     cheeks, lips, tongue,   | > 25% of the Plan | > ***Note:*** If  |
|     roof and floor of mouth | > allowance       | > you receive the |
|     when pathological       | >                 | > services of a   |
|     examination is          | > N               | > co-surgeon, you |
|     necessary               | on-participating: | > pay a second    |
|                             | > 25% of the Plan | > \$100 copayment |
| -   Surgery needed to       | > allowance, plus | > for those       |
|     correct accidental      | > any difference  | > services. No    |
|     injuries (see           | > between our     | > additional      |
|     Definitions) to jaws,   | > allowance and   | > copayment       |
|     cheeks, lips, tongue,   | > the billed      | > applies to the  |
|     roof and floor of mouth | > amount          | > services of     |
|                             | >                 | > assistant       |
| -   Excision of exostoses   | > ***Note:*** We  | > surgeons.       |
|     of jaws and hard palate | > provide         | >                 |
|                             | > benefits at 90% | > Participating/N |
| -   Incision and drainage   | > of the Plan     | on-participating: |
|     of abscesses and        | > allowance for   | > You pay all     |
|     cellulitis              | > services        | > charges         |
|                             | > provided in     | >                 |
| -   Incision and surgical   | > Preferred       | > ***Note:*** We  |
|     treatment of accessory  | > facilities by   | > provide         |
|     sinuses, salivary       | > Non-preferred   | > benefits at     |
|     glands, or ducts        | > radiologists,   | > 100% of the     |
|                             | > a               | > Plan allowance  |
| -   Reduction of            | nesthesiologists, | > for services    |
|     dislocations and        | > certified       | > provided in     |
|     excision of             | > registered      | > Preferred       |
|     temporomandibular       | > nurse           | > facilities by   |
|     joints                  | > anesthetists    | > Non-preferred   |
|                             | > (CRNAs),        | > radiologists,   |
| -   Removal of impacted     | > pathologists,   | > a               |
|     teeth                   | > and emergency   | nesthesiologists, |
|                             | > room            | > certified       |
|                             | > physicians. You | > registered      |
|                             | > are responsible | > nurse           |
|                             | > for any         | > anesthetists    |
|                             | > difference      | > (CRNAs),        |
|                             | > between our     | > pathologists,   |
|                             | > allowance and   | > emergency room  |
|                             | > the billed      | > physicians, and |
|                             | > amount.         | > assistant       |
|                             |                   | > surgeons        |
|                             |                   | > (including      |
|                             |                   | > assistant       |
|                             |                   | > surgeons in a   |
|                             |                   | > physician\'s    |
|                             |                   | > office). You    |
|                             |                   | > are responsible |
|                             |                   | > for any         |
|                             |                   | > difference      |
|                             |                   | > between our     |
|                             |                   | > allowance and   |
|                             |                   | > the billed      |
|                             |                   | > amount.         |
+-----------------------------+-------------------+-------------------+
| > *Not covered:*            | > *All charges*   | > *All charges*   |
|                             |                   |                   |
| -   *Oral implants and      |                   |                   |
|     transplants*            |                   |                   |
|                             |                   |                   |
| -   *Surgical procedures    |                   |                   |
|     that involve the teeth  |                   |                   |
|     or their supporting     |                   |                   |
|     structures (such as the |                   |                   |
|     periodontal membrane,   |                   |                   |
|     gingiva, and alveolar   |                   |                   |
|     bone), except as shown  |                   |                   |
|     above and in Section    |                   |                   |
|     5(h)*                   |                   |                   |
|                             |                   |                   |
| -   *Surgical procedures    |                   |                   |
|     involving orthodontic   |                   |                   |
|     care, dental implants,  |                   |                   |
|     or preparation of the   |                   |                   |
|     mouth for the fitting   |                   |                   |
|     or the continued use of |                   |                   |
|     dentures, except as     |                   |                   |
|     specifically shown      |                   |                   |
|     above and in Section    |                   |                   |
|     5(h)*                   |                   |                   |
+-----------------------------+-------------------+-------------------+

+--------------+--------------+-------------------+-------------------+
| # No         |              |                   |                   |
| te: The cale |              |                   |                   |
| ndar year de |              |                   |                   |
| ductible app |              |                   |                   |
| lies to almo |              |                   |                   |
| st all Stand |              |                   |                   |
| ard Option b |              |                   |                   |
| enefits in t |              |                   |                   |
| his Section. |              |                   |                   |
|              |              |                   |                   |
| # We say \   |              |                   |                   |
| "(No deducti |              |                   |                   |
| ble)\" when  |              |                   |                   |
| the Standard |              |                   |                   |
|  Option dedu |              |                   |                   |
| ctible does  |              |                   |                   |
| *not* apply. |              |                   |                   |
|              |              |                   |                   |
| **There is   |              |                   |                   |
| no calendar  |              |                   |                   |
| year         |              |                   |                   |
| deductible   |              |                   |                   |
| under Basic  |              |                   |                   |
| Option.**    |              |                   |                   |
+--------------+--------------+-------------------+-------------------+
| ##### O      |              | ### You Pay       | ### You P         |
| rgan/tissue  |              | − Standard Option | ay − Basic Option |
| transplants  |              |                   |                   |
+--------------+--------------+-------------------+-------------------+
| -   Cornea   | -   Kidney   | > Preferred: 10%  | > Preferred:      |
|              |              | > of the Plan     | > \$100 copayment |
| -   Heart    | -   Liver    | > allowance       | > per performing  |
|              |              | >                 | > surgeon         |
| ```{=html}   | ```{=html}   | > Participating:  | >                 |
| <!-- -->     | <!-- -->     | > 25% of the Plan | > ***Note:*** If  |
| ```          | ```          | > allowance       | > you receive the |
| -            | -   Pancreas | >                 | > services of a   |
|   Heart-lung |              | > N               | > co-surgeon, you |
|              |              | on-participating: | > pay a second    |
|              |              | > 25% of the Plan | > \$100 copayment |
|              |              | > allowance, plus | > for those       |
|              |              | > any difference  | > services. No    |
|              |              | > between our     | > additional      |
|              |              | > allowance and   | > copayment       |
|              |              | > the billed      | > applies to the  |
|              |              | > amount          | > services of     |
|              |              | >                 | > assistant       |
|              |              | > ***Note:*** We  | > surgeons.       |
|              |              | > provide         | >                 |
|              |              | > benefits at 90% | > Participating/N |
|              |              | > of the Plan     | on-participating: |
|              |              | > allowance for   | > You pay all     |
|              |              | > services        | > charges         |
|              |              | > provided in     | >                 |
|              |              | > Preferred       | > ***Note:*** We  |
|              |              | > facilities by   | > provide         |
|              |              | > Non-preferred   | > benefits at     |
|              |              | > radiologists,   | > 100% of the     |
|              |              | > a               | > Plan allowance  |
|              |              | nesthesiologists, | > for services    |
|              |              | > certified       | > provided in     |
|              |              | > registered      | > Preferred       |
|              |              | > nurse           | > facilities by   |
|              |              | > anesthetists    | > Non-preferred   |
|              |              | > (CRNAs),        | > radiologists,   |
|              |              | > pathologists,   | > a               |
|              |              | > and emergency   | nesthesiologists, |
|              |              | > room            | > certified       |
|              |              | > physicians. You | > registered      |
|              |              | > are responsible | > nurse           |
|              |              | > for any         | > anesthetists    |
|              |              | > difference      | > (CRNAs),        |
|              |              | > between our     | > pathologists,   |
|              |              | > allowance and   | > emergency room  |
|              |              | > the billed      | > physicians, and |
|              |              | > amount.         | > assistant       |
|              |              |                   | > surgeons        |
|              |              |                   | > (including      |
|              |              |                   | > assistant       |
|              |              |                   | > surgeons in a   |
|              |              |                   | > physician\'s    |
|              |              |                   | > office). You    |
|              |              |                   | > are responsible |
|              |              |                   | > for any         |
|              |              |                   | > difference      |
|              |              |                   | > between our     |
|              |              |                   | > allowance and   |
|              |              |                   | > the billed      |
|              |              |                   | > amount.         |
+--------------+--------------+-------------------+-------------------+
| -   Single   |              |                   |                   |
|     or       |              |                   |                   |
|     double   |              |                   |                   |
|     lung:    |              |                   |                   |
|     only for |              |                   |                   |
|     the      |              |                   |                   |
|              |              |                   |                   |
|    following |              |                   |                   |
|              |              |                   |                   |
|    end-stage |              |                   |                   |
|              |              |                   |                   |
|    pulmonary |              |                   |                   |
|              |              |                   |                   |
|    diseases: |              |                   |                   |
|              |              |                   |                   |
|    pulmonary |              |                   |                   |
|              |              |                   |                   |
|    fibrosis, |              |                   |                   |
|     primary  |              |                   |                   |
|              |              |                   |                   |
|    pulmonary |              |                   |                   |
|     h        |              |                   |                   |
| ypertension, |              |                   |                   |
|     and      |              |                   |                   |
|              |              |                   |                   |
|    emphysema |              |                   |                   |
|              |              |                   |                   |
| -   Double   |              |                   |                   |
|     lung:    |              |                   |                   |
|     only for |              |                   |                   |
|     patients |              |                   |                   |
|     with     |              |                   |                   |
|              |              |                   |                   |
|    end-stage |              |                   |                   |
|     cystic   |              |                   |                   |
|     fibrosis |              |                   |                   |
|              |              |                   |                   |
| -            |              |                   |                   |
|   Intestinal |              |                   |                   |
|              |              |                   |                   |
|  transplants |              |                   |                   |
|     (small   |              |                   |                   |
|              |              |                   |                   |
|   intestine) |              |                   |                   |
|     and the  |              |                   |                   |
|     small    |              |                   |                   |
|              |              |                   |                   |
|    intestine |              |                   |                   |
|     with the |              |                   |                   |
|     liver or |              |                   |                   |
|     small    |              |                   |                   |
|              |              |                   |                   |
|    intestine |              |                   |                   |
|     with     |              |                   |                   |
|     multiple |              |                   |                   |
|     organs   |              |                   |                   |
|     such as  |              |                   |                   |
|     the      |              |                   |                   |
|     liver,   |              |                   |                   |
|     stomach, |              |                   |                   |
|     and      |              |                   |                   |
|     pancreas |              |                   |                   |
+--------------+--------------+-------------------+-------------------+

Organ/tissue transplants -- *continued on next page*

+-----------------------------+-------------------+-------------------+
| # Note: The calenda         |                   |                   |
| r year deductible applies t |                   |                   |
| o almost all Standard Optio |                   |                   |
| n benefits in this Section. |                   |                   |
|                             |                   |                   |
| #                           |                   |                   |
|  We say \"(No deductible)\" |                   |                   |
|  when the Standard Option d |                   |                   |
| eductible does *not* apply. |                   |                   |
|                             |                   |                   |
| **There is no calendar year |                   |                   |
| deductible under Basic      |                   |                   |
| Option.**                   |                   |                   |
+-----------------------------+-------------------+-------------------+
| ##### Organ/tissu           | ### You Pay       | ### You P         |
| e transplants *(continued)* | − Standard Option | ay − Basic Option |
+-----------------------------+-------------------+-------------------+
| > Bone marrow and stem cell | > Preferred: 10%  | > Preferred:      |
| > transplants, limited to:  | > of the Plan     | > \$100 copayment |
|                             | > allowance       | > per performing  |
| -   Allogeneic bone marrow  | >                 | > surgeon         |
|     transplants and         | > Participating:  | >                 |
|     allogeneic cord blood   | > 25% of the Plan | > ***Note:*** If  |
|     stem cell transplants   | > allowance       | > you receive the |
|     (from related or        | >                 | > services of a   |
|     unrelated donors) for:  | > N               | > co-surgeon, you |
|                             | on-participating: | > pay a second    |
| ```{=html}                  | > 25% of the Plan | > \$100 copayment |
| <!-- -->                    | > allowance, plus | > for those       |
| ```                         | > any difference  | > services. No    |
| -   Advanced neuroblastoma  | > between our     | > additional      |
|                             | > allowance and   | > copayment       |
| -   Infantile malignant     | > the billed      | > applies to the  |
|     osteopetrosis           | > amount          | > services of     |
|                             | >                 | > assistant       |
| -   Severe combined         | > ***Note:*** We  | > surgeons.       |
|     immunodeficiency        | > provide         | >                 |
|                             | > benefits at 90% | > Participating/N |
| -   Mucopolysaccharidosis   | > of the Plan     | on-participating: |
|     (e.g.*,* Hunter,        | > allowance for   | > You pay all     |
|     Hurler\'s, Sanfilippo,  | > services        | > charges         |
|     Maroteaux‑Lamy          | > provided in     | >                 |
|     variants)               | > Preferred       | > ***Note:*** We  |
|                             | > facilities by   | > provide         |
| -   Mucolipidosis (e.g.,    | > Non-preferred   | > benefits at     |
|     Gaucher\'s disease,     | > radiologists,   | > 100% of the     |
|     metachromatic           | > a               | > Plan allowance  |
|     leukodystrophy,         | nesthesiologists, | > for services    |
|     adrenoleukodystrophy)   | > certified       | > provided in     |
|                             | > registered      | > Preferred       |
| -   Severe or very severe   | > nurse           | > facilities by   |
|     aplastic anemia         | > anesthetists    | > Non-preferred   |
|                             | > (CRNAs),        | > radiologists,   |
| -   Thalassemia major       | > pathologists,   | > a               |
|     (homozygous             | > and emergency   | nesthesiologists, |
|     beta‑thalassemia)       | > room            | > certified       |
|                             | > physicians. You | > registered      |
| ```{=html}                  | > are responsible | > nurse           |
| <!-- -->                    | > for any         | > anesthetists    |
| ```                         | > difference      | > (CRNAs),        |
| -   Sickle cell anemia      | > between our     | > pathologists,   |
|                             | > allowance and   | > emergency room  |
| ```{=html}                  | > the billed      | > physicians, and |
| <!-- -->                    | > amount.         | > assistant       |
| ```                         |                   | > surgeons        |
| -   Phagocytic deficiency   |                   | > (including      |
|     diseases (e.g.,         |                   | > assistant       |
|     Wiskott-Aldrich         |                   | > surgeons in a   |
|     syndrome)               |                   | > physician\'s    |
|                             |                   | > office). You    |
|                             |                   | > are responsible |
|                             |                   | > for any         |
|                             |                   | > difference      |
|                             |                   | > between our     |
|                             |                   | > allowance and   |
|                             |                   | > the billed      |
|                             |                   | > amount.         |
+-----------------------------+-------------------+-------------------+

Organ/tissue transplants -- *continued on next page*

+-----------------------------+-------------------+-------------------+
| # Note: The calenda         |                   |                   |
| r year deductible applies t |                   |                   |
| o almost all Standard Optio |                   |                   |
| n benefits in this Section. |                   |                   |
|                             |                   |                   |
| #                           |                   |                   |
|  We say \"(No deductible)\" |                   |                   |
|  when the Standard Option d |                   |                   |
| eductible does *not* apply. |                   |                   |
|                             |                   |                   |
| **There is no calendar year |                   |                   |
| deductible under Basic      |                   |                   |
| Option.**                   |                   |                   |
+-----------------------------+-------------------+-------------------+
| ##### Organ/tissu           | ### You Pay       | ### You P         |
| e transplants *(continued)* | − Standard Option | ay − Basic Option |
+-----------------------------+-------------------+-------------------+
| Bone marrow and stem cell   | > Preferred: 10%  | > Preferred:      |
| transplants, limited to:    | > of the Plan     | > \$100 copayment |
| *(continued)*               | > allowance       | > per performing  |
|                             | >                 | > surgeon         |
| -   Allogeneic bone marrow  | > Participating:  | >                 |
|     transplants, allogeneic | > 25% of the Plan | > ***Note:*** If  |
|     cord blood stem cell    | > allowance       | > you receive the |
|     transplants (from       | >                 | > services of a   |
|     related or unrelated    | > N               | > co-surgeon, you |
|     donors) and allogeneic  | on-participating: | > pay a second    |
|     peripheral blood stem   | > 25% of the Plan | > \$100 copayment |
|     cell transplants for:   | > allowance, plus | > for those       |
|                             | > any difference  | > services. No    |
| ```{=html}                  | > between our     | > additional      |
| <!-- -->                    | > allowance and   | > copayment       |
| ```                         | > the billed      | > applies to the  |
| -   Acute lymphocytic or    | > amount          | > services of     |
|     non-lymphocytic (i.e.,  | >                 | > assistant       |
|     myelogenous) leukemia   | > ***Note:*** We  | > surgeons.       |
|                             | > provide         | >                 |
| -   Advanced Hodgkin\'s     | > benefits at 90% | > Participating/N |
|     lymphoma                | > of the Plan     | on-participating: |
|                             | > allowance for   | > You pay all     |
| -   Advanced non-Hodgkin\'s | > services        | > charges         |
|     lymphoma                | > provided in     | >                 |
|                             | > Preferred       | > ***Note:*** We  |
| -   Chronic myelogenous     | > facilities by   | > provide         |
|     leukemia                | > Non-preferred   | > benefits at     |
|                             | > radiologists,   | > 100% of the     |
| -   Advanced forms of       | > a               | > Plan allowance  |
|     myelodysplastic         | nesthesiologists, | > for services    |
|     syndromes               | > certified       | > provided in     |
|                             | > registered      | > Preferred       |
| ```{=html}                  | > nurse           | > facilities by   |
| <!-- -->                    | > anesthetists    | > Non-preferred   |
| ```                         | > (CRNAs),        | > radiologists,   |
| -   Autologous bone marrow  | > pathologists,   | > a               |
|     transplants and         | > and emergency   | nesthesiologists, |
|     autologous peripheral   | > room            | > certified       |
|     blood stem cell         | > physicians. You | > registered      |
|     transplants             | > are responsible | > nurse           |
|     (collectively referred  | > for any         | > anesthetists    |
|     to as autologous stem   | > difference      | > (CRNAs),        |
|     cell support) for:      | > between our     | > pathologists,   |
|                             | > allowance and   | > emergency room  |
| ```{=html}                  | > the billed      | > physicians, and |
| <!-- -->                    | > amount.         | > assistant       |
| ```                         |                   | > surgeons        |
| -   Acute lymphocytic or    |                   | > (including      |
|     nonlymphocytic (i.e.,   |                   | > assistant       |
|     myelogenous) leukemia   |                   | > surgeons in a   |
|                             |                   | > physician\'s    |
| -   Advanced Hodgkin\'s     |                   | > office). You    |
|     lymphoma                |                   | > are responsible |
|                             |                   | > for any         |
| -   Advanced non-Hodgkin\'s |                   | > difference      |
|     lymphoma                |                   | > between our     |
|                             |                   | > allowance and   |
| -   Advanced neuroblastoma  |                   | > the billed      |
|                             |                   | > amount.         |
| -   Amyloidosis             |                   |                   |
|                             |                   |                   |
| -   Testicular,             |                   |                   |
|     Mediastinal,            |                   |                   |
|     Retroperitoneal, and    |                   |                   |
|     Ovarian germ cell       |                   |                   |
|     tumors                  |                   |                   |
|                             |                   |                   |
| ```{=html}                  |                   |                   |
| <!-- -->                    |                   |                   |
| ```                         |                   |                   |
| -   Multiple myeloma        |                   |                   |
+-----------------------------+-------------------+-------------------+

Organ/tissue transplants -- *continued on next page*

+-----------------------------+-------------------+-------------------+
| # Note: The calenda         |                   |                   |
| r year deductible applies t |                   |                   |
| o almost all Standard Optio |                   |                   |
| n benefits in this Section. |                   |                   |
|                             |                   |                   |
| #                           |                   |                   |
|  We say \"(No deductible)\" |                   |                   |
|  when the Standard Option d |                   |                   |
| eductible does *not* apply. |                   |                   |
|                             |                   |                   |
| **There is no calendar year |                   |                   |
| deductible under Basic      |                   |                   |
| Option.**                   |                   |                   |
+-----------------------------+-------------------+-------------------+
| **Organ/tissue              | ### You Pay       | ### You P         |
| transplants** *(continued)* | − Standard Option | ay − Basic Option |
+-----------------------------+-------------------+-------------------+
| -   Extraction or           | > Preferred: 10%  | > Preferred:      |
|     reinfusion of bone      | > of the Plan     | > \$100 copayment |
|     marrow, blood stem      | > allowance       | > per performing  |
|     cells, or cord blood as | >                 | > surgeon         |
|     a source of stem cells  | > Participating:  | >                 |
|     as part of a covered    | > 25% of the Plan | > ***Note:*** If  |
|     allogeneic or           | > allowance       | > you receive the |
|     autologous bone marrow  | >                 | > services of a   |
|     transplant or blood     | > N               | > co-surgeon, you |
|     stem cell transplant    | on-participating: | > pay a second    |
|     support procedure       | > 25% of the Plan | > \$100 copayment |
|                             | > allowance, plus | > for those       |
| ```{=html}                  | > any difference  | > services. No    |
| <!-- -->                    | > between our     | > additional      |
| ```                         | > allowance and   | > copayment       |
| -   Marrow harvesting in    | > the billed      | > applies to the  |
|     anticipation of a       | > amount          | > services of     |
|     covered autologous bone | >                 | > assistant       |
|     marrow transplant, for  | > ***Note:*** We  | > surgeons.       |
|     patients diagnosed at   | > provide         | >                 |
|     the time of harvesting  | > benefits at 90% | > Participating/N |
|     with one of the         | > of the Plan     | on-participating: |
|     conditions listed on    | > allowance for   | > You pay all     |
|     page 51, 54, or 55      | > services        | > charges         |
|                             | > provided in     | >                 |
| ```{=html}                  | > Preferred       | > ***Note:*** We  |
| <!-- -->                    | > facilities by   | > provide         |
| ```                         | > Non-preferred   | > benefits at     |
| -   Collection, processing, | > radiologists,   | > 100% of the     |
|     storage, and            | > a               | > Plan allowance  |
|     distribution of cord    | nesthesiologists, | > for services    |
|     blood only when         | > certified       | > provided in     |
|     performed by a cord     | > registered      | > Preferred       |
|     blood bank approved by  | > nurse           | > facilities by   |
|     the FDA                 | > anesthetists    | > Non-preferred   |
|                             | > (CRNAs),        | > radiologists,   |
| -   Storage of harvested    | > pathologists,   | > a               |
|     bone marrow, blood stem | > and emergency   | nesthesiologists, |
|     cells, or cord blood as | > room            | > certified       |
|     a source of stem cells, | > physicians. You | > registered      |
|     only when a covered     | > are responsible | > nurse           |
|     transplant has already  | > for any         | > anesthetists    |
|     been scheduled          | > difference      | > (CRNAs),        |
|                             | > between our     | > pathologists,   |
| -   Related medical and     | > allowance and   | > emergency room  |
|     hospital expenses of    | > the billed      | > physicians, and |
|     the donor, as part of a | > amount.         | > assistant       |
|     covered transplant      |                   | > surgeons        |
|     procedure               |                   | > (including      |
|                             |                   | > assistant       |
| ```{=html}                  |                   | > surgeons in a   |
| <!-- -->                    |                   | > physician\'s    |
| ```                         |                   | > office). You    |
| -   Related services or     |                   | > are responsible |
|     supplies provided to    |                   | > for any         |
|     the recipient           |                   | > difference      |
|                             |                   | > between our     |
| > ***Note:*** See Section   |                   | > allowance and   |
| > 5(a) for coverage for     |                   | > the billed      |
| > related services, such as |                   | > amount.         |
| > chemotherapy and/or       |                   |                   |
| > radiation therapy and     |                   |                   |
| > drugs administered to     |                   |                   |
| > stimulate or mobilize     |                   |                   |
| > stem cells for covered    |                   |                   |
| > transplant procedures.    |                   |                   |
+-----------------------------+-------------------+-------------------+

Organ/tissue transplants -- *continued on next page*

+-----------------------------+-------------------+-------------------+
| # Note: The calenda         |                   |                   |
| r year deductible applies t |                   |                   |
| o almost all Standard Optio |                   |                   |
| n benefits in this Section. |                   |                   |
|                             |                   |                   |
| #                           |                   |                   |
|  We say \"(No deductible)\" |                   |                   |
|  when the Standard Option d |                   |                   |
| eductible does *not* apply. |                   |                   |
|                             |                   |                   |
| **There is no calendar year |                   |                   |
| deductible under Basic      |                   |                   |
| Option.**                   |                   |                   |
+-----------------------------+-------------------+-------------------+
| > **Organ/tissue            |                   |                   |
| > transplants**             |                   |                   |
| > *(continued)*             |                   |                   |
+-----------------------------+-------------------+-------------------+
| > **Organ/Tissue            |                   |                   |
| > Transplants at Blue       |                   |                   |
| > Quality Centers for       |                   |                   |
| > Transplant (BQCT)**       |                   |                   |
| >                           |                   |                   |
| > We participate in the     |                   |                   |
| > Blue Quality Centers for  |                   |                   |
| > Transplant (BQCT), a      |                   |                   |
| > centers of excellence     |                   |                   |
| > program for the           |                   |                   |
| > organ/tissue transplants  |                   |                   |
| > listed below. You will    |                   |                   |
| > receive enhanced benefits |                   |                   |
| > if you use a BQCT         |                   |                   |
| > facility.                 |                   |                   |
| >                           |                   |                   |
| > **All members (including  |                   |                   |
| > those who have Medicare   |                   |                   |
| > Part A or another group   |                   |                   |
| > health insurance policy   |                   |                   |
| > as their primary payer)   |                   |                   |
| > must contact us at the    |                   |                   |
| > customer service number   |                   |                   |
| > listed on the back of     |                   |                   |
| > their ID card before      |                   |                   |
| > obtaining services.** You |                   |                   |
| > will be referred to the   |                   |                   |
| > designated Plan           |                   |                   |
| > transplant coordinator    |                   |                   |
| > for information about     |                   |                   |
| > BQCT and approved         |                   |                   |
| > facilities.               |                   |                   |
+-----------------------------+-------------------+-------------------+
| -   Heart                   |                   |                   |
|                             |                   |                   |
| ```{=html}                  |                   |                   |
| <!-- -->                    |                   |                   |
| ```                         |                   |                   |
| -   Heart-lung              |                   |                   |
|                             |                   |                   |
| -   Liver                   |                   |                   |
|                             |                   |                   |
| ```{=html}                  |                   |                   |
| <!-- -->                    |                   |                   |
| ```                         |                   |                   |
| -   Pancreas                |                   |                   |
|                             |                   |                   |
| ```{=html}                  |                   |                   |
| <!-- -->                    |                   |                   |
| ```                         |                   |                   |
| -   Simultaneous            |                   |                   |
|     pancreas-kidney         |                   |                   |
|                             |                   |                   |
| ```{=html}                  |                   |                   |
| <!-- -->                    |                   |                   |
| ```                         |                   |                   |
| -   Single or double lung:  |                   |                   |
|     only for the following  |                   |                   |
|     end-stage pulmonary     |                   |                   |
|     diseases: pulmonary     |                   |                   |
|     fibrosis, primary       |                   |                   |
|     pulmonary hypertension, |                   |                   |
|     and emphysema           |                   |                   |
|                             |                   |                   |
| ```{=html}                  |                   |                   |
| <!-- -->                    |                   |                   |
| ```                         |                   |                   |
| -   Double lung: only       |                   |                   |
|     available for patients  |                   |                   |
|     with end-stage cystic   |                   |                   |
|     fibrosis                |                   |                   |
|                             |                   |                   |
| ```{=html}                  |                   |                   |
| <!-- -->                    |                   |                   |
| ```                         |                   |                   |
| -   Bone marrow and stem    |                   |                   |
|     cell transplants listed |                   |                   |
|     on pages 50, 51, 54,    |                   |                   |
|     and 55                  |                   |                   |
|                             |                   |                   |
| ```{=html}                  |                   |                   |
| <!-- -->                    |                   |                   |
| ```                         |                   |                   |
| -   Related transplant      |                   |                   |
|     services listed on page |                   |                   |
|     52                      |                   |                   |
+-----------------------------+-------------------+-------------------+
| > ***Note:*** Benefits for  |                   |                   |
| > cornea, kidney-only, and  |                   |                   |
| > intestinal transplants    |                   |                   |
| > are not available through |                   |                   |
| > BQCT. See page 49 for     |                   |                   |
| > benefit information for   |                   |                   |
| > these transplants.        |                   |                   |
| >                           |                   |                   |
| > ***Note:*** See Section   |                   |                   |
| > 5(c) for our benefits for |                   |                   |
| > facility care.            |                   |                   |
| >                           |                   |                   |
| > ***Note:*** Members will  |                   |                   |
| > not be responsible for    |                   |                   |
| > separate cost-sharing for |                   |                   |
| > the included professional |                   |                   |
| > services (see page 12).   |                   |                   |
| >                           |                   |                   |
| > ***Note:*** See below and |                   |                   |
| > page 54 for limitations   |                   |                   |
| > to bone marrow and stem   |                   |                   |
| > cell transplant coverage. |                   |                   |
| >                           |                   |                   |
| > ***Note:*** See page 12   |                   |                   |
| > for special instructions  |                   |                   |
| > regarding all admissions  |                   |                   |
| > to BQCT institutions.     |                   |                   |
+-----------------------------+-------------------+-------------------+
| > **Organ/tissue            | **You Pay −       | ##### You P       |
| > transplants**             | Standard Option** | ay − Basic Option |
| > *(continued)*             |                   |                   |
+-----------------------------+-------------------+-------------------+
| > Limitations for all       |                   |                   |
| > transplants               |                   |                   |
| >                           |                   |                   |
| > \(1\) You must obtain     |                   |                   |
| > prior approval (see page  |                   |                   |
| > 15) from the Local Plan,  |                   |                   |
| > for both the procedure    |                   |                   |
| > and the facility, for the |                   |                   |
| > following transplant      |                   |                   |
| > procedures:               |                   |                   |
|                             |                   |                   |
| -   Bone marrow, cord blood |                   |                   |
|     stem cell, and          |                   |                   |
|     peripheral blood stem   |                   |                   |
|     cell transplant support |                   |                   |
|     procedures              |                   |                   |
|                             |                   |                   |
| ```{=html}                  |                   |                   |
| <!-- -->                    |                   |                   |
| ```                         |                   |                   |
| -   Heart                   |                   |                   |
|                             |                   |                   |
| -   Heart-lung              |                   |                   |
|                             |                   |                   |
| -   Liver                   |                   |                   |
|                             |                   |                   |
| -   Lung (single/double)    |                   |                   |
|                             |                   |                   |
| ```{=html}                  |                   |                   |
| <!-- -->                    |                   |                   |
| ```                         |                   |                   |
| -   Pancreas                |                   |                   |
|                             |                   |                   |
| ```{=html}                  |                   |                   |
| <!-- -->                    |                   |                   |
| ```                         |                   |                   |
| -   Simultaneous            |                   |                   |
|     pancreas-kidney         |                   |                   |
|                             |                   |                   |
| ```{=html}                  |                   |                   |
| <!-- -->                    |                   |                   |
| ```                         |                   |                   |
| -   Intestinal transplants  |                   |                   |
|     (small intestine with   |                   |                   |
|     or without other        |                   |                   |
|     organs)                 |                   |                   |
+-----------------------------+-------------------+-------------------+

Organ/tissue transplants -- *continued on next page*

+-----------------------------+-------------------+-------------------+
| # Note: The calenda         |                   |                   |
| r year deductible applies t |                   |                   |
| o almost all Standard Optio |                   |                   |
| n benefits in this Section. |                   |                   |
|                             |                   |                   |
| #                           |                   |                   |
|  We say \"(No deductible)\" |                   |                   |
|  when the Standard Option d |                   |                   |
| eductible does *not* apply. |                   |                   |
|                             |                   |                   |
| **There is no calendar year |                   |                   |
| deductible under Basic      |                   |                   |
| Option.**                   |                   |                   |
+-----------------------------+-------------------+-------------------+
| **Organ/tissue              | ### You Pay       | ### You P         |
| transplants** *(continued)* | − Standard Option | ay − Basic Option |
+-----------------------------+-------------------+-------------------+
| (2) For the following       | > Preferred: 10%  | > Preferred:      |
|     procedures, we provide  | > of the Plan     | > \$100 copayment |
|     benefits **only** when  | > allowance       | > per performing  |
|     conducted at a Cancer   | >                 | > surgeon         |
|     Research Facility (see  | > Participating:  | >                 |
|     page 12) and performed  | > 25% of the Plan | > ***Note:*** If  |
|     as part of a clinical   | > allowance       | > you receive the |
|     trial that meets the    | >                 | > services of a   |
|     requirements shown      | > N               | > co-surgeon, you |
|     below:                  | on-participating: | > pay a second    |
|                             | > 25% of the Plan | > \$100 copayment |
| -   Allogeneic bone marrow  | > allowance, plus | > for those       |
|     transplants, syngeneic  | > any difference  | > services. No    |
|     bone marrow             | > between our     | > additional      |
|     transplants, and        | > allowance and   | > copayment       |
|     allogeneic peripheral   | > the billed      | > applies to the  |
|     blood stem cell         | > amount          | > services of     |
|     transplants for:        | >                 | > assistant       |
|                             | > ***Note:*** We  | > surgeons.       |
| ```{=html}                  | > provide         | >                 |
| <!-- -->                    | > benefits at 90% | > Participating/N |
| ```                         | > of the Plan     | on-participating: |
| -   Multiple myeloma        | > allowance for   | > You pay all     |
|                             | > services        | > charges         |
| -   Chronic lymphocytic     | > provided in     | >                 |
|     leukemia                | > Preferred       | > ***Note:*** We  |
|                             | > facilities by   | > provide         |
| -   Early stage (indolent   | > Non-preferred   | > benefits at     |
|     or non-advanced) small  | > radiologists,   | > 100% of the     |
|     cell lymphocytic        | > a               | > Plan allowance  |
|     lymphoma                | nesthesiologists, | > for services    |
|                             | > certified       | > provided in     |
| ```{=html}                  | > registered      | > Preferred       |
| <!-- -->                    | > nurse           | > facilities by   |
| ```                         | > anesthetists    | > Non-preferred   |
| -   Nonmyeloablative        | > (CRNAs),        | > radiologists,   |
|     allogeneic stem cell    | > pathologists,   | > a               |
|     transplants for:        | > and emergency   | nesthesiologists, |
|                             | > room            | > certified       |
| ```{=html}                  | > physicians. You | > registered      |
| <!-- -->                    | > are responsible | > nurse           |
| ```                         | > for any         | > anesthetists    |
| -   Chronic myelogenous     | > difference      | > (CRNAs),        |
|     leukemia                | > between our     | > pathologists,   |
|                             | > allowance and   | > emergency room  |
| -   Acute lymphocytic or    | > the billed      | > physicians, and |
|     non-lymphocytic (i.e.,  | > amount.         | > assistant       |
|     myelogenous) leukemia   |                   | > surgeons        |
|                             |                   | > (including      |
| -   Advanced Hodgkin\'s     |                   | > assistant       |
|     lymphoma                |                   | > surgeons in a   |
|                             |                   | > physician\'s    |
| -   Advanced non-Hodgkin\'s |                   | > office). You    |
|     lymphoma                |                   | > are responsible |
|                             |                   | > for any         |
| -   Advanced forms of       |                   | > difference      |
|     myelodysplastic         |                   | > between our     |
|     syndromes               |                   | > allowance and   |
|                             |                   | > the billed      |
| -   Multiple myeloma        |                   | > amount.         |
|                             |                   |                   |
| -   Chronic lymphocytic     |                   |                   |
|     leukemia                |                   |                   |
|                             |                   |                   |
| -   Early stage (indolent   |                   |                   |
|     or non-advanced) small  |                   |                   |
|     cell lymphocytic        |                   |                   |
|     lymphoma                |                   |                   |
|                             |                   |                   |
| ```{=html}                  |                   |                   |
| <!-- -->                    |                   |                   |
| ```                         |                   |                   |
| -   Renal cell carcinoma    |                   |                   |
|                             |                   |                   |
| ```{=html}                  |                   |                   |
| <!-- -->                    |                   |                   |
| ```                         |                   |                   |
| -   Autologous bone marrow  |                   |                   |
|     transplants and         |                   |                   |
|     autologous peripheral   |                   |                   |
|     blood stem cell         |                   |                   |
|     transplants             |                   |                   |
|     (collectively referred  |                   |                   |
|     to as autologous stem   |                   |                   |
|     cell support) for:      |                   |                   |
|                             |                   |                   |
| ```{=html}                  |                   |                   |
| <!-- -->                    |                   |                   |
| ```                         |                   |                   |
| -   Breast cancer           |                   |                   |
|                             |                   |                   |
| -   Epithelial ovarian      |                   |                   |
|     cancer                  |                   |                   |
|                             |                   |                   |
| -   Chronic myelogenous     |                   |                   |
|     leukemia                |                   |                   |
|                             |                   |                   |
| -   Chronic lymphocytic     |                   |                   |
|     leukemia                |                   |                   |
|                             |                   |                   |
| -   Early stage (indolent   |                   |                   |
|     or non-advanced) small  |                   |                   |
|     cell lymphocytic        |                   |                   |
|     lymphoma                |                   |                   |
+-----------------------------+-------------------+-------------------+

Organ/tissue transplants -- *continued on next page*

+-----------------------------+-------------------+-------------------+
| # Note: The calenda         |                   |                   |
| r year deductible applies t |                   |                   |
| o almost all Standard Optio |                   |                   |
| n benefits in this Section. |                   |                   |
|                             |                   |                   |
| #                           |                   |                   |
|  We say \"(No deductible)\" |                   |                   |
|  when the Standard Option d |                   |                   |
| eductible does *not* apply. |                   |                   |
|                             |                   |                   |
| **There is no calendar year |                   |                   |
| deductible under Basic      |                   |                   |
| Option.**                   |                   |                   |
+-----------------------------+-------------------+-------------------+
| **Organ/tissue              | ### You Pay       | ### You P         |
| transplants** *(continued)* | − Standard Option | ay − Basic Option |
+-----------------------------+-------------------+-------------------+
| -   Autologous bone marrow  | > Preferred: 10%  | > Preferred:      |
|     or peripheral blood     | > of the Plan     | > \$100 copayment |
|     stem cell transplants   | > allowance       | > per performing  |
|     when performed in       | >                 | > surgeon         |
|     specific NIH-funded,    | > Participating:  | >                 |
|     randomized,             | > 25% of the Plan | > ***Note:*** If  |
|     multi-center,           | > allowance       | > you receive the |
|     comparative trials for  | >                 | > services of a   |
|     the following           | > N               | > co-surgeon, you |
|     autoimmune diseases:    | on-participating: | > pay a second    |
|                             | > 25% of the Plan | > \$100 copayment |
| ```{=html}                  | > allowance, plus | > for those       |
| <!-- -->                    | > any difference  | > services. No    |
| ```                         | > between our     | > additional      |
| -   Systemic sclerosis      | > allowance and   | > copayment       |
|                             | > the billed      | > applies to the  |
| -   Systemic lupus          | > amount          | > services of     |
|     erythematosus           | >                 | > assistant       |
|                             | > ***Note:*** We  | > surgeons.       |
| -   Multiple sclerosis      | > provide         | >                 |
|                             | > benefits at 90% | > Participating/N |
|     For these bone marrow   | > of the Plan     | on-participating: |
|     transplant procedures   | > allowance for   | > You pay all     |
|     and related services or | > services        | > charges         |
|     supplies covered only   | > provided in     | >                 |
|     through clinical        | > Preferred       | > ***Note:*** We  |
|     trials:                 | > facilities by   | > provide         |
|                             | > Non-preferred   | > benefits at     |
| 1.  You must contact our    | > radiologists,   | > 100% of the     |
|     Clinical Trials         | > a               | > Plan allowance  |
|     Information Unit at     | nesthesiologists, | > for services    |
|     1-800-225-2268 for      | > certified       | > provided in     |
|     prior approval (see     | > registered      | > Preferred       |
|     page 15);               | > nurse           | > facilities by   |
|                             | > anesthetists    | > Non-preferred   |
| 2.  The clinical trial must | > (CRNAs),        | > radiologists,   |
|     be reviewed and         | > pathologists,   | > a               |
|     approved by the         | > and emergency   | nesthesiologists, |
|     Institutional Review    | > room            | > certified       |
|     Board of the Cancer     | > physicians. You | > registered      |
|     Research Facility where | > are responsible | > nurse           |
|     the procedure is to be  | > for any         | > anesthetists    |
|     delivered; and          | > difference      | > (CRNAs),        |
|                             | > between our     | > pathologists,   |
| 3.  The patient must be     | > allowance and   | > emergency room  |
|     properly and lawfully   | > the billed      | > physicians, and |
|     registered in the       | > amount.         | > assistant       |
|     clinical trial, meeting |                   | > surgeons        |
|     all the eligibility     |                   | > (including      |
|     requirements of the     |                   | > assistant       |
|     trial.                  |                   | > surgeons in a   |
|                             |                   | > physician\'s    |
| > If a non-randomized       |                   | > office). You    |
| > clinical trial meeting    |                   | > are responsible |
| > these requirements is not |                   | > for any         |
| > available at a Cancer     |                   | > difference      |
| > Research Facility where   |                   | > between our     |
| > you are eligible, we will |                   | > allowance and   |
| > arrange for the           |                   | > the billed      |
| > transplant to be provided |                   | > amount.         |
| > at another                |                   |                   |
| > Plan-designated           |                   |                   |
| > transplant facility.      |                   |                   |
+-----------------------------+-------------------+-------------------+
| > *Not covered:*            | > *All charges*   | > *All charges*   |
|                             |                   |                   |
| -   *Transplants for any    |                   |                   |
|     diagnosis not listed as |                   |                   |
|     covered*                |                   |                   |
|                             |                   |                   |
| -   *Donor screening tests  |                   |                   |
|     and donor search        |                   |                   |
|     expenses, except those  |                   |                   |
|     performed for the       |                   |                   |
|     actual donor*           |                   |                   |
+-----------------------------+-------------------+-------------------+

+-----------------------------+-------------------+-------------------+
| # Note: The calenda         |                   |                   |
| r year deductible applies t |                   |                   |
| o almost all Standard Optio |                   |                   |
| n benefits in this Section. |                   |                   |
|                             |                   |                   |
| #                           |                   |                   |
|  We say \"(No deductible)\" |                   |                   |
|  when the Standard Option d |                   |                   |
| eductible does *not* apply. |                   |                   |
|                             |                   |                   |
| **There is no calendar year |                   |                   |
| deductible under Basic      |                   |                   |
| Option.**                   |                   |                   |
+-----------------------------+-------------------+-------------------+
| # Anesthesia                | ### You Pay       | ### You P         |
|                             | − Standard Option | ay − Basic Option |
+-----------------------------+-------------------+-------------------+
| > Anesthesia (including     | > Preferred: 10%  | > Preferred:      |
| > acupuncture) for covered  | > of the Plan     | > Nothing         |
| > surgical services when    | > allowance       | >                 |
| > requested by the          | >                 | > Participating/N |
| > attending physician and   | > Participating:  | on-participating: |
| > performed by:             | > 25% of the Plan | > You pay all     |
|                             | > allowance       | > charges         |
| -   a certified registered  | >                 | >                 |
|     nurse anesthetist       | > N               | > ***Note:*** We  |
|     (CRNA), or              | on-participating: | > provide         |
|                             | > 25% of the Plan | > benefits at     |
| -   a physician other than  | > allowance, plus | > 100% of the     |
|     the operating physician | > any difference  | > Plan allowance  |
|     (surgeon) or the        | > between our     | > for services    |
|     assistant               | > allowance and   | > provided in     |
|                             | > the billed      | > Preferred       |
| > Professional services     | > amount          | > facilities by   |
| > provided in:              | >                 | > Non-preferred   |
|                             | > ***Note:*** We  | >                 |
| -   Hospital (inpatient)    | > provide         | anesthesiologists |
|                             | > benefits at 90% | > and certified   |
| -   Hospital outpatient     | > of the Plan     | > registered      |
|     department              | > allowance for   | > nurse           |
|                             | > services        | > anesthetists    |
| -   Skilled nursing         | > provided in     | > (CRNAs). You    |
|     facility                | > Preferred       | > are responsible |
|                             | > facilities by   | > for any         |
| -   Ambulatory surgical     | > Non-preferred   | > difference      |
|     center                  | >                 | > between our     |
|                             | anesthesiologists | > allowance and   |
| -   Office                  | > and certified   | > the billed      |
|                             | > registered      | > amount.         |
| > Anesthesia services       | > nurse           |                   |
| > consist of administration | > anesthetists    |                   |
| > by injection or           | > (CRNAs). You    |                   |
| > inhalation of a drug or   | > are responsible |                   |
| > other anesthetic agent    | > for any         |                   |
| > (including acupuncture)   | > difference      |                   |
| > to obtain muscular        | > between our     |                   |
| > relaxation, loss of       | > allowance and   |                   |
| > sensation, or loss of     | > the billed      |                   |
| > consciousness.            | > amount.         |                   |
| >                           |                   |                   |
| > ***Note:*** See Section   |                   |                   |
| > 5(c) for our payment      |                   |                   |
| > levels for anesthesia     |                   |                   |
| > services billed by a      |                   |                   |
| > facility.                 |                   |                   |
+-----------------------------+-------------------+-------------------+

+---+---+-----------------------------------------------------------+---+---+
| # |   |                                                           |   |   |
| # |   |                                                           |   |   |
|   |   |                                                           |   |   |
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+---+---+-----------------------------------------------------------+---+---+
|   | * | **Here are some important things you should keep in mind  | * |   |
|   | * | about these benefits:**                                   | * |   |
|   | I |                                                           | I |   |
|   | * | -   Please remember that all benefits are subject to the  | * |   |
|   | * |     definitions, limitations, and exclusions in this      | * |   |
|   |   |     brochure and are payable only when we determine they  |   |   |
|   | * |     are medically necessary.                              | * |   |
|   | * |                                                           | * |   |
|   | M | ```{=html}                                                | M |   |
|   | * | <!-- -->                                                  | * |   |
|   | * | ```                                                       | * |   |
|   |   | -   In this section, unlike Sections 5(a) and 5(b), the   |   |   |
|   | * |     **Standard Option** calendar year deductible applies  | * |   |
|   | * |     to only a few benefits. In that case, we added        | * |   |
|   | P |     \"(calendar year deductible applies)\" when it        | P |   |
|   | * |     applies. The calendar year deductible is \$250 per    | * |   |
|   | * |     person (\$500 per family) under Standard Option.      | * |   |
|   |   |                                                           |   |   |
|   | * | ```{=html}                                                | * |   |
|   | * | <!-- -->                                                  | * |   |
|   | O | ```                                                       | O |   |
|   | * | -   **Under Basic Option,** there is **no calendar year   | * |   |
|   | * |     deductible**.                                         | * |   |
|   |   |                                                           |   |   |
|   | * | -   **Under Basic Option,** **you must use Preferred      | * |   |
|   | * |     providers in order to receive benefits. See page 12   | * |   |
|   | R |     for the exceptions to this requirement.**             | R |   |
|   | * |                                                           | * |   |
|   | * | ```{=html}                                                | * |   |
|   |   | <!-- -->                                                  |   |   |
|   | * | ```                                                       | * |   |
|   | * | -   Be sure to read Section 4, *Your costs for covered    | * |   |
|   | T |     services*, for valuable information about how cost    | T |   |
|   | * |     sharing works, with special sections for members who  | * |   |
|   | * |     are age 65 or over. Also read Section 9 about         | * |   |
|   |   |     coordinating benefits with other coverage, including  |   |   |
|   | * |     Medicare.                                             | * |   |
|   | * |                                                           | * |   |
|   | A | ```{=html}                                                | A |   |
|   | * | <!-- -->                                                  | * |   |
|   | * | ```                                                       | * |   |
|   |   | -   **YOU MUST GET PRECERTIFICATION OF HOSPITAL STAYS;    |   |   |
|   | * |     FAILURE TO DO SO WILL RESULT IN A \$500 PENALTY.**    | * |   |
|   | * |     Please refer to the precertification information      | * |   |
|   | N |     listed in Section 3 to be sure which services require | N |   |
|   | * |     precertification.                                     | * |   |
|   | * |                                                           | * |   |
|   |   | ```{=html}                                                |   |   |
|   | * | <!-- -->                                                  | * |   |
|   | * | ```                                                       | * |   |
|   | T | -   You should be aware that some PPO hospitals may have  | T |   |
|   | * |     non-PPO professional providers on staff.              | * |   |
|   | * |                                                           | * |   |
|   |   | ```{=html}                                                |   |   |
|   |   | <!-- -->                                                  |   |   |
|   |   | ```                                                       |   |   |
|   |   | -   We base payment on whether a facility or a health     |   |   |
|   |   |     care professional bills for the services or supplies. |   |   |
|   |   |     You will find that some benefits are listed in more   |   |   |
|   |   |     than one section of the brochure. This is because how |   |   |
|   |   |     they are paid depends on what type of provider bills  |   |   |
|   |   |     for the service. For example, physical therapy is     |   |   |
|   |   |     paid differently depending on whether it is billed by |   |   |
|   |   |     an inpatient facility, a doctor, a physical           |   |   |
|   |   |     therapist, or an outpatient facility.                 |   |   |
|   |   |                                                           |   |   |
|   |   | -   The amounts listed below are for the charges billed   |   |   |
|   |   |     by the facility (i.e., hospital or surgical center)   |   |   |
|   |   |     or ambulance service for your inpatient surgery or    |   |   |
|   |   |     care. Any costs associated with the professional      |   |   |
|   |   |     charge (i.e.*,* physicians, etc.) are listed in       |   |   |
|   |   |     Sections 5(a) or 5(b).                                |   |   |
|   |   |                                                           |   |   |
|   |   | ```{=html}                                                |   |   |
|   |   | <!-- -->                                                  |   |   |
|   |   | ```                                                       |   |   |
|   |   | -   PPO benefits apply only when you use a PPO provider.  |   |   |
|   |   |     When no PPO provider is available, non-PPO benefits   |   |   |
|   |   |     apply.                                                |   |   |
+---+---+-----------------------------------------------------------+---+---+

+-----------------------------+-------------------+-------------------+
| **Benefit Description**     | **You Pay**       |                   |
+-----------------------------+-------------------+-------------------+
| ### N                       |                   |                   |
| ote: The Standard Option ca |                   |                   |
| lendar year deductible appl |                   |                   |
| ies ONLY when we say below: |                   |                   |
|                             |                   |                   |
| \"(calendar year deductible |                   |                   |
| applies).\" **There is no   |                   |                   |
| calendar year deductible    |                   |                   |
| under Basic Option.**       |                   |                   |
+-----------------------------+-------------------+-------------------+
| **Inpatient hospital**      | ### You Pay       | **You Pay − Basic |
|                             | − Standard Option | Option**          |
+-----------------------------+-------------------+-------------------+
| > Room and board, such as:  | > Preferred:      | > Preferred:      |
|                             | > \$100 per       | > \$100 per day   |
| -   semiprivate or          | > admission       | > copayment up to |
|     intensive care          | > copayment for   | > \$500 per       |
|     accommodations          | > unlimited days  | > admission for   |
|                             | >                 | > unlimited days  |
| -   general nursing care    | > Member: \$300   | >                 |
|                             | > per admission   | > M               |
| -   meals and special diets | > copayment for   | ember/Non-member: |
|                             | > unlimited days  | > You pay all     |
| > ***Note:*** We cover a    | >                 | > charges         |
| > private room only when    | > Non-member:     |                   |
| > you must be isolated to   | > \$300 per       |                   |
| > prevent contagion, when   | > admission       |                   |
| > your isolation is         | > copayment for   |                   |
| > required by law, or when  | > unlimited days, |                   |
| > a Preferred or Member     | > plus 30% of the |                   |
| > hospital only has private | > Plan allowance, |                   |
| > rooms. Otherwise, we will | > and any         |                   |
| > pay the hospital\'s       | > remaining       |                   |
| > average semiprivate rate  | > balance after   |                   |
| > as determined by the      | > our payment     |                   |
| > Local Plan. If a          | >                 |                   |
| > Non-member hospital only  | > ***Note:*** If  |                   |
| > has private rooms, we     | > you are         |                   |
| > base our payment on the   | > admitted to a   |                   |
| > average semiprivate rate  | > Non-member      |                   |
| > as determined by the      | > facility due to |                   |
| > Local Plan.               | > a **medical     |                   |
|                             | > emergency or    |                   |
|                             | > accidental      |                   |
|                             | > injury**, you   |                   |
|                             | > pay a \$300 per |                   |
|                             | > admission       |                   |
|                             | > copayment for   |                   |
|                             | > unlimited days  |                   |
|                             | > and we then     |                   |
|                             | > provide         |                   |
|                             | > benefits at     |                   |
|                             | > 100% of the     |                   |
|                             | > Plan allowance. |                   |
|                             | > You are         |                   |
|                             | > responsible for |                   |
|                             | > any remaining   |                   |
|                             | > balance after   |                   |
|                             | > our payment.    |                   |
+-----------------------------+-------------------+-------------------+

Inpatient hospital -- *continued on next page*

+-----------------------------+-------------------+-------------------+
| ### N                       |                   |                   |
| ote: The Standard Option ca |                   |                   |
| lendar year deductible appl |                   |                   |
| ies ONLY when we say below: |                   |                   |
|                             |                   |                   |
| \"(calendar year deductible |                   |                   |
| applies).\" **There is no   |                   |                   |
| calendar year deductible    |                   |                   |
| under Basic Option.**       |                   |                   |
+-----------------------------+-------------------+-------------------+
| ######## Inpat              | ### You Pay       | **You Pay − Basic |
| ient hospital *(continued)* | − Standard Option | Option**          |
+-----------------------------+-------------------+-------------------+
| #### Other hospital serv    | > Preferred:      | > Preferred:      |
| ices and supplies, such as: | > \$100 per       | > \$100 per day   |
|                             | > admission       | > copayment up to |
| -   Operating, recovery,    | > copayment for   | > \$500 per       |
|     maternity, and other    | > unlimited days  | > admission for   |
|     treatment rooms         | >                 | > unlimited days  |
|                             | > Member: \$300   | >                 |
| -   Prescribed drugs        | > per admission   | > M               |
|                             | > copayment for   | ember/Non-member: |
| -   Diagnostic laboratory   | > unlimited days  | > You pay all     |
|     tests, pathology        | >                 | > charges         |
|     services, MRIs, machine | > Non-member:     |                   |
|     diagnostic tests, and   | > \$300 per       |                   |
|     X-rays                  | > admission       |                   |
|                             | > copayment for   |                   |
| -   Administration of blood | > unlimited days, |                   |
|     or blood plasma         | > plus 30% of the |                   |
|                             | > Plan allowance, |                   |
| -   Dressings, splints,     | > and any         |                   |
|     casts, and sterile tray | > remaining       |                   |
|     services                | > balance after   |                   |
|                             | > our payment     |                   |
| -   Internal prosthetic     |                   |                   |
|     devices                 |                   |                   |
|                             |                   |                   |
| ```{=html}                  |                   |                   |
| <!-- -->                    |                   |                   |
| ```                         |                   |                   |
| -   Other medical supplies  |                   |                   |
|     and equipment,          |                   |                   |
|     including oxygen        |                   |                   |
|                             |                   |                   |
| ```{=html}                  |                   |                   |
| <!-- -->                    |                   |                   |
| ```                         |                   |                   |
| -   Anesthetics and         |                   |                   |
|     anesthesia services     |                   |                   |
|                             |                   |                   |
| ```{=html}                  |                   |                   |
| <!-- -->                    |                   |                   |
| ```                         |                   |                   |
| -   Take-home items         |                   |                   |
|                             |                   |                   |
| -   Pre-admission testing   |                   |                   |
|     recognized as part of   |                   |                   |
|     the hospital admissions |                   |                   |
|     process                 |                   |                   |
|                             |                   |                   |
| > ***Note:*** Here are some |                   |                   |
| > things to keep in mind:   |                   |                   |
|                             |                   |                   |
| -   You do not need to      |                   |                   |
|     precertify your normal  |                   |                   |
|     delivery; see page 14   |                   |                   |
|     for other               |                   |                   |
|     circumstances, such as  |                   |                   |
|     extended stays for you  |                   |                   |
|     or your baby.           |                   |                   |
|                             |                   |                   |
| ```{=html}                  |                   |                   |
| <!-- -->                    |                   |                   |
| ```                         |                   |                   |
| -   If you need to stay     |                   |                   |
|     longer in the hospital  |                   |                   |
|     than initially planned, |                   |                   |
|     we will cover an        |                   |                   |
|     extended stay if it is  |                   |                   |
|     medically necessary.    |                   |                   |
|     However, you must       |                   |                   |
|     precertify the extended |                   |                   |
|     stay. See Section 3 for |                   |                   |
|     information on          |                   |                   |
|     requesting additional   |                   |                   |
|     days.                   |                   |                   |
|                             |                   |                   |
| > • We pay inpatient        |                   |                   |
| > hospital benefits for an  |                   |                   |
| > admission in connection   |                   |                   |
| > with dental procedures    |                   |                   |
| > only when a non-dental    |                   |                   |
| > physical impairment       |                   |                   |
| > exists that makes         |                   |                   |
| > hospitalization necessary |                   |                   |
| > to safeguard the health   |                   |                   |
| > of the patient. We        |                   |                   |
| > provide benefits for      |                   |                   |
| > dental procedures as      |                   |                   |
| > shown in Section 5(h).    |                   |                   |
| >                           |                   |                   |
| > ***Note:*** See pages     |                   |                   |
| > 31-32 for covered         |                   |                   |
| > maternity services*.*     |                   |                   |
| >                           |                   |                   |
| > ***Note:*** See page 42   |                   |                   |
| > for coverage of blood and |                   |                   |
| > blood products.           |                   |                   |
+-----------------------------+-------------------+-------------------+

Inpatient hospital -- *continued on next page*

+-----------------------------+-------------------+-------------------+
| ### N                       |                   |                   |
| ote: The Standard Option ca |                   |                   |
| lendar year deductible appl |                   |                   |
| ies ONLY when we say below: |                   |                   |
|                             |                   |                   |
| \"(calendar year deductible |                   |                   |
| applies).\" **There is no   |                   |                   |
| calendar year deductible    |                   |                   |
| under Basic Option.**       |                   |                   |
+-----------------------------+-------------------+-------------------+
| ######## Inpat              | ### You Pay       | ### You P         |
| ient hospital *(continued)* | − Standard Option | ay − Basic Option |
+-----------------------------+-------------------+-------------------+
| > *Not covered:*            | > *All charges*   | > *All charges*   |
| >                           |                   |                   |
| > *Hospital room and board  |                   |                   |
| > expenses when in our      |                   |                   |
| > judgement, a hospital     |                   |                   |
| > admission or portion of   |                   |                   |
| > an admission is:*         |                   |                   |
|                             |                   |                   |
| -   *Custodial care*        |                   |                   |
|                             |                   |                   |
| ```{=html}                  |                   |                   |
| <!-- -->                    |                   |                   |
| ```                         |                   |                   |
| -   *Convalescent care or a |                   |                   |
|     rest cure*              |                   |                   |
|                             |                   |                   |
| -   *Domiciliary care       |                   |                   |
|     provided because care   |                   |                   |
|     in the home is not      |                   |                   |
|     available or            |                   |                   |
|     unsuitable*             |                   |                   |
|                             |                   |                   |
| ```{=html}                  |                   |                   |
| <!-- -->                    |                   |                   |
| ```                         |                   |                   |
| -   *Not medically          |                   |                   |
|     necessary, such as when |                   |                   |
|     services did not        |                   |                   |
|     require the             |                   |                   |
|     acute/subacute hospital |                   |                   |
|     inpatient (overnight)   |                   |                   |
|     setting but could have  |                   |                   |
|     been provided safely    |                   |                   |
|     and adequately in a     |                   |                   |
|     physician\'s office,    |                   |                   |
|     the outpatient          |                   |                   |
|     department of a         |                   |                   |
|     hospital, or some other |                   |                   |
|     setting, without        |                   |                   |
|     adversely affecting     |                   |                   |
|     your condition or the   |                   |                   |
|     quality of medical care |                   |                   |
|     you receive. Some       |                   |                   |
|     examples are:*          |                   |                   |
|                             |                   |                   |
| ```{=html}                  |                   |                   |
| <!-- -->                    |                   |                   |
| ```                         |                   |                   |
| -   *Admissions for, or     |                   |                   |
|     > consisting primarily  |                   |                   |
|     > of, observation       |                   |                   |
|     > and/or evaluation     |                   |                   |
|     > that could have been  |                   |                   |
|     > provided safely and   |                   |                   |
|     > adequately in some    |                   |                   |
|     > other setting (such   |                   |                   |
|     > as a physician\'s     |                   |                   |
|     > office)*              |                   |                   |
|                             |                   |                   |
| -   *Admissions primarily   |                   |                   |
|     for diagnostic studies, |                   |                   |
|     laboratory and          |                   |                   |
|     pathology services,     |                   |                   |
|     X-rays, MRIs, or        |                   |                   |
|     machine diagnostic      |                   |                   |
|     tests that could have   |                   |                   |
|     been provided safely    |                   |                   |
|     and adequately in some  |                   |                   |
|     other setting (such as  |                   |                   |
|     the outpatient          |                   |                   |
|     department of a         |                   |                   |
|     hospital or a           |                   |                   |
|     physician\'s office)*   |                   |                   |
|                             |                   |                   |
| > ***Note:** If we          |                   |                   |
| > determine that a hospital |                   |                   |
| > admission is one of the   |                   |                   |
| > types listed above, we    |                   |                   |
| > will not provide benefits |                   |                   |
| > for inpatient room and    |                   |                   |
| > board or inpatient        |                   |                   |
| > physician care. However,  |                   |                   |
| > we will provide benefits  |                   |                   |
| > for covered services or   |                   |                   |
| > supplies other than room  |                   |                   |
| > and board and inpatient   |                   |                   |
| > physician care at the     |                   |                   |
| > level that we would have  |                   |                   |
| > paid if they had been     |                   |                   |
| > provided in some other    |                   |                   |
| > setting.*                 |                   |                   |
|                             |                   |                   |
| -   *Admission to           |                   |                   |
|     noncovered facilities,  |                   |                   |
|     such as nursing homes,  |                   |                   |
|     extended care           |                   |                   |
|     facilities, schools,    |                   |                   |
|     residential treatment   |                   |                   |
|     centers*                |                   |                   |
|                             |                   |                   |
| -   *Personal comfort       |                   |                   |
|     items, such as guest    |                   |                   |
|     meals and beds,         |                   |                   |
|     telephone, television,  |                   |                   |
|     beauty and barber       |                   |                   |
|     services*               |                   |                   |
|                             |                   |                   |
| ```{=html}                  |                   |                   |
| <!-- -->                    |                   |                   |
| ```                         |                   |                   |
| -   *Inpatient private duty |                   |                   |
|     > nursing*              |                   |                   |
+-----------------------------+-------------------+-------------------+
| ### N                       |                   |                   |
| ote: The Standard Option ca |                   |                   |
| lendar year deductible appl |                   |                   |
| ies ONLY when we say below: |                   |                   |
|                             |                   |                   |
| \"(calendar year deductible |                   |                   |
| applies).\" **There is no   |                   |                   |
| calendar year deductible    |                   |                   |
| under Basic Option.**       |                   |                   |
+-----------------------------+-------------------+-------------------+
| ####                        | ### You Pay       | **You Pay − Basic |
| **Outpatient hospital or am | − Standard Option | Option**          |
| bulatory surgical center**  |                   |                   |
+-----------------------------+-------------------+-------------------+
| > Outpatient **medical      | > Preferred       | > Preferred: \$30 |
| > services** performed and  | > facilities: 10% | > copayment per   |
| > billed for by a hospital  | > of the Plan     | > day per         |
| > or freestanding           | > allowance       | > facility        |
| > ambulatory facility, such | > (calendar year  | >                 |
| > as:                       | > deductible      | > M               |
|                             | > applies)        | ember/Non-member: |
| -   Use of special          | >                 | > You pay all     |
|     treatment rooms         | > Member          | > charges         |
|                             | > facilities: 25% | >                 |
| -   Diagnostic tests, such  | > of the Plan     | > ***Note:*** For |
|     as laboratory and       | > allowance       | > outpatient      |
|     pathology services,     | > (calendar year  | > diagnostic      |
|     MRIs, machine           | > deductible      | > tests billed    |
|     diagnostic tests, and   | > applies)        | > for by a Member |
|     X-rays                  | >                 | > or Non-member   |
|                             | > Non-member      | > facility, you   |
| -   Chemotherapy and        | > facilities: 25% | > pay a \$30      |
|     radiation therapy       | > of the Plan     | > copayment, plus |
|                             | > allowance       | > any difference  |
| ```{=html}                  | > (calendar year  | > between our     |
| <!-- -->                    | > deductible      | > allowance and   |
| ```                         | > applies); plus  | > the billed      |
| -   Intravenous             | > any difference  | > amount.         |
|     (IV)/infusion therapy   | > between our     |                   |
|                             | > allowance and   |                   |
| -   Cardiac rehabilitation  | > the billed      |                   |
|                             | > amount          |                   |
| -   Physical, occupational, |                   |                   |
|     and speech therapy      |                   |                   |
|                             |                   |                   |
| -   Renal dialysis          |                   |                   |
|                             |                   |                   |
| -   Visits to the           |                   |                   |
|     outpatient department   |                   |                   |
|     of a hospital for       |                   |                   |
|     non-emergency medical   |                   |                   |
|     care                    |                   |                   |
|                             |                   |                   |
| -   Administration of       |                   |                   |
|     blood, blood plasma,    |                   |                   |
|     and other biologicals   |                   |                   |
|                             |                   |                   |
| > ***Note:*** See page 63   |                   |                   |
| > for our coverage of       |                   |                   |
| > biologicals.              |                   |                   |
| >                           |                   |                   |
| > ***Note:*** See pages     |                   |                   |
| > 27-30 for covered         |                   |                   |
| > preventive services for   |                   |                   |
| > adults and children.      |                   |                   |
| >                           |                   |                   |
| > ***Note:*** See pages     |                   |                   |
| > 67-71 for our payment     |                   |                   |
| > levels for care related   |                   |                   |
| > to a medical emergency or |                   |                   |
| > accidental injury.        |                   |                   |
+-----------------------------+-------------------+-------------------+

Outpatient hospital or ambulatory surgical center -- *continued on next
page*

+-----------------------------+-------------------+-------------------+
| ### N                       |                   |                   |
| ote: The Standard Option ca |                   |                   |
| lendar year deductible appl |                   |                   |
| ies ONLY when we say below: |                   |                   |
|                             |                   |                   |
| \"(calendar year deductible |                   |                   |
| applies).\" **There is no   |                   |                   |
| calendar year deductible    |                   |                   |
| under Basic Option.**       |                   |                   |
+-----------------------------+-------------------+-------------------+
| #### **Outpatient           | ### You Pay       | ### You P         |
| hospital or ambulatory surg | − Standard Option | ay − Basic Option |
| ical center** *(continued)* |                   |                   |
+-----------------------------+-------------------+-------------------+
| > Outpatient **surgery and  | > Preferred       | > Preferred: \$30 |
| > related services**        | > facilities: 10% | > copayment per   |
| > performed and billed for  | > of the Plan     | > day per         |
| > by a hospital or          | > allowance       | > facility        |
| > freestanding ambulatory   | >                 | >                 |
| > facility, such as:        | > Member          | > M               |
|                             | > facilities: 25% | ember/Non-member: |
| -   Operating, recovery,    | > of the Plan     | > You pay all     |
|     and other treatment     | > allowance       | > charges         |
|     rooms                   | >                 | >                 |
|                             | > Non-member      | > ***Note:*** For |
| -   Anesthetics and         | > facilities: 25% | > outpatient      |
|     anesthesia services     | > of the Plan     | > diagnostic      |
|                             | > allowance, plus | > tests billed    |
| ```{=html}                  | > any difference  | > for by a Member |
| <!-- -->                    | > between our     | > or Non-member   |
| ```                         | > allowance and   | > facility, you   |
| -   Pre-surgical testing    | > the billed      | > pay a \$30      |
|     performed within one    | > amount          | > copayment, plus |
|     business day of the     |                   | > any difference  |
|     covered surgical        |                   | > between our     |
|     services                |                   | > allowance and   |
|                             |                   | > the billed      |
| -   Facility supplies for   |                   | > amount.         |
|     hemophilia home care    |                   |                   |
|                             |                   |                   |
| -   Diagnostic tests, such  |                   |                   |
|     as laboratory and       |                   |                   |
|     pathology services,     |                   |                   |
|     MRIs, machine           |                   |                   |
|     diagnostic tests, and   |                   |                   |
|     X-rays                  |                   |                   |
|                             |                   |                   |
| -   Visits to the           |                   |                   |
|     outpatient department   |                   |                   |
|     of a hospital for       |                   |                   |
|     non-emergency surgical  |                   |                   |
|     care                    |                   |                   |
|                             |                   |                   |
| -   Administration of       |                   |                   |
|     blood, blood plasma,    |                   |                   |
|     and other biologicals   |                   |                   |
|                             |                   |                   |
| > ***Note:*** See page 63   |                   |                   |
| > for our coverage of       |                   |                   |
| > biologicals.              |                   |                   |
| >                           |                   |                   |
| > ***Note:*** See pages     |                   |                   |
| > 67-71 for our payment     |                   |                   |
| > levels for care related   |                   |                   |
| > to a medical emergency or |                   |                   |
| > accidental injury.        |                   |                   |
| >                           |                   |                   |
| > ***Note:*** We cover      |                   |                   |
| > outpatient hospital       |                   |                   |
| > services and supplies     |                   |                   |
| > related to dental         |                   |                   |
| > procedures only when a    |                   |                   |
| > non-dental physical       |                   |                   |
| > impairment exists that    |                   |                   |
| > makes the hospital        |                   |                   |
| > setting necessary to      |                   |                   |
| > safeguard the health of   |                   |                   |
| > the patient. See Section  |                   |                   |
| > 5(h), *Dental benefits*,  |                   |                   |
| > for additional benefit    |                   |                   |
| > information.              |                   |                   |
| >                           |                   |                   |
| > ***Note:*** See pages     |                   |                   |
| > 31-32 for covered         |                   |                   |
| > maternity services.       |                   |                   |
+-----------------------------+-------------------+-------------------+

Outpatient hospital or ambulatory surgical center -- *continued on next
page*

+-----------------------------+-------------------+-------------------+
| ### N                       |                   |                   |
| ote: The Standard Option ca |                   |                   |
| lendar year deductible appl |                   |                   |
| ies ONLY when we say below: |                   |                   |
|                             |                   |                   |
| \"(calendar year deductible |                   |                   |
| applies).\" **There is no   |                   |                   |
| calendar year deductible    |                   |                   |
| under Basic Option.**       |                   |                   |
+-----------------------------+-------------------+-------------------+
| #### **Outpatient           | ### You Pay       | ### You P         |
| hospital or ambulatory surg | − Standard Option | ay − Basic Option |
| ical center** *(continued)* |                   |                   |
+-----------------------------+-------------------+-------------------+
| > Outpatient **drugs and    | > Preferred       | > Preferred: 30%  |
| > supplies** billed for by  | > facilities: 10% | > of the Plan     |
| > a hospital or             | > of the Plan     | > allowance       |
| > freestanding ambulatory   | > allowance       | >                 |
| > facility, such as:        | > (calendar year  | > ***Note:*** You |
|                             | > deductible      | > may also be     |
| -   Prescribed drugs        | > applies)        | > responsible for |
|                             | >                 | > paying a \$30   |
| ```{=html}                  | > Member          | > copayment per   |
| <!-- -->                    | > facilities: 25% | > day per         |
| ```                         | > of the Plan     | > facility for    |
| -   Blood and blood plasma, | > allowance       | > outpatient      |
|     if not donated or       | > (calendar year  | > services.       |
|     replaced, and other     | > deductible      | >                 |
|     biologicals             | > applies)        | > M               |
|                             | >                 | ember/Non-member: |
| -   Dressings, splints,     | > Non-member      | > You pay all     |
|     casts, and sterile tray | > facilities: 25% | > charges         |
|     services                | > of the Plan     |                   |
|                             | > allowance       |                   |
| -   Orthopedic and          | > (calendar year  |                   |
|     prosthetic devices      | > deductible      |                   |
|                             | > applies); plus  |                   |
| -   Other medical supplies, | > any difference  |                   |
|     including oxygen        | > between our     |                   |
|                             | > allowance and   |                   |
| -   Durable medical         | > the billed      |                   |
|     equipment               | > amount          |                   |
|                             |                   |                   |
| > ***Note:*** See pages 61  |                   |                   |
| > and 62 for outpatient     |                   |                   |
| > benefits coverage related |                   |                   |
| > to administration of      |                   |                   |
| > blood, blood plasma, and  |                   |                   |
| > other biologicals.        |                   |                   |
+-----------------------------+-------------------+-------------------+

+-----------------------------+-------------------+-------------------+
| ### N                       |                   |                   |
| ote: The Standard Option ca |                   |                   |
| lendar year deductible appl |                   |                   |
| ies ONLY when we say below: |                   |                   |
|                             |                   |                   |
| \"(calendar year deductible |                   |                   |
| applies).\" **There is no   |                   |                   |
| calendar year deductible    |                   |                   |
| under Basic Option.**       |                   |                   |
+-----------------------------+-------------------+-------------------+
| ### Extende                 | ### You Pay       | ### You P         |
| d care benefits/Skilled nur | − Standard Option | ay − Basic Option |
| sing care facility benefits |                   |                   |
+-----------------------------+-------------------+-------------------+
| > Limited to the following  | > Preferred:      | > *All charges*   |
| > benefits for Medicare     | > Nothing         |                   |
| > Part A copayments:        | >                 |                   |
| >                           | > Part            |                   |
| > When Medicare Part A is   | icipating/Member: |                   |
| > the primary payer         | > Nothing         |                   |
| > (meaning that it pays     | >                 |                   |
| > first) and has made       | > Non-particip    |                   |
| > payment, **Standard       | ating/Non-member: |                   |
| > Option** provides limited | > Nothing         |                   |
| > secondary benefits.       | >                 |                   |
| >                           | > ***Note:*** You |                   |
| > We pay the applicable     | > pay all charges |                   |
| > Medicare Part A           | > not paid by     |                   |
| > copayments incurred **in  | > Medicare after  |                   |
| > full** during the first   | > the 30^th^ day. |                   |
| > through the 30^th^ day of |                   |                   |
| > confinement for each      |                   |                   |
| > benefit period (as        |                   |                   |
| > defined by Medicare) in a |                   |                   |
| > qualified skilled nursing |                   |                   |
| > facility. A qualified     |                   |                   |
| > skilled nursing facility  |                   |                   |
| > is a facility that        |                   |                   |
| > specializes in skilled    |                   |                   |
| > nursing care performed by |                   |                   |
| > or under the supervision  |                   |                   |
| > of licensed nurses,       |                   |                   |
| > skilled rehabilitation    |                   |                   |
| > services, and other       |                   |                   |
| > related care, and meets   |                   |                   |
| > Medicare\'s special       |                   |                   |
| > qualifying criteria, but  |                   |                   |
| > is not an institution     |                   |                   |
| > that primarily cares for  |                   |                   |
| > and treats mental         |                   |                   |
| > diseases.                 |                   |                   |
| >                           |                   |                   |
| > If Medicare pays the      |                   |                   |
| > first 20 days in full,    |                   |                   |
| > Plan benefits will begin  |                   |                   |
| > on the 21^st^ day (when   |                   |                   |
| > Medicare Part A           |                   |                   |
| > copayments begin) and     |                   |                   |
| > will end on the 30^th^    |                   |                   |
| > day.                      |                   |                   |
| >                           |                   |                   |
| > ***Note:*** See pages 36  |                   |                   |
| > and 37 for benefits       |                   |                   |
| > provided for outpatient   |                   |                   |
| > physical, occupational,   |                   |                   |
| > and speech therapy when   |                   |                   |
| > billed by a skilled       |                   |                   |
| > nursing facility. See     |                   |                   |
| > Section 5(f) for benefits |                   |                   |
| > for prescription drugs.   |                   |                   |
| >                           |                   |                   |
| > ***Note:* If you do not   |                   |                   |
| > have Medicare Part A, we  |                   |                   |
| > do not provide benefits   |                   |                   |
| > for skilled nursing       |                   |                   |
| > facility care.**          |                   |                   |
+-----------------------------+-------------------+-------------------+

+-----------------------------+-------------------+-------------------+
| ### N                       |                   |                   |
| ote: The Standard Option ca |                   |                   |
| lendar year deductible appl |                   |                   |
| ies ONLY when we say below: |                   |                   |
|                             |                   |                   |
| \"(calendar year deductible |                   |                   |
| applies).\" **There is no   |                   |                   |
| calendar year deductible    |                   |                   |
| under Basic Option.**       |                   |                   |
+-----------------------------+-------------------+-------------------+
| #### **Hospice care**       | ### You Pay       | ### You P         |
|                             | − Standard Option | ay − Basic Option |
+-----------------------------+-------------------+-------------------+
| > **Hospice care** is an    | > Nothing         | > Nothing         |
| > integrated set of         |                   |                   |
| > services and supplies     |                   |                   |
| > designed to provide       |                   |                   |
| > palliative and supportive |                   |                   |
| > care to terminally ill    |                   |                   |
| > patients in their homes.  |                   |                   |
| >                           |                   |                   |
| > We provide the following  |                   |                   |
| > **home hospice** **care** |                   |                   |
| > benefits for members with |                   |                   |
| > a life expectancy of six  |                   |                   |
| > months or less **when     |                   |                   |
| > prior approval is         |                   |                   |
| > obtained from the Local   |                   |                   |
| > Plan** and the home       |                   |                   |
| > hospice agency is         |                   |                   |
| > approved by the Local     |                   |                   |
| > Plan:                     |                   |                   |
|                             |                   |                   |
| -   Physician visits        |                   |                   |
|                             |                   |                   |
| -   Nursing care            |                   |                   |
|                             |                   |                   |
| -   Medical social services |                   |                   |
|                             |                   |                   |
| -   Physical therapy        |                   |                   |
|                             |                   |                   |
| -   Services of home health |                   |                   |
|     aides                   |                   |                   |
|                             |                   |                   |
| -   Durable medical         |                   |                   |
|     equipment rental        |                   |                   |
|                             |                   |                   |
| -   Prescription drugs      |                   |                   |
|                             |                   |                   |
| ```{=html}                  |                   |                   |
| <!-- -->                    |                   |                   |
| ```                         |                   |                   |
| -   Medical supplies        |                   |                   |
+-----------------------------+-------------------+-------------------+
| > **Inpatient hospice** for | > Preferred:      | > Preferred:      |
| > members receiving home    | > \$100 per       | > \$100 per day   |
| > hospice care benefits:    | > admission       | > copayment up to |
| >                           | > copayment       | > \$500 per       |
| > Benefits are provided for | >                 | > admission       |
| > up to five (5)            | > Member: \$300   | >                 |
| > consecutive days in a     | > per admission   | > M               |
| > hospital or a             | > copayment       | ember/Non-member: |
| > freestanding hospice      | >                 | > You pay all     |
| > inpatient facility.       | > Non-member:     | > charges         |
| >                           | > \$300 per       |                   |
| > Each inpatient stay must  | > admission       |                   |
| > be separated by at least  | > copayment plus  |                   |
| > 21 days.                  | > 30% of the Plan |                   |
| >                           | > allowance, and  |                   |
| > These covered inpatient   | > any remaining   |                   |
| > hospice benefits are      | > balance after   |                   |
| > available only when       | > our payment     |                   |
| > inpatient services are    |                   |                   |
| > necessary to:             |                   |                   |
|                             |                   |                   |
| -   control pain and manage |                   |                   |
|     the patient\'s          |                   |                   |
|     symptoms; or            |                   |                   |
|                             |                   |                   |
| -   provide an interval of  |                   |                   |
|     relief (respite) to the |                   |                   |
|     family                  |                   |                   |
|                             |                   |                   |
| > ***Note:* You are         |                   |                   |
| > responsible for making    |                   |                   |
| > sure that the home        |                   |                   |
| > hospice care provider has |                   |                   |
| > received prior approval   |                   |                   |
| > from the Local Plan**     |                   |                   |
| > (see page 14 for          |                   |                   |
| > instructions). Please     |                   |                   |
| > check with your Local     |                   |                   |
| > Plan and/or your PPO      |                   |                   |
| > directory for listings of |                   |                   |
| > approved agencies.        |                   |                   |
+-----------------------------+-------------------+-------------------+
| > *Not covered: Homemaker   | > *All charges*   | > *All charges*   |
| > or bereavement services*  |                   |                   |
+-----------------------------+-------------------+-------------------+

+-----------------------------+-------------------+-------------------+
| ### N                       |                   |                   |
| ote: The Standard Option ca |                   |                   |
| lendar year deductible appl |                   |                   |
| ies ONLY when we say below: |                   |                   |
|                             |                   |                   |
| \"(calendar year deductible |                   |                   |
| applies).\" **There is no   |                   |                   |
| calendar year deductible    |                   |                   |
| under Basic Option.**       |                   |                   |
+-----------------------------+-------------------+-------------------+
| **Ambulance**               | ### You Pay       | ### You P         |
|                             | − Standard Option | ay − Basic Option |
+-----------------------------+-------------------+-------------------+
| > Local professional        | > Preferred: 10%  | > Preferred: \$50 |
| > ambulance **transport     | > of the Plan     | > copayment per   |
| > services** to or from the | > allowance       | > trip            |
| > nearest hospital equipped | >                 | >                 |
| > to adequately treat your  | > Part            | > Par             |
| > condition, when medically | icipating/Member: | ticipating/Member |
| > appropriate, and:         | > 10% of the Plan | > or              |
|                             | > allowance       | > Non-particip    |
| -   Associated with covered | >                 | ating/Non-member: |
|     hospital inpatient care | > Non-particip    | > \$50 copayment  |
|                             | ating/Non-member: | > per trip        |
| ```{=html}                  | > 10% of the Plan |                   |
| <!-- -->                    | > allowance, plus |                   |
| ```                         | > any difference  |                   |
| -   Related to medical      | > between our     |                   |
|     emergency               | > allowance and   |                   |
|                             | > the billed      |                   |
| -   Associated with covered | > amount          |                   |
|     hospice care            |                   |                   |
+-----------------------------+-------------------+-------------------+
| > Local professional        | > Preferred:      | > Preferred: \$50 |
| > ambulance **transport     | > Nothing (No     | > copayment per   |
| > services** to or from the | > deductible)     | > trip            |
| > nearest hospital equipped | >                 | >                 |
| > to adequately treat your  | > Part            | > Par             |
| > condition, when medically | icipating/Member: | ticipating/Member |
| > appropriate, and when     | > Nothing (No     | > or              |
| > related to accidental     | > deductible)     | > Non-particip    |
| > injury                    | >                 | ating/Non-member: |
|                             | > Non-particip    | > \$50 copayment  |
|                             | ating/Non-member: | > per trip        |
|                             | > Any difference  |                   |
|                             | > between the     |                   |
|                             | > Plan allowance  |                   |
|                             | > and the billed  |                   |
|                             | > amount (No      |                   |
|                             | > deductible)     |                   |
|                             | >                 |                   |
|                             | > ***Note:***     |                   |
|                             | > These benefit   |                   |
|                             | > levels apply    |                   |
|                             | > only if you     |                   |
|                             | > receive care in |                   |
|                             | > connection      |                   |
|                             | > with, and       |                   |
|                             | > within 72 hours |                   |
|                             | > after, an       |                   |
|                             | > accidental      |                   |
|                             | > injury. For     |                   |
|                             | > services        |                   |
|                             | > received after  |                   |
|                             | > 72 hours, see   |                   |
|                             | > above.          |                   |
+-----------------------------+-------------------+-------------------+

+---+---+-----------------------------------------------------------+---+---+
| # |   |                                                           |   |   |
| # |   |                                                           |   |   |
|   |   |                                                           |   |   |
| S |   |                                                           |   |   |
| e |   |                                                           |   |   |
| c |   |                                                           |   |   |
| t |   |                                                           |   |   |
| i |   |                                                           |   |   |
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| n |   |                                                           |   |   |
|   |   |                                                           |   |   |
| 5 |   |                                                           |   |   |
|   |   |                                                           |   |   |
| ( |   |                                                           |   |   |
| d |   |                                                           |   |   |
| ) |   |                                                           |   |   |
| . |   |                                                           |   |   |
|   |   |                                                           |   |   |
| E |   |                                                           |   |   |
| m |   |                                                           |   |   |
| e |   |                                                           |   |   |
| r |   |                                                           |   |   |
| g |   |                                                           |   |   |
| e |   |                                                           |   |   |
| n |   |                                                           |   |   |
| c |   |                                                           |   |   |
| y |   |                                                           |   |   |
|   |   |                                                           |   |   |
| s |   |                                                           |   |   |
| e |   |                                                           |   |   |
| r |   |                                                           |   |   |
| v |   |                                                           |   |   |
| i |   |                                                           |   |   |
| c |   |                                                           |   |   |
| e |   |                                                           |   |   |
| s |   |                                                           |   |   |
| / |   |                                                           |   |   |
| a |   |                                                           |   |   |
| c |   |                                                           |   |   |
| c |   |                                                           |   |   |
| i |   |                                                           |   |   |
| d |   |                                                           |   |   |
| e |   |                                                           |   |   |
| n |   |                                                           |   |   |
| t |   |                                                           |   |   |
| s |   |                                                           |   |   |
+---+---+-----------------------------------------------------------+---+---+
|   | * | > **Here are some important things you should keep in     | * |   |
|   | * | > mind about these benefits:**                            | * |   |
|   | I |                                                           | I |   |
|   | * | -   Please remember that all benefits are subject to the  | * |   |
|   | * |     definitions, limitations, and exclusions in this      | * |   |
|   |   |     brochure and are payable only when we determine they  |   |   |
|   | * |     are medically necessary.                              | * |   |
|   | * |                                                           | * |   |
|   | M | -   **Under Standard Option,** the calendar year          | M |   |
|   | * |     deductible is \$250 per person (\$500 per family).    | * |   |
|   | * |     The calendar year deductible applies to almost all    | * |   |
|   |   |     **Standard Option** benefits in this Section. We      |   |   |
|   | * |     added \"(No deductible)\" to show when the calendar   | * |   |
|   | * |     year deductible does not apply.                       | * |   |
|   | P |                                                           | P |   |
|   | * | -   **Under Basic Option,** there is **no calendar year   | * |   |
|   | * |     deductible**.                                         | * |   |
|   |   |                                                           |   |   |
|   | * | -   **Under Basic Option, you must use Preferred          | * |   |
|   | * |     providers in order to receive benefits, except in     | * |   |
|   | O |     cases of medical emergency or accidental injury.      | O |   |
|   | * |     Refer to the guidelines appearing below for           | * |   |
|   | * |     additional information.**                             | * |   |
|   |   |                                                           |   |   |
|   | * | ```{=html}                                                | * |   |
|   | * | <!-- -->                                                  | * |   |
|   | R | ```                                                       | R |   |
|   | * | -   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  | * |   |
|   | T |     Medicare.                                             | T |   |
|   | * |                                                           | * |   |
|   | * | ```{=html}                                                | * |   |
|   |   | <!-- -->                                                  |   |   |
|   | * | ```                                                       | * |   |
|   | * | -   PPO benefits apply only when you use a PPO provider.  | * |   |
|   | A |     When no PPO provider is available, non-PPO benefits   | A |   |
|   | * |     apply.                                                | * |   |
|   | * |                                                           | * |   |
|   |   |                                                           |   |   |
|   | * |                                                           | * |   |
|   | * |                                                           | * |   |
|   | N |                                                           | N |   |
|   | * |                                                           | * |   |
|   | * |                                                           | * |   |
|   |   |                                                           |   |   |
|   | * |                                                           | * |   |
|   | * |                                                           | * |   |
|   | T |                                                           | T |   |
|   | * |                                                           | * |   |
|   | * |                                                           | * |   |
+---+---+-----------------------------------------------------------+---+---+
| > |   |                                                           |   |   |
|   |   |                                                           |   |   |
| * |   |                                                           |   |   |
| * |   |                                                           |   |   |
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| a |   |                                                           |   |   |
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| , |   |                                                           |   |   |
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| l |   |                                                           |   |   |
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| f |   |                                                           |   |   |
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| m |   |                                                           |   |   |
| a |   |                                                           |   |   |
| n |   |                                                           |   |   |
| > |   |                                                           |   |   |
|   |   |                                                           |   |   |
| a |   |                                                           |   |   |
| n |   |                                                           |   |   |
| d |   |                                                           |   |   |
| > |   |                                                           |   |   |
|   |   |                                                           |   |   |
| h |   |                                                           |   |   |
| e |   |                                                           |   |   |
| r |   |                                                           |   |   |
| > |   |                                                           |   |   |
|   |   |                                                           |   |   |
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| b |   |                                                           |   |   |
| o |   |                                                           |   |   |
| r |   |                                                           |   |   |
| n |   |                                                           |   |   |
| > |   |                                                           |   |   |
|   |   |                                                           |   |   |
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| l |   |                                                           |   |   |
| d |   |                                                           |   |   |
| . |   |                                                           |   |   |
+---+---+-----------------------------------------------------------+---+---+

+-----------------------------+-------------------+-------------------+
| **Benefit Description**     | **You Pay**       |                   |
+-----------------------------+-------------------+-------------------+
| # Note: The calenda         |                   |                   |
| r year deductible applies t |                   |                   |
| o almost all Standard Optio |                   |                   |
| n benefits in this Section. |                   |                   |
|                             |                   |                   |
| #                           |                   |                   |
|  We say \"(No deductible)\" |                   |                   |
|  when the Standard Option d |                   |                   |
| eductible does *not* apply. |                   |                   |
|                             |                   |                   |
| **There is no calendar year |                   |                   |
| deductible under Basic      |                   |                   |
| Option.**                   |                   |                   |
+-----------------------------+-------------------+-------------------+
| ######## Accidental injury  | ### You Pay       | **You Pay − Basic |
|                             | − Standard Option | Option**          |
+-----------------------------+-------------------+-------------------+
| -   **Physician services**  | > Preferred:      | > Preferred       |
|     in the hospital         | > Nothing (No     | > emergency room: |
|     outpatient department,  | > deductible)     | >                 |
|     urgent care center, or  | >                 | > \$50 copayment  |
|     physician\'s office,    | > Part            | > per visit       |
|     including X-rays, MRIs, | icipating/Member: | >                 |
|     laboratory and          | > Nothing (No     | > Par             |
|     pathology services, and | > deductible)     | ticipating/Member |
|     machine diagnostic      | >                 | > emergency room: |
|     tests                   | > Non-particip    | >                 |
|                             | ating/Non-member: | > \$50 copayment  |
| -   Related outpatient      | > Any difference  | > per visit       |
|     **hospital services**   | > between the     | >                 |
|     and supplies, including | > Plan allowance  | > Non-partici     |
|     X-rays, MRIs,           | > and the billed  | pating/Non-member |
|     laboratory and          | > amount (No      | > emergency room: |
|     pathology services, and | > deductible)     | > \$50 copayment  |
|     machine diagnostic      | >                 | > per visit       |
|     tests                   | > ***Note:***     | >                 |
|                             | > These benefit   | > ***Note:*** You |
| > ***Note:*** We pay        | > levels apply    | > are responsible |
| > Inpatient professional    | > only if you     | > for the         |
| > and hospital benefits if  | > receive care in | > applicable      |
| > you are admitted \[see    | > connection      | > copayment as    |
| > Sections 5(a), 5(b), and  | > with, and       | > shown above. If |
| > 5(c)\].                   | > within 72 hours | > you use a       |
| >                           | > after, an       | > Non-preferred   |
| > ***Note:*** See Section   | > accidental      | > provider, you   |
| > 5(h) for dental benefits  | > injury. For     | > may also be     |
| > for accidental injuries.  | > services        | > responsible for |
|                             | > received after  | > any difference  |
|                             | > 72 hours,       | > between our     |
|                             | > regular medical | > allowance and   |
|                             | > and outpatient  | > the billed      |
|                             | > hospital        | > amount.         |
|                             | > benefits apply. | >                 |
|                             | > See Section     | > ***Note:*** If  |
|                             | > 5(a), Medical   | > you are         |
|                             | > services and    | > admitted        |
|                             | > supplies,       | > directly to the |
|                             | > Section 5(b),   | > hospital from   |
|                             | > Surgical        | > the emergency   |
|                             | > procedures, and | > room, you do    |
|                             | > Section 5(c),   | > not have to pay |
|                             | > Outpatient      | > the \$50        |
|                             | > hospital, for   | > emergency room  |
|                             | > the benefits we | > copayment.      |
|                             | > provide.        | > However, the    |
|                             |                   | > \$100 per day   |
|                             |                   | > copayment for   |
|                             |                   | > Preferred       |
|                             |                   | > inpatient care  |
|                             |                   | > still applies.  |
|                             |                   | >                 |
|                             |                   | > ***Note:*** All |
|                             |                   | > follow-up care  |
|                             |                   | > must be         |
|                             |                   | > performed and   |
|                             |                   | > billed for by   |
|                             |                   | > Preferred       |
|                             |                   | > providers to be |
|                             |                   | > eligible for    |
|                             |                   | > benefits.       |
+-----------------------------+-------------------+-------------------+

Accidental injury -- *continued on next page*

+-----------------------------+-------------------+-------------------+
| # Note: The calenda         |                   |                   |
| r year deductible applies t |                   |                   |
| o almost all Standard Optio |                   |                   |
| n benefits in this Section. |                   |                   |
|                             |                   |                   |
| #                           |                   |                   |
|  We say \"(No deductible)\" |                   |                   |
|  when the Standard Option d |                   |                   |
| eductible does *not* apply. |                   |                   |
|                             |                   |                   |
| **There is no calendar year |                   |                   |
| deductible under Basic      |                   |                   |
| Option.**                   |                   |                   |
+-----------------------------+-------------------+-------------------+
| ######## Acci               | ### You Pay       | ## You pa         |
| dental injury *(continued)* | − Standard Option | y -- Basic Option |
+-----------------------------+-------------------+-------------------+
|                             |                   | > For the         |
|                             |                   | > following       |
|                             |                   | > places of       |
|                             |                   | > service, you    |
|                             |                   | > **must**        |
|                             |                   | > receive care    |
|                             |                   | > from a          |
|                             |                   | > Preferred       |
|                             |                   | > provider:       |
|                             |                   | >                 |
|                             |                   | > **Preferred**   |
|                             |                   | > urgent care     |
|                             |                   | > center:         |
|                             |                   | >                 |
|                             |                   | > \$30 copayment  |
|                             |                   | > per visit       |
|                             |                   | >                 |
|                             |                   | > **Preferred**   |
|                             |                   | > primary care    |
|                             |                   | > provider or     |
|                             |                   | > other health    |
|                             |                   | > care            |
|                             |                   | > professional\'s |
|                             |                   | > office:         |
|                             |                   | >                 |
|                             |                   | > \$20 copayment  |
|                             |                   | > per visit       |
|                             |                   | >                 |
|                             |                   | > **Preferred**   |
|                             |                   | > specialist\'s   |
|                             |                   | > office:         |
|                             |                   | >                 |
|                             |                   | > \$30 copayment  |
|                             |                   | > per visit       |
|                             |                   | >                 |
|                             |                   | > Par             |
|                             |                   | ticipating/Member |
|                             |                   | > (for other than |
|                             |                   | > emergency       |
|                             |                   | > room): You pay  |
|                             |                   | > all charges     |
|                             |                   | >                 |
|                             |                   | > Non-partici     |
|                             |                   | pating/Non-member |
|                             |                   | > (for other than |
|                             |                   | > emergency       |
|                             |                   | > room): You pay  |
|                             |                   | > all charges     |
+-----------------------------+-------------------+-------------------+
| > *Not covered:*            | > *All charges*   | > *All charges*   |
|                             |                   |                   |
| -   *Oral surgery except as |                   |                   |
|     shown in Section 5(b)*  |                   |                   |
|                             |                   |                   |
| ```{=html}                  |                   |                   |
| <!-- -->                    |                   |                   |
| ```                         |                   |                   |
| -   *Injury to the teeth    |                   |                   |
|     while eating*           |                   |                   |
+-----------------------------+-------------------+-------------------+

+-----------------------------+-------------------+-------------------+
| # Note: The calenda         |                   |                   |
| r year deductible applies t |                   |                   |
| o almost all Standard Optio |                   |                   |
| n benefits in this Section. |                   |                   |
|                             |                   |                   |
| #                           |                   |                   |
|  We say \"(No deductible)\" |                   |                   |
|  when the Standard Option d |                   |                   |
| eductible does *not* apply. |                   |                   |
|                             |                   |                   |
| **There is no calendar year |                   |                   |
| deductible under Basic      |                   |                   |
| Option.**                   |                   |                   |
+-----------------------------+-------------------+-------------------+
| **Medical emergency**       | ### You Pay       | ######### You pa  |
|                             | − Standard Option | y -- Basic Option |
+-----------------------------+-------------------+-------------------+
| -   **Physician services**  | > Preferred: 10%  | > Preferred       |
|     in the hospital         | > of the Plan     | > emergency room: |
|     outpatient department,  | > allowance       | >                 |
|     urgent care center, or  | >                 | > \$50 copayment  |
|     physician\'s office,    | > ***Note:*** If  | > per visit       |
|     including X-rays, MRIs, | > you receive     | >                 |
|     laboratory and          | > services in a   | > Par             |
|     pathology services, and | > Preferred       | ticipating/Member |
|     machine diagnostic      | > physician\'s    | > emergency room: |
|     tests                   | > office, you pay | >                 |
|                             | > a \$15          | > \$50 copayment  |
| -   Related outpatient      | > copayment (No   | > per visit       |
|     **hospital services**   | > deductible) for | >                 |
|     and supplies, including | > the office      | > Non-partici     |
|     X-rays, MRIs,           | > visit, and 10%  | pating/Non-member |
|     laboratory and          | > of the Plan     | > emergency room: |
|     pathology services, and | > allowance for   | > \$50 copayment  |
|     machine diagnostic      | > all other       | > per visit       |
|     tests                   | > services        | >                 |
|                             | > (deductible     | > ***Note:*** You |
| > ***Note:*** We pay        | > applies).       | > are responsible |
| > Inpatient professional    | >                 | > for the         |
| > and hospital benefits if  | > Part            | > applicable      |
| > you are admitted as a     | icipating/Member: | > copayment as    |
| > result of a medical       | > 25% of the Plan | > shown above. If |
| > emergency \[see Sections  | > allowance       | > you use a       |
| > 5(a), 5(b), and 5(c)\].   | >                 | > Non-preferred   |
| >                           | > Non-particip    | > provider, you   |
| > ***Note:*** Please refer  | ating/Non-member: | > may also be     |
| > to Section 3 for          | > 25% of the Plan | > responsible for |
| > information about         | > allowance, plus | > any difference  |
| > precertifying emergency   | > any difference  | > between our     |
| > hospital admissions.      | > between our     | > allowance and   |
|                             | > allowance and   | > the billed      |
|                             | > the billed      | > amount.         |
|                             | > amount          | >                 |
|                             | >                 | > ***Note:*** If  |
|                             | > ***Note:***     | > you are         |
|                             | > These benefit   | > admitted        |
|                             | > levels **do**   | > directly to the |
|                             | > **not** apply   | > hospital from   |
|                             | > if you receive  | > the emergency   |
|                             | > care in         | > room, you do    |
|                             | > connection      | > not have to pay |
|                             | > with, and       | > the \$50        |
|                             | > within 72 hours | > emergency room  |
|                             | > after, an       | > copayment.      |
|                             | > accidental      | > However, the    |
|                             | > injury. See     | > \$100 per day   |
|                             | > Accidental      | > copayment for   |
|                             | > Injury benefits | > Preferred       |
|                             | > on pages 67-69  | > inpatient care  |
|                             | > for the         | > still applies.  |
|                             | > benefits we     | >                 |
|                             | > provide.        | > ***Note:*** All |
|                             |                   | > follow-up care  |
|                             |                   | > must be         |
|                             |                   | > performed and   |
|                             |                   | > billed for by   |
|                             |                   | > Preferred       |
|                             |                   | > providers to be |
|                             |                   | > eligible for    |
|                             |                   | > benefits.       |
|                             |                   | >                 |
|                             |                   | > For the         |
|                             |                   | > following       |
|                             |                   | > places of       |
|                             |                   | > service, you    |
|                             |                   | > **must**        |
|                             |                   | > receive care    |
|                             |                   | > from a          |
|                             |                   | > Preferred       |
|                             |                   | > provider:       |
|                             |                   | >                 |
|                             |                   | > **Preferred**   |
|                             |                   | > urgent care     |
|                             |                   | > center:         |
|                             |                   | >                 |
|                             |                   | > \$30 copayment  |
|                             |                   | > per visit       |
|                             |                   | >                 |
|                             |                   | > **Preferred**   |
|                             |                   | > primary care    |
|                             |                   | > provider or     |
|                             |                   | > other health    |
|                             |                   | > care            |
|                             |                   | > professional\'s |
|                             |                   | > office:         |
|                             |                   | >                 |
|                             |                   | > \$20 copayment  |
|                             |                   | > per visit       |
|                             |                   | >                 |
|                             |                   | > **Preferred**   |
|                             |                   | > specialist\'s   |
|                             |                   | > office:         |
|                             |                   | >                 |
|                             |                   | > \$30 copayment  |
|                             |                   | > per visit       |
|                             |                   | >                 |
|                             |                   | > Par             |
|                             |                   | ticipating/Member |
|                             |                   | > (for other than |
|                             |                   | > emergency       |
|                             |                   | > room): You pay  |
|                             |                   | > all charges     |
|                             |                   | >                 |
|                             |                   | > Non-partici     |
|                             |                   | pating/Non-member |
|                             |                   | > (for other than |
|                             |                   | > emergency       |
|                             |                   | > room): You pay  |
|                             |                   | > all charges     |
+-----------------------------+-------------------+-------------------+

+-----------------------------+-------------------+-------------------+
| # Note: The calenda         |                   |                   |
| r year deductible applies t |                   |                   |
| o almost all Standard Optio |                   |                   |
| n benefits in this Section. |                   |                   |
|                             |                   |                   |
| #                           |                   |                   |
|  We say \"(No deductible)\" |                   |                   |
|  when the Standard Option d |                   |                   |
| eductible does *not* apply. |                   |                   |
|                             |                   |                   |
| **There is no calendar year |                   |                   |
| deductible under Basic      |                   |                   |
| Option.**                   |                   |                   |
+-----------------------------+-------------------+-------------------+
| **Ambulance**               | ### You Pay       | ######### You pa  |
|                             | − Standard Option | y -- Basic Option |
+-----------------------------+-------------------+-------------------+
| > Local professional        | > Preferred: 10%  | > Preferred: \$50 |
| > ambulance **transport     | > of the Plan     | > copayment per   |
| > services** to or from the | > allowance (No   | > trip            |
| > nearest hospital equipped | > deductible)     | >                 |
| > to adequately treat your  | >                 | > Par             |
| > condition, when medically | > Part            | ticipating/Member |
| > appropriate, and:         | icipating/Member: | > or              |
|                             | > 10% of the Plan | > Non-particip    |
| -   Associated with covered | > allowance (No   | ating/Non-member: |
|     hospital inpatient care | > deductible)     | > \$50 copayment  |
|                             | >                 | > per trip        |
| -   Related to medical      | > Non-particip    |                   |
|     emergency               | ating/Non-member: |                   |
|                             | > 10% of the Plan |                   |
| -   Associated with covered | > allowance, plus |                   |
|     hospice care            | > any difference  |                   |
|                             | > between our     |                   |
| > ***Note:*** See Section   | > allowance and   |                   |
| > 5(c) for non-emergency    | > the billed      |                   |
| > ambulance services.       | > amount (No      |                   |
|                             | > deductible)     |                   |
+-----------------------------+-------------------+-------------------+
| > Local professional        | > Preferred:      | > Preferred: \$50 |
| > ambulance **transport     | > Nothing (No     | > copayment per   |
| > services** to or from the | > deductible)     | > trip            |
| > nearest hospital equipped | >                 | >                 |
| > to adequately treat your  | > Part            | > Par             |
| > condition, when medically | icipating/Member: | ticipating/Member |
| > appropriate, and when     | > Nothing (No     | > or              |
| > related to accidental     | > deductible)     | > Non-particip    |
| > injury                    | >                 | ating/Non-member: |
|                             | > Non-particip    | > \$50 copayment  |
|                             | ating/Non-member: | > per trip        |
|                             | > Any difference  |                   |
|                             | > between the     |                   |
|                             | > Plan allowance  |                   |
|                             | > and the billed  |                   |
|                             | > amount (No      |                   |
|                             | > deductible)     |                   |
|                             | >                 |                   |
|                             | > ***Note:***     |                   |
|                             | > These benefit   |                   |
|                             | > levels apply    |                   |
|                             | > only if you     |                   |
|                             | > receive care in |                   |
|                             | > connection      |                   |
|                             | > with, and       |                   |
|                             | > within 72 hours |                   |
|                             | > after, an       |                   |
|                             | > accidental      |                   |
|                             | > injury. For     |                   |
|                             | > services        |                   |
|                             | > received after  |                   |
|                             | > 72 hours, see   |                   |
|                             | > above.          |                   |
+-----------------------------+-------------------+-------------------+

+---+---+-----------------------+-------------------+-------------+---+---+
| # |   |                       |                   |             |   |   |
| # |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| S |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| c |   |                       |                   |             |   |   |
| t |   |                       |                   |             |   |   |
| i |   |                       |                   |             |   |   |
| o |   |                       |                   |             |   |   |
| n |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| 5 |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| ( |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| ) |   |                       |                   |             |   |   |
| . |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| M |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| n |   |                       |                   |             |   |   |
| t |   |                       |                   |             |   |   |
| a |   |                       |                   |             |   |   |
| l |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| h |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| a |   |                       |                   |             |   |   |
| l |   |                       |                   |             |   |   |
| t |   |                       |                   |             |   |   |
| h |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| a |   |                       |                   |             |   |   |
| n |   |                       |                   |             |   |   |
| d |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| s |   |                       |                   |             |   |   |
| u |   |                       |                   |             |   |   |
| b |   |                       |                   |             |   |   |
| s |   |                       |                   |             |   |   |
| t |   |                       |                   |             |   |   |
| a |   |                       |                   |             |   |   |
| n |   |                       |                   |             |   |   |
| c |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| a |   |                       |                   |             |   |   |
| b |   |                       |                   |             |   |   |
| u |   |                       |                   |             |   |   |
| s |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| b |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| n |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| f |   |                       |                   |             |   |   |
| i |   |                       |                   |             |   |   |
| t |   |                       |                   |             |   |   |
| s |   |                       |                   |             |   |   |
+---+---+-----------------------+-------------------+-------------+---+---+
|   | * | > **Here are some     |                   |             | * |   |
|   | * | > important things    |                   |             | * |   |
|   | I | > you should keep in  |                   |             | I |   |
|   | * | > mind about these    |                   |             | * |   |
|   | * | > benefits:**         |                   |             | * |   |
|   |   |                       |                   |             |   |   |
|   | * | -   Please remember   |                   |             | * |   |
|   | * |     that all benefits |                   |             | * |   |
|   | M |     are subject to    |                   |             | M |   |
|   | * |     the definitions,  |                   |             | * |   |
|   | * |     limitations, and  |                   |             | * |   |
|   |   |     exclusions in     |                   |             |   |   |
|   | * |     this brochure and |                   |             | * |   |
|   | * |     are payable only  |                   |             | * |   |
|   | P |     when we determine |                   |             | P |   |
|   | * |     they are          |                   |             | * |   |
|   | * |     medically         |                   |             | * |   |
|   |   |     necessary.        |                   |             |   |   |
|   | * |                       |                   |             | * |   |
|   | * | -   Under **Standard  |                   |             | * |   |
|   | O |     Option**, the     |                   |             | O |   |
|   | * |     calendar year     |                   |             | * |   |
|   | * |     deductible or,    |                   |             | * |   |
|   |   |     for facility      |                   |             |   |   |
|   | * |     care, the         |                   |             | * |   |
|   | * |     inpatient per     |                   |             | * |   |
|   | R |     admission copay,  |                   |             | R |   |
|   | * |     applies to almost |                   |             | * |   |
|   | * |     all benefits in   |                   |             | * |   |
|   |   |     this Section. We  |                   |             |   |   |
|   | * |     added \"(No       |                   |             | * |   |
|   | * |     deductible)\" to  |                   |             | * |   |
|   | T |     show when the     |                   |             | T |   |
|   | * |     deductible does   |                   |             | * |   |
|   | * |     not apply.        |                   |             | * |   |
|   |   |                       |                   |             |   |   |
|   | * | ```{=html}            |                   |             | * |   |
|   | * | <!-- -->              |                   |             | * |   |
|   | A | ```                   |                   |             | A |   |
|   | * | -   **Under**         |                   |             | * |   |
|   | * |     **Standard        |                   |             | * |   |
|   |   |     Option,** there   |                   |             |   |   |
|   | * |     is a maximum of   |                   |             | * |   |
|   | * |     25 visits per     |                   |             | * |   |
|   | N |     year for office   |                   |             | N |   |
|   | * |     visits, partial   |                   |             | * |   |
|   | * |     hospitalization,  |                   |             | * |   |
|   |   |     intensive         |                   |             |   |   |
|   | * |     outpatient        |                   |             | * |   |
|   | * |     treatment, and    |                   |             | * |   |
|   | T |     other hospital    |                   |             | T |   |
|   | * |     outpatient        |                   |             | * |   |
|   | * |     treatment. The    |                   |             | * |   |
|   |   |     first 25 visits   |                   |             |   |   |
|   |   |     under Standard    |                   |             |   |   |
|   |   |     Option each       |                   |             |   |   |
|   |   |     calendar year by  |                   |             |   |   |
|   |   |     Preferred         |                   |             |   |   |
|   |   |     providers and     |                   |             |   |   |
|   |   |     Non-preferred     |                   |             |   |   |
|   |   |     providers count   |                   |             |   |   |
|   |   |     toward this       |                   |             |   |   |
|   |   |     maximum. This     |                   |             |   |   |
|   |   |     maximum may be    |                   |             |   |   |
|   |   |     waived for        |                   |             |   |   |
|   |   |     services received |                   |             |   |   |
|   |   |     from Preferred    |                   |             |   |   |
|   |   |     providers.        |                   |             |   |   |
|   |   |                       |                   |             |   |   |
|   |   | ```{=html}            |                   |             |   |   |
|   |   | <!-- -->              |                   |             |   |   |
|   |   | ```                   |                   |             |   |   |
|   |   | -   Under **Standard  |                   |             |   |   |
|   |   |     Option**, you may |                   |             |   |   |
|   |   |     choose to get     |                   |             |   |   |
|   |   |     care In-Network   |                   |             |   |   |
|   |   |     (Preferred) or    |                   |             |   |   |
|   |   |     Out-of-Network    |                   |             |   |   |
|   |   |     (Non-preferred).  |                   |             |   |   |
|   |   |     When you use a    |                   |             |   |   |
|   |   |     Preferred         |                   |             |   |   |
|   |   |     provider, he or   |                   |             |   |   |
|   |   |     she must submit a |                   |             |   |   |
|   |   |     treatment plan to |                   |             |   |   |
|   |   |     us **prior to     |                   |             |   |   |
|   |   |     your ninth        |                   |             |   |   |
|   |   |     outpatient        |                   |             |   |   |
|   |   |     visit** in order  |                   |             |   |   |
|   |   |     to maximize the   |                   |             |   |   |
|   |   |     benefits you      |                   |             |   |   |
|   |   |     receive.          |                   |             |   |   |
|   |   |     Preferred         |                   |             |   |   |
|   |   |     benefits are      |                   |             |   |   |
|   |   |     payable when the  |                   |             |   |   |
|   |   |     care is           |                   |             |   |   |
|   |   |     clinically        |                   |             |   |   |
|   |   |     appropriate to    |                   |             |   |   |
|   |   |     treat your        |                   |             |   |   |
|   |   |     condition and     |                   |             |   |   |
|   |   |     when you receive  |                   |             |   |   |
|   |   |     the care as part  |                   |             |   |   |
|   |   |     of a treatment    |                   |             |   |   |
|   |   |     plan that we      |                   |             |   |   |
|   |   |     approve.          |                   |             |   |   |
|   |   |     Cost-sharing and  |                   |             |   |   |
|   |   |     limitations for   |                   |             |   |   |
|   |   |     In-Network        |                   |             |   |   |
|   |   |     (Preferred)       |                   |             |   |   |
|   |   |     mental health and |                   |             |   |   |
|   |   |     substance abuse   |                   |             |   |   |
|   |   |     benefits are no   |                   |             |   |   |
|   |   |     greater than for  |                   |             |   |   |
|   |   |     similar benefits  |                   |             |   |   |
|   |   |     for other         |                   |             |   |   |
|   |   |     illnesses and     |                   |             |   |   |
|   |   |     conditions.       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
|   |   | ```{=html}            |                   |             |   |   |
|   |   | <!-- -->              |                   |             |   |   |
|   |   | ```                   |                   |             |   |   |
|   |   | -   **Under Basic     |                   |             |   |   |
|   |   |     Option, you must  |                   |             |   |   |
|   |   |     call us for prior |                   |             |   |   |
|   |   |     approval before   |                   |             |   |   |
|   |   |     receiving care.** |                   |             |   |   |
|   |   |     We will provide   |                   |             |   |   |
|   |   |     you with the      |                   |             |   |   |
|   |   |     names and phone   |                   |             |   |   |
|   |   |     numbers of        |                   |             |   |   |
|   |   |     several Preferred |                   |             |   |   |
|   |   |     providers and     |                   |             |   |   |
|   |   |     tell you how many |                   |             |   |   |
|   |   |     visits we are     |                   |             |   |   |
|   |   |     initially         |                   |             |   |   |
|   |   |     approving. You    |                   |             |   |   |
|   |   |     may then choose   |                   |             |   |   |
|   |   |     which of those    |                   |             |   |   |
|   |   |     providers you     |                   |             |   |   |
|   |   |     would like to     |                   |             |   |   |
|   |   |     see. **You must   |                   |             |   |   |
|   |   |     use Preferred     |                   |             |   |   |
|   |   |     providers in      |                   |             |   |   |
|   |   |     order to receive  |                   |             |   |   |
|   |   |     Basic Option      |                   |             |   |   |
|   |   |     benefits.**       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
|   |   | ```{=html}            |                   |             |   |   |
|   |   | <!-- -->              |                   |             |   |   |
|   |   | ```                   |                   |             |   |   |
|   |   | -   **Under Basic     |                   |             |   |   |
|   |   |     Option,** there   |                   |             |   |   |
|   |   |     is **no calendar  |                   |             |   |   |
|   |   |     year              |                   |             |   |   |
|   |   |     deductible**.     |                   |             |   |   |
|   |   |                       |                   |             |   |   |
|   |   | ```{=html}            |                   |             |   |   |
|   |   | <!-- -->              |                   |             |   |   |
|   |   | ```                   |                   |             |   |   |
|   |   | -   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         |                   |             |   |   |
|   |   |     Medicare.         |                   |             |   |   |
|   |   |                       |                   |             |   |   |
|   |   | ```{=html}            |                   |             |   |   |
|   |   | <!-- -->              |                   |             |   |   |
|   |   | ```                   |                   |             |   |   |
|   |   | -   **YOU MUST GET    |                   |             |   |   |
|   |   |     PRECERTIFICATION  |                   |             |   |   |
|   |   |     OF HOSPITAL       |                   |             |   |   |
|   |   |     STAYS; FAILURE TO |                   |             |   |   |
|   |   |     DO SO WILL RESULT |                   |             |   |   |
|   |   |     IN A \$500        |                   |             |   |   |
|   |   |     PENALTY.** Please |                   |             |   |   |
|   |   |     refer to the      |                   |             |   |   |
|   |   |     precertification  |                   |             |   |   |
|   |   |     information       |                   |             |   |   |
|   |   |     listed in         |                   |             |   |   |
|   |   |     Section 3. Some   |                   |             |   |   |
|   |   |     other services    |                   |             |   |   |
|   |   |     also require      |                   |             |   |   |
|   |   |     prior approval.   |                   |             |   |   |
|   |   |     See the           |                   |             |   |   |
|   |   |     instructions      |                   |             |   |   |
|   |   |     after the         |                   |             |   |   |
|   |   |     benefits          |                   |             |   |   |
|   |   |     descriptions      |                   |             |   |   |
|   |   |     below.            |                   |             |   |   |
|   |   |                       |                   |             |   |   |
|   |   | ```{=html}            |                   |             |   |   |
|   |   | <!-- -->              |                   |             |   |   |
|   |   | ```                   |                   |             |   |   |
|   |   | -   **Standard Option |                   |             |   |   |
|   |   |     and Basic Option  |                   |             |   |   |
|   |   |     benefits** for    |                   |             |   |   |
|   |   |     Preferred         |                   |             |   |   |
|   |   |     (In-Network)      |                   |             |   |   |
|   |   |     mental health and |                   |             |   |   |
|   |   |     substance abuse   |                   |             |   |   |
|   |   |     care begin below  |                   |             |   |   |
|   |   |     and are continued |                   |             |   |   |
|   |   |     on the following  |                   |             |   |   |
|   |   |     pages. Standard   |                   |             |   |   |
|   |   |     Option benefits   |                   |             |   |   |
|   |   |     for Non-preferred |                   |             |   |   |
|   |   |     (Out-of-Network)  |                   |             |   |   |
|   |   |     care begin on     |                   |             |   |   |
|   |   |     page 76.          |                   |             |   |   |
|   |   |                       |                   |             |   |   |
|   |   | ```{=html}            |                   |             |   |   |
|   |   | <!-- -->              |                   |             |   |   |
|   |   | ```                   |                   |             |   |   |
|   |   | -   PPO benefits      |                   |             |   |   |
|   |   |     apply only when   |                   |             |   |   |
|   |   |     you use a PPO     |                   |             |   |   |
|   |   |     provider. When no |                   |             |   |   |
|   |   |     PPO provider is   |                   |             |   |   |
|   |   |     available,        |                   |             |   |   |
|   |   |     non-PPO benefits  |                   |             |   |   |
|   |   |     apply.            |                   |             |   |   |
+---+---+-----------------------+-------------------+-------------+---+---+
| * |   |                       | **You Pay**       |             |   |   |
| * |   |                       |                   |             |   |   |
| B |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| n |   |                       |                   |             |   |   |
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| t |   |                       |                   |             |   |   |
| D |   |                       |                   |             |   |   |
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+---+---+-----------------------+-------------------+-------------+---+---+
| # |   |                       |                   |             |   |   |
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|   |   |                       |                   |             |   |   |
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|   |   |                       |                   |             |   |   |
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| * |   |                       |                   |             |   |   |
| * |   |                       |                   |             |   |   |
+---+---+-----------------------+-------------------+-------------+---+---+
| # |   |                       | ### You Pay       | **You Pay − |   |   |
| # |   |                       | − Standard Option | Basic       |   |   |
| # |   |                       |                   | Option**    |   |   |
|   |   |                       |                   |             |   |   |
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|   |   |                       |                   |             |   |   |
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| n |   |                       |                   |             |   |   |
| - |   |                       |                   |             |   |   |
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| w |   |                       |                   |             |   |   |
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|   |   |                       |                   |             |   |   |
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| i |   |                       |                   |             |   |   |
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| s |   |                       |                   |             |   |   |
+---+---+-----------------------+-------------------+-------------+---+---+
| A |   |                       | Your cost sharing | Your cost   |   |   |
| l |   |                       | responsibilities  | sharing     |   |   |
| l |   |                       | are no greater    | respo       |   |   |
| d |   |                       | than for other    | nsibilities |   |   |
| i |   |                       | illnesses or      | are no      |   |   |
| a |   |                       | conditions.       | greater     |   |   |
| g |   |                       |                   | than for    |   |   |
| n |   |                       |                   | other       |   |   |
| o |   |                       |                   | illnesses   |   |   |
| s |   |                       |                   | or          |   |   |
| t |   |                       |                   | conditions. |   |   |
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| n |   |                       |                   |             |   |   |
| t |   |                       |                   |             |   |   |
| h |   |                       |                   |             |   |   |
| a |   |                       |                   |             |   |   |
| t |   |                       |                   |             |   |   |
| w |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| a |   |                       |                   |             |   |   |
| p |   |                       |                   |             |   |   |
| p |   |                       |                   |             |   |   |
| r |   |                       |                   |             |   |   |
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| . |   |                       |                   |             |   |   |
+---+---+-----------------------+-------------------+-------------+---+---+

Preferred (In-Network) benefits -- *continued on next page*

+-----------------------------+-------------------+-------------------+
| # Note: The calenda         |                   |                   |
| r year deductible applies t |                   |                   |
| o almost all Standard Optio |                   |                   |
| n benefits in this Section. |                   |                   |
|                             |                   |                   |
| #                           |                   |                   |
|  We say \"(No deductible)\" |                   |                   |
|  when the Standard Option d |                   |                   |
| eductible does *not* apply. |                   |                   |
|                             |                   |                   |
| **There is no calendar year |                   |                   |
| deductible under Basic      |                   |                   |
| Option.**                   |                   |                   |
+-----------------------------+-------------------+-------------------+
| ### Preferred (In-Netw      | ### You Pay       | **You Pay − Basic |
| ork) benefits *(continued)* | − Standard Option | Option**          |
+-----------------------------+-------------------+-------------------+
| > Professional services,    | > \$15 copayment  | > \$20 copayment  |
| > including individual or   | > for the visit,  | > per visit       |
| > group therapy by          | > up to two hours | >                 |
| > providers such as         | > per visit (No   | > ***Note:*** You |
| > psychiatrists,            | > deductible)     | > pay a \$30      |
| > psychologists, clinical   |                   | > copayment for   |
| > social workers, or        |                   | > outpatient      |
| > psychiatric nurses        |                   | > services billed |
|                             |                   | > for by a        |
| -   Office and home visits  |                   | > facility.       |
|                             |                   |                   |
| -   In a hospital           |                   |                   |
|     outpatient department   |                   |                   |
|     (except for emergency   |                   |                   |
|     rooms)                  |                   |                   |
|                             |                   |                   |
| -   Psychotherapy for       |                   |                   |
|     smoking cessation       |                   |                   |
|                             |                   |                   |
| -   Pharmacotherapy         |                   |                   |
|     (medication management) |                   |                   |
|                             |                   |                   |
| > ***Note:*** Additional    |                   |                   |
| > types of licensed         |                   |                   |
| > providers may be          |                   |                   |
| > available to you for      |                   |                   |
| > mental health and         |                   |                   |
| > substance abuse services. |                   |                   |
| > Consult your PPO          |                   |                   |
| > directory or contact your |                   |                   |
| > Local Plan at the mental  |                   |                   |
| > health and substance      |                   |                   |
| > abuse phone number on the |                   |                   |
| > back of your ID card.     |                   |                   |
+-----------------------------+-------------------+-------------------+
| > Other services:           | > 10% of the Plan | > Preferred       |
|                             | > allowance       | > primary care    |
| -   Psychological testing   | > (deductible     | > provider or     |
|                             | > applies)        | > other health    |
| > ***Note:*** Additional    | >                 | > care            |
| > types of licensed         | > ***Note:***     | > professional:   |
| > providers may be          | > Other services  | > \$20 copayment  |
| > available to you for      | > are not subject | > per visit       |
| > mental health and         | > to the two-hour | >                 |
| > substance abuse services. | > limit.          | > Preferred       |
| > Consult your PPO          |                   | > specialist:     |
| > directory or contact your |                   | > \$30 copayment  |
| > Local Plan at the mental  |                   | > per visit       |
| > health and substance      |                   | >                 |
| > abuse phone number on the |                   | > ***Note:*** You |
| > back of your ID card.     |                   | > pay a \$30      |
|                             |                   | > copayment for   |
|                             |                   | > outpatient      |
|                             |                   | > services billed |
|                             |                   | > for by a        |
|                             |                   | > facility.       |
|                             |                   | >                 |
|                             |                   | > ***Note:*** You |
|                             |                   | > pay 30% of the  |
|                             |                   | > Plan allowance  |
|                             |                   | > for drugs and   |
|                             |                   | > supplies.       |
+-----------------------------+-------------------+-------------------+
| -   Inpatient professional  | > 10% of the Plan | > Nothing         |
|     visits                  | > allowance       |                   |
|                             | >                 |                   |
| -   Professional charges    | > ***Note:***     |                   |
|     for facility-based      | > Intensive       |                   |
|     intensive outpatient    | > outpatient      |                   |
|     treatment               | > treatment is    |                   |
|                             | > not limited to  |                   |
|                             | > two hours per   |                   |
|                             | > visit but you   |                   |
|                             | > must obtain     |                   |
|                             | > prior approval. |                   |
+-----------------------------+-------------------+-------------------+
| -   Professional charges    | > 10% of the Plan | > Preferred: \$30 |
|     > for intensive         | > allowance       | > copayment per   |
|     > outpatient treatment  | >                 | > visit           |
|     > in a provider\'s      | > ***Note:***     |                   |
|     > office or other       | > Intensive       |                   |
|     > professional setting  | > outpatient      |                   |
|                             | > treatment is    |                   |
|                             | > not limited to  |                   |
|                             | > two hours per   |                   |
|                             | > visit but you   |                   |
|                             | > must obtain     |                   |
|                             | > prior approval. |                   |
+-----------------------------+-------------------+-------------------+
| -   Professional charges    | > 10% of the Plan | > \$20 copayment  |
|     > for outpatient        | > allowance       | > per visit       |
|     > diagnostic tests      |                   |                   |
+-----------------------------+-------------------+-------------------+

Preferred (In-Network) benefits -- *continued on next page*

+-----------------------------+-------------------+-------------------+
| # Note: The calenda         |                   |                   |
| r year deductible applies t |                   |                   |
| o almost all Standard Optio |                   |                   |
| n benefits in this Section. |                   |                   |
|                             |                   |                   |
| #                           |                   |                   |
|  We say \"(No deductible)\" |                   |                   |
|  when the Standard Option d |                   |                   |
| eductible does *not* apply. |                   |                   |
|                             |                   |                   |
| **There is no calendar year |                   |                   |
| deductible under Basic      |                   |                   |
| Option.**                   |                   |                   |
+-----------------------------+-------------------+-------------------+
| ### Preferred (In-Netw      | ### You Pay       | **You Pay − Basic |
| ork) benefits *(continued)* | − Standard Option | Option**          |
+-----------------------------+-------------------+-------------------+
| > Inpatient services        | > \$100 per       | > \$100 per day   |
| > provided and billed by a  | > admission       | > copayment up to |
| > hospital or other covered | > copayment (No   | > \$500 per       |
| > facility                  | > deductible)     | > admission       |
|                             |                   |                   |
| -   Room and board, such as |                   |                   |
|     semiprivate or          |                   |                   |
|     intensive               |                   |                   |
|     accommodations, general |                   |                   |
|     nursing care, meals and |                   |                   |
|     special diets, and      |                   |                   |
|     other hospital services |                   |                   |
|                             |                   |                   |
| -   Diagnostic tests        |                   |                   |
|                             |                   |                   |
| > ***Note:*** You must get  |                   |                   |
| > precertification of       |                   |                   |
| > inpatient hospital stays; |                   |                   |
| > failure to do so will     |                   |                   |
| > result in a \$500         |                   |                   |
| > penalty.                  |                   |                   |
+-----------------------------+-------------------+-------------------+
| > Outpatient services       | > 10% of the Plan | > \$30 copayment  |
| > provided and billed by a  | > allowance       | > per day per     |
| > hospital or other covered |                   | > facility        |
| > facility                  |                   | >                 |
|                             |                   | > ***Note:*** You |
| -   Diagnostic tests        |                   | > pay 30% of the  |
|                             |                   | > Plan allowance  |
| -   Services in the         |                   | > for drugs and   |
|     following approved      |                   | > supplies.       |
|     treatment programs      |                   |                   |
|     (must be prior          |                   |                   |
|     approved):              |                   |                   |
|                             |                   |                   |
| ```{=html}                  |                   |                   |
| <!-- -->                    |                   |                   |
| ```                         |                   |                   |
| -   partial hospitalization |                   |                   |
|                             |                   |                   |
| -   facility-based          |                   |                   |
|     intensive outpatient    |                   |                   |
|     treatment               |                   |                   |
+-----------------------------+-------------------+-------------------+
| > *Not covered:*            | > *All charges*   | > *All charges*   |
|                             |                   |                   |
| -   *Services we have not   |                   |                   |
|     approved*               |                   |                   |
|                             |                   |                   |
| -   *Educational or         |                   |                   |
|     training services*      |                   |                   |
|                             |                   |                   |
| -   *Psychoanalysis or      |                   |                   |
|     psychotherapy credited  |                   |                   |
|     toward earning a degree |                   |                   |
|     or furtherance of       |                   |                   |
|     education or training   |                   |                   |
|     regardless of diagnosis |                   |                   |
|     or symptoms that may be |                   |                   |
|     present*                |                   |                   |
+-----------------------------+-------------------+-------------------+

Preferred (In-Network) benefits -- *continued on next page*

+-----------------------------------------------------------------------+
| # Note: The calendar year deduc                                       |
| tible applies to almost all Standard Option benefits in this Section. |
|                                                                       |
| # We say \"(N                                                         |
| o deductible)\" when the Standard Option deductible does *not* apply. |
|                                                                       |
| **There is no calendar year deductible under Basic Option.**          |
+-----------------------------------------------------------------------+
| **Preferred (In-Network) benefits** *(continued)*                     |
+-----------------------------------------------------------------------+
| > **Authorization Procedures Standard Option:** To be eligible to     |
| > receive Preferred mental health and substance abuse benefits you    |
| > must see a Preferred provider, obtain a treatment plan, and follow  |
| > the applicable authorization processes.                             |
| >                                                                     |
| > To locate a Preferred provider, please refer to your PPO directory, |
| > visit our Web site at [www.fepblue.org](http://www.fepblue.org/),   |
| > or contact us at the mental health and substance abuse phone number |
| > shown on the back of your ID card*.*                                |
| >                                                                     |
| > **Basic Option:** To be eligible to receive mental health and       |
| > substance abuse benefits, you must call us for prior approval at    |
| > the mental health and substance abuse phone number on the back of   |
| > your ID card before you receive care. We will then provide you with |
| > the names and phone numbers of several Preferred providers to       |
| > choose from and tell you how many visits we are initially           |
| > approving.                                                          |
| >                                                                     |
| > **Precertification** You must get precertification of inpatient     |
| > hospital stays; failure to do so will result in a \$500 penalty.    |
| > Please refer to the precertification information listed in Section  |
| > 3 for additional information.                                       |
| >                                                                     |
| > **Prior Approval Standard Option:** Prior approval is required for  |
| > partial hospitalization and intensive outpatient treatment          |
| > programs.                                                           |
| >                                                                     |
| > **Basic Option:** Prior approval is required for all mental health  |
| > and substance abuse services.                                       |
| >                                                                     |
| > Prior to starting treatment, you, someone acting on your behalf,    |
| > your physician, or your hospital must call us at the mental health  |
| > and substance abuse phone number on the back of your ID card. We    |
| > will not pay for mental health and substance abuse services under   |
| > Basic Option or for partial hospitalization or intensive outpatient |
| > treatment programs under Standard Option, even at Preferred         |
| > facilities, until you obtain prior approval.                        |
| >                                                                     |
| > **Treatment Plans Standard Option:** **We provide Preferred         |
| > benefits only when you receive care as part of a treatment plan     |
| > that we have approved.** In order to maximize your benefits, your   |
| > provider must submit a treatment plan to us **prior to your ninth   |
| > outpatient visit**. When we approve the treatment plan, we will     |
| > give your provider authorization for additional visits or services. |
| > The services or number of additional visits authorized will depend  |
| > on the treatment plan. We may need to request updated treatment     |
| > plans as your treatment progresses. If a treatment plan is not      |
| > submitted or approved, we will provide only Non-preferred           |
| > (out-of-network) benefits. If you change providers, a new treatment |
| > plan must be submitted. We will be flexible in allowing additional  |
| > visits while your treatment plan is being prepared or under review. |
| >                                                                     |
| > **Basic Option:** We will work directly with your provider and may  |
| > request a treatment plan from your provider.                        |
| >                                                                     |
| > OPM will base its review of disputes about treatment plans on the   |
| > treatment plan\'s clinical appropriateness. OPM will generally not  |
| > order us to pay or provide one clinically appropriate treatment     |
| > plan in favor of another.                                           |
| >                                                                     |
| > **Preferred Limitation Under Standard Option,** if you do not       |
| > obtain an approved treatment plan, we will provide only             |
| > Non-preferred (out-of-network) benefits.                            |
+-----------------------------------------------------------------------+

+-----------------------------+-------------------+-------------------+
| # Note: The calenda         |                   |                   |
| r year deductible applies t |                   |                   |
| o almost all Standard Optio |                   |                   |
| n benefits in this Section. |                   |                   |
|                             |                   |                   |
| #                           |                   |                   |
|  We say \"(No deductible)\" |                   |                   |
|  when the Standard Option d |                   |                   |
| eductible does *not* apply. |                   |                   |
|                             |                   |                   |
| **There is no calendar year |                   |                   |
| deductible under Basic      |                   |                   |
| Option.**                   |                   |                   |
+-----------------------------+-------------------+-------------------+
| ### Non-preferre            | ### You Pay       | **You Pay − Basic |
| d (Out-of-Network) benefits | − Standard Option | Option**          |
+-----------------------------+-------------------+-------------------+
| > Professional services,    | > 40% of the Plan | > Participating/N |
| > including individual or   | > allowance for   | on-participating: |
| > group therapy, by         | > up to two hours | > You pay all     |
| > providers such as         | > per visit and   | > charges         |
| > psychiatrists,            | > up to 25        |                   |
| > psychologists, clinical   | > outpatient      |                   |
| > social workers, or        | > visits per      |                   |
| > psychiatric nurses, for:  | > calendar year;  |                   |
|                             | > all charges     |                   |
| -   Office and home visits  | > after 25        |                   |
|                             | > visits\*. You   |                   |
| -   In a hospital           | > may also be     |                   |
|     outpatient department   | > responsible for |                   |
|     (except for emergency   | > any difference  |                   |
|     rooms)                  | > between the     |                   |
|                             | > Plan allowance  |                   |
| ```{=html}                  | > and the billed  |                   |
| <!-- -->                    | > amount.         |                   |
| ```                         | >                 |                   |
| -   Psychotherapy for       | > \*The 25-visit  |                   |
|     smoking cessation       | > limit is a      |                   |
|                             | > combined        |                   |
|                             | > maximum for all |                   |
|                             | > outpatient      |                   |
|                             | > professional    |                   |
|                             | > care, partial   |                   |
|                             | >                 |                   |
|                             |  hospitalization, |                   |
|                             | > intensive       |                   |
|                             | > outpatient      |                   |
|                             | > treatment, and  |                   |
|                             | > outpatient      |                   |
|                             | > facility care,  |                   |
|                             | > whether         |                   |
|                             | > performed by    |                   |
|                             | > Preferred or    |                   |
|                             | > Non-preferred   |                   |
|                             | > providers, or   |                   |
|                             | > applied to your |                   |
|                             | > calendar year   |                   |
|                             | > deductible.     |                   |
+-----------------------------+-------------------+-------------------+
| > Other services:           | > 25% of the Plan | > Participating/N |
|                             | > allowance. You  | on-participating: |
| -   Pharmacotherapy         | > may also be     | > You pay all     |
|     (medication management) | > responsible for | > charges         |
|                             | > any difference  |                   |
| ```{=html}                  | > between the     |                   |
| <!-- -->                    | > Plan allowance  |                   |
| ```                         | > and the billed  |                   |
| -   Psychological testing   | > amount.         |                   |
|                             | >                 |                   |
|                             | > ***Note:***     |                   |
|                             | > Other services  |                   |
|                             | > are not subject |                   |
|                             | > to the 25-visit |                   |
|                             | > limitation.     |                   |
+-----------------------------+-------------------+-------------------+
| > Inpatient visits          | > 40% of the Plan | > Participating/N |
|                             | > allowance up to | on-participating: |
|                             | > 100 days per    | > You pay all     |
|                             | > calendar year;  | > charges         |
|                             | > all charges     |                   |
|                             | > after 100 days. |                   |
|                             | > You may also be |                   |
|                             | > responsible for |                   |
|                             | > any difference  |                   |
|                             | > between the     |                   |
|                             | > Plan allowance  |                   |
|                             | > and the billed  |                   |
|                             | > amount.         |                   |
+-----------------------------+-------------------+-------------------+

Non-preferred (Out-of-Network) benefits -- *continued on next page*

+-----------------------------+-------------------+-------------------+
| # Note: The calenda         |                   |                   |
| r year deductible applies t |                   |                   |
| o almost all Standard Optio |                   |                   |
| n benefits in this Section. |                   |                   |
|                             |                   |                   |
| #                           |                   |                   |
|  We say \"(No deductible)\" |                   |                   |
|  when the Standard Option d |                   |                   |
| eductible does *not* apply. |                   |                   |
|                             |                   |                   |
| **There is no calendar year |                   |                   |
| deductible under Basic      |                   |                   |
| Option.**                   |                   |                   |
+-----------------------------+-------------------+-------------------+
| **Non-preferred             | ### You Pay       | **You Pay − Basic |
| (Out-of-Network) benefits** | − Standard Option | Option**          |
| *(continued)*               |                   |                   |
+-----------------------------+-------------------+-------------------+
| > Inpatient services        | > \$400 copayment | > M               |
| > provided and billed by a  | > per day (No     | ember/Non-member: |
| > hospital or other covered | > deductible) up  | > You pay all     |
| > facility                  | > to 100 days per | > charges         |
|                             | > calendar year;  |                   |
| -   Room and board, such as | > all charges     |                   |
|     semiprivate or          | > after 100 days  |                   |
|     intensive               |                   |                   |
|     accommodations, general |                   |                   |
|     nursing care, meals and |                   |                   |
|     special diets, and      |                   |                   |
|     other hospital services |                   |                   |
|                             |                   |                   |
| > You must get              |                   |                   |
| > precertification of       |                   |                   |
| > inpatient hospital stays; |                   |                   |
| > failure to do so will     |                   |                   |
| > result in a \$500         |                   |                   |
| > penalty.                  |                   |                   |
+-----------------------------+-------------------+-------------------+
| > Outpatient services       | > 25% of the Plan | > M               |
| > provided and billed by a  | > allowance, plus | ember/Non-member: |
| > hospital or other covered | > any difference  | > You pay all     |
| > facility                  | > between the     | > charges         |
|                             | > Plan allowance  |                   |
| -   Psychological testing   | > and the billed  |                   |
|                             | > amount          |                   |
|                             | >                 |                   |
|                             | > ***Note:***     |                   |
|                             | > Psychological   |                   |
|                             | > testing is not  |                   |
|                             | > subject to the  |                   |
|                             | > visit           |                   |
|                             | > limitations.    |                   |
+-----------------------------+-------------------+-------------------+
| > Partial hospitalization   | > 25% of the Plan | > Par             |
| > and intensive outpatient  | > allowance, plus | ticipating/Member |
| > treatment                 | > any difference  | > or              |
|                             | > between the     | > Non-particip    |
|                             | > Plan allowance  | ating/Non-member: |
|                             | > and the billed  | > You pay all     |
|                             | > amount; all     | > charges         |
|                             | > charges after   |                   |
|                             | > 25 visits\*     |                   |
|                             | >                 |                   |
|                             | > ***Note:***     |                   |
|                             | > Visits that you |                   |
|                             | > pay for while   |                   |
|                             | > meeting your    |                   |
|                             | > deductible      |                   |
|                             | > count toward    |                   |
|                             | > the limit cited |                   |
|                             | > above.          |                   |
|                             | >                 |                   |
|                             | > \*The 25-visit  |                   |
|                             | > limit is a      |                   |
|                             | > combined        |                   |
|                             | > maximum for all |                   |
|                             | > outpatient      |                   |
|                             | > professional    |                   |
|                             | > care, partial   |                   |
|                             | >                 |                   |
|                             |  hospitalization, |                   |
|                             | > intensive       |                   |
|                             | > outpatient      |                   |
|                             | > treatment, and  |                   |
|                             | > outpatient      |                   |
|                             | > facility care,  |                   |
|                             | > whether         |                   |
|                             | > performed by    |                   |
|                             | > Preferred or    |                   |
|                             | > Non-preferred   |                   |
|                             | > providers, or   |                   |
|                             | > applied to your |                   |
|                             | > calendar year   |                   |
|                             | > deductible.     |                   |
+-----------------------------+-------------------+-------------------+

Non-preferred (Out-of-Network) benefits -- *continued on next page*

+-----------------------------+-------------------+-------------------+
| # Note: The calenda         |                   |                   |
| r year deductible applies t |                   |                   |
| o almost all Standard Optio |                   |                   |
| n benefits in this Section. |                   |                   |
|                             |                   |                   |
| #                           |                   |                   |
|  We say \"(No deductible)\" |                   |                   |
|  when the Standard Option d |                   |                   |
| eductible does *not* apply. |                   |                   |
|                             |                   |                   |
| **There is no calendar year |                   |                   |
| deductible under Basic      |                   |                   |
| Option.**                   |                   |                   |
+-----------------------------+-------------------+-------------------+
| ###                         | ### You Pay       | **You Pay − Basic |
|  Non-preferred (Out-of-Netw | − Standard Option | Option**          |
| ork) benefits *(continued)* |                   |                   |
+-----------------------------+-------------------+-------------------+
| > Inpatient care to treat   | > Non-preferred   | > M               |
| > substance abuse includes  | > facility: \$400 | ember/Non-member: |
| > room and board and        | > copayment per   | > You pay all     |
| > ancillary charges for     | > day (No         | > charges         |
| > confinements in a         | > deductible);    | >                 |
| > treatment facility for    | > all charges     | > Participating/N |
| > rehabilitative treatment  | > after 28 days   | on-participating: |
| > of alcoholism or          | > per lifetime    | > You pay all     |
| > substance abuse           | >                 | > charges         |
|                             | > Non-preferred   |                   |
|                             | > professional:   |                   |
|                             | > 40% of the Plan |                   |
|                             | > allowance; all  |                   |
|                             | > charges after   |                   |
|                             | > 28 days per     |                   |
|                             | > lifetime. You   |                   |
|                             | > may also be     |                   |
|                             | > responsible for |                   |
|                             | > any difference  |                   |
|                             | > between the     |                   |
|                             | > Plan allowance  |                   |
|                             | > and the billed  |                   |
|                             | > amount.         |                   |
|                             | >                 |                   |
|                             | > ***Note:***     |                   |
|                             | > Non-preferred   |                   |
|                             | > inpatient care  |                   |
|                             | > for the         |                   |
|                             | > treatment of    |                   |
|                             | > substance abuse |                   |
|                             | > is limited to   |                   |
|                             | > one treatment   |                   |
|                             | > program (28-day |                   |
|                             | > maximum) per    |                   |
|                             | > lifetime.       |                   |
+-----------------------------+-------------------+-------------------+
| > *Not covered:*            | > *All charges*   | > *All charges*   |
|                             |                   |                   |
| -   *Marital, family,       |                   |                   |
|     educational, or other   |                   |                   |
|     counseling or training  |                   |                   |
|     services*               |                   |                   |
|                             |                   |                   |
| ```{=html}                  |                   |                   |
| <!-- -->                    |                   |                   |
| ```                         |                   |                   |
| -   *Services performed by  |                   |                   |
|     a noncovered provider*  |                   |                   |
|                             |                   |                   |
| -   *Testing and treatment  |                   |                   |
|     for learning            |                   |                   |
|     disabilities and mental |                   |                   |
|     retardation*            |                   |                   |
|                             |                   |                   |
| -   *Services performed or  |                   |                   |
|     billed by schools,      |                   |                   |
|     residential treatment   |                   |                   |
|     centers, halfway        |                   |                   |
|     houses, or members of   |                   |                   |
|     their staffs*           |                   |                   |
|                             |                   |                   |
| ```{=html}                  |                   |                   |
| <!-- -->                    |                   |                   |
| ```                         |                   |                   |
| -   *Psychoanalysis or      |                   |                   |
|     psychotherapy credited  |                   |                   |
|     toward earning a degree |                   |                   |
|     or furtherance of       |                   |                   |
|     education or training   |                   |                   |
|     regardless of diagnosis |                   |                   |
|     or symptoms that may be |                   |                   |
|     present*                |                   |                   |
+-----------------------------+-------------------+-------------------+
| **Lifetime maximum**        |                   |                   |
| Non-preferred inpatient     |                   |                   |
| care for the treatment of   |                   |                   |
| substance abuse is limited  |                   |                   |
| to one treatment program    |                   |                   |
| (28-day maximum) per        |                   |                   |
| lifetime under **Standard** |                   |                   |
| **Option**.                 |                   |                   |
+-----------------------------+-------------------+-------------------+
| **Precertification** You    |                   |                   |
| must get precertification   |                   |                   |
| of the medical necessity of |                   |                   |
| your admission to a         |                   |                   |
| hospital or other covered   |                   |                   |
| facility. Report emergency  |                   |                   |
| admissions within two       |                   |                   |
| business days following the |                   |                   |
| day of admission, even if   |                   |                   |
| you have been discharged.   |                   |                   |
| Otherwise, we will reduce   |                   |                   |
| the benefits payable by     |                   |                   |
| \$500. See Section 3 for    |                   |                   |
| more information on         |                   |                   |
| precertification.           |                   |                   |
+-----------------------------+-------------------+-------------------+
| > See these sections of the |                   |                   |
| > brochure for more         |                   |                   |
| > valuable information      |                   |                   |
| > about these benefits:     |                   |                   |
|                             |                   |                   |
| -   Section 4, *Your costs  |                   |                   |
|     for covered services*,  |                   |                   |
|     for information about   |                   |                   |
|     catastrophic protection |                   |                   |
|     for mental health and   |                   |                   |
|     substance abuse         |                   |                   |
|     benefits.               |                   |                   |
|                             |                   |                   |
| ```{=html}                  |                   |                   |
| <!-- -->                    |                   |                   |
| ```                         |                   |                   |
| -   Section 7, *Filing a    |                   |                   |
|     claim for covered       |                   |                   |
|     services*, for          |                   |                   |
|     information about       |                   |                   |
|     submitting              |                   |                   |
|     Non-preferred claims.   |                   |                   |
+-----------------------------+-------------------+-------------------+

+---+---+-----------------------------------------------------------+---+---+
| # |   |                                                           |   |   |
| # |   |                                                           |   |   |
| # |   |                                                           |   |   |
|   |   |                                                           |   |   |
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| c |   |                                                           |   |   |
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| n |   |                                                           |   |   |
|   |   |                                                           |   |   |
| 5 |   |                                                           |   |   |
|   |   |                                                           |   |   |
| ( |   |                                                           |   |   |
| f |   |                                                           |   |   |
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| . |   |                                                           |   |   |
|   |   |                                                           |   |   |
| P |   |                                                           |   |   |
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| c |   |                                                           |   |   |
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| n |   |                                                           |   |   |
|   |   |                                                           |   |   |
| d |   |                                                           |   |   |
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| g |   |                                                           |   |   |
|   |   |                                                           |   |   |
| b |   |                                                           |   |   |
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| f |   |                                                           |   |   |
| i |   |                                                           |   |   |
| t |   |                                                           |   |   |
| s |   |                                                           |   |   |
+---+---+-----------------------------------------------------------+---+---+
|   | * | > **Here are some important things you should keep in     | * |   |
|   | * | > mind about these benefits:**                            | * |   |
|   | I |                                                           | I |   |
|   | * | -   We cover prescription drugs and supplies, as          | * |   |
|   | * |     described in the chart beginning on page 81.          | * |   |
|   |   |                                                           |   |   |
|   | * | ```{=html}                                                | * |   |
|   | * | <!-- -->                                                  | * |   |
|   | M | ```                                                       | M |   |
|   | * | -   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.                              | * |   |
|   | * |                                                           | * |   |
|   | P | ```{=html}                                                | P |   |
|   | * | <!-- -->                                                  | * |   |
|   | * | ```                                                       | * |   |
|   |   | -   **Under Standard Option,** the calendar year          |   |   |
|   | * |     deductible does **not** apply to prescriptions filled | * |   |
|   | * |     through the Retail Pharmacy Program or Mail Service   | * |   |
|   | O |     Prescription Drug Program. We added \"(calendar year  | O |   |
|   | * |     deductible applies)\" when it applies.                | * |   |
|   | * |                                                           | * |   |
|   |   | ```{=html}                                                |   |   |
|   | * | <!-- -->                                                  | * |   |
|   | * | ```                                                       | * |   |
|   | R | -   **Under Basic Option,** there is **no calendar year   | R |   |
|   | * |     deductible.**                                         | * |   |
|   | * |                                                           | * |   |
|   |   | ```{=html}                                                |   |   |
|   | * | <!-- -->                                                  | * |   |
|   | * | ```                                                       | * |   |
|   | T | -   **YOU MUST GET PRIOR APPROVAL FOR CERTAIN DRUGS, and  | T |   |
|   | * |     prior approval must be renewed periodically. Please   | * |   |
|   | * |     refer to the prior approval information shown on page | * |   |
|   |   |     85 of this Section and in Section 3.** Prior approval |   |   |
|   | * |     is part of our Patient Safety and Quality Monitoring  | * |   |
|   | * |     (PSQM) program. See page 85 of this Section for more  | * |   |
|   | A |     information about this important program.             | A |   |
|   | * |                                                           | * |   |
|   | * | ```{=html}                                                | * |   |
|   |   | <!-- -->                                                  |   |   |
|   | * | ```                                                       | * |   |
|   | * | -   Be sure to read Section 4, *Your costs for covered    | * |   |
|   | N |     services*, for valuable information about how cost    | N |   |
|   | * |     sharing works, with special sections for members who  | * |   |
|   | * |     are age 65 or over. Also read Section 9 about         | * |   |
|   |   |     coordinating benefits with other coverage, including  |   |   |
|   | * |     Medicare.                                             | * |   |
|   | * |                                                           | * |   |
|   | T | -   **Under Standard Option,** PPO benefits apply only    | T |   |
|   | * |     when you use a PPO provider. When no PPO provider is  | * |   |
|   | * |     available, non-PPO benefits apply.                    | * |   |
|   |   |                                                           |   |   |
|   |   | ```{=html}                                                |   |   |
|   |   | <!-- -->                                                  |   |   |
|   |   | ```                                                       |   |   |
|   |   | -   **Under Basic Option, you must use Preferred          |   |   |
|   |   |     providers in order to receive benefits. See page 12   |   |   |
|   |   |     for the exceptions to this requirement.**             |   |   |
|   |   |                                                           |   |   |
|   |   | ```{=html}                                                |   |   |
|   |   | <!-- -->                                                  |   |   |
|   |   | ```                                                       |   |   |
|   |   | -   Please note that retail pharmacies and internet       |   |   |
|   |   |     pharmacies that are Preferred under Standard Option   |   |   |
|   |   |     are not necessarily Preferred under Basic Option.     |   |   |
|   |   |     Refer to page 82 for information about locating       |   |   |
|   |   |     Preferred pharmacies.                                 |   |   |
|   |   |                                                           |   |   |
|   |   | ```{=html}                                                |   |   |
|   |   | <!-- -->                                                  |   |   |
|   |   | ```                                                       |   |   |
|   |   | -   **Under Standard Option,** you may use the Mail       |   |   |
|   |   |     Service Prescription Drug Program to fill your        |   |   |
|   |   |     prescriptions.                                        |   |   |
|   |   |                                                           |   |   |
|   |   | ```{=html}                                                |   |   |
|   |   | <!-- -->                                                  |   |   |
|   |   | ```                                                       |   |   |
|   |   | -   The Mail Service Prescription Drug Program **is not** |   |   |
|   |   |     available under **Basic Option.**                     |   |   |
+---+---+-----------------------------------------------------------+---+---+
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|   | f |                                                           |   |   |
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|   | o |                                                           |   |   |
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|   | e |                                                           |   |   |
|   | . |                                                           |   |   |
+---+---+-----------------------------------------------------------+---+---+

+---+--------------------------------------------------------------------+
|   | > **Under Basic Option,** we encourage you to ask your physician   |
|   | > to prescribe a brand-name drug from our formulary list when your |
|   | > physician believes a brand-name drug is necessary or when there  |
|   | > is no generic equivalent available. If you purchase a drug that  |
|   | > is not on our formulary list, your cost will be higher. (We      |
|   | > cover drugs that require a prescription whether or not they are  |
|   | > on our formulary list.)                                          |
|   | >                                                                  |
|   | > ***Note:*** Before filling your prescription, please check the   |
|   | > formulary status of your medication. Other than changes          |
|   | > resulting from new drugs or safety issues, the formulary list is |
|   | > updated twice a year. Prescription drugs are reviewed by the     |
|   | > Plan for safety and clinical efficacy. Drugs determined to be of |
|   | > equal therapeutic value and similar safety and efficacy are then |
|   | > evaluated on the basis of cost. Using lower cost formulary drugs |
|   | > will provide you with a high quality, cost-effective             |
|   | > prescription drug benefit.                                       |
|   | >                                                                  |
|   | > You can view our formulary on our Web site at                    |
|   | > [www.fepblue.org](http://www.fepblue.org/) or request a copy by  |
|   | > mail by calling 1-800-624-5060 (TDD: 1-800-624-5077). Any        |
|   | > savings we receive on the cost of drugs purchased under this     |
|   | > Plan from drug manufacturers are credited to the reserves held   |
|   | > for this Plan.                                                   |
|   |                                                                    |
|   | -   **Generic equivalents.**                                       |
|   |                                                                    |
|   | > **Standard Option:** By submitting your prescription (or those   |
|   | > of family members covered by the Plan) to your retail pharmacy   |
|   | > or the Mail Service Prescription Drug Program, you authorize     |
|   | > them to substitute any available Federally approved generic      |
|   | > equivalent, unless you or your physician specifically request a  |
|   | > brand-name drug.                                                 |
|   | >                                                                  |
|   | > **Basic Option:** By filling your prescriptions (or those of     |
|   | > family members covered by the Plan) at a Preferred retail        |
|   | > pharmacy or through a Preferred internet pharmacy, you authorize |
|   | > the pharmacist to substitute any available Federally approved    |
|   | > generic equivalent, unless you or your physician specifically    |
|   | > request a brand-name drug.                                       |
|   |                                                                    |
|   | -   **Why use generic drugs?** Generic drugs are lower-priced      |
|   |     drugs that are the therapeutic equivalent to more expensive    |
|   |     brand-name drugs. In most cases, they must contain the same    |
|   |     active ingredients and must be equivalent in strength and      |
|   |     dosage to the original brand-name product. Generics cost less  |
|   |     than the equivalent brand-name product. The U.S. Food and Drug |
|   |     Administration (FDA) sets quality standards for generic drugs  |
|   |     to ensure that these drugs meet the same standards of quality  |
|   |     and strength as brand-name drugs.                              |
|   |                                                                    |
|   | > You can save money by using generic drugs. However, you and your |
|   | > doctor have the option to request a brand-name drug even if a    |
|   | > generic option is available. Using the most cost-effective       |
|   | > medication saves money.                                          |
|   |                                                                    |
|   | -   **Disclosure of information.** As part of our administration   |
|   |     of prescription drug benefits, we may disclose information     |
|   |     about your prescription drug utilization, including the names  |
|   |     of your prescribing physicians, to any treating physicians or  |
|   |     dispensing pharmacies.                                         |
|   |                                                                    |
|   | ```{=html}                                                         |
|   | <!-- -->                                                           |
|   | ```                                                                |
|   | -   **These are the dispensing limitations.**                      |
|   |                                                                    |
|   | > **Standard Option:** You may purchase **up to** a 90-day supply  |
|   | > of covered drugs and supplies through the Retail Pharmacy        |
|   | > Program. You may purchase a supply of **more than** 21 days **up |
|   | > to** 90 days through the Mail Service Prescription Drug Program  |
|   | > for a single copayment.                                          |
|   | >                                                                  |
|   | > **Basic Option:** When you fill a prescription for the first     |
|   | > time, you may purchase **up to** a 34-day supply for a single    |
|   | > copayment. For additional copayments, you may purchase **up to** |
|   | > a 90-day supply for continuing prescriptions and for refills.    |
|   |                                                                    |
|   | ***Note:*** Certain drugs such as narcotics may have additional    |
|   | FDA limits on the quantities that a pharmacy may dispense. In      |
|   | addition, pharmacy dispensing practices are regulated by the state |
|   | where they are located and may also be determined by individual    |
|   | pharmacies. In most cases, refills cannot be obtained until 75% of |
|   | the prescription has been used. Call us or visit our Web site if   |
|   | you have any questions about dispensing limits. Please note that   |
|   | in the event of a national or other emergency, or if you are a     |
|   | reservist or National Guard member who is called to active         |
|   | military duty, you should contact us regarding your prescription   |
|   | drug needs. See the contact information below.                     |
|   |                                                                    |
|   | -   **Important contact information.**                             |
|   |                                                                    |
|   | > **Standard Option:** Retail Pharmacy Program: 1-800-624-5060     |
|   | > (TDD: 1-800-624-5077); Mail Service Prescription Drug Program:   |
|   | > 1-800-262-7890 (TDD: 1-800-446-7292); or                         |
|   | > [www.fepblue.org]{.underline}.                                   |
|   | >                                                                  |
|   | > **Basic Option:** Retail Pharmacy Program: 1-800-624-5060 (TDD:  |
|   | > 1-800-624-5077) or [www.fepblue.org]{.underline}.                |
+---+--------------------------------------------------------------------+

+-----------------------------+-------------------+-------------------+
| ### Cover                   | ### You Pay       | ### You P         |
| ed medications and supplies | − Standard Option | ay − Basic Option |
+-----------------------------+-------------------+-------------------+
| -   Drugs, vitamins and     | > See following   | > See following   |
|     minerals, and           | > pages           | > pages           |
|     nutritional supplements |                   |                   |
|     that by Federal law of  |                   |                   |
|     the United States       |                   |                   |
|     require a prescription  |                   |                   |
|     for their purchase      |                   |                   |
|                             |                   |                   |
| > ***Note:*** See Section   |                   |                   |
| > 5(a), page 42, for our    |                   |                   |
| > coverage of medical foods |                   |                   |
| > for children with inborn  |                   |                   |
| > errors of amino acid      |                   |                   |
| > metabolism and for        |                   |                   |
| > medical foods and         |                   |                   |
| > nutritional supplements   |                   |                   |
| > when administrated by     |                   |                   |
| > catheter or nasogastric   |                   |                   |
| > tube.                     |                   |                   |
|                             |                   |                   |
| -   Insulin                 |                   |                   |
|                             |                   |                   |
| -   Needles and disposable  |                   |                   |
|     syringes for the        |                   |                   |
|     administration of       |                   |                   |
|     covered medications     |                   |                   |
|                             |                   |                   |
| -   Drugs to aid smoking    |                   |                   |
|     cessation that require  |                   |                   |
|     a prescription by       |                   |                   |
|     Federal law             |                   |                   |
|                             |                   |                   |
| > ***Note:*** Prior         |                   |                   |
| > approval is required if   |                   |                   |
| > drug treatment extends    |                   |                   |
| > beyond the initial course |                   |                   |
| > of treatment. See Section |                   |                   |
| > 3 for more information.   |                   |                   |
|                             |                   |                   |
| -   Contraceptive drugs and |                   |                   |
|     devices, limited to:    |                   |                   |
|                             |                   |                   |
| ```{=html}                  |                   |                   |
| <!-- -->                    |                   |                   |
| ```                         |                   |                   |
| -   Depo-Provera\*          |                   |                   |
|                             |                   |                   |
| -   Diaphragms and          |                   |                   |
|     contraceptive rings\*   |                   |                   |
|                             |                   |                   |
| -   Intrauterine devices    |                   |                   |
|     (IUDs)                  |                   |                   |
|                             |                   |                   |
| -   Implantable             |                   |                   |
|     contraceptives\*        |                   |                   |
|                             |                   |                   |
| -   Oral and transdermal    |                   |                   |
|     contraceptives          |                   |                   |
|                             |                   |                   |
| > \*available only through  |                   |                   |
| > retail and internet       |                   |                   |
| > pharmacies                |                   |                   |
| >                           |                   |                   |
| > ***Note:*** See Family    |                   |                   |
| > planning in Section 5(a). |                   |                   |
+-----------------------------+-------------------+-------------------+

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

+-----------------------------+-------------------+-------------------+
| #                           | ### You Pay       | ### You P         |
| ####### Covered medications | − Standard Option | ay − Basic Option |
|  and supplies *(continued)* |                   |                   |
+-----------------------------+-------------------+-------------------+
| > Here is how to obtain     | > 25% of the Plan | > **First-time    |
| > your prescription drugs   | > allowance       | > purchase of a   |
| > and supplies:             |                   | > new             |
|                             |                   | > prescription**  |
| #### **Pr                   |                   | > up to a 34-day  |
| eferred Retail Pharmacies** |                   | > supply:         |
|                             |                   | >                 |
| -   Make sure you have your |                   | > Generic drug:   |
|     Plan ID card when       |                   | >                 |
|     you\'re ready to        |                   | > \$10 copayment  |
|     purchase your           |                   | >                 |
|     prescription            |                   | > Formulary       |
|                             |                   | > brand-name      |
| -   Go to any Preferred     |                   | >                 |
|     retail pharmacy,        |                   | > drug: \$25      |
|                             |                   | > copayment       |
| or                          |                   | >                 |
|                             |                   | > Non-formulary   |
| -   Visit our special Web   |                   | >                 |
|     site,                   |                   | > brand-name      |
|     [www.fepblue.org        |                   | > drug:           |
| ](http://www.fepblue.org/), |                   | >                 |
|     click on \"Pharmacy     |                   | > 50% of Plan     |
|     Programs,\" and follow  |                   | > allowance (\$35 |
|     the FEP Retail Pharmacy |                   | > minimum)        |
|     Providers link to fill  |                   | >                 |
|     your prescription and   |                   | > **Refills or    |
|     receive home delivery   |                   | > continuing      |
|                             |                   | > prescriptions** |
| -   For a listing of        |                   | > up to a 90-day  |
|     Preferred retail        |                   | > supply:         |
|     pharmacies, call the    |                   | >                 |
|     Retail Pharmacy Program |                   | > Generic drug:   |
|     at                      |                   | >                 |
|                             |                   | > \$10 copayment  |
| > 1-800-624-5060 (TDD:      |                   | > for each        |
| > 1-800-624-5077) or visit  |                   | > purchase of up  |
| > our Web site,             |                   | > to a 34-day     |
| > [www.fepblue.or           |                   | > supply (\$30    |
| g](http://www.fepblue.org/) |                   | > copayment for   |
| >                           |                   | > 90-day supply)  |
| > ***Note:*** Please be     |                   | >                 |
| > sure to request the       |                   | > Formulary       |
| > Preferred retail or       |                   | > brand-name      |
| > internet pharmacy listing |                   | >                 |
| > for your specific option. |                   | > drug: \$25      |
| > Retail and internet       |                   | > copayment for   |
| > pharmacies that are       |                   | > each purchase   |
| > Preferred under Standard  |                   | > of up to a      |
| > Option are not            |                   | > 34-day supply   |
| > necessarily Preferred     |                   | > (\$75 copayment |
| > under Basic Option.       |                   | > for 90-day      |
| >                           |                   | > supply)         |
| > ***Note:*** Retail and    |                   | >                 |
| > internet pharmacies that  |                   | > Non-formulary   |
| > are Preferred for         |                   | >                 |
| > prescription drugs are    |                   | > brand-name      |
| > not necessarily Preferred |                   | > drug:           |
| > for durable medical       |                   | >                 |
| > equipment (DME) and       |                   | > 50% of Plan     |
| > medical supplies. To      |                   | > allowance (\$35 |
| > receive Preferred         |                   | > minimum for     |
| > benefits for DME and      |                   | > each purchase   |
| > covered medical supplies, |                   | > of up to a      |
| > you must use a Preferred  |                   | > 34-day supply,  |
| > DME or medical supply     |                   | > or \$105        |
| > provider. See Section     |                   | > minimum for     |
| > 5(a) for the benefit      |                   | > 90-day supply)  |
| > levels that apply to DME  |                   | >                 |
| > and medical supplies.     |                   | > ***Note:*** If  |
| >                           |                   | > there is no     |
| > ***Note:*** For           |                   | > generic         |
| > prescription drugs billed |                   | > equivalent      |
| > for by a skilled nursing  |                   | > available, you  |
| > facility, nursing home,   |                   | > must still pay  |
| > or extended care          |                   | > the brand-name  |
| > facility, we provide      |                   | > copayment when  |
| > benefits as shown on this |                   | > you receive a   |
| > page for retail           |                   | > brand-name      |
| > pharmacy-obtained drugs,  |                   | > drug.           |
| > as long as the pharmacy   |                   | >                 |
| > supplying the drugs to    |                   | > ***Note:*** For |
| > the facility is a         |                   | > generic and     |
| > Preferred pharmacy. For a |                   | > brand-name drug |
| > list of the Preferred     |                   | > purchases, if   |
| > Network Long Term Care    |                   | > the cost of     |
| > pharmacies, call          |                   | > your            |
| >                           |                   | > prescription is |
| > 1-800-624-5060 (TDD:      |                   | > less than your  |
| > 1-800-624-5077) or visit  |                   | > cost-sharing    |
| > our Web site at           |                   | > amount noted    |
| > [www.fepblue.org          |                   | > above, you pay  |
| ](http://www.fepblue.org/). |                   | > only the cost   |
| > **For benefit information |                   | > of your         |
| > about drugs supplied by   |                   | > prescription.   |
| > Non-preferred pharmacies, |                   |                   |
| > please refer to the next  |                   |                   |
| > page.**                   |                   |                   |
| >                           |                   |                   |
| > ***Note:*** For           |                   |                   |
| > coordination of benefits  |                   |                   |
| > purposes, if you need a   |                   |                   |
| > statement of Preferred    |                   |                   |
| > retail pharmacy benefits  |                   |                   |
| > in order to file claims   |                   |                   |
| > with your other coverage  |                   |                   |
| > when this Plan is the     |                   |                   |
| > primary payer, call the   |                   |                   |
| > Retail Pharmacy Program   |                   |                   |
| > at 1-800-624-5060 (TDD:   |                   |                   |
| > 1-800-624-5077) or visit  |                   |                   |
| > our Web site at           |                   |                   |
| > [www.fepblue.org          |                   |                   |
| ](http://www.fepblue.org/). |                   |                   |
+-----------------------------+-------------------+-------------------+

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

+-----------------------------+-------------------+-------------------+
| **Covered medications and   | ### You Pay       | ### You P         |
| supplies** *(continued)*    | − Standard Option | ay − Basic Option |
+-----------------------------+-------------------+-------------------+
| > **Non-preferred Retail    | > 45% of the Plan | > *All charges*   |
| > Pharmacies**              | > allowance       |                   |
|                             | > (Average        |                   |
|                             | > wholesale price |                   |
|                             | > -- AWP), plus   |                   |
|                             | > any difference  |                   |
|                             | > between our     |                   |
|                             | > allowance and   |                   |
|                             | > the billed      |                   |
|                             | > amount          |                   |
|                             | >                 |                   |
|                             | > ***Note:*** If  |                   |
|                             | > you use a       |                   |
|                             | > Non-preferred   |                   |
|                             | > retail          |                   |
|                             | > pharmacy, you   |                   |
|                             | > must pay the    |                   |
|                             | > full cost of    |                   |
|                             | > the drug or     |                   |
|                             | > supply at the   |                   |
|                             | > time of         |                   |
|                             | > purchase and    |                   |
|                             | > file a claim    |                   |
|                             | > with the Retail |                   |
|                             | > Pharmacy        |                   |
|                             | > Program to be   |                   |
|                             | > reimbursed.     |                   |
|                             | > Please refer to |                   |
|                             | > Section 7 for   |                   |
|                             | > instructions on |                   |
|                             | > how to file     |                   |
|                             | > prescription    |                   |
|                             | > drug claims.    |                   |
+-----------------------------+-------------------+-------------------+
| > **Mail Service            | > Mail Service    | > No benefit      |
| > Prescription Drug         | > Program:        | >                 |
| > Program**                 | >                 | > ***Note:*** You |
| >                           | > \$10 generic    | > may request     |
| > Under Standard Option, if | >                 | > home delivery   |
| > your doctor orders more   | > \$35 brand-name | > of your         |
| > than a 21-day supply of   | >                 | > internet        |
| > covered drugs or          | > ***Note:*** If  | > prescription    |
| > supplies, up to a 90-day  | > there is no     | > drug purchases. |
| > supply, you can use this  | > generic         | > See page 82 of  |
| > service for your          | > equivalent      | > this Section    |
| > prescriptions and         | > available, you  | > for our payment |
| > refills.                  | > must still pay  | > levels for      |
| >                           | > the brand-name  | > drugs obtained  |
| > Please refer to Section 7 | > copayment when  | > through         |
| > for instructions on how   | > you receive a   | > Preferred       |
| > to use the Mail Service   | > brand-name      | > retail and      |
| > Prescription Drug         | > drug.           | > internet        |
| > Program.                  | >                 | > pharmacies.     |
| >                           | > ***Note:*** If  |                   |
| > ***Note:*** Not all drugs | > the cost of     |                   |
| > are available through the | > your            |                   |
| > Mail Service Prescription | > prescription is |                   |
| > Drug Program.             | > less than your  |                   |
|                             | > copayment, you  |                   |
|                             | > pay only the    |                   |
|                             | > cost of your    |                   |
|                             | > prescription.   |                   |
|                             | > The Mail        |                   |
|                             | > Service         |                   |
|                             | > Prescription    |                   |
|                             | > Drug Program    |                   |
|                             | > will charge you |                   |
|                             | > the lesser of   |                   |
|                             | > the             |                   |
|                             | > prescription    |                   |
|                             | > cost or the     |                   |
|                             | > copayment when  |                   |
|                             | > you place your  |                   |
|                             | > order. If you   |                   |
|                             | > have already    |                   |
|                             | > sent in your    |                   |
|                             | > copayment, they |                   |
|                             | > will credit     |                   |
|                             | > your account    |                   |
|                             | > with any        |                   |
|                             | > difference.     |                   |
+-----------------------------+-------------------+-------------------+

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

+-----------------------------+-------------------+-------------------+
| **Covered medications and   | ### You Pay       | ### You P         |
| supplies** *(continued)*    | − Standard Option | ay − Basic Option |
+-----------------------------+-------------------+-------------------+
| > **Drugs from other        | > Preferred: 10%  | > Preferred: 30%  |
| > sources**                 | > of the Plan     | > of the Plan     |
|                             | > allowance       | > allowance       |
| -   Covered prescription    | > (calendar year  | >                 |
|     drugs and supplies not  | > deductible      | > Par             |
|     obtained at a retail    | > applies)        | ticipating/Member |
|     pharmacy, through an    | >                 | > or              |
|     internet pharmacy, or,  | > Part            | > Non-particip    |
|     for Standard Option     | icipating/Member: | ating/Non-member: |
|     only, through the Mail  | > 25% of the Plan | > You pay all     |
|     Service Prescription    | > allowance       | > charges         |
|     Drug Program            | > (calendar year  |                   |
|                             | > deductible      |                   |
|     ***Note:*** Drugs       | > applies)        |                   |
|     purchased overseas must | >                 |                   |
|     be the equivalent to    | > Non-particip    |                   |
|     drugs that by Federal   | ating/Non-member: |                   |
|     law of the United       | > 25% of the Plan |                   |
|     States require a        | > allowance       |                   |
|     prescription.           | > (calendar year  |                   |
|                             | > deductible      |                   |
|     ***Note:*** For covered | > applies); plus  |                   |
|     prescription drugs and  | > any difference  |                   |
|     supplies purchased      | > between our     |                   |
|     outside of the United   | > allowance and   |                   |
|     States and Puerto Rico, | > the billed      |                   |
|     please submit claims on | > amount          |                   |
|     an Overseas Claim Form. |                   |                   |
|     See Section 5(i) for    |                   |                   |
|     information on how to   |                   |                   |
|     file claims for         |                   |                   |
|     overseas services.      |                   |                   |
|                             |                   |                   |
| -   Please refer to the     |                   |                   |
|     Sections indicated for  |                   |                   |
|     additional benefit      |                   |                   |
|     information when you    |                   |                   |
|     purchase drugs from a:  |                   |                   |
|                             |                   |                   |
| ```{=html}                  |                   |                   |
| <!-- -->                    |                   |                   |
| ```                         |                   |                   |
| -   Physician\'s office --  |                   |                   |
|     Section 5(a)            |                   |                   |
|                             |                   |                   |
| -   Home health care agency |                   |                   |
|     -- Section 5(a)         |                   |                   |
|                             |                   |                   |
| -   Hospital (inpatient or  |                   |                   |
|     outpatient) -- Section  |                   |                   |
|     5(c)                    |                   |                   |
|                             |                   |                   |
| -   Hospice agency --       |                   |                   |
|     Section 5(c)            |                   |                   |
+-----------------------------+-------------------+-------------------+

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

+-----------------------------+-------------------+-------------------+
| #                           | ### You Pay       | ### You P         |
| ####### Covered medications | − Standard Option | ay − Basic Option |
|  and supplies *(continued)* |                   |                   |
+-----------------------------+-------------------+-------------------+
| > **Patient Safety and      |                   |                   |
| > Quality Monitoring        |                   |                   |
| > (PSQM)**                  |                   |                   |
| >                           |                   |                   |
| > We have a special program |                   |                   |
| > to promote patient safety |                   |                   |
| > and monitor health care   |                   |                   |
| > quality. Our Patient      |                   |                   |
| > Safety and Quality        |                   |                   |
| > Monitoring (PSQM) program |                   |                   |
| > features a set of closely |                   |                   |
| > aligned programs that are |                   |                   |
| > designed to promote the   |                   |                   |
| > safe and appropriate use  |                   |                   |
| > of medications. Examples  |                   |                   |
| > of these programs         |                   |                   |
| > include:                  |                   |                   |
|                             |                   |                   |
| -   Prior approval -- As    |                   |                   |
|     described below, this   |                   |                   |
|     program requires that   |                   |                   |
|     approval be obtained    |                   |                   |
|     for certain             |                   |                   |
|     prescription drugs and  |                   |                   |
|     supplies before we      |                   |                   |
|     provide benefits for    |                   |                   |
|     them.                   |                   |                   |
|                             |                   |                   |
| ```{=html}                  |                   |                   |
| <!-- -->                    |                   |                   |
| ```                         |                   |                   |
| -   Safety checks -- Before |                   |                   |
|     your prescription is    |                   |                   |
|     filled, we perform      |                   |                   |
|     quality and safety      |                   |                   |
|     checks for usage        |                   |                   |
|     precautions, drug       |                   |                   |
|     interactions, drug      |                   |                   |
|     duplication, excessive  |                   |                   |
|     use, and frequency of   |                   |                   |
|     refills.                |                   |                   |
|                             |                   |                   |
| ```{=html}                  |                   |                   |
| <!-- -->                    |                   |                   |
| ```                         |                   |                   |
| -   Quantity allowances --  |                   |                   |
|     Specific allowances for |                   |                   |
|     several medications are |                   |                   |
|     based on FDA-approved   |                   |                   |
|     recommendations,        |                   |                   |
|     clinical studies, and   |                   |                   |
|     manufacturer            |                   |                   |
|     guidelines.             |                   |                   |
|                             |                   |                   |
| > For more information      |                   |                   |
| > about our PSQM program,   |                   |                   |
| > including listings of     |                   |                   |
| > drugs subject to prior    |                   |                   |
| > approval or quantity      |                   |                   |
| > allowances, visit our Web |                   |                   |
| > site at                   |                   |                   |
| > [www.fepblue.or           |                   |                   |
| g](http://www.fepblue.org/) |                   |                   |
| > or call the Retail        |                   |                   |
| > Pharmacy Program at       |                   |                   |
| > 1-800-624-5060            |                   |                   |
| >                           |                   |                   |
| > (TDD: 1-800-624-5077).    |                   |                   |
| >                           |                   |                   |
| > **Prior Approval**        |                   |                   |
| >                           |                   |                   |
| > As part of our Patient    |                   |                   |
| > Safety and Quality        |                   |                   |
| > Monitoring (PSQM) program |                   |                   |
| > (see above), **you must   |                   |                   |
| > make sure that your       |                   |                   |
| > physician obtains**       |                   |                   |
| > **prior approval for      |                   |                   |
| > certain prescription      |                   |                   |
| > drugs and supplies in     |                   |                   |
| > order to use your         |                   |                   |
| > prescription drug         |                   |                   |
| > coverage**. Prior         |                   |                   |
| > approval must be renewed  |                   |                   |
| > periodically. To obtain a |                   |                   |
| > list of these drugs and   |                   |                   |
| > supplies and to obtain    |                   |                   |
| > prior approval request    |                   |                   |
| > forms, call the Retail    |                   |                   |
| > Pharmacy Program at       |                   |                   |
| >                           |                   |                   |
| > 1-800-624-5060 (TDD:      |                   |                   |
| > 1-800-624-5077). You can  |                   |                   |
| > also obtain the list      |                   |                   |
| > through our Web site at   |                   |                   |
| > [www.fepblue.org          |                   |                   |
| ](http://www.fepblue.org/). |                   |                   |
| > Please read Section 3 for |                   |                   |
| > more information about    |                   |                   |
| > prior approval.           |                   |                   |
| >                           |                   |                   |
| > ***Note:*** If your       |                   |                   |
| > prescription requires     |                   |                   |
| > prior approval and you    |                   |                   |
| > have not yet obtained     |                   |                   |
| > prior approval, you must  |                   |                   |
| > pay the full cost of the  |                   |                   |
| > drug or supply at the     |                   |                   |
| > time of purchase and file |                   |                   |
| > a claim with the Retail   |                   |                   |
| > Pharmacy Program to be    |                   |                   |
| > reimbursed. Please refer  |                   |                   |
| > to Section 7 for          |                   |                   |
| > instructions on how to    |                   |                   |
| > file prescription drug    |                   |                   |
| > claims.                   |                   |                   |
+-----------------------------+-------------------+-------------------+

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

+-----------------------------+-------------------+-------------------+
| #                           | ### You Pay       | ### You P         |
| ####### Covered medications | − Standard Option | ay − Basic Option |
|  and supplies *(continued)* |                   |                   |
+-----------------------------+-------------------+-------------------+
| > *Not covered:*            | > *All charges*   | > *All charges*   |
|                             |                   |                   |
| -   *Medical supplies such  |                   |                   |
|     as dressings and        |                   |                   |
|     antiseptics*            |                   |                   |
|                             |                   |                   |
| -   *Drugs and supplies for |                   |                   |
|     cosmetic purposes*      |                   |                   |
|                             |                   |                   |
| -   *Drugs and supplies for |                   |                   |
|     weight loss*            |                   |                   |
|                             |                   |                   |
| -   *Drugs for orthodontic  |                   |                   |
|     care, dental implants,  |                   |                   |
|     and periodontal         |                   |                   |
|     disease*                |                   |                   |
|                             |                   |                   |
| -   *Medications and orally |                   |                   |
|     taken nutritional       |                   |                   |
|     supplements that do not |                   |                   |
|     require a prescription  |                   |                   |
|     under Federal law even  |                   |                   |
|     if your doctor          |                   |                   |
|     prescribes them or if a |                   |                   |
|     prescription is         |                   |                   |
|     required under your     |                   |                   |
|     State law*              |                   |                   |
|                             |                   |                   |
| > ***Note:*** See Section   |                   |                   |
| > 5(a), page 42, for our    |                   |                   |
| > coverage of medical foods |                   |                   |
| > for children with inborn  |                   |                   |
| > errors of amino acid      |                   |                   |
| > metabolism and for        |                   |                   |
| > medical foods and         |                   |                   |
| > nutritional supplements   |                   |                   |
| > when administrated by     |                   |                   |
| > catheter or nasogastric   |                   |                   |
| > tube.                     |                   |                   |
|                             |                   |                   |
| -   *Drugs for which prior  |                   |                   |
|     approval has been       |                   |                   |
|     denied or not obtained* |                   |                   |
|                             |                   |                   |
| -   *Infant formula other   |                   |                   |
|     than described on page  |                   |                   |
|     42*                     |                   |                   |
|                             |                   |                   |
| -   *Drugs and supplies     |                   |                   |
|     related to sex          |                   |                   |
|     transformations, sexual |                   |                   |
|     dysfunction, or sexual  |                   |                   |
|     inadequacy*             |                   |                   |
+-----------------------------+-------------------+-------------------+

+----------------------+-----------------------------------------------+
| ## Section 5 (       |                                               |
| g). Special features |                                               |
+----------------------+-----------------------------------------------+
| ######               | ###### **Description**                        |
|  **Special feature** |                                               |
+----------------------+-----------------------------------------------+
| > **Flexible         | Under the flexible benefits option, we        |
| > benefits option**  | determine the most effective way to provide   |
|                      | services.                                     |
|                      |                                               |
|                      | -   We may identify medically appropriate     |
|                      |     alternatives to traditional care and/or   |
|                      |     direct the provision of Plan benefits to  |
|                      |     a less costly alternative benefit.        |
|                      |                                               |
|                      | -   Alternative benefits are subject to our   |
|                      |     ongoing review.                           |
|                      |                                               |
|                      | -   By approving an alternative benefit, we   |
|                      |     cannot guarantee you will receive 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.                |
|                      |                                               |
|                      | ```{=html}                                    |
|                      | <!-- -->                                      |
|                      | ```                                           |
|                      | -   Our decision to offer or withdraw         |
|                      |     alternative benefits is not subject to    |
|                      |     OPM review under the disputed claims      |
|                      |     process.                                  |
|                      |                                               |
|                      | > ***Note:*** Under the Blue Cross and Blue   |
|                      | > Shield Service Benefit Plan, the flexible   |
|                      | > benefits option is also referred to as      |
|                      | > \"case management.\"                        |
+----------------------+-----------------------------------------------+
| > **Online customer  | By visiting our Web site,                     |
| > and claims         | [www.fepblue.org](http://www.fepblue.org/),   |
| > service**          | you may check the status of your claims,      |
|                      | change your address of record, request claim  |
|                      | forms, request a duplicate or replacement     |
|                      | Service Benefit Plan ID card, and access a    |
|                      | range of other service and information        |
|                      | options. It\'s easy! Give it a try and share  |
|                      | any suggestions you may have for improved     |
|                      | service by using the site\'s \"Contact Us\"   |
|                      | feature.                                      |
+----------------------+-----------------------------------------------+
| > **24-hour nurse    | Help with health concerns is available 24     |
| > line**             | hours a day, 365 days a year, by calling a    |
|                      | toll-free telephone number, 1-888-258-3432,   |
|                      | or by accessing our Web site,                 |
|                      | [                                             |
|                      | www.fepblue.org](http://www.Bluehealth.org/). |
|                      | The service, called Blue Health Connection,   |
|                      | offers health advice or health information    |
|                      | and counseling by registered nurses. Also     |
|                      | available is the AudioHealth Library with     |
|                      | hundreds of tapes, ranging from first aid to  |
|                      | infectious diseases to general health issues. |
|                      |                                               |
|                      | > You can get information about health care   |
|                      | > resources to help you find local doctors,   |
|                      | > hospitals, or other health care services    |
|                      | > affiliated with the Blue Cross and Blue     |
|                      | > Shield Service Benefit Plan. Contact us at  |
|                      | > the number above or visit our Web site for  |
|                      | > more information. Please keep in mind that  |
|                      | > benefits for any health care services you   |
|                      | > may seek after using Blue Health Connection |
|                      | > are subject to the terms of your coverage   |
|                      | > under this Plan.                            |
+----------------------+-----------------------------------------------+
| > **Services for the | > All Blue Cross and Blue Shield Plans        |
| > deaf and hearing   | > provide TDD access for the hearing impaired |
| > impaired**         | > to access information and receive answers   |
|                      | > to their questions.                         |
+----------------------+-----------------------------------------------+
| > **Travel           | > Please refer to Section 5(i) for benefit    |
| > benefit/services   | > and claims information for care you receive |
| > overseas**         | > outside the United States and Puerto Rico.  |
+----------------------+-----------------------------------------------+
| > Health support     | > The Service Benefit Plan is developing and  |
| > programs           | > may offer patient education and support     |
|                      | > programs for certain diagnoses in select    |
|                      | > locations on a pilot basis. One program we  |
|                      | > have developed is the Patient Safety Risk   |
|                      | > Reduction Pilot Program. We will notify you |
|                      | > if this pilot or other programs are         |
|                      | > available in your area.                     |
+----------------------+-----------------------------------------------+
| > Healthy Families   | > Healthy Families is a national health       |
| > Program            | > education prevention program that provides  |
|                      | > information to members and their families.  |
|                      | > The educational mailings assist members to  |
|                      | > understand and adopt healthy behaviors,     |
|                      | > reduce risk of injury and disease, and      |
|                      | > improve existing chronic conditions.        |
+----------------------+-----------------------------------------------+

+---+---+-----------------------+-------------------+-------------+---+---+
| # |   |                       |                   |             |   |   |
| # |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| S |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| c |   |                       |                   |             |   |   |
| t |   |                       |                   |             |   |   |
| i |   |                       |                   |             |   |   |
| o |   |                       |                   |             |   |   |
| n |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| 5 |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| ( |   |                       |                   |             |   |   |
| h |   |                       |                   |             |   |   |
| ) |   |                       |                   |             |   |   |
| . |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| D |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| n |   |                       |                   |             |   |   |
| t |   |                       |                   |             |   |   |
| a |   |                       |                   |             |   |   |
| l |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| b |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| n |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| f |   |                       |                   |             |   |   |
| i |   |                       |                   |             |   |   |
| t |   |                       |                   |             |   |   |
| s |   |                       |                   |             |   |   |
+---+---+-----------------------+-------------------+-------------+---+---+
|   | * | > **Here are some     |                   |             | * |   |
|   | * | > important things    |                   |             | * |   |
|   | I | > you should keep in  |                   |             | I |   |
|   | * | > mind about these    |                   |             | * |   |
|   | * | > benefits:**         |                   |             | * |   |
|   |   |                       |                   |             |   |   |
|   | * | -   Please remember   |                   |             | * |   |
|   | * |     that all benefits |                   |             | * |   |
|   | M |     are subject to    |                   |             | M |   |
|   | * |     the definitions,  |                   |             | * |   |
|   | * |     limitations, and  |                   |             | * |   |
|   |   |     exclusions in     |                   |             |   |   |
|   | * |     this brochure and |                   |             | * |   |
|   | * |     are payable only  |                   |             | * |   |
|   | P |     when we determine |                   |             | P |   |
|   | * |     they are          |                   |             | * |   |
|   | * |     medically         |                   |             | * |   |
|   |   |     necessary.        |                   |             |   |   |
|   | * |                       |                   |             | * |   |
|   | * | -   **Under Standard  |                   |             | * |   |
|   | O |     Option,** the     |                   |             | O |   |
|   | * |     calendar year     |                   |             | * |   |
|   | * |     deductible        |                   |             | * |   |
|   |   |     applies only to   |                   |             |   |   |
|   | * |     the accidental    |                   |             | * |   |
|   | * |     injury benefit    |                   |             | * |   |
|   | R |     below. We added   |                   |             | R |   |
|   | * |     \"(calendar year  |                   |             | * |   |
|   | * |     deductible        |                   |             | * |   |
|   |   |     applies)\" when   |                   |             |   |   |
|   | * |     it applies.       |                   |             | * |   |
|   | * |                       |                   |             | * |   |
|   | T | -   **Under Basic     |                   |             | T |   |
|   | * |     Option,** there   |                   |             | * |   |
|   | * |     is **no calendar  |                   |             | * |   |
|   |   |     year              |                   |             |   |   |
|   | * |     deductible**.     |                   |             | * |   |
|   | * |                       |                   |             | * |   |
|   | A | -   **Under Basic     |                   |             | A |   |
|   | * |     Option,** **you   |                   |             | * |   |
|   | * |     must use          |                   |             | * |   |
|   |   |     Preferred         |                   |             |   |   |
|   | * |     providers in      |                   |             | * |   |
|   | * |     order to receive  |                   |             | * |   |
|   | N |     benefits, except  |                   |             | N |   |
|   | * |     in cases of       |                   |             | * |   |
|   | * |     dental care       |                   |             | * |   |
|   |   |     resulting from an |                   |             |   |   |
|   | * |     accidental injury |                   |             | * |   |
|   | * |     as described      |                   |             | * |   |
|   | T |     below.**          |                   |             | T |   |
|   | * |                       |                   |             | * |   |
|   | * | ```{=html}            |                   |             | * |   |
|   |   | <!-- -->              |                   |             |   |   |
|   |   | ```                   |                   |             |   |   |
|   |   | -   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         |                   |             |   |   |
|   |   |     Medicare.         |                   |             |   |   |
|   |   |                       |                   |             |   |   |
|   |   | ```{=html}            |                   |             |   |   |
|   |   | <!-- -->              |                   |             |   |   |
|   |   | ```                   |                   |             |   |   |
|   |   | -   ***Note:*** We    |                   |             |   |   |
|   |   |     cover             |                   |             |   |   |
|   |   |     hospitalization   |                   |             |   |   |
|   |   |     for dental        |                   |             |   |   |
|   |   |     procedures only   |                   |             |   |   |
|   |   |     when a non-dental |                   |             |   |   |
|   |   |     physical          |                   |             |   |   |
|   |   |     impairment exists |                   |             |   |   |
|   |   |     that makes        |                   |             |   |   |
|   |   |     hospitalization   |                   |             |   |   |
|   |   |     necessary to      |                   |             |   |   |
|   |   |     safeguard the     |                   |             |   |   |
|   |   |     health of the     |                   |             |   |   |
|   |   |     patient (even if  |                   |             |   |   |
|   |   |     the dental        |                   |             |   |   |
|   |   |     procedure itself  |                   |             |   |   |
|   |   |     is not covered).  |                   |             |   |   |
|   |   |     See Section 5(c)  |                   |             |   |   |
|   |   |     for inpatient     |                   |             |   |   |
|   |   |     hospital          |                   |             |   |   |
|   |   |     benefits.         |                   |             |   |   |
+---+---+-----------------------+-------------------+-------------+---+---+
| * |   |                       | ### You Pay       | **You Pay − |   |   |
| * |   |                       | − Standard Option | Basic       |   |   |
| A |   |                       |                   | Option**    |   |   |
| c |   |                       |                   |             |   |   |
| c |   |                       |                   |             |   |   |
| i |   |                       |                   |             |   |   |
| d |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| n |   |                       |                   |             |   |   |
| t |   |                       |                   |             |   |   |
| a |   |                       |                   |             |   |   |
| l |   |                       |                   |             |   |   |
| i |   |                       |                   |             |   |   |
| n |   |                       |                   |             |   |   |
| j |   |                       |                   |             |   |   |
| u |   |                       |                   |             |   |   |
| r |   |                       |                   |             |   |   |
| y |   |                       |                   |             |   |   |
| b |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| n |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| f |   |                       |                   |             |   |   |
| i |   |                       |                   |             |   |   |
| t |   |                       |                   |             |   |   |
| * |   |                       |                   |             |   |   |
| * |   |                       |                   |             |   |   |
+---+---+-----------------------+-------------------+-------------+---+---+
| > |   |                       | > Preferred: 10%  | > \$20      |   |   |
|   |   |                       | > of the Plan     | > copayment |   |   |
| W |   |                       | > allowance       | >           |   |   |
| e |   |                       | > (calendar year  | > ***Note:* |   |   |
| > |   |                       | > deductible      | > We        |   |   |
|   |   |                       | > applies)        | > provide   |   |   |
| p |   |                       | >                 | > benefits  |   |   |
| r |   |                       | > Participating:  | > for       |   |   |
| o |   |                       | > 25% of the Plan | >           |   |   |
| v |   |                       | > allowance       |  accidental |   |   |
| i |   |                       | > (calendar year  | > dental    |   |   |
| d |   |                       | > deductible      | > injury    |   |   |
| e |   |                       | > applies)        | > care in   |   |   |
| > |   |                       | >                 | > cases of  |   |   |
|   |   |                       | > N               | > medical   |   |   |
| b |   |                       | on-participating: | > emergency |   |   |
| e |   |                       | > 25% of the Plan | > when      |   |   |
| n |   |                       | > allowance       | > performed |   |   |
| e |   |                       | > (calendar year  | > by        |   |   |
| f |   |                       | > deductible      | > Preferred |   |   |
| i |   |                       | > applies), plus  | > or        |   |   |
| t |   |                       | > any difference  | > No        |   |   |
| s |   |                       | > between our     | n-preferred |   |   |
| > |   |                       | > allowance and   | > p         |   |   |
|   |   |                       | > the billed      | roviders.** |   |   |
| f |   |                       | > amount          | > See       |   |   |
| o |   |                       | >                 | > Section   |   |   |
| r |   |                       | > ***Note:***     | > 5(d) for  |   |   |
| > |   |                       | > Under Standard  | > the       |   |   |
|   |   |                       | > Option, we      | > criteria  |   |   |
| s |   |                       | > first provide   | > we use to |   |   |
| e |   |                       | > benefits as     | > determine |   |   |
| r |   |                       | > shown in the    | > if        |   |   |
| v |   |                       | > Schedule of     | > emergency |   |   |
| i |   |                       | > Dental          | > care is   |   |   |
| c |   |                       | > Allowances on   | > required. |   |   |
| e |   |                       | > the following   | > You are   |   |   |
| s |   |                       | > pages. We then  | >           |   |   |
| , |   |                       | > pay benefits as | responsible |   |   |
| > |   |                       | > shown here for  | > for the   |   |   |
|   |   |                       | > any balances.   | >           |   |   |
| s |   |                       |                   |  applicable |   |   |
| u |   |                       |                   | > copayment |   |   |
| p |   |                       |                   | > as shown  |   |   |
| p |   |                       |                   | > above. If |   |   |
| l |   |                       |                   | > you use a |   |   |
| i |   |                       |                   | > No        |   |   |
| e |   |                       |                   | n-preferred |   |   |
| s |   |                       |                   | > provider, |   |   |
| , |   |                       |                   | > you may   |   |   |
| > |   |                       |                   | > also be   |   |   |
|   |   |                       |                   | >           |   |   |
| o |   |                       |                   | responsible |   |   |
| r |   |                       |                   | > for any   |   |   |
| > |   |                       |                   | >           |   |   |
|   |   |                       |                   |  difference |   |   |
| a |   |                       |                   | > between   |   |   |
| p |   |                       |                   | > our       |   |   |
| p |   |                       |                   | > allowance |   |   |
| l |   |                       |                   | > and the   |   |   |
| i |   |                       |                   | > billed    |   |   |
| a |   |                       |                   | > amount.   |   |   |
| n |   |                       |                   | >           |   |   |
| c |   |                       |                   | >           |   |   |
| e |   |                       |                   | ***Note:*** |   |   |
| s |   |                       |                   | > All       |   |   |
| > |   |                       |                   | > follow-up |   |   |
|   |   |                       |                   | > care must |   |   |
| f |   |                       |                   | > be        |   |   |
| o |   |                       |                   | > performed |   |   |
| r |   |                       |                   | > and       |   |   |
| > |   |                       |                   | > billed    |   |   |
|   |   |                       |                   | > for by    |   |   |
| d |   |                       |                   | > Preferred |   |   |
| e |   |                       |                   | > providers |   |   |
| n |   |                       |                   | > to be     |   |   |
| t |   |                       |                   | > eligible  |   |   |
| a |   |                       |                   | > for       |   |   |
| l |   |                       |                   | > benefits. |   |   |
| > |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| c |   |                       |                   |             |   |   |
| a |   |                       |                   |             |   |   |
| r |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| > |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| n |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| c |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| s |   |                       |                   |             |   |   |
| s |   |                       |                   |             |   |   |
| a |   |                       |                   |             |   |   |
| r |   |                       |                   |             |   |   |
| y |   |                       |                   |             |   |   |
| > |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| t |   |                       |                   |             |   |   |
| o |   |                       |                   |             |   |   |
| > |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| p |   |                       |                   |             |   |   |
| r |   |                       |                   |             |   |   |
| o |   |                       |                   |             |   |   |
| m |   |                       |                   |             |   |   |
| p |   |                       |                   |             |   |   |
| t |   |                       |                   |             |   |   |
| l |   |                       |                   |             |   |   |
| y |   |                       |                   |             |   |   |
| > |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| r |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| p |   |                       |                   |             |   |   |
| a |   |                       |                   |             |   |   |
| i |   |                       |                   |             |   |   |
| r |   |                       |                   |             |   |   |
| > |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| i |   |                       |                   |             |   |   |
| n |   |                       |                   |             |   |   |
| j |   |                       |                   |             |   |   |
| u |   |                       |                   |             |   |   |
| r |   |                       |                   |             |   |   |
| y |   |                       |                   |             |   |   |
| > |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| t |   |                       |                   |             |   |   |
| o |   |                       |                   |             |   |   |
| > |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| s |   |                       |                   |             |   |   |
| o |   |                       |                   |             |   |   |
| u |   |                       |                   |             |   |   |
| n |   |                       |                   |             |   |   |
| d |   |                       |                   |             |   |   |
| > |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| n |   |                       |                   |             |   |   |
| a |   |                       |                   |             |   |   |
| t |   |                       |                   |             |   |   |
| u |   |                       |                   |             |   |   |
| r |   |                       |                   |             |   |   |
| a |   |                       |                   |             |   |   |
| l |   |                       |                   |             |   |   |
| > |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| t |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| t |   |                       |                   |             |   |   |
| h |   |                       |                   |             |   |   |
| > |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| r |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| q |   |                       |                   |             |   |   |
| u |   |                       |                   |             |   |   |
| i |   |                       |                   |             |   |   |
| r |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| d |   |                       |                   |             |   |   |
| > |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| a |   |                       |                   |             |   |   |
| s |   |                       |                   |             |   |   |
| > |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| a |   |                       |                   |             |   |   |
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|   |   |                       |                   |             |   |   |
| r |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| s |   |                       |                   |             |   |   |
| u |   |                       |                   |             |   |   |
| l |   |                       |                   |             |   |   |
| t |   |                       |                   |             |   |   |
| > |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| o |   |                       |                   |             |   |   |
| f |   |                       |                   |             |   |   |
| , |   |                       |                   |             |   |   |
| > |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| a |   |                       |                   |             |   |   |
| n |   |                       |                   |             |   |   |
| d |   |                       |                   |             |   |   |
| > |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| d |   |                       |                   |             |   |   |
| i |   |                       |                   |             |   |   |
| r |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| c |   |                       |                   |             |   |   |
| t |   |                       |                   |             |   |   |
| l |   |                       |                   |             |   |   |
| y |   |                       |                   |             |   |   |
| > |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| r |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| l |   |                       |                   |             |   |   |
| a |   |                       |                   |             |   |   |
| t |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| d |   |                       |                   |             |   |   |
| > |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| t |   |                       |                   |             |   |   |
| o |   |                       |                   |             |   |   |
| , |   |                       |                   |             |   |   |
| > |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| a |   |                       |                   |             |   |   |
| n |   |                       |                   |             |   |   |
| > |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| a |   |                       |                   |             |   |   |
| c |   |                       |                   |             |   |   |
| c |   |                       |                   |             |   |   |
| i |   |                       |                   |             |   |   |
| d |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| n |   |                       |                   |             |   |   |
| t |   |                       |                   |             |   |   |
| a |   |                       |                   |             |   |   |
| l |   |                       |                   |             |   |   |
| > |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| i |   |                       |                   |             |   |   |
| n |   |                       |                   |             |   |   |
| j |   |                       |                   |             |   |   |
| u |   |                       |                   |             |   |   |
| r |   |                       |                   |             |   |   |
| y |   |                       |                   |             |   |   |
| . |   |                       |                   |             |   |   |
| > |   |                       |                   |             |   |   |
| > |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| * |   |                       |                   |             |   |   |
| * |   |                       |                   |             |   |   |
| * |   |                       |                   |             |   |   |
| N |   |                       |                   |             |   |   |
| o |   |                       |                   |             |   |   |
| t |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| : |   |                       |                   |             |   |   |
| * |   |                       |                   |             |   |   |
| * |   |                       |                   |             |   |   |
| * |   |                       |                   |             |   |   |
| > |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| A |   |                       |                   |             |   |   |
| n |   |                       |                   |             |   |   |
| > |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| * |   |                       |                   |             |   |   |
| * |   |                       |                   |             |   |   |
| a |   |                       |                   |             |   |   |
| c |   |                       |                   |             |   |   |
| c |   |                       |                   |             |   |   |
| i |   |                       |                   |             |   |   |
| d |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| n |   |                       |                   |             |   |   |
| t |   |                       |                   |             |   |   |
| a |   |                       |                   |             |   |   |
| l |   |                       |                   |             |   |   |
| > |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| i |   |                       |                   |             |   |   |
| n |   |                       |                   |             |   |   |
| j |   |                       |                   |             |   |   |
| u |   |                       |                   |             |   |   |
| r |   |                       |                   |             |   |   |
| y |   |                       |                   |             |   |   |
| * |   |                       |                   |             |   |   |
| * |   |                       |                   |             |   |   |
| > |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| i |   |                       |                   |             |   |   |
| s |   |                       |                   |             |   |   |
| > |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| a |   |                       |                   |             |   |   |
| n |   |                       |                   |             |   |   |
| > |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| i |   |                       |                   |             |   |   |
| n |   |                       |                   |             |   |   |
| j |   |                       |                   |             |   |   |
| u |   |                       |                   |             |   |   |
| r |   |                       |                   |             |   |   |
| y |   |                       |                   |             |   |   |
| > |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| c |   |                       |                   |             |   |   |
| a |   |                       |                   |             |   |   |
| u |   |                       |                   |             |   |   |
| s |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| d |   |                       |                   |             |   |   |
| > |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| b |   |                       |                   |             |   |   |
| y |   |                       |                   |             |   |   |
| > |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| a |   |                       |                   |             |   |   |
| n |   |                       |                   |             |   |   |
| > |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| x |   |                       |                   |             |   |   |
| t |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| r |   |                       |                   |             |   |   |
| n |   |                       |                   |             |   |   |
| a |   |                       |                   |             |   |   |
| l |   |                       |                   |             |   |   |
| > |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| f |   |                       |                   |             |   |   |
| o |   |                       |                   |             |   |   |
| r |   |                       |                   |             |   |   |
| c |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| > |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| o |   |                       |                   |             |   |   |
| r |   |                       |                   |             |   |   |
| > |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| l |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| m |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| n |   |                       |                   |             |   |   |
| t |   |                       |                   |             |   |   |
| > |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| s |   |                       |                   |             |   |   |
| u |   |                       |                   |             |   |   |
| c |   |                       |                   |             |   |   |
| h |   |                       |                   |             |   |   |
| > |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| a |   |                       |                   |             |   |   |
| s |   |                       |                   |             |   |   |
| > |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| a |   |                       |                   |             |   |   |
| > |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| b |   |                       |                   |             |   |   |
| l |   |                       |                   |             |   |   |
| o |   |                       |                   |             |   |   |
| w |   |                       |                   |             |   |   |
| > |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| o |   |                       |                   |             |   |   |
| r |   |                       |                   |             |   |   |
| > |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| f |   |                       |                   |             |   |   |
| a |   |                       |                   |             |   |   |
| l |   |                       |                   |             |   |   |
| l |   |                       |                   |             |   |   |
| > |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| a |   |                       |                   |             |   |   |
| n |   |                       |                   |             |   |   |
| d |   |                       |                   |             |   |   |
| > |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| t |   |                       |                   |             |   |   |
| h |   |                       |                   |             |   |   |
| a |   |                       |                   |             |   |   |
| t |   |                       |                   |             |   |   |
| > |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| r |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| q |   |                       |                   |             |   |   |
| u |   |                       |                   |             |   |   |
| i |   |                       |                   |             |   |   |
| r |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| s |   |                       |                   |             |   |   |
| > |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| i |   |                       |                   |             |   |   |
| m |   |                       |                   |             |   |   |
| m |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| d |   |                       |                   |             |   |   |
| i |   |                       |                   |             |   |   |
| a |   |                       |                   |             |   |   |
| t |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| > |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| a |   |                       |                   |             |   |   |
| t |   |                       |                   |             |   |   |
| t |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| n |   |                       |                   |             |   |   |
| t |   |                       |                   |             |   |   |
| i |   |                       |                   |             |   |   |
| o |   |                       |                   |             |   |   |
| n |   |                       |                   |             |   |   |
| . |   |                       |                   |             |   |   |
| > |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| I |   |                       |                   |             |   |   |
| n |   |                       |                   |             |   |   |
| j |   |                       |                   |             |   |   |
| u |   |                       |                   |             |   |   |
| r |   |                       |                   |             |   |   |
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| s |   |                       |                   |             |   |   |
| > |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| t |   |                       |                   |             |   |   |
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| > |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| t |   |                       |                   |             |   |   |
| h |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| > |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| t |   |                       |                   |             |   |   |
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| t |   |                       |                   |             |   |   |
| h |   |                       |                   |             |   |   |
| > |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| w |   |                       |                   |             |   |   |
| h |   |                       |                   |             |   |   |
| i |   |                       |                   |             |   |   |
| l |   |                       |                   |             |   |   |
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| > |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
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| a |   |                       |                   |             |   |   |
| t |   |                       |                   |             |   |   |
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| n |   |                       |                   |             |   |   |
| g |   |                       |                   |             |   |   |
| > |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| a |   |                       |                   |             |   |   |
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|   |   |                       |                   |             |   |   |
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|   |   |                       |                   |             |   |   |
| c |   |                       |                   |             |   |   |
| o |   |                       |                   |             |   |   |
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| d |   |                       |                   |             |   |   |
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| r |   |                       |                   |             |   |   |
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| d |   |                       |                   |             |   |   |
| > |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| a |   |                       |                   |             |   |   |
| c |   |                       |                   |             |   |   |
| c |   |                       |                   |             |   |   |
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| d |   |                       |                   |             |   |   |
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| t |   |                       |                   |             |   |   |
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| > |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| o |   |                       |                   |             |   |   |
| f |   |                       |                   |             |   |   |
| > |   |                       |                   |             |   |   |
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| > |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
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| c |   |                       |                   |             |   |   |
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| i |   |                       |                   |             |   |   |
| d |   |                       |                   |             |   |   |
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| . |   |                       |                   |             |   |   |
+---+---+-----------------------+-------------------+-------------+---+---+

Dental benefits -- *continued on next page*

+-------------------------------+-----------+-----------+-------------+
| **Dental benefits**           |           |           |             |
| *(continued)*                 |           |           |             |
+-------------------------------+-----------+-----------+-------------+
| **What is Covered**           |           |           |             |
|                               |           |           |             |
| **Standard Option** dental    |           |           |             |
| benefits are presented in the |           |           |             |
| chart beginning below and     |           |           |             |
| continuing on the following   |           |           |             |
| pages.                        |           |           |             |
|                               |           |           |             |
| **Basic Option** dental       |           |           |             |
| benefits appear on page 93.   |           |           |             |
|                               |           |           |             |
| ***Note:*** See Section 5(b)  |           |           |             |
| for our benefits for Oral and |           |           |             |
| maxillofacial surgery, and    |           |           |             |
| Section 5(c) for our benefits |           |           |             |
| for hospital services         |           |           |             |
| (inpatient/outpatient) in     |           |           |             |
| connection with dental        |           |           |             |
| services, available under     |           |           |             |
| both Standard Option and      |           |           |             |
| Basic Option.                 |           |           |             |
+-------------------------------+-----------+-----------+-------------+
| **Preferred Dental Network**  |           |           |             |
|                               |           |           |             |
| All Local Plans contract with |           |           |             |
| Preferred dentists who are    |           |           |             |
| available in most areas.      |           |           |             |
| Preferred dentists agree to   |           |           |             |
| accept a negotiated,          |           |           |             |
| discounted amount called the  |           |           |             |
| Maximum Allowable Charge      |           |           |             |
| (MAC) as payment in full for  |           |           |             |
| the following services. They  |           |           |             |
| will also file your dental    |           |           |             |
| claims for you. Under         |           |           |             |
| Standard Option, you are      |           |           |             |
| responsible, as an            |           |           |             |
| out-of-pocket expense, for    |           |           |             |
| the difference between the    |           |           |             |
| amount specified in this      |           |           |             |
| Schedule of Dental Allowances |           |           |             |
| and the MAC. To find a        |           |           |             |
| Preferred dentist near you,   |           |           |             |
| refer to the Preferred        |           |           |             |
| provider directory, visit our |           |           |             |
| Web site at                   |           |           |             |
| [                             |           |           |             |
| www.fepblue.org]{.underline}, |           |           |             |
| or call us at the customer    |           |           |             |
| service number on the back of |           |           |             |
| your ID card. You can also    |           |           |             |
| call us to obtain a copy of   |           |           |             |
| the applicable MAC listing.   |           |           |             |
|                               |           |           |             |
| ***Note:*** Dentists who are  |           |           |             |
| in our Preferred Dental       |           |           |             |
| Network are not necessarily   |           |           |             |
| Preferred providers for other |           |           |             |
| services covered by this Plan |           |           |             |
| under other benefit           |           |           |             |
| provisions (such as oral and  |           |           |             |
| maxillofacial surgery).       |           |           |             |
+-------------------------------+-----------+-----------+-------------+
| **Standard Option dental      |           |           |             |
| benefits**                    |           |           |             |
+-------------------------------+-----------+-----------+-------------+
| Under Standard Option, we pay |           |           |             |
| billed charges for the        |           |           |             |
| following services, up to the |           |           |             |
| amounts shown per service as  |           |           |             |
| listed in the Schedule of     |           |           |             |
| Dental Allowances below and   |           |           |             |
| on the following pages. This  |           |           |             |
| is a complete list of dental  |           |           |             |
| services covered under this   |           |           |             |
| benefit for Standard Option.  |           |           |             |
| There are no deductibles,     |           |           |             |
| copayments, or coinsurance.   |           |           |             |
| When you use Non-preferred    |           |           |             |
| dentists, you pay all charges |           |           |             |
| in excess of the listed fee   |           |           |             |
| schedule amounts. For         |           |           |             |
| Preferred dentists, you pay   |           |           |             |
| the difference between the    |           |           |             |
| fee schedule amount and the   |           |           |             |
| MAC (see above).              |           |           |             |
+-------------------------------+-----------+-----------+-------------+
| ### St                        | *         |           |             |
| andard Option dental benefits | *Standard |           |             |
|                               | Option    |           |             |
|                               | Only**    |           |             |
+-------------------------------+-----------+-----------+-------------+
| Service and ADA Code          | **We      |           | **You pay** |
|                               | pay**     |           |             |
+-------------------------------+-----------+-----------+-------------+
| > **Clinical oral             | **[To age | **[Age 13 | > All       |
| > evaluations**               | 13]{.und  | and       | > charges   |
| >                             | erline}** | o         | > in excess |
| > 0120 Periodic oral          |           | ver]{.und | > of the    |
| > evaluation\*                | \$12      | erline}** | > scheduled |
| >                             |           |           | > amounts   |
| > 0140 Limited oral           | \$14      | \$8       | > listed to |
| > evaluation                  |           |           | > the left  |
| >                             | \$14      | \$9       | >           |
| > 0150 Comprehensive oral     |           |           | >           |
| > evaluation                  | \$14      | \$9       | ***Note:*** |
| >                             |           |           | > For       |
| > 0160 Detailed and extensive |           | \$9       | > services  |
| > oral evaluation             |           |           | > performed |
|                               |           |           | > by        |
| *\*Limited to two per person  |           |           | > dentists  |
| per calendar year*            |           |           | > in our    |
|                               |           |           | > Preferred |
|                               |           |           | > Dental    |
|                               |           |           | > Network,  |
|                               |           |           | > you pay   |
|                               |           |           | > the       |
|                               |           |           | >           |
|                               |           |           |  difference |
|                               |           |           | > between   |
|                               |           |           | > the       |
|                               |           |           | > amounts   |
|                               |           |           | > listed to |
|                               |           |           | > the left  |
|                               |           |           | > and the   |
|                               |           |           | > Maximum   |
|                               |           |           | > Allowable |
|                               |           |           | > Charge    |
|                               |           |           | > (MAC).    |
+-------------------------------+-----------+-----------+-------------+
| > **Radiographs**             | \$36      | \$22      |             |
| >                             |           |           |             |
| > 0210 Intraoral complete     | \$7       | \$5       |             |
| > series                      |           |           |             |
| >                             | \$4       | \$3       |             |
| > 0220 Intraoral periapical   |           |           |             |
| > first film                  | \$12      | \$7       |             |
| >                             |           |           |             |
| > 0230 Intraoral periapical   | \$16      | \$10      |             |
| > each additional film        |           |           |             |
| >                             | \$6       | \$4       |             |
| > 0240 Intraoral occlusal     |           |           |             |
| > film                        | \$9       | \$6       |             |
| >                             |           |           |             |
| > 0250 Extraoral first film   | \$14      | \$9       |             |
| >                             |           |           |             |
| > 0260 Extraoral each         | \$19      | \$12      |             |
| > additional film             |           |           |             |
| >                             |           |           |             |
| > 0270 Bitewing -- single     |           |           |             |
| > film                        |           |           |             |
| >                             |           |           |             |
| > 0272 Bitewings -- two films |           |           |             |
|                               |           |           |             |
| 0274 Bitewings -- four films  |           |           |             |
+-------------------------------+-----------+-----------+-------------+

Dental benefits -- *continued on next page*

+-------------------------------+-----------+-----------+-------------+
| ### Standard Option           | *         |           |             |
| dental benefits *(continued)* | *Standard |           |             |
|                               | Option    |           |             |
|                               | Only**    |           |             |
+-------------------------------+-----------+-----------+-------------+
| Service and ADA Code          | **We      |           | **You pay** |
|                               | pay**     |           |             |
+-------------------------------+-----------+-----------+-------------+
| **Radiographs -- continued**  | > **[To   | **[Age 13 | > All       |
|                               | > age     | and       | > charges   |
| > 0277 Bitewings -- vertical  | >         | o         | > in excess |
| >                             |  13]{.und | ver]{.und | > of the    |
| > 0290 Posterior-anterior or  | erline}** | erline}** | > scheduled |
| > lateral skull and facial    | >         |           | > amounts   |
| > bone survey film            | > \$12    | \$7       | > listed to |
| >                             | >         |           | > the left  |
| > 0330 Panoramic film         | > \$45    | \$28      | >           |
|                               | >         |           | >           |
|                               | > \$36    | \$23      | ***Note:*** |
|                               |           |           | > For       |
|                               |           |           | > services  |
|                               |           |           | > performed |
|                               |           |           | > by        |
|                               |           |           | > dentists  |
|                               |           |           | > in our    |
|                               |           |           | > Preferred |
|                               |           |           | > Dental    |
|                               |           |           | > Network,  |
|                               |           |           | > you pay   |
|                               |           |           | > the       |
|                               |           |           | >           |
|                               |           |           |  difference |
|                               |           |           | > between   |
|                               |           |           | > the       |
|                               |           |           | > amounts   |
|                               |           |           | > listed to |
|                               |           |           | > the left  |
|                               |           |           | > and the   |
|                               |           |           | > Maximum   |
|                               |           |           | > Allowable |
|                               |           |           | > Charge    |
|                               |           |           | > (MAC).    |
+-------------------------------+-----------+-----------+-------------+
| > **Tests and laboratory      | \$11      | \$7       |             |
| > exams**                     |           |           |             |
| >                             |           |           |             |
| > 0460 Pulp vitality tests    |           |           |             |
+-------------------------------+-----------+-----------+-------------+
| > **Palliative treatment**    | \$24      | \$15      |             |
| >                             |           |           |             |
| > 9110 Palliative (emergency) | \$24      | \$15      |             |
| > treatment of dental pain -- |           |           |             |
| > minor procedure             |           |           |             |
| >                             |           |           |             |
| > 2940 Sedative filling       |           |           |             |
+-------------------------------+-----------+-----------+-------------+
| **Preventive**                | \-\--     | \$16      |             |
|                               |           |           |             |
| 1110. Prophylaxis -- adult\*  | \$22      | \$14      |             |
|                               |           |           |             |
| > 1120 Prophylaxis -- child\* | \$35      | \$22      |             |
| >                             |           |           |             |
| > 1201 Topical application of | \$13      | \$8       |             |
| > fluoride (including         |           |           |             |
| > prophylaxis) -- child\*     | \-\--     | \$8       |             |
|                               |           |           |             |
| 1203. Topical application of  | \-\--     | \$24      |             |
|       fluoride (prophylaxis   |           |           |             |
|       not included) -- child  |           |           |             |
|                               |           |           |             |
| > 1204 Topical application of |           |           |             |
| > fluoride (prophylaxis not   |           |           |             |
| > included) -- adult          |           |           |             |
|                               |           |           |             |
| 1205. Topical application of  |           |           |             |
|       fluoride (including     |           |           |             |
|       prophylaxis) -- adult\* |           |           |             |
|                               |           |           |             |
| > \**Limited to two per       |           |           |             |
| > person per calendar year*   |           |           |             |
+-------------------------------+-----------+-----------+-------------+
| > **Space maintenance         | \$94      | \$59      |             |
| > (passive**                  |           |           |             |
| >                             | \$139     | \$87      |             |
| > **appliances)**             |           |           |             |
| >                             | \$94      | \$59      |             |
| > 1510 Space maintainer --    |           |           |             |
| > fixed -- unilateral         | \$139     | \$87      |             |
| >                             |           |           |             |
| > 1515 Space maintainer --    | \$22      | \$14      |             |
| > fixed -- bilateral          |           |           |             |
| >                             |           |           |             |
| > 1520 Space maintainer --    |           |           |             |
| > removable -- unilateral     |           |           |             |
| >                             |           |           |             |
| > 1525 Space maintainer --    |           |           |             |
| > removable -- bilateral      |           |           |             |
|                               |           |           |             |
| 1550 Recementation of space   |           |           |             |
| maintainer                    |           |           |             |
+-------------------------------+-----------+-----------+-------------+

Dental benefits -- *continued on next page*

+-------------------------------+-----------+-----------+-------------+
| ### Standard Option           | *         |           |             |
| dental benefits *(continued)* | *Standard |           |             |
|                               | Option    |           |             |
|                               | Only**    |           |             |
+-------------------------------+-----------+-----------+-------------+
| Service and ADA Code          | **We      |           | **You pay** |
|                               | pay**     |           |             |
+-------------------------------+-----------+-----------+-------------+
| > **Amalgam restorations      | **[To age | **[Age 13 | > All       |
| > (including polishing**)     | 13]{.und  | and       | > charges   |
| >                             | erline}** | o         | > in excess |
| > 2140 Amalgam -- one         |           | ver]{.und | > of the    |
| > surface, primary or         | \$25      | erline}** | > scheduled |
| > permanent                   |           |           | > amounts   |
| >                             | \$37      | \$16      | > listed to |
| > 2150 Amalgam -- two         |           |           | > the left  |
| > surfaces, primary or        | \$50      | \$23      |             |
| > permanent                   |           |           | ***Note:*** |
| >                             | \$56      | \$31      | For         |
| > 2160 Amalgam -- three       |           |           | services    |
| > surfaces, primary or        |           | \$35      | performed   |
| > permanent                   |           |           | by dentists |
| >                             |           |           | in our      |
| > 2161 Amalgam -- four or     |           |           | Preferred   |
| > more surfaces, primary or   |           |           | Dental      |
| > permanent                   |           |           | Network,    |
|                               |           |           | you pay the |
|                               |           |           | difference  |
|                               |           |           | between the |
|                               |           |           | amounts     |
|                               |           |           | listed to   |
|                               |           |           | the left    |
|                               |           |           | and the     |
|                               |           |           | Maximum     |
|                               |           |           | Allowable   |
|                               |           |           | Charge      |
|                               |           |           | (MAC).      |
+-------------------------------+-----------+-----------+-------------+
| > **Filled or unfilled resin  | \$25      | \$16      |             |
| > restorations**              |           |           |             |
| >                             | \$37      | \$23      |             |
| > 2330 Resin -- one surface,  |           |           |             |
| > anterior                    | \$50      | \$31      |             |
| >                             |           |           |             |
| > 2331 Resin -- two surfaces, | \$56      | \$35      |             |
| > anterior                    |           |           |             |
| >                             | \$25      | \$16      |             |
| > 2332 Resin -- three         |           |           |             |
| > surfaces, anterior          | \$37      | \$23      |             |
| >                             |           |           |             |
| > 2335 Resin -- four or more  | \$50      | \$31      |             |
| > surfaces or involving       |           |           |             |
| > incisal angle (anterior)    | \$50      | \$31      |             |
| >                             |           |           |             |
| > 2391 Resin-based composite  |           |           |             |
| > -- one surface, posterior   |           |           |             |
| >                             |           |           |             |
| > 2392 Resin-based composite  |           |           |             |
| > -- two surfaces, posterior  |           |           |             |
| >                             |           |           |             |
| > 2393 Resin-based composite  |           |           |             |
| > -- three surfaces,          |           |           |             |
| > posterior                   |           |           |             |
| >                             |           |           |             |
| > 2394 Resin-based composite  |           |           |             |
| > -- four or more surfaces,   |           |           |             |
| > posterior                   |           |           |             |
+-------------------------------+-----------+-----------+-------------+
| > **Inlay restorations**      | \$25      | \$16      |             |
| >                             |           |           |             |
| > 2510 Inlay -- metallic --   | \$37      | \$23      |             |
| > one surface                 |           |           |             |
| >                             | \$50      | \$31      |             |
| > 2520 Inlay -- metallic --   |           |           |             |
| > two surfaces                | \$25      | \$16      |             |
| >                             |           |           |             |
| > 2530 Inlay -- metallic --   | \$37      | \$23      |             |
| > three or more surfaces      |           |           |             |
| >                             | \$50      | \$31      |             |
| > 2610 Inlay --               |           |           |             |
| > porcelain/ceramic -- one    |           |           |             |
| > surface                     |           |           |             |
| >                             |           |           |             |
| > 2620 Inlay --               |           |           |             |
| > porcelain/ceramic -- two    |           |           |             |
| > surfaces                    |           |           |             |
| >                             |           |           |             |
| > 2630 Inlay --               |           |           |             |
| > porcelain/ceramic -- three  |           |           |             |
| > or more surfaces            |           |           |             |
+-------------------------------+-----------+-----------+-------------+

Dental benefits -- *continued on next page*

+-------------------------------+-----------+-----------+-------------+
| ### Standard Option           | *         |           |             |
| dental benefits *(continued)* | *Standard |           |             |
|                               | Option    |           |             |
|                               | Only**    |           |             |
+-------------------------------+-----------+-----------+-------------+
| Service and ADA Code          | **We      |           | **You pay** |
|                               | pay**     |           |             |
+-------------------------------+-----------+-----------+-------------+
| > **Inlay restorations --     | **[To age | **[Age 13 | > All       |
| > continued**                 | 13]{.und  | and       | > charges   |
| >                             | erline}** | o         | > in excess |
| > 2650 Inlay --               |           | ver]{.und | > of the    |
| > composite/resin -- one      | \$25      | erline}** | > scheduled |
| > surface                     |           |           | > amounts   |
| >                             | \$37      | \$16      | > listed to |
| > 2651 Inlay --               |           |           | > the left  |
| > composite/resin -- two      | \$50      | \$23      | >           |
| > surfaces                    |           |           | >           |
| >                             |           | \$31      | ***Note:*** |
| > 2652 Inlay --               |           |           | > For       |
| > composite/resin -- three or |           |           | > services  |
| > more surfaces               |           |           | > performed |
|                               |           |           | > by        |
|                               |           |           | > dentists  |
|                               |           |           | > in our    |
|                               |           |           | > Preferred |
|                               |           |           | > Dental    |
|                               |           |           | > Network,  |
|                               |           |           | > you pay   |
|                               |           |           | > the       |
|                               |           |           | >           |
|                               |           |           |  difference |
|                               |           |           | > between   |
|                               |           |           | > the       |
|                               |           |           | > amounts   |
|                               |           |           | > listed to |
|                               |           |           | > the left  |
|                               |           |           | > and the   |
|                               |           |           | > Maximum   |
|                               |           |           | > Allowable |
|                               |           |           | > Charge    |
|                               |           |           | > (MAC).    |
+-------------------------------+-----------+-----------+-------------+
| **Other restorative           | \$13      | \$8       |             |
| services**                    |           |           |             |
|                               |           |           |             |
| 2951 Pin retention -- per     |           |           |             |
| tooth, in addition to         |           |           |             |
| restoration                   |           |           |             |
+-------------------------------+-----------+-----------+-------------+
| **Extractions** -- **includes | \$30      | \$19      |             |
| local**                       |           |           |             |
|                               | \$43      | \$27      |             |
| **anesthesia and routine      |           |           |             |
| post-**                       | \$71      | \$45      |             |
|                               |           |           |             |
| **operative care**            | \$43      | \$27      |             |
|                               |           |           |             |
| 7140 Extraction, erupted      |           |           |             |
| tooth or exposed root         |           |           |             |
|                               |           |           |             |
| 7210 Surgical removal of      |           |           |             |
| erupted tooth requiring       |           |           |             |
| elevation of mucoperiosteal   |           |           |             |
| flap and removal of bone      |           |           |             |
| and/or section of tooth       |           |           |             |
|                               |           |           |             |
| > 7250 Surgical removal of    |           |           |             |
| > residual tooth roots        |           |           |             |
| > (cutting procedure)         |           |           |             |
| >                             |           |           |             |
| > 9220 General anesthesia in  |           |           |             |
| > connection with covered     |           |           |             |
| > extractions                 |           |           |             |
+-------------------------------+-----------+-----------+-------------+
| # *Not covered: Any service n | >         | >         | > *All      |
| ot specifically listed above* | *Nothing* | *Nothing* | > charges*  |
+-------------------------------+-----------+-----------+-------------+

Dental benefits -- *continued on next page*

+-------------------------------+---+------------------+---+------------------+
| **Basic Option dental         |   |                  |   |                  |
| benefits**                    |   |                  |   |                  |
+-------------------------------+---+------------------+---+------------------+
| Under Basic Option, we        |   |                  |   |                  |
| provide benefits for the      |   |                  |   |                  |
| services listed below. You    |   |                  |   |                  |
| pay a \$20 copayment for each |   |                  |   |                  |
| evaluation, and we pay any    |   |                  |   |                  |
| balances in full. This is a   |   |                  |   |                  |
| complete list of dental       |   |                  |   |                  |
| services covered under this   |   |                  |   |                  |
| benefit for Basic Option. You |   |                  |   |                  |
| **must** use a Preferred      |   |                  |   |                  |
| dentist in order to receive   |   |                  |   |                  |
| benefits. For a list of       |   |                  |   |                  |
| Preferred dentists, please    |   |                  |   |                  |
| refer to the Preferred        |   |                  |   |                  |
| provider directory, visit our |   |                  |   |                  |
| Web site at                   |   |                  |   |                  |
| [                             |   |                  |   |                  |
| www.fepblue.org]{.underline}, |   |                  |   |                  |
| or call us at the customer    |   |                  |   |                  |
| service number on the back of |   |                  |   |                  |
| your ID card.                 |   |                  |   |                  |
+-------------------------------+---+------------------+---+------------------+
| ###                           | * |                  |   |                  |
|  Basic Option dental benefits | * |                  |   |                  |
|                               | B |                  |   |                  |
|                               | a |                  |   |                  |
|                               | s |                  |   |                  |
|                               | i |                  |   |                  |
|                               | c |                  |   |                  |
|                               | O |                  |   |                  |
|                               | p |                  |   |                  |
|                               | t |                  |   |                  |
|                               | i |                  |   |                  |
|                               | o |                  |   |                  |
|                               | n |                  |   |                  |
|                               | O |                  |   |                  |
|                               | n |                  |   |                  |
|                               | l |                  |   |                  |
|                               | y |                  |   |                  |
|                               | * |                  |   |                  |
|                               | * |                  |   |                  |
+-------------------------------+---+------------------+---+------------------+
| Service and ADA Code          | * |                  | * |                  |
|                               | * |                  | * |                  |
|                               | W |                  | Y |                  |
|                               | e |                  | o |                  |
|                               | p |                  | u |                  |
|                               | a |                  | p |                  |
|                               | y |                  | a |                  |
|                               | * |                  | y |                  |
|                               | * |                  | * |                  |
|                               |   |                  | * |                  |
+-------------------------------+---+------------------+---+------------------+
| > **Clinical oral             |   | > Preferred: All |   | > Preferred:     |
| > evaluations**               |   | > charges in     |   | > \$20 copayment |
| >                             |   | > excess of your |   | > per evaluation |
| > 0120 Periodic oral          |   | > \$20 copayment |   | >                |
| > evaluation                  |   | >                |   | >                |
| >                             |   | >                |   | Participating/No |
| > 0140 Limited oral           |   | Participating/No |   | n-participating: |
| > evaluation                  |   | n-participating: |   | >                |
| >                             |   | >                |   | > You pay all    |
| > 0150 Comprehensive oral     |   | > Nothing        |   | > charges        |
| > evaluation                  |   |                  |   |                  |
| >                             |   |                  |   |                  |
| > ***Note:*** Benefits are    |   |                  |   |                  |
| > limited to a combined total |   |                  |   |                  |
| > of 2 evaluations per person |   |                  |   |                  |
| > per calendar year for 0120  |   |                  |   |                  |
| > and 0150.                   |   |                  |   |                  |
+-------------------------------+---+------------------+---+------------------+
| > **Radiographs**             |   |                  |   |                  |
| >                             |   |                  |   |                  |
| > 0210 Intraoral -- complete  |   |                  |   |                  |
| > series including bitewings  |   |                  |   |                  |
| > *(limited to 1 complete     |   |                  |   |                  |
| > series every 3 years)*      |   |                  |   |                  |
| >                             |   |                  |   |                  |
| > 0270 Bitewing -- single     |   |                  |   |                  |
| > film                        |   |                  |   |                  |
| >                             |   |                  |   |                  |
| > 0272 Bitewings -- two films |   |                  |   |                  |
| >                             |   |                  |   |                  |
| > 0274 Bitewings -- four      |   |                  |   |                  |
| > films                       |   |                  |   |                  |
|                               |   |                  |   |                  |
| ***Note:*** Benefits are      |   |                  |   |                  |
| limited to a combined total   |   |                  |   |                  |
| of 4 films per person per     |   |                  |   |                  |
| calendar year for 0270, 0272, |   |                  |   |                  |
| and 0274.                     |   |                  |   |                  |
+-------------------------------+---+------------------+---+------------------+
| > **Preventive**              |   |                  |   |                  |
| >                             |   |                  |   |                  |
| > 1110 Prophylaxis -- adult   |   |                  |   |                  |
| > *(up to 2 per calendar      |   |                  |   |                  |
| > year)*                      |   |                  |   |                  |
| >                             |   |                  |   |                  |
| > 1120 Prophylaxis -- child   |   |                  |   |                  |
| > *(up to 2 per calendar      |   |                  |   |                  |
| > year)*                      |   |                  |   |                  |
| >                             |   |                  |   |                  |
| > 1201 Topical application of |   |                  |   |                  |
| > fluoride (including         |   |                  |   |                  |
| > prophylaxis) -- child *(up  |   |                  |   |                  |
| > to 2 per calendar year)*    |   |                  |   |                  |
| >                             |   |                  |   |                  |
| > 1203 Topical application of |   |                  |   |                  |
| > fluoride (prophylaxis not   |   |                  |   |                  |
| > included) -- child *(up to  |   |                  |   |                  |
| > 2 per calendar year)*       |   |                  |   |                  |
|                               |   |                  |   |                  |
| 1351. Sealant -- per tooth,   |   |                  |   |                  |
|       first and second molars |   |                  |   |                  |
|       only *(once per tooth   |   |                  |   |                  |
|       for children up to age  |   |                  |   |                  |
|       16 only)*               |   |                  |   |                  |
|                               |   |                  |   |                  |
| > ***Note:*** Benefits are    |   |                  |   |                  |
| > limited to a combined total |   |                  |   |                  |
| > of 2 visits per person per  |   |                  |   |                  |
| > calendar year for 1120 and  |   |                  |   |                  |
| > 1201.                       |   |                  |   |                  |
+-------------------------------+---+------------------+---+------------------+
| *Not covered: Any service not |   | > *Nothing*      |   | > *All charges*  |
| specifically listed above*    |   |                  |   |                  |
+-------------------------------+---+------------------+---+------------------+

+----------------+-----------------------------------------------------+
| ### Sectio     |                                                     |
| n 5 (i). Servi |                                                     |
| ces, drugs, an |                                                     |
| d supplies pro |                                                     |
| vided overseas |                                                     |
+----------------+-----------------------------------------------------+
| If you travel  |                                                     |
| or live        |                                                     |
| outside the    |                                                     |
| United States  |                                                     |
| and Puerto     |                                                     |
| Rico, you are  |                                                     |
| still entitled |                                                     |
| to the         |                                                     |
| benefits       |                                                     |
| described in   |                                                     |
| this brochure. |                                                     |
| Unless         |                                                     |
| otherwise      |                                                     |
| noted in this  |                                                     |
| section, the   |                                                     |
| same           |                                                     |
| definitions,   |                                                     |
| limitations,   |                                                     |
| and exclusions |                                                     |
| also apply.    |                                                     |
|                |                                                     |
| **Please note  |                                                     |
| that the       |                                                     |
| requirements   |                                                     |
| to obtain      |                                                     |
| pr             |                                                     |
| ecertification |                                                     |
| for inpatient  |                                                     |
| care and prior |                                                     |
| approval for   |                                                     |
| those services |                                                     |
| listed in      |                                                     |
| Section 3 do   |                                                     |
| not apply when |                                                     |
| you receive    |                                                     |
| care outside   |                                                     |
| the United     |                                                     |
| States.**      |                                                     |
+----------------+-----------------------------------------------------+
|                |                                                     |
+----------------+-----------------------------------------------------+
| **Overseas     | For professional care you receive overseas, we      |
| claims         | provide benefits at Preferred benefit levels using  |
| payment**      | an Overseas Fee Schedule as our Plan allowance.     |
|                | **Under Standard Option,** you must pay any         |
|                | difference between our payment and the amount       |
|                | billed, in addition to any applicable deductible,   |
|                | coinsurance, and/or copayment amounts. You must     |
|                | also pay any charges for noncovered services.       |
+----------------+-----------------------------------------------------+
|                |                                                     |
+----------------+-----------------------------------------------------+
|                | **Under Basic Option,** you pay any difference      |
|                | between our payment and the amount billed, as well  |
|                | as the applicable copayment or coinsurance. You     |
|                | must also pay any charges for noncovered services.  |
|                | **The requirement to use Preferred providers in     |
|                | order to receive benefits under Basic Option does   |
|                | not apply when you receive care outside the United  |
|                | States and Puerto Rico.**                           |
+----------------+-----------------------------------------------------+
|                |                                                     |
+----------------+-----------------------------------------------------+
|                | For facility care you receive overseas, we provide  |
|                | benefits at the Preferred level **under both        |
|                | Standard and Basic Options** after you pay the      |
|                | applicable copayment or coinsurance. Standard       |
|                | Option members are also responsible for any amounts |
|                | applied to the calendar year deductible for certain |
|                | outpatient facility services -- please see pages    |
|                | 61-63.                                              |
+----------------+-----------------------------------------------------+
|                |                                                     |
+----------------+-----------------------------------------------------+
| **Worldwide    | We have a network of participating hospitals        |
| Assistance     | overseas that will file your claims for inpatient   |
| Center**       | facility care for you -- without an advance payment |
|                | for the covered services you receive. The Worldwide |
|                | Assistance Center can help you locate a hospital in |
|                | our network near where you are staying. You may     |
|                | also view a list of our network hospitals on our    |
|                | Web site, [www.fepblue.org]{.underline}. Although   |
|                | we do not have a network of professionals overseas, |
|                | the Worldwide Assistance Center can also help you   |
|                | locate a physician. You will have to file a claim   |
|                | to us for reimbursement for professional services.  |
+----------------+-----------------------------------------------------+
|                |                                                     |
+----------------+-----------------------------------------------------+
|                | If you are overseas and need assistance locating    |
|                | providers, contact the Worldwide Assistance Center  |
|                | (provided by World Access Service Corporation), by  |
|                | calling the center collect at                       |
|                |                                                     |
|                | 1-804-673-1678. Members in the United States,       |
|                | Puerto Rico, or the Virgin Islands should call      |
|                |                                                     |
|                | 1-800-699-4337. World Access Service Corporation    |
|                | also offers emergency evacuation services to the    |
|                | nearest facility equipped to adequately treat your  |
|                | condition, translation services, and conversion of  |
|                | foreign medical bills to U.S. currency. You may     |
|                | contact one of their multilingual operators 24      |
|                | hours a day, 365 days a year.                       |
+----------------+-----------------------------------------------------+
|                |                                                     |
+----------------+-----------------------------------------------------+
| **Filing       |                                                     |
| overseas       |                                                     |
| claims**       |                                                     |
+----------------+-----------------------------------------------------+
|                |                                                     |
+----------------+-----------------------------------------------------+
| -   **Hospital | Most overseas providers are under no obligation to  |
|     and        | file claims on behalf of our members. **You may     |
|     physician  | need to pay for the services at the time you        |
|     care**     | receive them and then submit a claim to us for      |
|                | reimbursement.** To file a claim for covered        |
|                | hospital and physician services received outside    |
|                | the United States and Puerto Rico, send a completed |
|                | Overseas Claim Form and itemized bills to:          |
|                |                                                     |
|                | FEP Overseas Claims Section, CareFirst Blue Cross   |
|                | Blue Shield, P.O. Box 96242, Washington, DC         |
|                | 20090-6242. We will provide translation and         |
|                | currency conversion services for your overseas      |
|                | claims. Send any written inquiries concerning the   |
|                | processing of your overseas claims to this address  |
|                | or call us at 1-888-999-9862, using the appropriate |
|                | AT&T country codes available on our Web site under  |
|                | Contact Us. You may also obtain Overseas Claim      |
|                | Forms from this address, from our Web site          |
|                | ([www.fepblue.org]()), or from your Local Plan.     |
+----------------+-----------------------------------------------------+
|                |                                                     |
+----------------+-----------------------------------------------------+

+----------------+-----------------------------------------------------+
| -   **Pharmacy | Drugs purchased overseas must be the equivalent to  |
|     benefits** | drugs that by Federal law of the United States      |
|                | require a prescription. To file a claim for covered |
|                | drugs and supplies you purchase from pharmacies     |
|                | outside the United States and Puerto Rico, send a   |
|                | completed FEP Retail Prescription Drug Overseas     |
|                | Claim Form, along with itemized pharmacy receipts   |
|                | or bills, to: Blue Cross and Blue Shield Service    |
|                | Benefit Plan Retail Pharmacy Program, P.O. Box      |
|                | 52057, Phoenix, AZ 85072-2057. We will provide      |
|                | translation and currency conversion services for    |
|                | your overseas claims. You may obtain claim forms    |
|                | for your drug purchases by writing to this address, |
|                | by visiting our Web site,                           |
|                | [www.fepblue.org](http://www.fepblue.org/), or by   |
|                | calling 1-888-999-9862, using the appropriate AT&T  |
|                | country codes available on our Web site under       |
|                | Contact Us. Send any written inquiries concerning   |
|                | drugs you purchase to this address as well.         |
+----------------+-----------------------------------------------------+
|                |                                                     |
+----------------+-----------------------------------------------------+
|                | Please note that under both **Standard and Basic    |
|                | Options**, you may fill your prescriptions through  |
|                | a Preferred internet pharmacy only if the           |
|                | prescribing physician is licensed in the United     |
|                | States or Puerto Rico.                              |
+----------------+-----------------------------------------------------+
|                |                                                     |
+----------------+-----------------------------------------------------+
|                | **Under Standard Option**, you may order your       |
|                | prescription drugs from the Mail Service            |
|                | Prescription Drug Program only if:                  |
+----------------+-----------------------------------------------------+
|                |                                                     |
+----------------+-----------------------------------------------------+
|                | a)  Your address includes a U.S. zip code (such as  |
|                |     with APO and FPO addresses and in U.S.          |
|                |     territories) and                                |
+----------------+-----------------------------------------------------+
|                |                                                     |
+----------------+-----------------------------------------------------+
|                | b)  The prescribing physician is licensed in the    |
|                |     United States or Puerto Rico.                   |
+----------------+-----------------------------------------------------+
|                |                                                     |
+----------------+-----------------------------------------------------+
|                | Please see page 83 for more information about using |
|                | this program.                                       |
+----------------+-----------------------------------------------------+
|                |                                                     |
+----------------+-----------------------------------------------------+
|                | The Mail Service Prescription Drug Program is not   |
|                | available under **Basic Option**.                   |
+----------------+-----------------------------------------------------+
|                |                                                     |
+----------------+-----------------------------------------------------+

+-----------------------------------------------------------------------+
| > Section 6. General exclusions -- things we don\'t cover             |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| > The exclusions in this section apply to all benefits. **Although we |
| > may list a specific service as a benefit, we will not cover it      |
| > unless we determine it is medically necessary to prevent, diagnose, |
| > or treat your illness, disease, injury, or condition.**             |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
| > We do not cover the following:                                      |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
| -   Services, drugs, or supplies you receive while you are not        |
|     enrolled in this Plan;                                            |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
| -   Services, drugs, or supplies that are not medically necessary;    |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
| -   Services, drugs, or supplies not required according to accepted   |
|     standards of medical, dental, or psychiatric practice in the      |
|     United States;                                                    |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
| -   Experimental or investigational procedures, treatments, drugs, or |
|     devices;                                                          |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
| -   Services, drugs, or supplies related to abortions, except when    |
|     the life of the mother would be endangered if the fetus were      |
|     carried to term, or when the pregnancy is the result of an act of |
|     rape or incest;                                                   |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
| -   Services, drugs, or supplies related to sex transformations,      |
|     sexual dysfunction, or sexual inadequacy;                         |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
| -   Services, drugs, or supplies you receive from a provider or       |
|     facility barred from the FEHB Program;                            |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
| -   Services, drugs, or supplies you would not be charged for if you  |
|     had no health insurance coverage;                                 |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
| -   Services, drugs, or supplies you receive without charge while in  |
|     active military service;                                          |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
| -   Amounts charged that neither you nor we are legally obligated to  |
|     pay, such as amounts over the Medicare limiting charge or         |
|     equivalent Medicare amount as described in Section 4 under *Your  |
|     costs for covered services*, or State premium taxes, however      |
|     applied;                                                          |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
| -   Services, drugs, or supplies you receive from immediate relatives |
|     or household members, such as spouse, parent, child, brother, or  |
|     sister, by blood, marriage, or adoption;                          |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
| -   Services or supplies (except for medically necessary prescription |
|     drugs) that you receive from a noncovered facility, such as an    |
|     extended care facility or nursing home, except as specifically    |
|     described in Sections 5(a) and 5(c);                              |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
| -   Services, drugs, or supplies you receive from noncovered          |
|     providers except in medically underserved areas as specifically   |
|     described on page 11;                                             |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
| -   Services, drugs, or supplies you receive for cosmetic purposes;   |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
| -   Services, drugs, or supplies for the treatment of obesity, weight |
|     reduction, or dietary control, except for gastric bypass surgery  |
|     or gastric stapling procedures;                                   |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
| -   Services you receive from a provider that are outside the scope   |
|     of the provider\'s licensure or certification;                    |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
| -   Any dental or oral surgical procedures or drugs involving         |
|     orthodontic care, the teeth, dental implants, periodontal         |
|     disease, or preparing the mouth for the fitting or continued use  |
|     of dentures, except as specifically described in Section 5(h),    |
|     *Dental benefits*, and Section 5(b) under *Oral and maxillofacial |
|     surgery*;                                                         |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
| -   Orthodontic care for temporomandibular joint (TMJ) syndrome;      |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
| -   Services of standby physicians;                                   |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
| -   Self-care or self-help training;                                  |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
| -   Custodial care;                                                   |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
| -   Personal comfort items such as beauty and barber services, radio, |
|     television, or telephone;                                         |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
| -   Routine services, such as periodic physical examinations;         |
|     screening examinations; immunizations; and services or tests not  |
|     related to a specific diagnosis, illness, injury, set of          |
|     symptoms, or maternity care, except for those preventive services |
|     specifically covered under *Preventive care, adult and child* in  |
|     Sections 5(a) and 5(c) and screenings specifically listed on      |
|     pages 26 and 45;                                                  |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
| -   Recreational or educational therapy, and any related diagnostic   |
|     testing, except as provided by a hospital during a covered        |
|     inpatient stay; or                                                |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
| -   Services not specifically listed as covered.                      |
+-----------------------------------------------------------------------+

+-----------------------+----------------------------------------------+
| Section 7. Filing a   |                                              |
| claim for covered     |                                              |
| services              |                                              |
+-----------------------+----------------------------------------------+
|                       |                                              |
+-----------------------+----------------------------------------------+
| **How to claim        | To obtain claim forms or other claims filing |
| benefits**            | advice, or answers to your questions about   |
|                       | our benefits, contact us at the customer     |
|                       | service number on the back of your Service   |
|                       | Benefit Plan ID card, or at our Web site at  |
|                       | [www.fepblue.org](http://www.xxx/).          |
+-----------------------+----------------------------------------------+
|                       |                                              |
+-----------------------+----------------------------------------------+
|                       | In most cases, physicians and facilities     |
|                       | file claims for you. Just present your       |
|                       | Service Benefit Plan ID card when you        |
|                       | receive services. Your physician must file   |
|                       | on the HCFA-1500, Health Insurance Claim     |
|                       | Form. Your facility will file on the UB-92   |
|                       | form.                                        |
+-----------------------+----------------------------------------------+
|                       |                                              |
+-----------------------+----------------------------------------------+
|                       | When you must file a claim -- such as when   |
|                       | another group health plan is primary --      |
|                       | submit it on the HCFA-1500 or a claim form   |
|                       | that includes the information shown below.   |
|                       | Use a separate claim form for each family    |
|                       | member. For long or continuing hospital      |
|                       | stays, or other long-term care, you should   |
|                       | submit claims at least every 30 days. Bills  |
|                       | and receipts should be itemized and show:    |
+-----------------------+----------------------------------------------+
|                       |                                              |
+-----------------------+----------------------------------------------+
|                       | -   Name of patient and relationship to      |
|                       |     enrollee;                                |
+-----------------------+----------------------------------------------+
|                       |                                              |
+-----------------------+----------------------------------------------+
|                       | -   Plan identification number of the        |
|                       |     enrollee;                                |
+-----------------------+----------------------------------------------+
|                       |                                              |
+-----------------------+----------------------------------------------+
|                       | -   Name and address of person or firm       |
|                       |     providing the service or supply;         |
+-----------------------+----------------------------------------------+
|                       |                                              |
+-----------------------+----------------------------------------------+
|                       | -   Dates that services or supplies were     |
|                       |     furnished;                               |
+-----------------------+----------------------------------------------+
|                       |                                              |
+-----------------------+----------------------------------------------+
|                       | -   Diagnosis;                               |
+-----------------------+----------------------------------------------+
|                       |                                              |
+-----------------------+----------------------------------------------+
|                       | -   Type of each service or supply; and      |
+-----------------------+----------------------------------------------+
|                       |                                              |
+-----------------------+----------------------------------------------+
|                       | -   The charge for each service or supply.   |
+-----------------------+----------------------------------------------+
|                       |                                              |
+-----------------------+----------------------------------------------+
|                       | ***Note:*** Canceled checks, cash register   |
|                       | receipts, balance due statements, or bills   |
|                       | you prepare yourself are not acceptable      |
|                       | substitutes for itemized bills.              |
+-----------------------+----------------------------------------------+
|                       |                                              |
+-----------------------+----------------------------------------------+
|                       | In addition:                                 |
+-----------------------+----------------------------------------------+
|                       |                                              |
+-----------------------+----------------------------------------------+
|                       | -   You must send a copy of the explanation  |
|                       |     of benefits (EOB) form from any primary  |
|                       |     payer \[such as the Medicare Summary     |
|                       |     Notice (MSN)\] with your claim.          |
+-----------------------+----------------------------------------------+
|                       |                                              |
+-----------------------+----------------------------------------------+
|                       | -   Bills for home nursing care must show    |
|                       |     that the nurse is a registered or        |
|                       |     licensed practical nurse.                |
+-----------------------+----------------------------------------------+
|                       |                                              |
+-----------------------+----------------------------------------------+
|                       | -   Claims for rental or purchase of durable |
|                       |     medical equipment, private duty nursing, |
|                       |     and physical, occupational, and speech   |
|                       |     therapy, require a written statement     |
|                       |     from the physician specifying the        |
|                       |     medical necessity for the service or     |
|                       |     supply and the length of time needed.    |
+-----------------------+----------------------------------------------+
|                       |                                              |
+-----------------------+----------------------------------------------+
|                       | -   Claims for prescription drugs and        |
|                       |     supplies that are not received from the  |
|                       |     Retail Pharmacy Program, through a       |
|                       |     Preferred internet pharmacy, or through  |
|                       |     the Mail Service Prescription Drug       |
|                       |     Program must include receipts that show  |
|                       |     the prescription number, name of drug or |
|                       |     supply, prescribing physician\'s name,   |
|                       |     date, and charge. (See below for         |
|                       |     information on how to obtain benefits    |
|                       |     from the Retail Pharmacy Program, a      |
|                       |     Preferred internet pharmacy, and the     |
|                       |     Mail Service Prescription Drug Program.) |
+-----------------------+----------------------------------------------+
|                       |                                              |
+-----------------------+----------------------------------------------+

+-----------------------+----------------------------------------------+
| **Prescription drug   | > **Preferred Retail/Internet Pharmacies     |
| claims**              | > --** When you use Preferred retail         |
|                       | > pharmacies, show your Service Benefit Plan |
|                       | > ID card. Preferred retail pharmacies will  |
|                       | > file your claims for you. To use Preferred |
|                       | > internet pharmacies, go to our special Web |
|                       | > site,                                      |
|                       | >                                            |
|                       |  [www.fepblue.org](http://www.fepblue.org/), |
|                       | > click on \"Pharmacy Programs,\" and follow |
|                       | > the FEP Retail Pharmacy Providers link to  |
|                       | > fill your prescriptions and receive home   |
|                       | > delivery. Be sure to have your Service     |
|                       | > Benefit Plan ID card ready to complete     |
|                       | > your purchase. We reimburse the Preferred  |
|                       | > retail or internet pharmacy for your       |
|                       | > covered drugs and supplies. You pay the    |
|                       | > applicable coinsurance or copayment.       |
+-----------------------+----------------------------------------------+
|                       |                                              |
+-----------------------+----------------------------------------------+
|                       | ***Note:*** Even if you use Preferred        |
|                       | pharmacies, you will have to file a paper    |
|                       | claim form to obtain reimbursement if:       |
+-----------------------+----------------------------------------------+
|                       |                                              |
+-----------------------+----------------------------------------------+
|                       | -   You do not have a valid Service Benefit  |
|                       |     Plan ID card;                            |
+-----------------------+----------------------------------------------+
|                       |                                              |
+-----------------------+----------------------------------------------+
|                       | -   You do not use your valid Service        |
|                       |     Benefit Plan ID card at the time of      |
|                       |     purchase; or                             |
+-----------------------+----------------------------------------------+
|                       |                                              |
+-----------------------+----------------------------------------------+
|                       | -   You did not obtain prior approval when   |
|                       |     required (see page 15).                  |
+-----------------------+----------------------------------------------+
|                       |                                              |
+-----------------------+----------------------------------------------+
|                       | See the following paragraph for claim filing |
|                       | instructions.                                |
+-----------------------+----------------------------------------------+
|                       |                                              |
+-----------------------+----------------------------------------------+
|                       | **Non-Preferred Retail/Internet Pharmacies** |
+-----------------------+----------------------------------------------+
|                       |                                              |
+-----------------------+----------------------------------------------+
|                       | **Standard Option:** You must file a paper   |
|                       | claim for any covered drugs or supplies you  |
|                       | purchase at Non-preferred retail or internet |
|                       | pharmacies. Contact your Local Plan or call  |
|                       | 1-800-624-5060 to request a retail           |
|                       | prescription drug claim form to claim        |
|                       | benefits. Hearing-impaired members with TDD  |
|                       | equipment may call 1-800-624-5077. Follow    |
|                       | the instructions on the prescription drug    |
|                       | claim form and submit the completed form to: |
|                       | Blue Cross and Blue Shield Service Benefit   |
|                       | Plan Retail Pharmacy Program,                |
|                       |                                              |
|                       | P.O. Box 52057, Phoenix, AZ 85072-2057.      |
+-----------------------+----------------------------------------------+
|                       |                                              |
+-----------------------+----------------------------------------------+
|                       | **Basic Option:** There are **no benefits**  |
|                       | for drugs or supplies purchased at           |
|                       | Non-preferred retail or internet pharmacies. |
+-----------------------+----------------------------------------------+
|                       |                                              |
+-----------------------+----------------------------------------------+
|                       | **Mail Service Prescription Drug Program**   |
+-----------------------+----------------------------------------------+
|                       |                                              |
+-----------------------+----------------------------------------------+
|                       | **Standard Option:** We will send you        |
|                       | information on our Mail Service Prescription |
|                       | Drug Program, including an initial mail      |
|                       | order form. To use this program:             |
+-----------------------+----------------------------------------------+
|                       |                                              |
+-----------------------+----------------------------------------------+
|                       | 1)  Complete the initial mail order form;    |
+-----------------------+----------------------------------------------+
|                       |                                              |
+-----------------------+----------------------------------------------+
|                       | 2)  Enclose your prescription and copayment; |
+-----------------------+----------------------------------------------+
|                       |                                              |
+-----------------------+----------------------------------------------+
|                       | 3)  Mail your order to Medco Health          |
|                       |     Solutions, Inc., P.O. Box 30492, Tampa,  |
|                       |     FL 33633-0144; and                       |
+-----------------------+----------------------------------------------+
|                       |                                              |
+-----------------------+----------------------------------------------+
|                       | 4)  Allow approximately two weeks for        |
|                       |     delivery.                                |
+-----------------------+----------------------------------------------+
|                       |                                              |
+-----------------------+----------------------------------------------+
|                       | Alternatively, your physician may call in    |
|                       | your initial prescription at 1-800-262-7890  |
|                       | (TDD: 1-800-446-7292). You will be billed    |
|                       | later for the copayment.                     |
+-----------------------+----------------------------------------------+
|                       |                                              |
+-----------------------+----------------------------------------------+
|                       | After that, to order refills either call the |
|                       | same number or access our Web site at        |
|                       | [www.fepblue.org](http://www.fepblue.org/)   |
|                       | and either charge your copayment to your     |
|                       | credit card or have it billed to you later.  |
|                       | Allow approximately one week for delivery on |
|                       | refills.                                     |
+-----------------------+----------------------------------------------+
|                       |                                              |
+-----------------------+----------------------------------------------+
|                       | **Basic Option:** The Mail Service           |
|                       | Prescription Drug Program **is not**         |
|                       | available under Basic Option.                |
+-----------------------+----------------------------------------------+
|                       |                                              |
+-----------------------+----------------------------------------------+

  ------------------------ ----------------------------------------------
  **Records**              Keep a separate record of the medical expenses
                           of each covered family member, because
                           deductibles (under Standard Option) and
                           benefit maximums (such as those for outpatient
                           physical therapy or preventive dental care),
                           apply separately to each person. Save copies
                           of all medical bills, including those you
                           accumulate to satisfy a deductible under
                           Standard Option. In most instances they will
                           serve as evidence of your claim. We will not
                           provide duplicate or year-end statements.

                           

  **Deadline for filing    Send us your claim and appropriate
  your claim**             documentation as soon as possible. You must
                           submit the claim by December 31 of the year
                           after the year you received the service,
                           unless timely filing was prevented by
                           administrative operations of Government or
                           legal incapacity, provided you submitted the
                           claim as soon as reasonably possible. If we
                           return a claim or part of a claim for
                           additional information, you must resubmit it
                           within 90 days, or before the timely filing
                           period expires, whichever is later.

                           

                           ***Note:*** Once we pay benefits, there is a
                           three-year limitation on the reissuance of
                           uncashed checks.

                           

  **Overseas claims**      Please refer to the claims filing information
                           on pages 94 and 95 of this brochure.

                           

                           Please reply promptly when we ask for
                           additional information. We may delay
                           processing or deny your claim if you do not
                           respond.

  **When we need more      
  information**            

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

+---+------------------------------------------------------------------+
| S |                                                                  |
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+---+------------------------------------------------------------------+
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| i |                                                                  |
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| i |                                                                  |
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| a |                                                                  |
| t |                                                                  |
| i |                                                                  |
| o |                                                                  |
| n |                                                                  |
| o |                                                                  |
| r |                                                                  |
| p |                                                                  |
| r |                                                                  |
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| o |                                                                  |
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| : |                                                                  |
+---+------------------------------------------------------------------+
| * | **Description**                                                  |
| * |                                                                  |
| S |                                                                  |
| t |                                                                  |
| e |                                                                  |
| p |                                                                  |
| * |                                                                  |
| * |                                                                  |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
| * | Ask us in writing to reconsider our initial decision. Write to   |
| * | us at the address shown on your explanation of benefits (EOB)    |
| 1 | form. You must:                                                  |
| * |                                                                  |
| * |                                                                  |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | (a) Write to us within 6 months from the date of our decision;   |
|   |     and                                                          |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | (b) Send your request to us at the address shown on your         |
|   |     explanation of benefits (EOB) form for the Local Plan that   |
|   |     processed the claim (or, for Prescription drug benefits, our |
|   |     Retail Pharmacy Program or Mail Service Prescription Drug    |
|   |     Program); and                                                |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | (c) Include a statement about why you believe our initial        |
|   |     decision was wrong, based on specific benefit provisions in  |
|   |     this brochure; and                                           |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | (d) Include copies of documents that support your claim, such as |
|   |     physicians\' letters, operative reports, bills, medical      |
|   |     records, and explanation of benefits (EOB) forms.            |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
| * | We have 30 days from the date we receive your request to:        |
| * |                                                                  |
| 2 |                                                                  |
| * |                                                                  |
| * |                                                                  |
+---+------------------------------------------------------------------+
|   | (a) Pay the claim (or, if applicable, precertify your hospital   |
|   |     stay or grant your request for prior approval for a service, |
|   |     drug, or supply); or                                         |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | (b) Write to you and maintain our denial -- go to step 4; or     |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | (c) Ask you or your provider for more information. If we ask     |
|   |     your provider, we will send you a copy of our request -- go  |
|   |     to step 3.                                                   |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
| * | You or your provider must send the information so that we        |
| * | receive it within 60 days of our request. We will then decide    |
| 3 | within 30 more days.                                             |
| * |                                                                  |
| * |                                                                  |
+---+------------------------------------------------------------------+
|   | If we do not receive the information within 60 days, we will     |
|   | decide within 30 days of the date the information was due. We    |
|   | will base our decision on the information we already have.       |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | We will write to you with our decision.                          |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
| * | If you do not agree with our decision, you may ask OPM to review |
| * | it.                                                              |
| 4 |                                                                  |
| * |                                                                  |
| * |                                                                  |
+---+------------------------------------------------------------------+
|   | You must write to OPM within:                                    |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | -   90 days after the date of our letter upholding our initial   |
|   |     decision; or                                                 |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | -   120 days after you first wrote to us -- if we did not answer |
|   |     that request in some way within 30 days; or                  |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | -   120 days after we asked for additional information -- if we  |
|   |     did not send you a decision within 30 days after we received |
|   |     the additional information.                                  |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | Write to OPM at: United States Office of Personnel Management,   |
|   | Insurance Services Programs, Health Insurance Group 1, 1900 E    |
|   | Street, NW, Washington, DC 20415-3610.                           |
+---+------------------------------------------------------------------+

***The disputed claims process (continued)***

+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | Send OPM the following information:                              |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | -   A statement about why you believe our decision was wrong,    |
|   |     based on specific benefit provisions in this brochure;       |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | -   Copies of documents that support your claim, such as         |
|   |     physicians\' letters, operative reports, bills, medical      |
|   |     records, and explanation of benefits (EOB) forms;            |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | -   Copies of all letters you sent to us about the claim;        |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | -   Copies of all letters we sent to you about the claim; and    |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | -   Your daytime phone number and the best time to call.         |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | ***Note:*** If you want OPM to review more than one claim, you   |
|   | must clearly identify which documents apply to which claim.      |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | ***Note:*** You are the only person who has a right to file a    |
|   | disputed claim with OPM. Parties acting as your representative,  |
|   | such as medical providers, must include a copy of your specific  |
|   | written consent with the review request.                         |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | ***Note:*** The above deadlines may be extended if you show that |
|   | you were unable to meet the deadline because of reasons beyond   |
|   | your control.                                                    |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
| * | OPM will review your disputed claim request and will use the     |
| * | information it collects from you and us to decide whether our    |
| 5 | decision is correct. OPM will determine if we correctly applied  |
| * | the terms of our contract when we denied your claim or request   |
| * | for service. OPM will send you a final decision within 60 days.  |
|   | There are no other administrative appeals.                       |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
| > |                                                                  |
|   |                                                                  |
| I |                                                                  |
| f |                                                                  |
| > |                                                                  |
|   |                                                                  |
| y |                                                                  |
| o |                                                                  |
| u |                                                                  |
| > |                                                                  |
|   |                                                                  |
| d |                                                                  |
| o |                                                                  |
| > |                                                                  |
|   |                                                                  |
| n |                                                                  |
| o |                                                                  |
| t |                                                                  |
| > |                                                                  |
|   |                                                                  |
| a |                                                                  |
| g |                                                                  |
| r |                                                                  |
| e |                                                                  |
| e |                                                                  |
| > |                                                                  |
|   |                                                                  |
| w |                                                                  |
| i |                                                                  |
| t |                                                                  |
| h |                                                                  |
| > |                                                                  |
|   |                                                                  |
| O |                                                                  |
| P |                                                                  |
| M |                                                                  |
| \ |                                                                  |
| ' |                                                                  |
| s |                                                                  |
| > |                                                                  |
|   |                                                                  |
| d |                                                                  |
| e |                                                                  |
| c |                                                                  |
| i |                                                                  |
| s |                                                                  |
| i |                                                                  |
| o |                                                                  |
| n |                                                                  |
| , |                                                                  |
| > |                                                                  |
|   |                                                                  |
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+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
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|   |                                                                  |
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| : |                                                                  |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | -   If we expedite our review and maintain our denial, we will   |
|   |     inform OPM so that they can give your claim expedited        |
|   |     treatment too, or                                            |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | -   You may call OPM\'s Health Insurance Group 1 at              |
|   |     1-202-606-0727 between 8 a.m. and 5 p.m. eastern time.       |
+---+------------------------------------------------------------------+

+----------------------+-----------------------------------------------+
| Section 9.           |                                               |
| Coordinating         |                                               |
| benefits with other  |                                               |
| coverage             |                                               |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
| When you have other  | You must tell us if you or a covered family   |
|                      | member has coverage under another group       |
| health coverage      | health plan or have automobile insurance that |
|                      | pays health care expenses without regard to   |
|                      | fault. This is called \"double coverage.\"    |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | When you have double coverage, one plan       |
|                      | normally pays its benefits in full as the     |
|                      | primary payer and the other plan pays a       |
|                      | reduced benefit as the secondary payer. We,   |
|                      | like other insurers, determine which coverage |
|                      | is primary according to the National          |
|                      | Association of Insurance Commissioners\'      |
|                      | guidelines. For example:                      |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | -   If you are covered under our Plan as a    |
|                      |     dependent, any group health insurance you |
|                      |     have from your employer will pay primary  |
|                      |     and we will pay secondary.                |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | -   If you are an annuitant under our Plan    |
|                      |     and also are actively employed, any group |
|                      |     health insurance you have from your       |
|                      |     employer will pay primary and we will pay |
|                      |     secondary.                                |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | -   When you are entitled to the payment of   |
|                      |     health care expenses under automobile     |
|                      |     insurance, including no-fault insurance   |
|                      |     and other insurance that pays without     |
|                      |     regard to fault, your automobile          |
|                      |     insurance is the primary payer and we are |
|                      |     the secondary payer.                      |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | When we are the primary payer, we will pay    |
|                      | the benefits described in this brochure.      |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | When we are the secondary payer, we will      |
|                      | determine our allowance. After the primary    |
|                      | plan pays, we will pay what is left of our    |
|                      | allowance, up to our regular benefit. We will |
|                      | not pay more than our allowance. For example, |
|                      | we will generally only make up the difference |
|                      | between the primary payer\'s benefits payment |
|                      | and 100% of the Plan allowance, subject to    |
|                      | our applicable deductible (under Standard     |
|                      | Option) and coinsurance or copayment amounts, |
|                      | except when Medicare is the primary payer     |
|                      | (see Section 4). Thus, it is possible that    |
|                      | the combined payments from both plans may not |
|                      | equal the entire amount billed by the         |
|                      | provider.                                     |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | ***Note:*** When we pay secondary to primary  |
|                      | coverage you have from a prepaid plan (HMO),  |
|                      | we base our benefits on your out-of-pocket    |
|                      | liability under the prepaid plan (generally,  |
|                      | the prepaid plan\'s copayments), subject to   |
|                      | our deductible (under Standard Option) and    |
|                      | coinsurance or copayment amounts.             |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | In certain circumstances when we are          |
|                      | secondary and there is no adverse effect on   |
|                      | you (that is, you do not pay any more), we    |
|                      | may also take advantage of any provider       |
|                      | discount arrangements your primary plan may   |
|                      | have and only make up the difference between  |
|                      | the primary plan\'s payment and the amount    |
|                      | the provider has agreed to accept as payment  |
|                      | in full from the primary plan.                |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | ***Note:*** Any visit limitations that apply  |
|                      | to your care under this Plan are still in     |
|                      | effect when we are the secondary payer.       |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | Remember: Even if you do not file a claim     |
|                      | with your other plan, you must still tell us  |
|                      | that you have double coverage, and you must   |
|                      | also send us documents about your other       |
|                      | coverage if we ask for them.                  |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
| What is Medicare?    | Medicare is a health insurance program for:   |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | -   People 65 years of age and older.         |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | -   Some people with disabilities, under 65   |
|                      |     years of age.                             |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | -   People with End Stage Renal Disease       |
|                      |     (permanent kidney failure requiring       |
|                      |     dialysis or a transplant).                |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+

+----------------------+-----------------------------------------------+
|                      | Medicare has two parts:                       |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | -   Part A (Hospital Insurance). Most people  |
|                      |     do not have to pay for Part A. If you or  |
|                      |     your spouse worked for at least 10 years  |
|                      |     in Medicare-covered employment, you       |
|                      |     should be able to qualify for             |
|                      |     premium-free Part A insurance. (Someone   |
|                      |     who was a Federal employee on January 1,  |
|                      |     1983 or since automatically qualifies.)   |
|                      |     Otherwise, if you are age 65 or older,    |
|                      |     you may be able to buy it. Contact        |
|                      |     1-800-MEDICARE for more information.      |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | -   Part B (Medical Insurance). Most people   |
|                      |     pay monthly for Part B. Generally, Part B |
|                      |     premiums are withheld from your monthly   |
|                      |     Social Security check or your retirement  |
|                      |     check*.*                                  |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | If you are eligible for Medicare, you may     |
|                      | have choices in how you get your health care. |
|                      | Medicare + Choice is the term used to         |
|                      | describe the various health plan choices      |
|                      | available to Medicare beneficiaries. The      |
|                      | information in the next few pages shows how   |
|                      | we coordinate benefits with Medicare,         |
|                      | depending on the type of Medicare + Choice    |
|                      | plan you have.                                |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
| -   **The Original   | The Original Medicare Plan (Original          |
|     Medicare Plan**  | Medicare) is available everywhere in the      |
|                      | United States. It is the way everyone used to |
| **(Part A or Part    | get Medicare benefits and is the way most     |
| B)**                 | people get their Medicare Part A and Part B   |
|                      | benefits now. You may go to any doctor,       |
|                      | specialist, or hospital that accepts          |
|                      | Medicare. The Original Medicare Plan pays its |
|                      | share and you pay your share. Some things are |
|                      | not covered under the Original Medicare Plan, |
|                      | such as most prescription drugs.              |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | When you are enrolled in Original Medicare    |
|                      | along with this Plan, you still need to       |
|                      | follow the rules in this brochure for us to   |
|                      | cover your care. For example, you must        |
|                      | continue to obtain prior approval for some    |
|                      | prescription drugs and organ/tissue           |
|                      | transplants before we will pay benefits.      |
|                      | However, you do not have to precertify        |
|                      | inpatient hospital stays when Medicare Part A |
|                      | is primary (see page 14 for exception).       |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | **Claims process when you have the Original   |
|                      | Medicare Plan --** You probably will never    |
|                      | have to file a claim form when you have both  |
|                      | our Plan and the Original Medicare Plan.      |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | -   When we are the primary payer, we process |
|                      |     the claim first.                          |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | -   When the Original Medicare Plan is the    |
|                      |     primary payer, Medicare processes your    |
|                      |     claim first. In most cases, your claims   |
|                      |     will be coordinated automatically and we  |
|                      |     will then provide secondary benefits for  |
|                      |     the covered charges. You will not need to |
|                      |     do anything. To find out if you need to   |
|                      |     do something to file your claims, call us |
|                      |     at the customer service number on the     |
|                      |     back of your Service Benefit Plan ID card |
|                      |     or visit our Web site at                  |
|                      |                                               |
|                      |   [www.fepblue.org](http://www.fepblue.org/). |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+

+----------------------+-----------------------------------------------+
|                      | **We waive some costs if the Original         |
|                      | Medicare Plan is your primary payer --** We   |
|                      | will waive some out-of-pocket costs as        |
|                      | follows:                                      |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | **When Medicare Part A is primary** **--**    |
+----------------------+-----------------------------------------------+
|                      | -   Under **Standard Option**, we will waive  |
|                      |     our:                                      |
|                      |                                               |
|                      | ```{=html}                                    |
|                      | <!-- -->                                      |
|                      | ```                                           |
|                      | -   Inpatient hospital per-admission          |
|                      |     copayments;                               |
|                      |                                               |
|                      | -   Inpatient Non-member hospital             |
|                      |     coinsurance; and                          |
|                      |                                               |
|                      | -   Non-Preferred inpatient per-day           |
|                      |     copayments for mental                     |
|                      |     conditions/substance abuse care.          |
|                      |                                               |
|                      | ```{=html}                                    |
|                      | <!-- -->                                      |
|                      | ```                                           |
|                      | -   Under **Basic Option**, we will waive     |
|                      |     our:                                      |
|                      |                                               |
|                      | ```{=html}                                    |
|                      | <!-- -->                                      |
|                      | ```                                           |
|                      | -   Inpatient hospital per-day copayments.    |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | ***Note:*** Once you have exhausted your      |
|                      | Medicare Part A benefits, we become primary.  |
+----------------------+-----------------------------------------------+
|                      | -   Under **Standard Option**, you must then  |
|                      |     pay any difference between our allowance  |
|                      |     and the billed amount at Non-member       |
|                      |     hospitals.                                |
|                      |                                               |
|                      | -   Under **Basic Option**, you must then pay |
|                      |     the inpatient hospital per-day            |
|                      |     copayments.                               |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | **When Medicare Part B is primary --**        |
+----------------------+-----------------------------------------------+
|                      | -   Under **Standard Option**, we will waive  |
|                      |     our:                                      |
|                      |                                               |
|                      | ```{=html}                                    |
|                      | <!-- -->                                      |
|                      | ```                                           |
|                      | -   Calendar year deductible;                 |
|                      |                                               |
|                      | -   Coinsurance for services and supplies     |
|                      |     provided by physicians and other covered  |
|                      |     health care professionals (inpatient and  |
|                      |     outpatient, including mental conditions   |
|                      |     and substance abuse care);                |
|                      |                                               |
|                      | -   Copayments for office visits to Preferred |
|                      |     physicians and other health care          |
|                      |     professionals;                            |
|                      |                                               |
|                      | -   Copayments for routine physical           |
|                      |     examinations and preventive (screening)   |
|                      |     services performed by Preferred           |
|                      |     physicians, other health care             |
|                      |     professionals, and facilities; and        |
|                      |                                               |
|                      | -   Outpatient facility coinsurance for       |
|                      |     medical, surgical, preventive, and mental |
|                      |     conditions and substance abuse care.      |
|                      |                                               |
|                      | ```{=html}                                    |
|                      | <!-- -->                                      |
|                      | ```                                           |
|                      | -   Under **Basic Option**, we will waive     |
|                      |     our:                                      |
|                      |                                               |
|                      | ```{=html}                                    |
|                      | <!-- -->                                      |
|                      | ```                                           |
|                      | -   Copayments and coinsurance for care       |
|                      |     received from covered professional and    |
|                      |     facility providers.                       |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | ***Note:*** We do not waive benefit           |
|                      | limitations, such as the 25-visit limit for   |
|                      | home nursing visits. In addition, we do not   |
|                      | waive any coinsurance or copayments for       |
|                      | prescription drugs.                           |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
| -   Tell us about    | You must tell us if you or a covered family   |
|     your             | member has Medicare coverage, and let us      |
|                      | obtain information about services denied or   |
| > Medicare coverage  | paid under Medicare if we ask. You must also  |
|                      | tell us about other coverage you or your      |
|                      | covered family members may have, as this      |
|                      | coverage may affect the primary/secondary     |
|                      | status of this Plan and Medicare.             |
+----------------------+-----------------------------------------------+

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

+----------------------------------------------------+------+----------+
| **Primary Payer Chart**                            |      |          |
+----------------------------------------------------+------+----------+
| **A. When you − or your covered spouse − are age   | *    |          |
| 65 or over and have Medicare and you. . .**        | *The |          |
|                                                    | pri  |          |
|                                                    | mary |          |
|                                                    | p    |          |
|                                                    | ayer |          |
|                                                    | for  |          |
|                                                    | the  |          |
|                                                    | in   |          |
|                                                    | divi |          |
|                                                    | dual |          |
|                                                    | with |          |
|                                                    | Medi |          |
|                                                    | care |          |
|                                                    | is.  |          |
|                                                    | .    |          |
|                                                    | .**  |          |
+----------------------------------------------------+------+----------+
|                                                    | **Me | **This   |
|                                                    | dica | Plan**   |
|                                                    | re** |          |
+----------------------------------------------------+------+----------+
| 1\) Are an active employee with the Federal        |      |          |
| government and**...**                              |      |          |
|                                                    |      |          |
| > • You have FEHB coverage on your own or through  |      |          |
| > your spouse who is also an active employee       |      |          |
+----------------------------------------------------+------+----------+
| > • You have FEHB coverage through your spouse who |      |          |
| > is an annuitant                                  |      |          |
+----------------------------------------------------+------+----------+
| 2\) Are an annuitant and**...**                    |      |          |
|                                                    |      |          |
| > • You have FEHB coverage on your own or through  |      |          |
| > your spouse who is also an annuitant             |      |          |
+----------------------------------------------------+------+----------+
| > • You have FEHB coverage through your spouse who |      |          |
| > is an active employee                            |      |          |
+----------------------------------------------------+------+----------+
| 3\) Are a reemployed annuitant with the Federal    | \*   |          |
| government and your position is excluded from the  |      |          |
| FEHB (your employing office will know if this is   |      |          |
| the case)                                          |      |          |
+----------------------------------------------------+------+----------+
| 4\) Are a reemployed annuitant with the Federal    |      |          |
| government and your position is not excluded from  |      |          |
| the FEHB (your employing office will know if this  |      |          |
| is the case) and**...**                            |      |          |
|                                                    |      |          |
| > • You have FEHB coverage on your own or through  |      |          |
| > your spouse who is also an active employee       |      |          |
+----------------------------------------------------+------+----------+
| > • You have FEHB coverage through your spouse who |      |          |
| > is an annuitant                                  |      |          |
+----------------------------------------------------+------+----------+
| 5\) Are a Federal judge who retired under title    | \*   |          |
| 28, U.S.C., or a Tax Court judge who retired under |      |          |
| Section 7447 of title 26, U.S.C. (or if your       |      |          |
| covered spouse is this type of judge)              |      |          |
+----------------------------------------------------+------+----------+
| 6\) Are enrolled in Part B only, regardless of     | for  | for      |
| your employment status                             | Part | other    |
|                                                    | B    | services |
|                                                    | serv |          |
|                                                    | ices |          |
+----------------------------------------------------+------+----------+
| 7\) Are a former Federal employee receiving        | \*\* |          |
| Workers\' Compensation and the Office of Workers\' |      |          |
| Compensation Programs has determined that you are  |      |          |
| unable to return to duty                           |      |          |
+----------------------------------------------------+------+----------+
| **B. When you or a covered family member...**      |      |          |
+----------------------------------------------------+------+----------+
| 1\) Have Medicare solely based on end stage renal  |      |          |
| disease (ESRD) and**...**                          |      |          |
|                                                    |      |          |
| > • It is within the first 30 months of            |      |          |
| > eligibility for or entitlement to Medicare due   |      |          |
| > to ESRD                                          |      |          |
| >                                                  |      |          |
| > (30-month coordination period)                   |      |          |
+----------------------------------------------------+------+----------+
| > • It is beyond the 30-month coordination period  |      |          |
| > and you or a family member are still entitled to |      |          |
| > Medicare due to ESRD                             |      |          |
+----------------------------------------------------+------+----------+
| 2\) Become eligible for Medicare due to ESRD while |      | for the  |
| already a Medicare beneficiary and**...**          |      | 30-month |
|                                                    |      | coor     |
| > • This Plan was the primary payer before         |      | dination |
| > eligibility due to ESRD                          |      | period   |
+----------------------------------------------------+------+----------+
| > • Medicare was the primary payer before          |      |          |
| > eligibility due to ESRD                          |      |          |
+----------------------------------------------------+------+----------+
| **C. When either you or your spouse are eligible   |      |          |
| for Medicare solely due to disability and you**    |      |          |
+----------------------------------------------------+------+----------+
| 1\) Are an active employee with the Federal        |      |          |
| government and**...**                              |      |          |
|                                                    |      |          |
| > • You have FEHB coverage on your own or through  |      |          |
| > your spouse who is also an active employee       |      |          |
+----------------------------------------------------+------+----------+
| > • You have FEHB coverage through your spouse who |      |          |
| > is an annuitant                                  |      |          |
+----------------------------------------------------+------+----------+
| 2\) Are an annuitant and**...**                    |      |          |
|                                                    |      |          |
| > • You have FEHB coverage on your own or through  |      |          |
| > your spouse who is also an annuitant             |      |          |
+----------------------------------------------------+------+----------+
| > • You have FEHB coverage through your spouse who |      |          |
| > is an active employee                            |      |          |
+----------------------------------------------------+------+----------+
| **D. When you are covered under the FEHB Spouse    |      |          |
| Equity provision as a former spouse**              |      |          |
+----------------------------------------------------+------+----------+

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

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

+----------------------+-----------------------------------------------+
| **Medicare +         | If you are eligible for Medicare, you may     |
| Choice**             | choose to enroll in and get your Medicare     |
|                      | benefits from a Medicare + Choice plan. These |
|                      | are health care choices (like HMOs) in some   |
|                      | areas of the country. In most Medicare +      |
|                      | Choice plans, you can only go to doctors,     |
|                      | specialists, or hospitals that are part of    |
|                      | the plan. Medicare + Choice plans provide all |
|                      | the benefits that Original Medicare covers.   |
|                      | Some cover extras, like prescription drugs.   |
|                      | To learn more about enrolling in a Medicare + |
|                      | Choice plan, contact Medicare at              |
|                      | 1-800-MEDICARE (1-800-633-4227) or at         |
|                      | [www.medicare.gov](http://www.medicare.gov/). |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | If you enroll in a Medicare + Choice plan,    |
|                      | the following options are available to you:   |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | **This Plan and another plan\'s Medicare +    |
|                      | Choice plan:** You may enroll in another      |
|                      | plan\'s Medicare + Choice plan and also       |
|                      | remain enrolled in our FEHB Plan. If you      |
|                      | enroll in a Medicare + Choice plan, tell us.  |
|                      | We will need to know whether you are in the   |
|                      | Original Medicare Plan or in a Medicare +     |
|                      | Choice plan so we can correctly coordinate    |
|                      | benefits with Medicare.                       |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | Under Standard Option, we will still provide  |
|                      | benefits when your Medicare + Choice plan is  |
|                      | primary, even out of the Medicare + Choice    |
|                      | plan\'s network and/or service area, but we   |
|                      | will not waive any of our copayments,         |
|                      | coinsurance, or deductibles, if you receive   |
|                      | services from providers who do not            |
|                      | participate in the Medicare + Choice plan.    |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | Under Basic Option, we provide benefits for   |
|                      | care received from Preferred providers when   |
|                      | your Medicare + Choice plan is primary, even  |
|                      | out of the Medicare + Choice plan\'s network  |
|                      | and/or service area. However, we will not     |
|                      | waive any of our copayments or coinsurance    |
|                      | for services you receive from Preferred       |
|                      | providers who do not participate in the       |
|                      | Medicare + Choice plan. Please remember that  |
|                      | you must receive care from Preferred          |
|                      | providers in order to receive Basic Option    |
|                      | benefits. See page 12 for the exceptions to   |
|                      | this requirement.                             |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | **Suspended FEHB coverage to enroll in a      |
|                      | Medicare + Choice** **plan:** If you are an   |
|                      | annuitant or former spouse, you can suspend   |
|                      | your FEHB coverage and enroll in a Medicare + |
|                      | Choice plan, eliminating your FEHB premium.   |
|                      | (OPM does not contribute to your Medicare +   |
|                      | Choice plan premium.) For information on      |
|                      | suspending your FEHB enrollment, contact your |
|                      | retirement office. If you later want to       |
|                      | re-enroll in the FEHB Program, generally you  |
|                      | may do so only at the next Open Season unless |
|                      | you involuntarily lose coverage or move out   |
|                      | of the Medicare + Choice plan\'s service      |
|                      | area.                                         |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
| -   **Private        | A physician may ask you to sign a private     |
|     contract with    | contract agreeing that you can be billed      |
|     your physician** | directly for services ordinarily covered by   |
|                      | the Original Medicare Plan. Should you sign   |
|                      | an agreement, Medicare will not pay any       |
|                      | portion of the charges, and we will not       |
|                      | increase our payment. We will still limit our |
|                      | payment to the amount we would have paid      |
|                      | after the Original Medicare Plan\'s payment.  |
|                      | You will be responsible for paying the        |
|                      | difference between the billed amount and the  |
|                      | amount we paid.                               |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+

+----------------------+-----------------------------------------------+
| **TRICARE and        | TRICARE is the health care program for        |
| CHAMPVA**            | eligible dependents of military persons and   |
|                      | retirees of the military. TRICARE includes    |
|                      | the CHAMPUS program. CHAMPVA provides health  |
|                      | coverage to disabled Veterans and their       |
|                      | eligible dependents. If TRICARE or CHAMPVA    |
|                      | and this Plan cover you, we pay first. See    |
|                      | your TRICARE or CHAMPVA Health Benefits       |
|                      | Advisor if you have questions about these     |
|                      | programs.                                     |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | **Suspended FEHB coverage to enroll in        |
|                      | TRICARE or CHAMPVA:** If you are an annuitant |
|                      | or former spouse, you can suspend your FEHB   |
|                      | coverage to enroll in one of these programs,  |
|                      | eliminating your FEHB premium. (OPM does not  |
|                      | contribute to any applicable plan premiums.)  |
|                      | For information on suspending your FEHB       |
|                      | enrollment, contact your retirement office.   |
|                      | If you later want to reenroll in the FEHB     |
|                      | Program, generally you may do so only at the  |
|                      | next Open Season unless you involuntarily     |
|                      | lose coverage under these programs.           |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
| **Workers\'          | We do not cover services that:                |
| Compensation**       |                                               |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | -   You need because of a workplace-related   |
|                      |     illness or injury that the Office of      |
|                      |     Workers\' Compensation Programs (OWCP) or |
|                      |     a similar Federal or State agency         |
|                      |     determines they must provide; or          |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | -   OWCP or a similar agency pays for through |
|                      |     a third-party injury settlement or other  |
|                      |     similar proceeding that is based on a     |
|                      |     claim you filed under OWCP or similar     |
|                      |     laws.                                     |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | Once OWCP or a similar agency pays its        |
|                      | maximum benefits for your treatment, we will  |
|                      | cover your care.                              |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
| **Medicaid**         | When you have this Plan and Medicaid, we pay  |
|                      | first.                                        |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | **Suspended FEHB coverage to enroll in        |
|                      | Medicaid or a similar State-sponsored program |
|                      | of medical assistance:** If you are an        |
|                      | annuitant or former spouse, you can suspend   |
|                      | your FEHB coverage to enroll in one of these  |
|                      | State programs, eliminating your FEHB         |
|                      | premium. For information on suspending your   |
|                      | FEHB enrollment, contact your retirement      |
|                      | office. If you later want to re-enroll in the |
|                      | FEHB Program, generally you may do so only at |
|                      | the next Open Season unless you involuntarily |
|                      | lose coverage under the State program.        |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
| **When other         | We do not cover services and supplies when a  |
| Government agencies  | local, State, or Federal Government agency    |
| are responsible for  | directly or indirectly pays for them.         |
| your care**          |                                               |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+

+----------------------+-----------------------------------------------+
| **When others are    | If another person or entity, through an act   |
| responsible**        | or omission, causes you to suffer an injury   |
|                      | or illness, and if we pay benefits for that   |
| **for injuries**     | injury or illness, you must agree to the      |
|                      | following:                                    |
+----------------------+-----------------------------------------------+
|                      | -   All recoveries you obtain (whether by     |
|                      |     lawsuit, settlement, or otherwise), no    |
|                      |     matter how described or designated, must  |
|                      |     be used to reimburse us in full for       |
|                      |     benefits we paid. Our share of any        |
|                      |     recovery extends only to the amount of    |
|                      |     benefits we have paid or will pay to you  |
|                      |     or, if applicable, to your heirs,         |
|                      |     administrators, successors, or assignees. |
+----------------------+-----------------------------------------------+
|                      | -   We will not reduce our share of any       |
|                      |     recovery unless we agree in writing to a  |
|                      |     reduction, (1) because you do not receive |
|                      |     the full amount of damages that you       |
|                      |     claimed or (2) because you had to pay     |
|                      |     attorneys\' fees. This is our right of    |
|                      |     recovery.                                 |
+----------------------+-----------------------------------------------+
|                      | -   If you do not seek damages for your       |
|                      |     illness or injury, you must permit us to  |
|                      |     initiate recovery on your behalf          |
|                      |     (including the right to bring suit in     |
|                      |     your name). This is called subrogation.   |
+----------------------+-----------------------------------------------+
|                      | -   If we pursue a recovery of the benefits   |
|                      |     we have paid, you must cooperate in doing |
|                      |     what is reasonably necessary to assist    |
|                      |     us. You must not take any action that may |
|                      |     prejudice our rights to recover.          |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | You must tell us promptly if you have a claim |
|                      | against another party for a condition that we |
|                      | have paid or may pay benefits for, and you    |
|                      | must tell us about any recoveries you obtain, |
|                      | whether in or out of court. We may seek a     |
|                      | lien on the proceeds of your claim in order   |
|                      | to reimburse ourselves to the full amount of  |
|                      | benefits we have paid or will pay.            |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | We may request that you assign to us (1) your |
|                      | right to bring an action or (2) your right to |
|                      | the proceeds of a claim for your illness or   |
|                      | injury. We may delay processing of your       |
|                      | claims until you provide the assignment.      |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | ***Note:*** We will pay the costs of any      |
|                      | covered services you receive that are in      |
|                      | excess of any recoveries made.                |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | The following are examples of circumstances   |
|                      | in which we may subrogate or assert a right   |
|                      | of recovery:                                  |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | -   When you or your dependent are injured on |
|                      |     premises owned by a third party; or       |
+----------------------+-----------------------------------------------+
|                      | -   When you or your dependent are injured    |
|                      |     and benefits are available to you or your |
|                      |     dependent, under any law or under any     |
|                      |     type of insurance, including, but not     |
|                      |     limited to:                               |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | -   Personal injury protection benefits       |
|                      |                                               |
|                      | -   Uninsured and underinsured motorist       |
|                      |     coverage (does not include no-fault       |
|                      |     automobile insurance)                     |
|                      |                                               |
|                      | -   Workers\' compensation benefits           |
|                      |                                               |
|                      | -   Medical reimbursement coverage            |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | Contact us if you need more information about |
|                      | subrogation.                                  |
+----------------------+-----------------------------------------------+

+----------------------+-----------------------------------------------+
| Section 10.          |                                               |
| Definitions of terms |                                               |
| we use in this       |                                               |
| brochure             |                                               |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
| **Accidental         | An injury caused by an external force or      |
| injury**             | element such as a blow or fall that requires  |
|                      | immediate medical attention, including animal |
|                      | bites and poisonings. ***Note:*** Injuries to |
|                      | the teeth while eating are **not** considered |
|                      | accidental injuries. Dental care for          |
|                      | accidental injury is limited to dental        |
|                      | treatment necessary to repair sound natural   |
|                      | teeth.                                        |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
| **Admission**        | The period from entry (admission) as an       |
|                      | inpatient into a hospital (or other covered   |
|                      | facility) until discharge. In counting days   |
|                      | of inpatient care, the date of entry and the  |
|                      | date of discharge count as the same day.      |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
| **Assignment**       | An authorization by the enrollee or spouse    |
|                      | for us to issue payment of benefits directly  |
|                      | to the provider. We reserve the right to pay  |
|                      | you, the enrollee, directly for all covered   |
|                      | services.                                     |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
| **Calendar year**    | January 1 through December 31 of the same     |
|                      | year. For new enrollees, the calendar year    |
|                      | begins on the effective date of their         |
|                      | enrollment and ends on December 31 of the     |
|                      | same year.                                    |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
| **Carrier**          | The Blue Cross and Blue Shield Association,   |
|                      | on behalf of the local Blue Cross and Blue    |
|                      | Shield Plans.                                 |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
| **Coinsurance**      | Coinsurance is the percentage of our          |
|                      | allowance that you must pay for your care.    |
|                      | You may also be responsible for additional    |
|                      | amounts. See page 16.                         |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
| **Copayment**        | A copayment is a fixed amount of money you    |
|                      | pay when you receive covered services. See    |
|                      | page 16.                                      |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
| **Cosmetic surgery** | Any surgical procedure or any portion of a    |
|                      | procedure performed primarily to improve      |
|                      | physical appearance through change in bodily  |
|                      | form, except for repair of accidental injury, |
|                      | or to restore or correct a part of the body   |
|                      | that has been altered as a result of disease  |
|                      | or surgery or to correct a congenital         |
|                      | anomaly.                                      |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
| **Covered services** | Services we provide benefits for, as          |
|                      | described in this brochure.                   |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
| **Custodial care**   | Treatment or services, regardless of who      |
|                      | recommends them or where they are provided,   |
|                      | that a person not medically skilled could     |
|                      | perform safely and reasonably, or that mainly |
|                      | assist the patient with daily living          |
|                      | activities, such as:                          |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | 1.  Personal care, including help in walking, |
|                      |     getting in and out of bed, bathing,       |
|                      |     eating (by spoon, tube, or gastrostomy),  |
|                      |     exercising, or dressing;                  |
|                      |                                               |
|                      | 2.  Homemaking, such as preparing meals or    |
|                      |     special diets;                            |
|                      |                                               |
|                      | 3.  Moving the patient;                       |
|                      |                                               |
|                      | 4.  Acting as companion or sitter;            |
|                      |                                               |
|                      | 5.  Supervising medication that can usually   |
|                      |     be self-administered; or                  |
|                      |                                               |
|                      | 6.  Treatment or services that any person can |
|                      |     perform with minimal instruction, such as |
|                      |     recording pulse, temperature, and         |
|                      |     respiration; or administration and        |
|                      |     monitoring of feeding systems.            |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | Custodial care that lasts 90 days or more is  |
|                      | sometimes known as Long Term Care. The        |
|                      | Carrier, its medical staff, and/or an         |
|                      | independent medical review determines which   |
|                      | services are custodial care.                  |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
| **Deductible**       | A deductible is a fixed amount of covered     |
|                      | expenses you must incur for certain covered   |
|                      | services and supplies in a calendar year      |
|                      | before we start paying benefits for those     |
|                      | services. See page 16.                        |
+----------------------+-----------------------------------------------+

+----------------------+-----------------------------------------------+
| **Durable medical    | Equipment and supplies that:                  |
| equipment**          |                                               |
+----------------------+-----------------------------------------------+
|                      | 1.  Are prescribed by your physician (i.e.,   |
|                      |     the physician who 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.    |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
| **Experimental or    | A drug, device, or biological product is      |
| investigational      | experimental or investigational if the drug,  |
| services**           | device, or biological product cannot be       |
|                      | lawfully marketed without approval of the     |
|                      | U.S. Food and Drug Administration (FDA); and, |
|                      | approval for marketing has not been given at  |
|                      | the time it is furnished. ***Note:***         |
|                      | Approval means all forms of acceptance by the |
|                      | FDA.                                          |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | A medical treatment or procedure, or a drug,  |
|                      | device, or biological product, is             |
|                      | experimental or investigational if:           |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | 1.  Reliable evidence shows that it is the    |
|                      |     subject of ongoing phase I, II, or III    |
|                      |     clinical trials or under study to         |
|                      |     determine its maximum tolerated dose, its |
|                      |     toxicity, its safety, its efficacy, or    |
|                      |     its efficacy as compared with the         |
|                      |     standard means of treatment or diagnosis; |
|                      |     or                                        |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | 2.  Reliable evidence shows that the          |
|                      |     consensus of opinion among experts        |
|                      |     regarding the drug, device, or biological |
|                      |     product or medical treatment or           |
|                      |     procedure, is that further studies or     |
|                      |     clinical trials are necessary to          |
|                      |     determine its maximum tolerated dose, its |
|                      |     toxicity, its safety, its efficacy, or    |
|                      |     its efficacy as compared with the         |
|                      |     standard means of treatment or diagnosis. |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | > Reliable evidence shall mean only:          |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | -   published reports and articles in the     |
|                      |     authoritative medical and scientific      |
|                      |     literature;                               |
|                      |                                               |
|                      | -   the written protocol or protocols used by |
|                      |     the treating facility or the protocol(s)  |
|                      |     of another facility studying              |
|                      |     substantially the same drug, device, or   |
|                      |     biological product or medical treatment   |
|                      |     or procedure; or                          |
|                      |                                               |
|                      | -   the written informed consent used by the  |
|                      |     treating facility or by another facility  |
|                      |     studying substantially the same drug,     |
|                      |     device, or biological product or medical  |
|                      |     treatment or procedure.                   |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | Each Local Plan has a Medical Review          |
|                      | department that determines whether a claimed  |
|                      | service is experimental or investigational    |
|                      | after consulting with internal or external    |
|                      | experts or nationally recognized guidelines   |
|                      | in a particular field or specialty.           |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | For more detailed information, contact your   |
|                      | Local Plan at the customer service telephone  |
|                      | number located on the back of your Service    |
|                      | Benefit Plan ID card.                         |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
| **Group health       | Health care coverage that you are eligible    |
| coverage**           | for based on your employment, or your         |
|                      | membership in or connection with a particular |
|                      | organization or group, that provides payment  |
|                      | for medical services or supplies, or that     |
|                      | pays a specific amount of more than \$200 per |
|                      | day for hospitalization (including extension  |
|                      | of any of these benefits through COBRA).      |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
| **Intensive          | A comprehensive, structured outpatient        |
| outpatient care**    | treatment program that includes extended      |
|                      | periods of individual or group therapy        |
|                      | sessions designed to assist members with      |
|                      | mental health and/or substance abuse          |
|                      | conditions. It is an intermediate setting     |
|                      | between traditional outpatient therapy and    |
|                      | partial hospitalization, typically performed  |
|                      | in an outpatient facility or outpatient       |
|                      | professional office setting. Program sessions |
|                      | may occur more than one day per week.         |
|                      | Timeframes and frequency will vary based upon |
|                      | diagnosis and severity of illness.            |
+----------------------+-----------------------------------------------+

+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
| **Lifetime maximum** | The maximum amount the Plan will pay on your  |
|                      | behalf for covered services you receive while |
|                      | you are enrolled in your option. Benefit      |
|                      | amounts accrued are accumulated in a          |
|                      | permanent record regardless of the number of  |
|                      | enrollment changes. Please see page 78.       |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
| **Local Plan**       | A Blue Cross and/or Blue Shield Plan that     |
|                      | serves a specific geographic area.            |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
| **Medical            | We determine whether services, drugs,         |
| necessity**          | supplies, or equipment provided by a hospital |
|                      | or other covered provider are:                |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | 1.  Appropriate to prevent, diagnose, or      |
|                      |     treat your condition, illness, or injury; |
|                      |                                               |
|                      | 2.  Consistent with standards of good medical |
|                      |     practice in the United States;            |
|                      |                                               |
|                      | 3.  Not primarily for the personal comfort or |
|                      |     convenience of the patient, the family,   |
|                      |     or the provider;                          |
|                      |                                               |
|                      | 4.  Not part of or associated with scholastic |
|                      |     education or vocational training of the   |
|                      |     patient; and                              |
|                      |                                               |
|                      | 5.  In the case of inpatient care, cannot be  |
|                      |     provided safely on an outpatient basis.   |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | The fact that one of our covered providers    |
|                      | has prescribed, recommended, or approved a    |
|                      | service or supply does not, in itself, make   |
|                      | it medically necessary or covered under this  |
|                      | Plan.                                         |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
| **Mental             | Conditions and diseases listed in the most    |
| conditions/substance | recent edition of the International           |
| abuse**              | Classification of Diseases (ICD) as           |
|                      | psychoses, neurotic disorders, or personality |
|                      | disorders; other nonpsychotic mental          |
|                      | disorders listed in the ICD; or disorders     |
|                      | listed in the ICD requiring treatment for     |
|                      | abuse of, or dependence upon, substances such |
|                      | as alcohol, narcotics, or hallucinogens.      |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
| **Partial            | An intensive facility-based treatment program |
| hospitalization**    | during which an interdisciplinary team        |
|                      | provides care related to mental health and/or |
|                      | substance abuse conditions. Program sessions  |
|                      | may occur more than one day per week and may  |
|                      | be full or half days, evenings, and/or        |
|                      | weekends. The duration of care per session is |
|                      | less than 24 hours. Timeframes and frequency  |
|                      | will vary based upon diagnosis and severity   |
|                      | of illness.                                   |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
| **Plan allowance**   | Our Plan allowance is the amount we use to    |
|                      | determine our payment and your coinsurance    |
|                      | for covered services. Fee-for-service plans   |
|                      | determine their allowances in different ways. |
|                      | If the amount your provider bills for covered |
|                      | services is less than our allowance, we base  |
|                      | our payment, and your share (coinsurance,     |
|                      | deductible, and/or copayments), on the billed |
|                      | amount. We determine our allowance as         |
|                      | follows:                                      |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | -   **PPO providers** **--** Our allowance    |
|                      |     (which we may refer to as the \"PPA\" for |
|                      |     \"Preferred Provider Allowance\") is the  |
|                      |     negotiated amount that Preferred          |
|                      |     providers (hospitals and other            |
|                      |     facilities, physicians, and other covered |
|                      |     health care professionals that contract   |
|                      |     with each local Blue Cross and Blue       |
|                      |     Shield Plan, and retail and internet      |
|                      |     pharmacies that contract with AdvancePCS) |
|                      |     have agreed to accept as payment in full, |
|                      |     when we pay primary benefits.             |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | > Our PPO allowance includes any known        |
|                      | > discounts that can be accurately calculated |
|                      | > at the time your claim is processed. For    |
|                      | > PPO facilities, we sometimes refer to our   |
|                      | > allowance as the \"Preferred rate.\" The    |
|                      | > Preferred rate may be subject to a periodic |
|                      | > adjustment after your claim is processed    |
|                      | > that may decrease or increase the amount of |
|                      | > our payment that is due to the facility.    |
|                      | > However, your cost sharing (if any) does    |
|                      | > not change. If our payment amount is        |
|                      | > decreased, we credit the amount of the      |
|                      | > decrease to the reserves of this Plan. If   |
|                      | > our payment amount is increased, we pay     |
|                      | > that cost on your behalf. (See page 89 for  |
|                      | > special information about limits on the     |
|                      | > amounts Preferred dentists can charge you   |
|                      | > under Standard Option.)                     |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+

+----------------------+-----------------------------------------------+
|                      | -   **Participating providers --** Our        |
|                      |     allowance (which we may refer to as the   |
|                      |     \"PAR\" for \"Participating Provider      |
|                      |     Allowance\") is the negotiated amount     |
|                      |     that these providers (hospitals and other |
|                      |     facilities, physicians, and other covered |
|                      |     health care professionals that contract   |
|                      |     with some local Blue Cross and Blue       |
|                      |     Shield Plans) have agreed to accept as    |
|                      |     payment in full, when we pay primary      |
|                      |     benefits. For facilities, we sometimes    |
|                      |     refer to our allowance as the \"Member    |
|                      |     rate.\" The member rate includes any      |
|                      |     known discounts that can be accurately    |
|                      |     calculated at the time your claim is      |
|                      |     processed, and may be subject to a        |
|                      |     periodic adjustment after your claim is   |
|                      |     processed that may decrease or increase   |
|                      |     the amount of our payment that is due to  |
|                      |     the facility. However, your cost sharing  |
|                      |     (if any) does not change. If our payment  |
|                      |     amount is decreased, we credit the amount |
|                      |     of the decrease to the reserves of this   |
|                      |     Plan. If our payment amount is increased, |
|                      |     we pay that cost on your behalf.          |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | -   **Non-participating providers --** We     |
|                      |     have no agreements with these providers.  |
|                      |     We determine our allowance as follows:    |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | -   For inpatient services by hospitals and   |
|                      |     other facilities that do not contract     |
|                      |     with your local Blue Cross and Blue       |
|                      |     Shield Plan, our allowance is the billed  |
|                      |     charge or the average semiprivate rate    |
|                      |     (e.g., for room and board, and other      |
|                      |     hospital charges) charged for inpatient   |
|                      |     care by similar institutions in the same  |
|                      |     area, as determined by your Local Plan;   |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | -   For outpatient services by hospitals and  |
|                      |     other facilities that do not contract     |
|                      |     with your local Blue Cross and Blue       |
|                      |     Shield Plan, our allowance is the billed  |
|                      |     amount (minus any amounts for noncovered  |
|                      |     services);                                |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | -   For physicians and other covered health   |
|                      |     care professionals that do not contract   |
|                      |     with your local Blue Cross and Blue       |
|                      |     Shield Plan, our allowance is equal to    |
|                      |     the greater of 1) the Medicare            |
|                      |     participating fee schedule amount for the |
|                      |     service or supply in the geographic area  |
|                      |     in which it was performed or obtained (or |
|                      |     60% of the billed charge if there is no   |
|                      |     equivalent Medicare fee schedule amount)  |
|                      |     or 2) 80% of the 2004 Usual, Customary,   |
|                      |     and Reasonable (UCR) amount for the       |
|                      |     service or supply in the geographic area  |
|                      |     in which it was performed or obtained.    |
|                      |     Local Plans determine the UCR amount in   |
|                      |     different ways. Contact your Local Plan   |
|                      |     if you need more information. We may      |
|                      |     refer to our allowance for                |
|                      |     Non-participating providers as the        |
|                      |     \"NPA\" (for \"Non-participating Provider |
|                      |     Allowance\");                             |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | -   For prescription drugs furnished by       |
|                      |     retail and internet pharmacies that do    |
|                      |     not contract with AdvancePCS, our         |
|                      |     allowance is the average wholesale price  |
|                      |     (\"AWP\") of a drug on the date it is     |
|                      |     dispensed, as set forth in the most       |
|                      |     current version of First DataBank\'s      |
|                      |     National Drug Data File; and              |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | -   For services you receive outside of the   |
|                      |     United States and Puerto Rico from        |
|                      |     providers that do not contract with us or |
|                      |     with World Access, Inc., our allowance is |
|                      |     an Overseas Fee Schedule that is based on |
|                      |     amounts comparable to what Participating  |
|                      |     providers in the Washington, DC, area     |
|                      |     have agreed to accept.                    |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | Non-participating providers are under no      |
|                      | obligation to accept our allowance as payment |
|                      | in full. If you use Non-participating         |
|                      | providers, you will be responsible for any    |
|                      | difference between our payment and the billed |
|                      | amount, including any applicable copayments,  |
|                      | coinsurance, or deductibles.                  |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | For more information, see *Differences        |
|                      | between our allowance and the bill* in        |
|                      | Section 4. For more information about how we  |
|                      | pay providers overseas, see pages 18, 94, and |
|                      | 95.                                           |
+----------------------+-----------------------------------------------+

+----------------------+-----------------------------------------------+
| **Precertification** | The requirement to contact the local Blue     |
|                      | Cross and Blue Shield Plan serving the area   |
|                      | where the services will be performed before   |
|                      | being admitted to the hospital for inpatient  |
|                      | care, or within two business days following   |
|                      | an emergency admission.                       |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
| **Preferred provider | > An arrangement between Local Plans and      |
| organization**       | > physicians, hospitals, health care          |
|                      | > institutions, and other covered health care |
| **(PPO)              | > professionals (or for retail and internet   |
| arrangement**        | > pharmacies, between pharmacies and          |
|                      | > AdvancePCS) to provide services to you at a |
|                      | > reduced cost. The PPO provides you with an  |
|                      | > opportunity to reduce your out-of-pocket    |
|                      | > expenses for care by selecting your         |
|                      | > facilities and providers from among a       |
|                      | > specific group. PPO providers are available |
|                      | > in most locations; using them whenever      |
|                      | > possible helps contain health care costs    |
|                      | > and reduces your out-of-pocket costs. The   |
|                      | > selection of PPO providers is solely the    |
|                      | > Local Plan\'s (or for pharmacies,           |
|                      | > AdvancePCS\'s) responsibility. We cannot    |
|                      | > guarantee that any specific provider will   |
|                      | > continue to participate in these PPO        |
|                      | > arrangements.                               |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
| **Prior approval**   | Written assurance that benefits will be       |
|                      | provided by:                                  |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | 1.  The Local Plan where the services will be |
|                      |     performed;                                |
|                      |                                               |
|                      | 2.  The Retail Pharmacy Program (for          |
|                      |     prescription drugs and supplies purchased |
|                      |     through Preferred retail and internet     |
|                      |     pharmacies) or the Mail Service           |
|                      |     Prescription Drug Program; or             |
|                      |                                               |
|                      | 3.  The Blue Cross and Blue Shield            |
|                      |     Association Clinical Trials Information   |
|                      |     Unit for certain organ/tissue transplants |
|                      |     we cover only in clinical trials. See     |
|                      |     Section 5(b).                             |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | For more information, see the benefit         |
|                      | descriptions in Section 5 and *How to get     |
|                      | approval for . . . other services* on pages   |
|                      | 14-15. See Section 5(e) for special           |
|                      | authorization requirements for mental health  |
|                      | and substance abuse benefits.                 |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
| **Routine services** | Services that are not related to a specific   |
|                      | illness, injury, set of symptoms, or          |
|                      | maternity care.                               |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
| **Sound natural      | A tooth that is whole or properly restored    |
| tooth**              | (restoration with amalgams only); is without  |
|                      | impairment, periodontal or other conditions;  |
|                      | and is not in need of the treatment provided  |
|                      | for any reason other than an accidental       |
|                      | injury. For purposes of this Plan, a tooth    |
|                      | previously restored with a crown, inlay,      |
|                      | onlay, or porcelain restoration, or treated   |
|                      | by endodontics, is not considered a sound     |
|                      | natural tooth.                                |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
| **Transplant         | A defined number of consecutive days          |
| period**             | associated with a covered organ/tissue        |
|                      | transplant procedure.                         |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
| **Us/We/Our**        | \"Us,\" \"we,\" and \"our\" refer to the Blue |
|                      | Cross and Blue Shield Service Benefit Plan,   |
|                      | and the local Blue Cross and Blue Shield      |
|                      | Plans that administer it.                     |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
| **You/Your**         | \"You\" and \"your\" refer to the enrollee    |
|                      | (the contract holder eligible for enrollment  |
|                      | and coverage under the Federal Employees      |
|                      | Health Benefits Program and enrolled in the   |
|                      | Plan) and each covered family member.         |
+----------------------+-----------------------------------------------+

+----------------------+-----------------------------------------------+
| Section 11. FEHB     |                                               |
| facts                |                                               |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
| Coverage information |                                               |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
| -   No pre-existing  | We will not refuse to cover the treatment of  |
|     condition        | a condition that you had before you enrolled  |
|     limitation       | in this Plan solely because you had the       |
|                      | condition before you enrolled.                |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
| -   Where you can    | See                                           |
|     get information  | [www.opm.gov/ins                              |
|     about enrolling  | ure/health](http://www.opm.gov/insure/health) |
|     in the FEHB      | for enrollment information as well as:        |
|     Program          |                                               |
|                      | • Information on the FEHB Program and plans   |
|                      | available to you                              |
|                      |                                               |
|                      | • A health plan comparison tool               |
|                      |                                               |
|                      | • A list of agencies who participate in       |
|                      | Employee Express                              |
|                      |                                               |
|                      | • A link to Employee Express                  |
|                      |                                               |
|                      | • Information on and links to other           |
|                      | electronic enrollment systems                 |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | Also, your employing or retirement office can |
|                      | answer your questions, and give you a *Guide  |
|                      | to Federal Employees Health Benefits Plans,*  |
|                      | brochures for other plans, and other          |
|                      | materials you need to make an informed        |
|                      | decision about your FEHB coverage. These      |
|                      | materials tell you:                           |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | -   When you may change your enrollment;      |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | -   How you can cover your family members;    |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | -   What happens when you transfer to another |
|                      |     Federal agency, go on leave without pay,  |
|                      |     enter military service, or retire;        |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | -   When your enrollment ends; and            |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | -   When the next Open Season for enrollment  |
|                      |     begins.                                   |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | We don\'t determine who is eligible for       |
|                      | coverage and, in most cases, cannot change    |
|                      | your enrollment status without information    |
|                      | from your employing or retirement office.     |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
| -   Types of         | Self Only coverage is for you alone. Self and |
|     coverage         | Family coverage is for you, your spouse, and  |
|     available        | your unmarried dependent children under age   |
|                      | 22, including any foster children or          |
| > for you and your   | stepchildren your employing or retirement     |
| > family             | office authorizes coverage for. Under certain |
|                      | circumstances, you may also continue coverage |
|                      | for a disabled child 22 years of age or older |
|                      | who is incapable of self-support.             |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | If you have a Self Only enrollment, you may   |
|                      | change to a Self and Family enrollment if you |
|                      | marry, give birth, or add a child to your     |
|                      | family. You may change your enrollment 31     |
|                      | days before to 60 days after that event. The  |
|                      | Self and Family enrollment begins on the      |
|                      | first day of the pay period in which the      |
|                      | child is born or becomes an eligible family   |
|                      | member. When you change to Self and Family    |
|                      | because you marry, the change is effective on |
|                      | the first day of the pay period that begins   |
|                      | after your employing office receives your     |
|                      | enrollment form; benefits will not be         |
|                      | available to your spouse until you marry.     |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | Your employing or retirement office will      |
|                      | **not** notify you when a family member is no |
|                      | longer eligible to receive health benefits,   |
|                      | nor will we. Please tell us immediately when  |
|                      | you add or remove family members from your    |
|                      | coverage for any reason, including divorce,   |
|                      | or when your child under age 22 marries or    |
|                      | turns 22.                                     |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | If you or one of your family members is       |
|                      | enrolled in one FEHB plan, that person may    |
|                      | not be enrolled in or covered as a family     |
|                      | member by another FEHB plan.                  |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
| -   Children\'s      | OPM has implemented the Federal Employees     |
|     Equity Act       | Health Benefits Children\'s Equity Act of     |
|                      | 2000. This law mandates that you be enrolled  |
|                      | for Self and Family coverage in the FEHB      |
|                      | Program, if you are an employee subject to a  |
|                      | court or administrative order requiring you   |
|                      | to provide health benefits for your           |
|                      | child(ren).                                   |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | If this law applies to you, you must enroll   |
|                      | for Self and Family coverage in a health plan |
|                      | that provides full benefits in the area where |
|                      | your children live or provide documentation   |
|                      | to your employing office that you have        |
|                      | obtained other health benefits coverage for   |
|                      | your children. If you do not do so, your      |
|                      | employing office will enroll you              |
|                      | involuntarily as follows:                     |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | -   If you have no FEHB coverage, your        |
|                      |     employing office will enroll you for Self |
|                      |     and Family coverage in the Blue Cross and |
|                      |     Blue Shield Service Benefit Plan\'s Basic |
|                      |     Option.                                   |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | -   If you have a Self Only enrollment in a   |
|                      |     fee-for-service plan or in an HMO that    |
|                      |     serves the area where your children live, |
|                      |     your employing office will change your    |
|                      |     enrollment to Self and Family in the same |
|                      |     option of the same plan; or               |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | -   If you are enrolled in an HMO that does   |
|                      |     not serve the area where the children     |
|                      |     live, your employing office will change   |
|                      |     your enrollment to Self and Family in the |
|                      |     Blue Cross and Blue Shield Service        |
|                      |     Benefit Plan\'s Basic Option.             |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | As long as the court/administrative order is  |
|                      | in effect, and you have at least one child    |
|                      | identified in the order who is still eligible |
|                      | under the FEHB Program, you cannot cancel     |
|                      | your enrollment, change to Self Only, or      |
|                      | change to a plan that doesn\'t serve the area |
|                      | in which your children live, unless you       |
|                      | provide documentation that you have other     |
|                      | coverage for the children. If the             |
|                      | court/administrative order is still in effect |
|                      | when you retire, and you have at least one    |
|                      | child still eligible for FEHB coverage, you   |
|                      | must continue your FEHB coverage into         |
|                      | retirement (if eligible) and cannot cancel    |
|                      | your coverage, change to Self Only, or change |
|                      | to a plan that doesn\'t serve the area in     |
|                      | which your children live as long as the       |
|                      | court/administrative order is in effect.      |
|                      | Contact your employing office for further     |
|                      | information.                                  |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
| -   When benefits    | The benefits in this brochure are effective   |
|     and              | on January 1. If you joined this Plan during  |
|                      | Open Season, your coverage begins on the      |
| > premiums start     | first day of your first pay period that       |
|                      | starts on or after January 1. If you changed  |
|                      | plans or plan options during Open Season and  |
|                      | you receive care between January 1 and the    |
|                      | effective date of coverage under your new     |
|                      | plan or option, your claims will be paid      |
|                      | according to the 2004 benefits of your old    |
|                      | plan or option. However, if your old plan     |
|                      | left the FEHB Program at the end of the year, |
|                      | you are covered under that plan\'s 2003       |
|                      | benefits until the effective date of your     |
|                      | coverage with your new plan. Annuitants\'     |
|                      | coverage and premiums begin on January 1. If  |
|                      | you joined at any other time during the year, |
|                      | your employing office will tell you the       |
|                      | effective date of coverage.                   |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
| -   Your medical and | > We will keep your medical and claims        |
|     claims records   | > information confidential. Please note that  |
|     are confidential | > as part of our administration of this       |
|                      | > contract, we may disclose your medical and  |
|                      | > claims information (including your          |
|                      | > prescription drug utilization) to any       |
|                      | > treating physicians or dispensing           |
|                      | > pharmacies.                                 |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
| -   When you retire  | When you retire, you can usually stay in the  |
|                      | FEHB Program. Generally, you must have been   |
|                      | enrolled in the FEHB Program for the last     |
|                      | five years of your Federal service. If you do |
|                      | not meet this requirement, you may be         |
|                      | eligible for other forms of coverage, such as |
|                      | Temporary Continuation of Coverage (TCC).     |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
| When you lose        |                                               |
| benefits             |                                               |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
| -   When FEHB        | You will receive an additional 31 days of     |
|     coverage ends    | coverage, for no additional premium, when:    |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | -   Your enrollment ends, unless you cancel   |
|                      |     your enrollment, or                       |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | -   You are a family member no longer         |
|                      |     eligible for coverage.                    |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | You may be eligible for spouse equity         |
|                      | coverage, or Temporary Continuation of        |
|                      | Coverage (TCC), or a conversion policy (a     |
|                      | non-FEHB individual policy).                  |
+----------------------+-----------------------------------------------+

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

+----------------------+---+--------------------------+-------+--------+---+
| ## Two new F         |   |                          |       |        |   |
| ederal Programs comp |   |                          |       |        |   |
| lement FEHB benefits |   |                          |       |        |   |
+----------------------+---+--------------------------+-------+--------+---+
|                      |   |                          |       |        |   |
+----------------------+---+--------------------------+-------+--------+---+
| ##### I              | O |                          |       |        |   |
| mportant information | P |                          |       |        |   |
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+----------------------+---+--------------------------+-------+--------+---+
|                      |   |                          |       |        |   |
+----------------------+---+--------------------------+-------+--------+---+
| ###                  |   |                          |       |        |   |
| ## The Federal Flexi |   |                          |       |        |   |
| ble Spending Account |   |                          |       |        |   |
|  Program − *FSAFEDS* |   |                          |       |        |   |
+----------------------+---+--------------------------+-------+--------+---+
|                      |   |                          |       |        |   |
+----------------------+---+--------------------------+-------+--------+---+
| **• What is an       | I |                          |       |        |   |
| FSA?**               | t |                          |       |        |   |
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+----------------------+---+--------------------------+-------+--------+---+
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|                      | : |                          |       |        |   |
+----------------------+---+--------------------------+-------+--------+---+
|                      |   |                          |       |        |   |
+----------------------+---+--------------------------+-------+--------+---+
| > **Health Care      | • |                          |       |        |   |
| > Flexible**         | C |                          |       |        |   |
| >                    | o |                          |       |        |   |
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| > Account**          | e |                          |       |        |   |
| >                    | r |                          |       |        |   |
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|                      | : |                          |       |        |   |
+----------------------+---+--------------------------+-------+--------+---+
|                      |   |                          |       |        |   |
+----------------------+---+--------------------------+-------+--------+---+
|                      |   | **Annual Tax Savings     | *     | **W    |   |
|                      |   | Example**                | *With | ithout |   |
|                      |   |                          | FSA** | FSA**  |   |
+----------------------+---+--------------------------+-------+--------+---+
|                      |   | If your taxable income   | \$5   | \$     |   |
|                      |   | is:                      | 0,000 | 50,000 |   |
+----------------------+---+--------------------------+-------+--------+---+
|                      |   | And you deposit this     | \$    | -\$0-  |   |
|                      |   | amount into an FSA:      | 2,000 |        |   |
+----------------------+---+--------------------------+-------+--------+---+
|                      |   | Your taxable income is   | \$4   | \$     |   |
|                      |   | now:                     | 8,000 | 50,000 |   |
+----------------------+---+--------------------------+-------+--------+---+
|                      |   | Subtract Federal &       | \$1   | \$     |   |
|                      |   | Social Security taxes:   | 3,807 | 14,383 |   |
+----------------------+---+--------------------------+-------+--------+---+
|                      |   | If you spend after-tax   | -\$0- | \$     |   |
|                      |   | dollars for expenses:    |       | 2,000  |   |
+----------------------+---+--------------------------+-------+--------+---+
|                      |   | Your real spendable      | \$3   | \$     |   |
|                      |   | income is:               | 4,193 | 33,617 |   |
+----------------------+---+--------------------------+-------+--------+---+
|                      |   | **Your tax savings:**    | **\$  | **-    |   |
|                      |   |                          | 576** | \$0-** |   |
+----------------------+---+--------------------------+-------+--------+---+
|                      |   |                          |       |        |   |
+----------------------+---+--------------------------+-------+--------+---+
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+----------------------+---+--------------------------+-------+--------+---+
|                      |   |                          |       |        |   |
+----------------------+---+--------------------------+-------+--------+---+
| **• Tax credits      | Y |                          |       |        |   |
| and**                | o |                          |       |        |   |
|                      | u |                          |       |        |   |
| > **deductions**     | * |                          |       |        |   |
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|                      | . |                          |       |        |   |
+----------------------+---+--------------------------+-------+--------+---+
|                      |   |                          |       |        |   |
+----------------------+---+--------------------------+-------+--------+---+
| **To find out more   | C |                          |       |        |   |
| and**                | a |                          |       |        |   |
|                      | l |                          |       |        |   |
| **to request an      | l |                          |       |        |   |
| application**        | 1 |                          |       |        |   |
|                      | - |                          |       |        |   |
|                      | 8 |                          |       |        |   |
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|                      | 3 |                          |       |        |   |
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|                      | 3 |                          |       |        |   |
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|                      | ( |                          |       |        |   |
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|                      | p |                          |       |        |   |
|                      | : |                          |       |        |   |
|                      | / |                          |       |        |   |
|                      | / |                          |       |        |   |
|                      | w |                          |       |        |   |
|                      | w |                          |       |        |   |
|                      | w |                          |       |        |   |
|                      | . |                          |       |        |   |
|                      | l |                          |       |        |   |
|                      | t |                          |       |        |   |
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|                      | f |                          |       |        |   |
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|                      | d |                          |       |        |   |
|                      | s |                          |       |        |   |
|                      | . |                          |       |        |   |
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|                      | . |                          |       |        |   |
+----------------------+---+--------------------------+-------+--------+---+

  -----------------------------------------------------------------------
  **Index**

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

Do not rely on this page; it is for your convenience and may not show
all pages where the terms appear. This Index is not an official
statement of benefits.

**A**ccidental injury 58, 67-69, 71, 88, 110 Acupuncture 36, 43, 56

Allergy tests 34

Allogeneic (donor) bone marrow transplant 50-55

Ambulance 66, 71

Anesthesia 56, 59, 62

Autologous bone marrow transplant 51-55

Average wholesale price (AWP) 83, 113

**B**iopsies 45

Birthing centers 11, 31

Blood and blood plasma 42, 59, 61-63

Blue Quality Centers for Transplant (BQCT) 12, 53

Breast cancer screening 28-29

Breast reconstruction 47

**C**ancer screenings 28-29

Cardiac rehabilitation 35, 61

Case management 87

Casts 45, 59, 63

Catastrophic protection 19-20

Certificate of Group Health Plan Coverage 117

CHAMPVA 108

Chemotherapy 35, 61

Chiropractic 43

Cholesterol tests 27

Circumcision 32, 46

Claims and claim filing 98-100

Coinsurance 16-17, 110

Colorectal cancer screening 28-29

Confidentiality 116

Congenital anomalies 47, 110

Contraceptive devices and drugs 33, 81

Coordination of benefits 103-109

Copayments 16, 110

Cosmetic surgery 46, 47, 97, 110

Covered providers 10-12

Custodial care 97, 110

**D**eductible 16, 110

Definitions 110-114

Dental care 48, 88-93, 97

Diabetic education 10, 44

Diagnostic services 24-26

Disputed claims process 101-102

DoD facilities (MTFs) 20

Donor expenses (transplants) 52, 55

Durable medical equipment 41, 111

**E**mergency 58, 67-71, 88

Enrollment questions 10, 115-117

Exclusions 97

Experimental or investigational 97, 111

Eyeglasses 38-39, 96

**F**amily planning 33

Fecal occult blood test 27-29

Foot care 39

Formulary 79-80

Freestanding ambulatory facilities 11, 61-63

**H**earing services 38

Home nursing care 42

Hospice care 14, 65

Hospital 11, 57-63

**I**mmunizations 30

Independent laboratories 10, 26-27

Infertility 33-34

Inpatient hospital benefits 57-60

Inpatient physician benefits 25-26, 45-55

Insulin 81

Internet pharmacies 79-84, 95, 99

**L**aboratory and pathology services 26-30, 59-62, 68, 70

Lifetime maximum 78, 112

**M**achine diagnostic tests 26-27, 59-62, 68, 70

Magnetic Resonance Imaging (MRIs) 26, 59-62, 68, 70

Mail Service Prescription Drugs 79-80, 83, 95, 99

Mammograms 27, 28, 29

Maternity benefits 14, 31-32, 59

Medicaid 108

Medical foods 42, 86

Medically necessary 13-14, 60, 97, 112

Medically underserved areas 11, 43

Medicare 14, 21-22, 64, 103-107

Member/Non-member facilities 7, 8

Mental health 15, 72-78, 112

**N**eurological testing 25

Newborn care 24, 25, 30, 32

Nurse 10-11, 42, 65, 73, 76

Nurse help line (Blue Health Connection) 87

**O**bstetrical care 31-32

Occupational therapy 37, 61

Office visits 24-30, 39, 44, 70, 73, 76

Oral statements 4

Orthopedic devices 40, 63

Ostomy and catheter supplies 42

Other covered health care professionals 10-11

Out-of-pocket expenses 16-20

Outpatient facility benefits 61-63

Overpayments 20

Overseas claims 18, 84, 94-95

Oxygen 41, 42, 59, 63

**P**ap test 27, 28, 29

Participating/Non-participating providers 7-8, 113

Patient Safety and Quality Monitoring Program 79, 85

Patients\' Bill of Rights 8

Pharmacotherapy 24, 25, 35, 73, 76

Physical examination 27, 30

Physical therapy 36, 61

Physician 10, 11

Plan allowance 17-19, 112-113

Pre-admission testing 59

Precertification 13-14, 114

Pre-existing conditions 115, 117

Preferred Provider Organization (PPO) 7-8, 114

Prescription drugs 15, 79-86

Preventive care, adult, children 27-30

Primary care providers 10

Prior approval 14-15, 114

Prostate cancer screening 28, 29

Prosthetic devices 40, 63

Psychologist 10, 73, 76

Psychotherapy 72-78

**R**adiation therapy 35, 61

Renal dialysis 35, 61

Room and board 58, 60, 74, 77, 78

**S**econd surgical opinion 25

Skilled nursing facility care 64

Smoking cessation 15, 44, 73, 76, 81

Social Worker 10, 73, 76

Speech therapy 37, 61

Stem cell transplant support 15, 50-55

Sterilization procedures 33, 46

Subrogation 109

Substance abuse 72-78, 112

Surgery 45-48

-   Assistant surgeon 31, 46

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-   Multiple procedures 46

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-   Oral and maxillofacial surgery 48

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-   Outpatient 45-48, 62

-   Reconstructive 47

    Syringes 81

    **T**emporary Continuation of Coverage (TCC) 117

    Transplants 15, 45, 49-55

TRICARE 108

**V**A facilities 20

Vision services 38-39

**W**eight control 46, 86, 97

Wheelchairs 41

Workers\' compensation 106, 108

**X**-rays 26, 27, 43, 59-62, 68, 70

+-----------------------------------------------------------------------+
| **Summary of benefits for the Blue Cross and Blue Shield Service      |
| Benefit Plan**                                                        |
|                                                                       |
| **Standard Option -- 2004**                                           |
+-----------------------------------------------------------------------+

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

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

    • Below, an asterisk (\*) means the item is subject to the \$250 per
    person (\$500 per family) calendar year deductible. If you use a
    Non-PPO physician or other health care professional, you generally
    pay any difference between our allowance and the billed amount, in
    addition to any share of our allowance shown below.

+--------------------------+---+-------------------------------------+----+
| **Benefits**             | * |                                     | #  |
|                          | * |                                     | Pa |
|                          | Y |                                     | ge |
|                          | o |                                     |    |
|                          | u |                                     |    |
|                          | P |                                     |    |
|                          | a |                                     |    |
|                          | y |                                     |    |
|                          | * |                                     |    |
|                          | * |                                     |    |
+--------------------------+---+-------------------------------------+----+
| Medical services         | P |                                     | >  |
| provided by physicians:  | P |                                     |  2 |
|                          | O |                                     | 4- |
| • Diagnostic and         | : |                                     | 26 |
| treatment services       | 1 |                                     |    |
| provided in the office   | 0 |                                     |    |
|                          | % |                                     |    |
|                          | \ |                                     |    |
|                          | * |                                     |    |
|                          | o |                                     |    |
|                          | f |                                     |    |
|                          | o |                                     |    |
|                          | u |                                     |    |
|                          | r |                                     |    |
|                          | a |                                     |    |
|                          | l |                                     |    |
|                          | l |                                     |    |
|                          | o |                                     |    |
|                          | w |                                     |    |
|                          | a |                                     |    |
|                          | n |                                     |    |
|                          | c |                                     |    |
|                          | e |                                     |    |
|                          | ; |                                     |    |
|                          | \ |                                     |    |
|                          | $ |                                     |    |
|                          | 1 |                                     |    |
|                          | 5 |                                     |    |
|                          | p |                                     |    |
|                          | e |                                     |    |
|                          | r |                                     |    |
|                          | o |                                     |    |
|                          | f |                                     |    |
|                          | f |                                     |    |
|                          | i |                                     |    |
|                          | c |                                     |    |
|                          | e |                                     |    |
|                          | v |                                     |    |
|                          | i |                                     |    |
|                          | s |                                     |    |
|                          | i |                                     |    |
|                          | t |                                     |    |
|                          |   |                                     |    |
|                          | N |                                     |    |
|                          | o |                                     |    |
|                          | n |                                     |    |
|                          | - |                                     |    |
|                          | P |                                     |    |
|                          | P |                                     |    |
|                          | O |                                     |    |
|                          | : |                                     |    |
|                          | 2 |                                     |    |
|                          | 5 |                                     |    |
|                          | % |                                     |    |
|                          | \ |                                     |    |
|                          | * |                                     |    |
|                          | o |                                     |    |
|                          | f |                                     |    |
|                          | o |                                     |    |
|                          | u |                                     |    |
|                          | r |                                     |    |
|                          | a |                                     |    |
|                          | l |                                     |    |
|                          | l |                                     |    |
|                          | o |                                     |    |
|                          | w |                                     |    |
|                          | a |                                     |    |
|                          | n |                                     |    |
|                          | c |                                     |    |
|                          | e |                                     |    |
+--------------------------+---+-------------------------------------+----+
| Services provided by a   | P |                                     | >  |
| hospital:                | P |                                     |  5 |
|                          | O |                                     | 7- |
| -   Inpatient            | : |                                     | 60 |
|                          | \ |                                     |    |
|                          | $ |                                     |    |
|                          | 1 |                                     |    |
|                          | 0 |                                     |    |
|                          | 0 |                                     |    |
|                          | p |                                     |    |
|                          | e |                                     |    |
|                          | r |                                     |    |
|                          | a |                                     |    |
|                          | d |                                     |    |
|                          | m |                                     |    |
|                          | i |                                     |    |
|                          | s |                                     |    |
|                          | s |                                     |    |
|                          | i |                                     |    |
|                          | o |                                     |    |
|                          | n |                                     |    |
|                          |   |                                     |    |
|                          | N |                                     |    |
|                          | o |                                     |    |
|                          | n |                                     |    |
|                          | - |                                     |    |
|                          | P |                                     |    |
|                          | P |                                     |    |
|                          | O |                                     |    |
|                          | : |                                     |    |
|                          | \ |                                     |    |
|                          | $ |                                     |    |
|                          | 3 |                                     |    |
|                          | 0 |                                     |    |
|                          | 0 |                                     |    |
|                          | p |                                     |    |
|                          | e |                                     |    |
|                          | r |                                     |    |
|                          | a |                                     |    |
|                          | d |                                     |    |
|                          | m |                                     |    |
|                          | i |                                     |    |
|                          | s |                                     |    |
|                          | s |                                     |    |
|                          | i |                                     |    |
|                          | o |                                     |    |
|                          | n |                                     |    |
+--------------------------+---+-------------------------------------+----+
| -   Outpatient           | P |                                     | >  |
|                          | P |                                     |  6 |
|                          | O |                                     | 1- |
|                          | : |                                     | 63 |
|                          | 1 |                                     |    |
|                          | 0 |                                     |    |
|                          | % |                                     |    |
|                          | \ |                                     |    |
|                          | * |                                     |    |
|                          | o |                                     |    |
|                          | f |                                     |    |
|                          | o |                                     |    |
|                          | u |                                     |    |
|                          | r |                                     |    |
|                          | a |                                     |    |
|                          | l |                                     |    |
|                          | l |                                     |    |
|                          | o |                                     |    |
|                          | w |                                     |    |
|                          | a |                                     |    |
|                          | n |                                     |    |
|                          | c |                                     |    |
|                          | e |                                     |    |
|                          | ( |                                     |    |
|                          | n |                                     |    |
|                          | o |                                     |    |
|                          | d |                                     |    |
|                          | e |                                     |    |
|                          | d |                                     |    |
|                          | u |                                     |    |
|                          | c |                                     |    |
|                          | t |                                     |    |
|                          | i |                                     |    |
|                          | b |                                     |    |
|                          | l |                                     |    |
|                          | e |                                     |    |
|                          | f |                                     |    |
|                          | o |                                     |    |
|                          | r |                                     |    |
|                          | s |                                     |    |
|                          | u |                                     |    |
|                          | r |                                     |    |
|                          | g |                                     |    |
|                          | e |                                     |    |
|                          | r |                                     |    |
|                          | y |                                     |    |
|                          | ) |                                     |    |
|                          |   |                                     |    |
|                          | N |                                     |    |
|                          | o |                                     |    |
|                          | n |                                     |    |
|                          | - |                                     |    |
|                          | P |                                     |    |
|                          | P |                                     |    |
|                          | O |                                     |    |
|                          | : |                                     |    |
|                          | 2 |                                     |    |
|                          | 5 |                                     |    |
|                          | % |                                     |    |
|                          | \ |                                     |    |
|                          | * |                                     |    |
|                          | o |                                     |    |
|                          | f |                                     |    |
|                          | o |                                     |    |
|                          | u |                                     |    |
|                          | r |                                     |    |
|                          | a |                                     |    |
|                          | l |                                     |    |
|                          | l |                                     |    |
|                          | o |                                     |    |
|                          | w |                                     |    |
|                          | a |                                     |    |
|                          | n |                                     |    |
|                          | c |                                     |    |
|                          | e |                                     |    |
|                          | ( |                                     |    |
|                          | n |                                     |    |
|                          | o |                                     |    |
|                          | d |                                     |    |
|                          | e |                                     |    |
|                          | d |                                     |    |
|                          | u |                                     |    |
|                          | c |                                     |    |
|                          | t |                                     |    |
|                          | i |                                     |    |
|                          | b |                                     |    |
|                          | l |                                     |    |
|                          | e |                                     |    |
|                          | f |                                     |    |
|                          | o |                                     |    |
|                          | r |                                     |    |
|                          | s |                                     |    |
|                          | u |                                     |    |
|                          | r |                                     |    |
|                          | g |                                     |    |
|                          | e |                                     |    |
|                          | r |                                     |    |
|                          | y |                                     |    |
|                          | ) |                                     |    |
+--------------------------+---+-------------------------------------+----+
| Emergency benefits:      | P |                                     | >  |
|                          | P |                                     |  6 |
| -   Accidental injury    | O |                                     | 7- |
|                          | : |                                     | 69 |
|                          | N |                                     |    |
|                          | o |                                     |    |
|                          | t |                                     |    |
|                          | h |                                     |    |
|                          | i |                                     |    |
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|                          | f |                                     |    |
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|                          | p |                                     |    |
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|                          | 7 |                                     |    |
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+--------------------------+---+-------------------------------------+----+
| • Medical emergency      | R |                                     | >  |
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+--------------------------+---+-------------------------------------+----+
| Mental health and        | I |                                     | >  |
| substance abuse          | n |                                     |  7 |
| treatment                | - |                                     | 2- |
|                          | N |                                     | 78 |
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+--------------------------+---+-------------------------------------+----+
| Prescription drugs       | R |                                     | >  |
|                          | e |                                     |  7 |
|                          | t |                                     | 9- |
|                          | a |                                     | 86 |
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+--------------------------+---+-------------------------------------+----+
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+--------------------------+---+-------------------------------------+----+
| Dental care              | S |                                     | >  |
|                          | c |                                     |  4 |
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+--------------------------+---+-------------------------------------+----+
| Special features:        |   |                                     | >  |
| Flexible benefits        |   |                                     | 87 |
| option; online customer  |   |                                     |    |
| and claims service;      |   |                                     |    |
| 24-hour nurse line;      |   |                                     |    |
| services for deaf and    |   |                                     |    |
| hearing impaired; travel |   |                                     |    |
| benefit/services         |   |                                     |    |
| overseas; health support |   |                                     |    |
| programs; and Healthy    |   |                                     |    |
| Families Program         |   |                                     |    |
+--------------------------+---+-------------------------------------+----+
| Protection against       |   | Nothing after \$4,000 (PPO) or      | >  |
| catastrophic costs       |   | \$6,000 (PPO/Non-PPO) per contract  |  1 |
|                          |   | per year; some costs do not count   | 9- |
| (your catastrophic       |   | toward this protection              | 20 |
| protection out-of-pocket |   |                                     |    |
| maximum)                 |   |                                     |    |
+--------------------------+---+-------------------------------------+----+

+-----------------------------------------------------------------------+
| **Summary of benefits for the Blue Cross and Blue Shield Service      |
| Benefit Plan**                                                        |
|                                                                       |
| **Basic Option -- 2004**                                              |
+-----------------------------------------------------------------------+

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

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

> • Basic Option does not provide benefits when you use Non-preferred
> providers. For a list of the exceptions to this requirement, see page
> 12. There is no deductible for Basic Option.

+-------------------------+--------------------------------------+----+
| # Benefits              | **You Pay**                          | #  |
|                         |                                      | Pa |
|                         |                                      | ge |
+-------------------------+--------------------------------------+----+
| Medical services        | PPO: \$20 per office visit for       | >  |
| provided by physicians: | primary care physicians and other    |  2 |
|                         | health care professionals; \$30 per  | 4- |
| > • Diagnostic and      | office visit for specialists         | 26 |
| > treatment services    |                                      |    |
| > provided in the       | Non-PPO: You pay all charges         |    |
| > office                |                                      |    |
+-------------------------+--------------------------------------+----+
| Services provided by a  | PPO: \$100 per day up to \$500 per   | 5  |
| hospital:               | admission                            | 7- |
|                         |                                      | 60 |
| • Inpatient             | Non-PPO: You pay all charges         |    |
+-------------------------+--------------------------------------+----+
| -   Outpatient          | PPO: \$30 per day per facility       | 6  |
|                         |                                      | 1- |
|                         | Non-PPO: You pay all charges         | 63 |
+-------------------------+--------------------------------------+----+
| Emergency benefits:     | PPO: \$50 copayment for emergency    | >  |
|                         | room care; \$30 copayment for urgent |  6 |
| • Accidental injury     | care                                 | 7- |
|                         |                                      | 69 |
|                         | Non-PPO: \$50 copayment for          |    |
|                         | emergency room care                  |    |
+-------------------------+--------------------------------------+----+
| -   Medical emergency   | Same as for accidental injury        | >  |
|                         |                                      | 70 |
+-------------------------+--------------------------------------+----+
| Mental health and       | In-Network (PPO): Regular cost       | >  |
| substance abuse         | sharing, such as \$20 office visit   |  7 |
| treatment               | copayment (prior approval required); | 2- |
|                         | \$100 per day up to \$500 per        | 78 |
|                         | inpatient admission                  |    |
|                         |                                      |    |
|                         | Out-of-Network (Non-PPO): You pay    |    |
|                         | all charges                          |    |
+-------------------------+--------------------------------------+----+
| Prescription drugs      | Retail Pharmacy Program:             | >  |
|                         |                                      |  7 |
|                         | • PPO: \$10 generic/\$25 formulary   | 9- |
|                         | brand-name per prescription/50%      | 86 |
|                         | coinsurance (\$35 minimum) for       |    |
|                         | non-formulary brand-name drugs.      |    |
|                         | 34-day maximum supply on initial     |    |
|                         | prescription; up to 90 days for      |    |
|                         | refills with 3 copayments            |    |
|                         |                                      |    |
|                         | • Non-PPO: You pay all charges       |    |
+-------------------------+--------------------------------------+----+
| Dental care             | PPO: \$20 copayment per evaluation   | >  |
|                         | (exam, cleaning, and x-rays); most   |  4 |
|                         | services limited to 2 per year;      | 8, |
|                         | sealants for children up to age 16;  | >  |
|                         | \$20 copayment for dental services   | 88 |
|                         | required due to accidental injury;   | -8 |
|                         | regular benefits for covered oral    | 9, |
|                         | and maxillofacial surgery            | >  |
|                         |                                      | 93 |
|                         | Non-PPO: You pay all charges         |    |
+-------------------------+--------------------------------------+----+
| Special features:       |                                      | >  |
| Flexible benefits       |                                      | 87 |
| option; online customer |                                      |    |
| and claims service;     |                                      |    |
| 24-hour nurse line;     |                                      |    |
| services for deaf and   |                                      |    |
| hearing impaired;       |                                      |    |
| travel benefit/services |                                      |    |
| overseas; health        |                                      |    |
| support programs; and   |                                      |    |
| Healthy Families        |                                      |    |
| Program                 |                                      |    |
+-------------------------+--------------------------------------+----+
| Protection against      | Nothing after \$5,000 (PPO) per      | >  |
| catastrophic costs      | contract per year; some costs do not |  1 |
|                         | count toward this protection         | 9- |
| (your catastrophic      |                                      | 20 |
| protection              |                                      |    |
| out-of-pocket maximum)  |                                      |    |
+-------------------------+--------------------------------------+----+

**2004 Rate Information for**

**Blue Cross and Blue Shield Service Benefit Plan**

> **Non-Postal rates** apply to most non-Postal enrollees. If you are in
> a special enrollment category, refer to the FEHB Guide for that
> category or contact the agency that maintains your health benefits
> enrollment.
>
> **Postal rates** apply to career Postal Service employees. Most
> employees should refer to the FEHB Guide for United States Postal
> Service Employees, RI 70-2. Different postal rates apply and a special
> FEHB guide is published for Postal Service Inspectors and Office of
> Inspector General (OIG) employees (see RI 70-2IN).
>
> Postal rates do not apply to non-career postal employees, postal
> retirees, or associate members of any postal employee organization who
> are not career postal employees. Refer to the applicable FEHB Guide.

+--------------+-----+-------+-------+-------+-------+-------+-------+
|              |     | **    |       |       |       | **P   |       |
|              |     | Non-P |       |       |       | ostal |       |
|              |     | ostal |       |       |       | Prem  |       |
|              |     | Prem  |       |       |       | ium** |       |
|              |     | ium** |       |       |       |       |       |
+--------------+-----+-------+-------+-------+-------+-------+-------+
|              |     | **    |       | *     |       | **    |       |
|              |     | Biwee |       | *Mont |       | Biwee |       |
|              |     | kly** |       | hly** |       | kly** |       |
+--------------+-----+-------+-------+-------+-------+-------+-------+
| **Type of**  | **  | **Gov | **Y   | **Gov | **Y   | **U   | **Y   |
|              | Cod | \'t** | our** | \'t** | our** | SPS** | our** |
| **           | e** |       |       |       |       |       |       |
| Enrollment** |     | **Sh  | **Sh  | **Sh  | **Sh  | **Sh  | **Sh  |
|              |     | are** | are** | are** | are** | are** | are** |
+--------------+-----+-------+-------+-------+-------+-------+-------+

+--------------+-----+-------+-------+-------+-------+-------+-------+
| Standard     | *   | \$1   | *     | **    | \$1   | **    | *     |
| Option       | *10 | 21.40 | *\$48 | \$263 | 05.95 | \$143 | *\$26 |
|              | 4** |       | .90** | .03** |       | .32** | .98** |
| **Self       |     |       |       |       |       |       |       |
| Only**       |     |       |       |       |       |       |       |
+--------------+-----+-------+-------+-------+-------+-------+-------+
| **Standard   | *   | **    | \$1   | **    | \$2   | **    | *     |
| Option**     | *10 | \$277 | 12.88 | \$600 | 44.58 | \$327 | *\$62 |
|              | 5** | .09** |       | .36** |       | .12** | .85** |
| **Self and   |     |       |       |       |       |       |       |
| Family**     |     |       |       |       |       |       |       |
+--------------+-----+-------+-------+-------+-------+-------+-------+
| **Basic      | *   | **    | *     | **    | *     | **    | *     |
| Option**     | *11 | \$113 | *\$37 | \$246 | *\$82 | \$134 | *\$17 |
|              | 1** | .99** | .99** | .97** | .32** | .88** | .10** |
| **Self       |     |       |       |       |       |       |       |
| Only**       |     |       |       |       |       |       |       |
+--------------+-----+-------+-------+-------+-------+-------+-------+
| **Basic      | *   | **    | *     | **    | **    | **    | *     |
| Option**     | *11 | \$266 | *\$88 | \$578 | \$192 | \$315 | *\$40 |
|              | 2** | .99** | .99** | .47** | .82** | .93** | .05** |
| **Self and   |     |       |       |       |       |       |       |
| Family**     |     |       |       |       |       |       |       |
+--------------+-----+-------+-------+-------+-------+-------+-------+