**Kaiser Foundation Health Plan**

**of the Mid-Atlantic States, Inc.**

[http://members.kaiserpermanente.org](http://members.kaiserpermanente.org/)

![](media/image1.png){width="1.211111111111111in" height="0.59375in"}
**2004**

**A Health Maintenance Organization**![](media/image2.png){width="1.5in"
height="1.5118055555555556in"}

**Serving:** *Metropolitan Washington, DC Area and*

#########  Metropolitan Baltimore, Maryland Area

Enrollment in this Plan is limited. You must live or work in our

geographic service area to enroll. See page 9 for requirements.

![](media/image3.png){width="1.0527777777777778in"
height="1.0527777777777778in"}

Enrollment codes for this Plan:

**E31 Self Only**

**E32 Self and Family**

![](media/image4.bmp)

![](media/image5.png)

> **RI 73-047**

![](media/image6.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/image7.png){width="2.5833333333333335in"
> height="0.7291666666666666in"}
>
> Kay Coles James
>
> Director

![](media/image8.png){width="1.195138888888889in"
height="1.0354166666666667in"}
![](media/image9.png){width="1.1715277777777777in"
height="0.9208333333333333in"}

# **Notice of the Office of Personnel Management's**

# **Privacy Practices**

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

By law, the 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.

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  Table of Contents
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Introduction 5

Plain Language 5

Stop Health Care Fraud! 5

Preventing medical mistakes 6

Section 1. Facts about this HMO plan 8

How we pay providers 8

Your Rights 8

Service Area 9

Section 2. How we change for 2004 10

Program-wide changes 10

Changes to this Plan 10

Section 3. How you get care 11

Identification cards 11

Where you get covered care 11

• Plan providers 11

• Plan facilities 11

What you must do to get covered care 11

• Primary care 12

• Specialty care 12

• Hospital care 13

Circumstances beyond our control 13

Services requiring our prior approval 13

Section 4. Your costs for covered services 15

• Copayments 15

• Deductible 15

• Coinsurance 15

• Fees when you fail to make your copayment or coinsurance 15

Your catastrophic protection out-of-pocket maximum for copayments and
coinsurance 15

Section 5. Benefits 16

Overview 16

(a) Medical services and supplies provided by physicians and other
    health care professionals 17

(b) Surgical and anesthesia services provided by physicians and other
    health care professionals 30

(c) Services provided by a hospital or other facility, and ambulance
    services 34

(d) Emergency services/accidents 38

(e) Mental health and substance abuse benefits 40

(f) Prescription drug benefits 43

(g) Special features 47

> • Flexible benefits option 47
>
> • 24 hour nurse line 47
>
> • Services for deaf and hearing impaired 47
>
> • Centers of Excellence 47
>
> • Travel benefit 48
>
> • Services from other Kaiser Permanente plans 49

(h) Dental benefits 50

(i) Non-FEHB benefits available to Plan members 59

Section 6. General exclusions -- things we don\'t cover 60

Section 7. Filing a claim for covered services 61

Section 8. The disputed claims process 62

Section 9. Coordinating benefits with other coverage 64

When you have other health coverage 64

-   What is Medicare? 64

-   Should I enroll in Medicare? 64

-   If you do enroll in Medicare Part B 65

-   The Original Medicare Plan (Part A or Part B) 65

-   Medicare managed care plan 67

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-   TRICARE and CHAMPVA 68

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-   Workers' Compensation 68

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-   Medicaid 69

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-   When other Government agencies are responsible for your care 69

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-   When others are responsible for injuries 69

Section 10. Definitions of terms we use in this brochure 70

Section 11. FEHB facts 72

Coverage information 72

-   No pre-existing condition limitation 72

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-   Where you can get information about enrolling in the FEHB Program 72

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-   Types of coverage available for you and your family 72

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-   Children\'s Equity Act 73

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-   When benefits and premiums start 73

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-   When you retire 73

When you lose benefits 74

• When FEHB coverage ends 74

• Spouse equity coverage 74

• Temporary continuation of coverage (TCC) 74

• Converting to individual coverage 74

• Getting a Certificate of Group Health Plan Coverage 75

Two new Federal Programs complement FEHB benefits 76

The Federal Flexible Spending Account Program -- *FSAFEDS* 76

The Federal Long Term Care Insurance Program 79

Index.......... 81

Summary of benefits 82

Rates..........................................................................................................................Back
cover

  -----------------------------------------------------------------------
  Introduction

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

This brochure describes the benefits of Kaiser Foundation Health Plan of
the Mid-Atlantic States, Inc., under our contract (CS 1763) with the
United States Office of Personnel Management, as authorized by the
Federal Employees Health Benefits law. The address for Kaiser Foundation
Health Plan of the Mid-Atlantic States, Inc.\'s administrative office
is:

Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.

2101 East Jefferson Street

Rockville, Maryland 20852

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

If you are enrolled in this Plan, you are entitled to the benefits
described in this brochure. If you are enrolled in self and family
coverage, each eligible family member is also entitled to these
benefits. You do not have a right to benefits that were available before
January 1, 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 10. 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\" or
    \"Plan\" means Kaiser Foundation Health Plan of the Mid-Atlantic
    States, Inc.

-   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.

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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 this brochure,
let us 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 Office of
Personnel Management, Insurance Services Program Planning & Evaluation
Group, 1900 E Street NW, Washington, DC 20415-3650.

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  Stop Health Care Fraud!

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

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

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

**[Protect Yourself From Fraud]{.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.

-   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:

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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 301/468-6000
    inside the Washington, DC metropolitan area or at 800/777-7902
    outside the Washington, DC metropolitan area, and explain the
    situation. Our TTY telephone number is 301/879-6380.

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-   If we do not resolve the issue:

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

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

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

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

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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.

-   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?

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-   [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 healthcare 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 healthcare 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 healthcare 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 healthcare delivery system.

  -----------------------------------------------------------------------
  **Section 1. Facts about this HMO plan**

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

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

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

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

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

How we pay providers

We pay the Mid-Atlantic Permanente Medical Group, P.C., and contracted
community specialists and ancillary providers to provide your medical,
surgical, mental health, substance abuse, ophthalmology, optometry, and
dental services. We contract with local community hospitals to provide
hospitalization services. These Plan providers accept a negotiated
payment from us.

**Your Rights**

OPM requires that all FEHB plans provide certain information to their
FEHB members. You may get information about us, our networks, providers,
and facilities. OPM's FEHB website
([www.opm.gov/insure](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.

-   Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.
    (Kaiser Permanente), is a federally qualified Health Maintenance
    Organization.

-   This Plan is part of the Kaiser Permanente Medical Care Program, a
    group of not-for-profit organizations and contracting medical groups
    that serve over 8 million members nationwide.

-   Kaiser Permanente is a Maryland non-profit corporation licensed in
    the Commonwealth of Virginia, the District of Columbia and the State
    of Maryland.

-   Kaiser Permanente began delivering prepaid healthcare services to
    Washington, DC residents in December 1972.

-   Kaiser Permanente presently serves approximately 506,000 members in
    the Washington, DC and Baltimore, Maryland metropolitan areas.

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-   Kaiser Permanente credentials its Plan providers in accord with
    national standards.

If you want more information, call us at 301/468-6000 inside the
Washington, DC metropolitan area or at 800/777-7902 outside the
Washington, DC metropolitan area. Our TTY telephone number is
301/879-6380. Write to us at Kaiser Foundation Health Plan of the
Mid-Atlantic States, Inc., Attention: Member Services Department, 2101
E. Jefferson Street, Rockville, Maryland, 20852 or by fax at
301/816-6192. You may visit our website at
[http://members.kaiserpermanente.org](http://members.kaiserpermanente.org/).

**Service Area**

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

-   **The District of Columbia**

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-   **The following Virginia counties:**

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-   Arlington

-   Fairfax

-   Loudoun

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-   Prince William

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-   **The following Virginia cities**:

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-   Alexandria

-   Falls Church

-   Fairfax

-   Manassas

-   Manassas Park

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-   **The following Maryland counties:**

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-   Anne Arundel

-   Baltimore

-   Carroll

-   Harford

-   Howard

-   Montgomery

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-   Prince Georges

Portions of the following Maryland counties, as indicated by the zip
codes below, are also within the service area:

-   Calvert -- 20639, 20678, 20689, 20714, 20732, 20736, and 20754 zip
    codes only

-   Charles -- 20601, 20602, 20603, 20604, 20612, 20616, 20617, 20637,
    20640, 20643, 20646, 20658, 20675, 20677, and 20695 zip codes only

-   Frederick -- 21701, 21702, 21703, 21704, 21705, 21709, 21710, 21714,
    21716, 21717, 21718, 21754, 21755, 21758, 21759, 21762, 21769,
    21770, 21771, 21774, 21775, 21777, 21790, 21792, and 21793 zip codes
    only

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-   **Baltimore City, MD**

Ordinarily, you must receive your care from physicians, hospitals, and
other providers who contract with us. However, we are part of the Kaiser
Permanente Medical Care Program, and if you are visiting another Kaiser
Permanente service area, you can receive virtually all of the benefits
of this Plan at any other Kaiser Permanente facility, including our mail
order prescription program. You must pay the charges or copayments
imposed by the Kaiser Permanente Plan you are visiting, with the
exception of mail order prescriptions which are administered by your
home Plan. See Section 5(g), Special Features, for more details. We also
pay for certain follow-up services or continuing care services while you
are traveling outside the service area, as described on page 48; and for
emergency care obtained from any non-Plan provider, as described on page
38. We will not pay for any other health care services.

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

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  **Section 2. How we change for 2004**

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

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

**Program-wide changes**

-   We added information regarding two new Federal Programs that
    complement FEHB benefits, the Federal Flexible Spending Account
    Programs -- FSAFEDS and the Federal Long Term Care Insurance
    Program. See page 76.

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

-   We added information regarding enrolling in Medicare. See page 64.

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-   We revised the Medicare Primary Payer Chart. See page 66.

**Changes to this Plan**

-   Your share of the non-Postal premium will increase by 18.4% for Self
    Only or 18.5% for Self and Family.

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-   We decreased the copayments for allergy injections from a split
    copayment of \$10/\$20 to a flat \$10 copayment.

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-   We now cover outpatient cardiac rehabilitation services.

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-   We now cover bilevel pressure devices (BIPAP equipment).

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-   We have increased the copayment for services received at an urgent
    care center from a split copayment of \$10/\$20 to a flat \$20
    copayment.

-   When your visit takes place in a primary care department, you pay a
    copayment of \$10 per office visit. When your visit takes place in a
    specialty care department, you pay a copayment of \$20 per office
    visit.

  -----------------------------------------------------------------------
  Section 3. How you get care
  -----------------------------------------------------------------------

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+--------------------------+-------------------------------------------+
| **Identification cards** | We will send you an identification (ID)   |
|                          | card when you enroll. You should carry    |
|                          | your ID card with you at all times. You   |
|                          | must show it whenever you receive         |
|                          | services from a Plan provider, or fill a  |
|                          | prescription at a Plan pharmacy. Until    |
|                          | you receive your ID card, use your copy   |
|                          | of the health benefits election form,     |
|                          | SF-2809, your health benefits enrollment  |
|                          | confirmation (for annuitants), your       |
|                          | Employee Express confirmation letter, or  |
|                          | write to us at Kaiser Foundation Health   |
|                          | Plan of the Mid-Atlantic States, Inc.,    |
|                          | Attn: Member Services Correspondence,     |
|                          | 2101 E. Jefferson St., Rockville, MD      |
|                          | 20852. Members may submit inquiries,      |
|                          | requests and complaints through our       |
|                          | website                                   |
|                          | [http://members.kaiserpermanente.or       |
|                          | g](http://members.kaiserpermanente.org/). |
|                          | A Member Services representative will     |
|                          | work with you to answer questions and     |
|                          | resolve issues, including ID card issues. |
|                          |                                           |
|                          | If you do not receive your ID card within |
|                          | 30 days after we have received your       |
|                          | enrollment from your payroll office, or   |
|                          | if you need replacement cards, call us at |
|                          | 301/468-6000 inside the Washington, DC    |
|                          | metropolitan area or at 800/777-7902      |
|                          | outside the Washington, DC metropolitan   |
|                          | area. Our TTY telephone number is         |
|                          | 301/879-6380. You may also request        |
|                          | replacement cards through our website at  |
|                          | [http://members.kaiserpermanente.or       |
|                          | g](http://members.kaiserpermanente.org/). |
+--------------------------+-------------------------------------------+
| **Where you get covered  | You get care from "Plan providers" and    |
| care**                   | "Plan facilities." You will only pay      |
|                          | copayments or coinsurance, and you will   |
|                          | not have to file claims, except for       |
|                          | emergency, urgent care services outside   |
|                          | our service area, and for covered         |
|                          | services while you travel.                |
+--------------------------+-------------------------------------------+
| > **• Plan providers**   | Our Plan providers are physicians and     |
|                          | other health care professionals in our    |
|                          | service area that we contract with to     |
|                          | provide covered services to our members.  |
|                          | We contract with the Mid-Atlantic         |
|                          | Permanente Medical Group, P.C., to        |
|                          | provide or arrange for primary care       |
|                          | services and specialty care services for  |
|                          | our members.                              |
|                          |                                           |
|                          | Our Provider Directory lists the Plan     |
|                          | providers, with locations and phone       |
|                          | numbers. Directories are updated annually |
|                          | and are available at the time of          |
|                          | enrollment. However, our online Provider  |
|                          | Directory is updated biweekly. Our        |
|                          | website address is                        |
|                          | <http://members.kaiserpermanente.org/>.   |
+--------------------------+-------------------------------------------+
| > **• Plan facilities**  | Plan facilities are hospitals and other   |
|                          | facilities in our service area that we    |
|                          | contract with to provide covered services |
|                          | to our members.                           |
|                          |                                           |
|                          | If you are visiting another Kaiser        |
|                          | Permanente service area, you may receive  |
|                          | health care services at those Kaiser      |
|                          | Permanente facilities. Under the          |
|                          | circumstances specified in this brochure  |
|                          | you may receive follow-up or continuing   |
|                          | care while you travel anywhere.           |
|                          |                                           |
|                          | Our Provider Directory lists the Plan     |
|                          | facilities. Directories are updated       |
|                          | annually and are available at the time of |
|                          | enrollment. However, our online Provider  |
|                          | Directory is updated biweekly. Our        |
|                          | website address is                        |
|                          | [http://members.kaiserpermanente.or       |
|                          | g](http://members.kaiserpermanente.org/). |
+--------------------------+-------------------------------------------+
| **What you must do to    | It depends on the type of care you need.  |
| get covered care**       | First, you and each family member must    |
|                          | choose a primary care physician. This     |
|                          | decision is important since your primary  |
|                          | care physician provides or arranges for   |
|                          | most of your health care.                 |
|                          |                                           |
|                          | To choose a primary care physician you    |
|                          | can either select one from our Provider   |
|                          | Directory, on our website is              |
|                          | [http://members.kaiserpermanente.o        |
|                          | rg](http://members.kaiserpermanente.org/) |
|                          | or you can call us at 301/468-6000 inside |
|                          | the Washington, DC metropolitan area or   |
|                          | at 800/777-7902 outside the Washington,   |
|                          | DC metropolitan area. Our TTY telephone   |
|                          | number is 301/879-6380. We are happy to   |
|                          | assist you in selecting a primary care    |
|                          | physician.                                |
+--------------------------+-------------------------------------------+
| **• Primary care**       | We require you to choose a primary care   |
|                          | physician when you enroll. Your primary   |
|                          | care physician can be an internal         |
|                          | medicine physician, an                    |
|                          | obstetrician/gynecologist, a              |
|                          | pediatrician, or a family practice        |
|                          | physician. Your primary care physician    |
|                          | will provide most of your health care, or |
|                          | give you a referral to see a specialist.  |
|                          |                                           |
|                          | If you want to change primary care        |
|                          | physicians or if your primary care        |
|                          | physician leaves the Plan, call us. We    |
|                          | will help you select a new one.           |
+--------------------------+-------------------------------------------+
| **• Specialty care**     | Your primary care physician will refer    |
|                          | you to a specialist for needed care. When |
|                          | you receive a referral from your primary  |
|                          | care physician, you must return to the    |
|                          | primary care physician after the          |
|                          | consultation, unless your primary care    |
|                          | physician authorized a certain number of  |
|                          | visits without additional referrals. The  |
|                          | primary care physician must provide or    |
|                          | authorize all follow-up care. Do not go   |
|                          | to the specialist for return visits       |
|                          | unless your primary care physician gives  |
|                          | you a referral. You may see an            |
|                          | optometrist or our mental health and      |
|                          | substance abuse Plan providers without a  |
|                          | referral. Members may obtain mental       |
|                          | health and substance abuse services       |
|                          | without a primary care referral by        |
|                          | directly calling KPMAS' Behavioral Health |
|                          | Access Unit at 866/530-8778 to arrange    |
|                          | for services.                             |
|                          |                                           |
|                          | Here are other things you should know     |
|                          | about specialty care:                     |
|                          |                                           |
|                          | -   If you need to see a specialist       |
|                          |     frequently because of a chronic,      |
|                          |     complex, or serious medical           |
|                          |     condition, your primary care          |
|                          |     physician will work with the          |
|                          |     specialist, in consultation with you, |
|                          |     to develop a treatment plan that      |
|                          |     allows you to see your specialist for |
|                          |     a certain number of visits without    |
|                          |     additional referrals. Your primary    |
|                          |     care physician will use our criteria  |
|                          |     when creating your treatment plan.    |
|                          |                                           |
|                          | ```{=html}                                |
|                          | <!-- -->                                  |
|                          | ```                                       |
|                          | -   If you are seeing a specialist when   |
|                          |     you enroll in our Plan, talk to your  |
|                          |     primary care physician. Your primary  |
|                          |     care physician will decide what       |
|                          |     treatment you need. If he or she      |
|                          |     decides to refer you to a specialist, |
|                          |     ask if you can see your current       |
|                          |     specialist. If your current           |
|                          |     specialist does not participate with  |
|                          |     us, you must receive treatment from a |
|                          |     specialist who does. Generally, we    |
|                          |     will not pay for you to see a         |
|                          |     specialist who does not participate   |
|                          |     with our Plan.                        |
|                          |                                           |
|                          | ```{=html}                                |
|                          | <!-- -->                                  |
|                          | ```                                       |
|                          | -   If you are seeing a specialist and    |
|                          |     your specialist leaves the Plan, call |
|                          |     your primary care physician, who will |
|                          |     arrange for you to see another        |
|                          |     specialist. You may receive services  |
|                          |     from your current specialist until we |
|                          |     can make arrangements for you to see  |
|                          |     someone else.                         |
|                          |                                           |
|                          | ```{=html}                                |
|                          | <!-- -->                                  |
|                          | ```                                       |
|                          | -   If you have a chronic or disabling    |
|                          |     condition and lose access to your     |
|                          |     specialist because we:                |
|                          |                                           |
|                          | ---terminate our contract with your       |
|                          | specialist for other than cause; or       |
|                          |                                           |
|                          | ---drop out of the Federal Employees      |
|                          | Health Benefits (FEHB) Program and you    |
|                          | enroll in another FEHB plan; or           |
|                          |                                           |
|                          | ---reduce our service area and you enroll |
|                          | in another FEHB plan,                     |
|                          |                                           |
|                          | you may be able to continue seeing your   |
|                          | specialist for up to 90 days after you    |
|                          | receive notice of the change. Contact us  |
|                          | or, if we drop out of the Program,        |
|                          | contact your new plan.                    |
|                          |                                           |
|                          | If you are in the second or third         |
|                          | trimester of pregnancy, you can continue  |
|                          | to see your specialist until the end of   |
|                          | your postpartum care, even if it is       |
|                          | beyond the 90 days.                       |
+--------------------------+-------------------------------------------+
| **• Hospital care**      | Your Plan primary care physician or       |
|                          | specialist will make necessary hospital   |
|                          | arrangements and supervise your care.     |
|                          | This includes admission to a skilled      |
|                          | nursing or other type of facility.        |
|                          |                                           |
|                          | If you are in the hospital when your      |
|                          | enrollment in our Plan begins, call our   |
|                          | Member Services department immediately at |
|                          | 301/468-6000 inside the Washington, DC    |
|                          | metropolitan area or at 800/777-7902      |
|                          | outside the Washington, DC metropolitan   |
|                          | area. Our TTY telephone number is         |
|                          | 301/879-6380.                             |
|                          |                                           |
|                          | If you are new to the FEHB Program, we    |
|                          | will arrange for you to receive care. If  |
|                          | you changed from another FEHB plan to us, |
|                          | your former plan will pay for the         |
|                          | hospital stay until:                      |
|                          |                                           |
|                          | -   You are discharged, not merely moved  |
|                          |     to an alternative care center; or     |
|                          |                                           |
|                          | -   The day your benefits from your       |
|                          |     former plan run out; or               |
|                          |                                           |
|                          | -   The 92^nd^ day after you become a     |
|                          |     member of this Plan,                  |
|                          |                                           |
|                          | whichever happens first.                  |
|                          |                                           |
|                          | These provisions apply only to the        |
|                          | benefits of the hospitalized person. If   |
|                          | your plan terminates participation in the |
|                          | FEHB Program in whole or in part, or if   |
|                          | OPM orders an enrollment change, this     |
|                          | continuation of coverage provision does   |
|                          | not apply. In such case, the hospitalized |
|                          | family member's benefits under the new    |
|                          | plan begin on the effective date of       |
|                          | enrollment.                               |
+--------------------------+-------------------------------------------+
| **Circumstances beyond   | Under certain extraordinary               |
| our control**            | circumstances, such as natural disasters, |
|                          | we may have to delay your services or we  |
|                          | may be unable to provide them. In that    |
|                          | case, we will make all reasonable efforts |
|                          | to provide you with the necessary care.   |
+--------------------------+-------------------------------------------+
| **Services requiring our | Your primary care physician has authority |
| prior approval**         | to refer you for most services. For       |
|                          | certain services, however, your physician |
|                          | must obtain approval from us. Before      |
|                          | giving approval, we consider if the       |
|                          | service is covered, medically necessary,  |
|                          | and follows generally accepted medical    |
|                          | practice.                                 |
|                          |                                           |
|                          | We call this review and approval process  |
|                          | precertification. Your physician must     |
|                          | obtain precertification for the following |
|                          | services:                                 |
|                          |                                           |
|                          | -   Acupuncture                           |
|                          |                                           |
|                          | -   All inpatient services, except        |
|                          |     maternity                             |
|                          |                                           |
|                          | -   Adenoids or tonsil removal            |
|                          |                                           |
|                          | -   Breast surgery not associated with    |
|                          |     cancer                                |
|                          |                                           |
|                          | -   Carpal tunnel surgery                 |
|                          |                                           |
|                          | -   Chiropractic services                 |
|                          |                                           |
|                          | -   Clinical trials                       |
|                          |                                           |
|                          | -   Durable medical equipment             |
|                          |                                           |
|                          | -   Gastric bypass surgery                |
|                          |                                           |
|                          | -   Home health care                      |
|                          |                                           |
|                          | -   Hospice care                          |
|                          |                                           |
|                          | -   Hysterectomy                          |
|                          |                                           |
|                          | -   Infertility treatment                 |
|                          |                                           |
|                          | -   Infusion therapy                      |
|                          |                                           |
|                          | -   Injectable medications                |
|                          |                                           |
|                          | -   MRI                                   |
|                          |                                           |
|                          | -   Nasal surgery                         |
|                          |                                           |
|                          | -   Occupational therapy                  |
|                          |                                           |
|                          | -   Oral surgery                          |
|                          |                                           |
|                          | -   Organ transplants                     |
|                          |                                           |
|                          | -   Pain clinics                          |
|                          |                                           |
|                          | -   Physical therapy                      |
|                          |                                           |
|                          | -   Pulmonary therapy                     |
|                          |                                           |
|                          | -   Prosthetics                           |
|                          |                                           |
|                          | -   Reconstructive surgery                |
|                          |                                           |
|                          | -   Sclerotherapy for varicose veins      |
|                          |                                           |
|                          | -   Speech therapy                        |
|                          |                                           |
|                          | -   Spinal surgery not associated with    |
|                          |     cancer                                |
|                          |                                           |
|                          | -   Sleep studies                         |
|                          |                                           |
|                          | -   Surgical procedures                   |
|                          |                                           |
|                          | -   Temporomandibular Joint surgery       |
|                          |                                           |
|                          | -   Tubes in the ears                     |
|                          |                                           |
|                          | Requests for these services are made to   |
|                          | your primary care physician just like any |
|                          | other referral. Your primary care         |
|                          | physician submits the request, with       |
|                          | supporting documentation. It takes an     |
|                          | average of 2 working days to process the  |
|                          | request. You should call your primary     |
|                          | care physician's office if you have not   |
|                          | been notified of the outcome of the       |
|                          | review within 5 working days. If your     |
|                          | request is not approved, you have a right |
|                          | to appeal by calling inside the           |
|                          | Washington, DC Metropolitan area at       |
|                          | 301/468-6000 or toll free at              |
|                          | 800/777-7902. Our TTY is 301/879-6380.    |
|                          | After business hours, for urgent          |
|                          | situations, you may call                  |
|                          | Appointments/Advice to request an appeal  |
|                          | at 703/359-7878, 800/777-7904, TTY is     |
|                          | 703/359-7616 or 800/700-4901. If you wish |
|                          | additional services, you must make the    |
|                          | request to your primary care physician.   |
|                          |                                           |
|                          | Emergency services do not require         |
|                          | precertification. However, you or your    |
|                          | family member must notify the Plan within |
|                          | 48 hours, or as soon as reasonably        |
|                          | possible.                                 |
+--------------------------+-------------------------------------------+

  -----------------------------------------------------------------------
  Section 4. Your costs for covered services
  -----------------------------------------------------------------------

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

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

**• Copayments** A copayment is a fixed amount of money you pay to the
provider, facility, pharmacy, etc., when you receive services. Example:
When your visit takes place in a primary care department, you pay a
copayment of \$10 per office visit. When your visit takes place in a
specialty care department, you pay a copayment of \$20 per office visit.

> **• Deductible** We do not have a deductible.

**• Coinsurance** Coinsurance is the percentage of our allowance that
you must pay for certain services you receive. Example: In our Plan, you
pay 50% of our allowance for infertility services, ovulation stimulants,
weight management drugs, smoking cessation drugs, and oxygen and
equipment for home use after the first three months.

-   **Fees when you fail to** If you do not pay your copayment or
    coinsurance at the time you receive

> **make your copayment** services, we will bill you. You will be
> required to pay a \$10 charge for
>
> **or coinsurance** each bill sent for unpaid services.

**Your catastrophic protection** After your copayments and coinsurance
total \$1,500 per person or \$3,000

**out-of-pocket maximum** **for** per family enrollment in any calendar
year, you do not have to pay any

**copayments and coinsurance** more for covered services. However,
copayments for the following services do not count toward your
catastrophic protection out-of-pocket maximum, and you must continue to
pay copayments and coinsurance for these services:

-   Prescription drugs

-   Chiropractic and acupuncture services

-   Dental services

-   Follow-up and continuing care outside the service area

-   Infertility services

-   Any non-FEHB benefits

**Be sure to keep accurate records of your copayments and coinsurance
since you are responsible for informing us when you reach the maximum.**

+-----------------------------------------------------------------------+
| **Section 5. Benefits -- OVERVIEW**                                   |
|                                                                       |
| ***(See page 10 for how our benefits changed this year and page 82    |
| 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, claim
filing advice, or more information about our benefits, contact us at
301/468-6000 inside the Washington, DC metropolitan area or at
800/777-7902 outside the Washington, DC metropolitan area. Our TTY
telephone number is 301/879-6380. You can also visit our website at
[http://members.kaiserpermanente.org](http://members.kaiserpermanente.org/).

(a) Medical services and supplies provided by physicians and other
    health care professionals 17-29

+---------------------------------+------------------------------------+
| •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 (DME)   |
|                                 |                                    |
| •Family planning                | •Home health services              |
|                                 |                                    |
| •Infertility services           | •Chiropractic                      |
|                                 |                                    |
| •Allergy care                   | •Alternative treatments            |
|                                 |                                    |
| •Treatment therapies            | •Educational classes and programs  |
|                                 |                                    |
| •Physical and occupational      |                                    |
| therapies                       |                                    |
|                                 |                                    |
| •Speech therapy                 |                                    |
+---------------------------------+------------------------------------+

(b) Surgical and anesthesia services provided by physicians and other
    health care professionals 30-33

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

(c) Services provided by a hospital or other facility, and ambulance
    services 34-37

+---------------------------------+------------------------------------+
| •Inpatient hospital             | • Skilled nursing care benefits    |
|                                 |                                    |
| •Outpatient hospital or         | •Hospice care                      |
| ambulatory surgical center      |                                    |
|                                 | •Ambulance                         |
+---------------------------------+------------------------------------+

\(d\) Emergency services/accidents 38-39

+---------------------------------+------------------------------------+
| •Emergency within our service   | •Ambulance                         |
| area                            |                                    |
|                                 |                                    |
| •Emergency outside our service  |                                    |
| area                            |                                    |
+---------------------------------+------------------------------------+

(e) Mental health and substance abuse benefits 40-42

(f) Prescription drug benefits 43-46

(g) Special features 47-49

+---------------------------------+------------------------------------+
| •Flexible benefits option       | •Centers of Excellence             |
|                                 |                                    |
| •24 hour nurse line             | •Travel benefit                    |
|                                 |                                    |
| •Services for the deaf and      | • Services from other Kaiser       |
| hearing impaired                | Permanente Plans                   |
+---------------------------------+------------------------------------+

(h) Dental benefits 50-58

(i) Non-FEHB benefits available to Plan members 59

Summary of benefits 82

+---+---+-------------------------------------+----------------+---+---+---+
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| f |   |                                     |                |   |   |   |
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| o |   |                                     |                |   |   |   |
| n |   |                                     |                |   |   |   |
| a |   |                                     |                |   |   |   |
| l |   |                                     |                |   |   |   |
| s |   |                                     |                |   |   |   |
| * |   |                                     |                |   |   |   |
| * |   |                                     |                |   |   |   |
+---+---+-------------------------------------+----------------+---+---+---+
|   | * | **Here are some important things to |                | * |   |   |
|   | * | keep in mind about these            |                | * |   |   |
|   | I | benefits:**                         |                | I |   |   |
|   | * |                                     |                | * |   |   |
|   | * | -   Please remember that all        |                | * |   |   |
|   |   |     benefits are subject to the     |                |   |   |   |
|   | * |     definitions, limitations, and   |                | * |   |   |
|   | * |     exclusions in this brochure and |                | * |   |   |
|   | M |     we cover them only when we      |                | M |   |   |
|   | * |     determine they are medically    |                | * |   |   |
|   | * |     necessary.                      |                | * |   |   |
|   |   |                                     |                |   |   |   |
|   | * | -   Plan physicians must provide or |                | * |   |   |
|   | * |     arrange your care.              |                | * |   |   |
|   | P |                                     |                | P |   |   |
|   | * | -   Be sure to read Section 4,      |                | * |   |   |
|   | * |     *Your costs for covered         |                | * |   |   |
|   |   |     services,* for valuable         |                |   |   |   |
|   | * |     information about how cost      |                | * |   |   |
|   | * |     sharing works. Also read        |                | * |   |   |
|   | O |     Section 9 about coordinating    |                | O |   |   |
|   | * |     benefits with other coverage,   |                | * |   |   |
|   | * |     including with Medicare.        |                | * |   |   |
|   |   |     Different copayments apply for  |                |   |   |   |
|   | * |     primary care visits and         |                | * |   |   |
|   | * |     specialty care visits. Please   |                | * |   |   |
|   | R |     refer to Section 10,            |                | R |   |   |
|   | * |     *Definitions*, to learn more    |                | * |   |   |
|   | * |     about when your primary and     |                | * |   |   |
|   |   |     specialty care copayments will  |                |   |   |   |
|   | * |     apply.                          |                | * |   |   |
|   | * |                                     |                | * |   |   |
|   | T | -   We have no calendar year        |                | T |   |   |
|   | * |     deductible.                     |                | * |   |   |
|   | * |                                     |                | * |   |   |
|   |   |                                     |                |   |   |   |
|   | * |                                     |                | * |   |   |
|   | * |                                     |                | * |   |   |
|   | A |                                     |                | A |   |   |
|   | * |                                     |                | * |   |   |
|   | * |                                     |                | * |   |   |
|   |   |                                     |                |   |   |   |
|   | * |                                     |                | * |   |   |
|   | * |                                     |                | * |   |   |
|   | N |                                     |                | N |   |   |
|   | * |                                     |                | * |   |   |
|   | * |                                     |                | * |   |   |
|   |   |                                     |                |   |   |   |
|   | * |                                     |                | * |   |   |
|   | * |                                     |                | * |   |   |
|   | T |                                     |                | T |   |   |
|   | * |                                     |                | * |   |   |
|   | * |                                     |                | * |   |   |
+---+---+-------------------------------------+----------------+---+---+---+
| # |   |                                     | > **You Pay**  |   |   |   |
| # |   |                                     |                |   |   |   |
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+---+---+-------------------------------------+----------------+---+---+---+
| # |   |                                     |                |   |   |   |
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| * |   |                                     |                |   |   |   |
| * |   |                                     |                |   |   |   |
+---+---+-------------------------------------+----------------+---+---+---+
| P |   |                                     | \$10 per visit |   |   |   |
| r |   |                                     | in a primary   |   |   |   |
| o |   |                                     | care           |   |   |   |
| f |   |                                     | department     |   |   |   |
| e |   |                                     | (except        |   |   |   |
| s |   |                                     | nothing for    |   |   |   |
| s |   |                                     | children from  |   |   |   |
| i |   |                                     | infancy        |   |   |   |
| o |   |                                     | through age 4) |   |   |   |
| n |   |                                     |                |   |   |   |
| a |   |                                     | \$20 per visit |   |   |   |
| l |   |                                     | in specialty   |   |   |   |
| s |   |                                     | care and       |   |   |   |
| e |   |                                     | urgent care    |   |   |   |
| r |   |                                     | departments    |   |   |   |
| v |   |                                     |                |   |   |   |
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+---+---+-------------------------------------+----------------+---+---+---+
| - |   |                                     | Nothing        |   |   |   |
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|   |   |                                     |                |   |   |   |
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|   |   |                                     |                |   |   |   |
| E |   |                                     |                |   |   |   |
| l |   |                                     |                |   |   |   |
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| c |   |                                     |                |   |   |   |
| t |   |                                     |                |   |   |   |
| r |   |                                     |                |   |   |   |
| o |   |                                     |                |   |   |   |
| c |   |                                     |                |   |   |   |
| a |   |                                     |                |   |   |   |
| r |   |                                     |                |   |   |   |
| d |   |                                     |                |   |   |   |
| i |   |                                     |                |   |   |   |
| o |   |                                     |                |   |   |   |
| g |   |                                     |                |   |   |   |
| r |   |                                     |                |   |   |   |
| a |   |                                     |                |   |   |   |
| m |   |                                     |                |   |   |   |
|   |   |                                     |                |   |   |   |
|   |   |                                     |                |   |   |   |
|   |   |                                     |                |   |   |   |
|   |   |                                     |                |   |   |   |
| a |   |                                     |                |   |   |   |
| n |   |                                     |                |   |   |   |
| d |   |                                     |                |   |   |   |
|   |   |                                     |                |   |   |   |
|   |   |                                     |                |   |   |   |
|   |   |                                     |                |   |   |   |
|   |   |                                     |                |   |   |   |
| E |   |                                     |                |   |   |   |
| E |   |                                     |                |   |   |   |
| G |   |                                     |                |   |   |   |
+---+---+-------------------------------------+----------------+---+---+---+

+---------------------------------------------+------------------------+
| ### **Preventive care, adult**              | **You pay**            |
+---------------------------------------------+------------------------+
| Routine screenings, such as:                | \$10 per visit in a    |
|                                             | primary care           |
| -   Total blood cholesterol                 | department             |
|                                             |                        |
| -   Colorectal cancer screening, including  | > \$20 per visit in a  |
|                                             | > specialty care       |
| > ---Fecal occult blood test                | > department           |
| >                                           |                        |
| > ---Sigmoidoscopy - every five years       |                        |
| > starting at age 50                        |                        |
+---------------------------------------------+------------------------+
| -   Bone mass measurement for prevention,   |                        |
|     diagnosis and treatment of osteoporosis |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Routine Prostate Specific Antigen (PSA) |                        |
|     test- one annually for men age 40 and   |                        |
|     older                                   |                        |
|                                             |                        |
| -   Chlamydia screenings -- women under age |                        |
|     20 who are sexually active and women    |                        |
|     over age 20 with multiple risk factors  |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Routine pap smear                       |                        |
|                                             |                        |
| -   Travel consultations                    |                        |
|                                             |                        |
| > Note: You should consult with your        |                        |
| > physician to determine what is            |                        |
| > appropriate for you.                      |                        |
+---------------------------------------------+------------------------+
| > Routine immunizations, limited to:        |                        |
|                                             |                        |
| -   Tetanus-diphtheria (Td) booster - once  |                        |
|     every 10 years, ages 19 and over        |                        |
|     (except as provided for under Childhood |                        |
|     immunizations)                          |                        |
|                                             |                        |
| -   Influenza/pneumococcal vaccines,        |                        |
|     annually, age 65 and over               |                        |
|                                             |                        |
| -   Travel immunizations and vaccines       |                        |
|                                             |                        |
| > Note: You pay only one copayment if you   |                        |
| > receive your routine screening or         |                        |
| > immunization on the same day as your      |                        |
| > office visit.                             |                        |
+---------------------------------------------+------------------------+
| > Routine mammogram -- Covered for women    | > Nothing              |
| > age 35 and older, as follows:             |                        |
|                                             |                        |
| -   From age 35 to 39, one during this      |                        |
|     five-year period                        |                        |
|                                             |                        |
| -   From age 40 to 64, one every calendar   |                        |
|     year                                    |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   At age 65 and older, one every two      |                        |
|     consecutive calendar years              |                        |
+---------------------------------------------+------------------------+
| *Not covered:*                              | > *All charges*        |
|                                             |                        |
| *Physical exams required for:*              |                        |
|                                             |                        |
| -   *Obtaining or continuing employment*    |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Participating in employee programs*    |                        |
|                                             |                        |
| -   *Insurance or licensing*                |                        |
|                                             |                        |
| -   *Court ordered for parole or probation* |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Attending schools*                     |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| ##### Preventive care, children             | > **You pay**          |
+---------------------------------------------+------------------------+
| -   Childhood immunizations recommended by  | \$10 per visit in a    |
|     the American Academy of Pediatrics      | primary care           |
|                                             | department (except     |
| ```{=html}                                  | nothing for children   |
| <!-- -->                                    | from infancy through   |
| ```                                         | age 4)                 |
| -   Examinations, such as:                  |                        |
|                                             | \$20 per visit in a    |
| > ---Eye exams to determine the need for    | specialty care         |
| > vision correction                         | department             |
| >                                           |                        |
| > ---Ear exams to determine the need for    |                        |
| > hearing correction                        |                        |
|                                             |                        |
| -   Travel consultations                    |                        |
|                                             |                        |
| -   Travel immunizations and vaccines       |                        |
+---------------------------------------------+------------------------+
| *Not covered:*                              | > *All charges*        |
|                                             |                        |
| *Physical exams required for:*              |                        |
|                                             |                        |
| -   *Obtaining or continuing employment*    |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Participating in employee programs*    |                        |
|                                             |                        |
| -   *Insurance or licensing*                |                        |
|                                             |                        |
| -   *Court ordered for parole or probation* |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Attending schools*                     |                        |
+---------------------------------------------+------------------------+
| ######## Maternity care                     |                        |
+---------------------------------------------+------------------------+
| > Complete maternity (obstetrical) care,    | \$10 for the first     |
| > such as:                                  | office visit to        |
|                                             | confirm pregnancy      |
| -   Prenatal care                           |                        |
|                                             | Nothing once pregnancy |
| -   Delivery                                | is confirmed through   |
|                                             | the post-partum office |
| -   Postnatal care                          | visit                  |
|                                             |                        |
| > Note: Here are some things to keep in     |                        |
| > mind:                                     |                        |
|                                             |                        |
| -   You do not need to precertify your      |                        |
|     normal delivery.                        |                        |
|                                             |                        |
| -   You may remain in the hospital up to 48 |                        |
|     hours after a regular delivery and 96   |                        |
|     hours after a cesarean delivery. Your   |                        |
|     inpatient stay will be extended if      |                        |
|     medically necessary.                    |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   We cover routine nursery care of the    |                        |
|     newborn child during the covered        |                        |
|     portion of the mother's maternity stay. |                        |
|     We cover other care of an infant who    |                        |
|     requires non-routine treatment only if  |                        |
|     the infant is covered under a Self and  |                        |
|     Family enrollment.                      |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   We pay hospitalization and surgeon      |                        |
|     services (delivery) the same as for     |                        |
|     illness and injury. See Hospital        |                        |
|     benefits (Section 5 (c)) and Surgery    |                        |
|     benefits (Section 5 (b))*.*             |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | *All charges*          |
|                                             |                        |
| -   *Routine sonograms to determine fetal   |                        |
|     age, size, or sex*                      |                        |
+---------------------------------------------+------------------------+
| ######## Family planning                    | > **You pay**          |
+---------------------------------------------+------------------------+
| -   Family planning services, including     | \$10 per visit in a    |
|     counseling                              | primary care           |
|                                             | department             |
| -   Voluntary sterilization (See Surgical   |                        |
|     procedures Section 5 (b))               | \$20 per visit in a    |
|                                             | specialty care         |
| -   Information on birth control            | department             |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Genetic counseling                      |                        |
|                                             |                        |
| > Note: We cover surgically implanted       |                        |
| > time-release contraceptive drugs,         |                        |
| > injectable contraceptive drugs,           |                        |
| > intrauterine devices (IUDs), and          |                        |
| > diaphragms under the prescription drug    |                        |
| > benefit.                                  |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges*        |
|                                             |                        |
| -   *Reversal of voluntary surgical         |                        |
|     sterilization*                          |                        |
+---------------------------------------------+------------------------+
| ######## Infertility services               |                        |
+---------------------------------------------+------------------------+
| Diagnosis and treatment of involuntary      | 50% of our allowance   |
| infertility                                 |                        |
|                                             |                        |
| -   Artificial insemination                 |                        |
|                                             |                        |
| > ---intravaginal insemination (IVI)        |                        |
| >                                           |                        |
| > ---intra-cervical insemination (ICI)      |                        |
| >                                           |                        |
| > ---intrauterine insemination (IUI)        |                        |
|                                             |                        |
| -   Fertility Drugs                         |                        |
|                                             |                        |
| > Note: We cover injectable fertility drugs |                        |
| > under the prescription drug benefit.      |                        |
+---------------------------------------------+------------------------+
| -   In vitro fertilization, (limited to     | 50% of our allowance;  |
|     three (3) attempts per live birth) if:  | Plan pays up to        |
|                                             | \$100,000 in a         |
| ---your oocytes are fertilized with your    | Member's lifetime      |
| spouse's sperm;                             |                        |
|                                             |                        |
| > ---you and your spouse have a history of  |                        |
| > infertility of at least 2 years duration; |                        |
| > or                                        |                        |
| >                                           |                        |
| > ---the infertility is associated with     |                        |
| > endometriosis, exposure in utero to       |                        |
| > diethylstilbestrol, commonly known as     |                        |
| > DES, blockage of, or surgical removal of, |                        |
| > one or both fallopian tubes (lateral or   |                        |
| > bilateral salpingectomy, or abnormal male |                        |
| > factors, including oligospermia,          |                        |
| > contributing to the infertility;          |                        |
| >                                           |                        |
| > ---you have been unable to become         |                        |
| > pregnant through a less costly            |                        |
| > infertility treatment for which coverage  |                        |
| > is available under the Plan               |                        |
+---------------------------------------------+------------------------+
| ######## Infertility services *(continued)* | > **You pay**          |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges*        |
| >                                           |                        |
| > *These exclusions apply to fertile as     |                        |
| > well as infertile individuals or          |                        |
| > couples:*                                 |                        |
|                                             |                        |
| -   *Assisted reproductive technology (ART) |                        |
|     procedures, such as:*                   |                        |
|                                             |                        |
| > ---*gamete intrafallopian transfer        |                        |
| > (GIFT)*                                   |                        |
| >                                           |                        |
| > ---*zygote intrafallopian transfer        |                        |
| > (ZIFT)*                                   |                        |
|                                             |                        |
| -   *Donor semen and donor eggs, including  |                        |
|     retrieval of eggs*                      |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Storage and freezing of eggs*          |                        |
|                                             |                        |
| > *Note: Infertility services are not       |                        |
| > available when either member of the       |                        |
| > family has been voluntarily surgically    |                        |
| > sterilized.*                              |                        |
+---------------------------------------------+------------------------+
| > **Allergy care**                          |                        |
+---------------------------------------------+------------------------+
| -   Testing and treatment                   | \$10 per visit in a    |
|                                             | primary care           |
|                                             | department             |
|                                             |                        |
|                                             | \$20 per visit in a    |
|                                             | specialty care         |
|                                             | department             |
+---------------------------------------------+------------------------+
| -   Allergy injection                       | \$10 per visit         |
|                                             |                        |
| > Note: Allergy serum is covered in full as |                        |
| > a part of the office visit copayment.     |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges*        |
|                                             |                        |
| -   *Provocative food testing*              |                        |
|                                             |                        |
| -   *Sublingual allergy desensitization*    |                        |
+---------------------------------------------+------------------------+
| ######## Treatment therapies                |                        |
+---------------------------------------------+------------------------+
| -   Respiratory and inhalation therapy      | \$10 per visit in a    |
|                                             | primary care           |
| -   Intravenous/Infusion Therapy            | department (except     |
|                                             | nothing for children   |
| > Note: We cover growth hormone therapy     | from infancy through   |
| > (GHT) under the prescription drug         | age 4)                 |
| > benefit.                                  |                        |
|                                             | \$20 per visit in a    |
| -   Qualified medical clinical trials that  | specialty care         |
|     provide treatment for life-threatening  | department             |
|     conditions or for preventive, early     |                        |
|     detection, or treatment studies of      |                        |
|     cancer for Phases I, II, III and IV     |                        |
|                                             |                        |
| -   Dialysis -- Hemodialysis and peritoneal |                        |
|     dialysis                                |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Chemotherapy and radiation therapy      |                        |
|                                             |                        |
| > Note: We limit high dose chemotherapy in  |                        |
| > association with autologous bone marrow   |                        |
| > transplants to those transplants listed   |                        |
| > under Organ/tissue transplants.           |                        |
+---------------------------------------------+------------------------+
| ######## Treatment therapies *(continued)*  | > **You pay**          |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | *All charges*          |
|                                             |                        |
| -   *Long term rehabilitative therapy*      |                        |
|                                             |                        |
| -   *Cognitive therapy*                     |                        |
|                                             |                        |
| -   *Chemotherapy supported by a bone       |                        |
|     marrow transplant or with stem cell     |                        |
|     support, for any diagnosis not listed   |                        |
|     as covered*                             |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Sleep therapy*                         |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Thermography and related services*     |                        |
+---------------------------------------------+------------------------+
| > **Physical and occupational therapies**   |                        |
+---------------------------------------------+------------------------+
| > Inpatient Services -- up to 2 consecutive | > \$100 per admission  |
| > months of therapy per condition:          |                        |
|                                             |                        |
| -   Physical therapy by a qualified Plan    |                        |
|     therapist in consultation with a Plan   |                        |
|     physician to restore bodily function    |                        |
|     when you have a total or partial loss   |                        |
|     of bodily function due to illness or    |                        |
|     injury                                  |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Occupational therapy by a Plan          |                        |
|     therapist in consultation with a Plan   |                        |
|     physician to assist you in achieving    |                        |
|     and maintaining self-care and improved  |                        |
|     functioning in other activities of      |                        |
|     daily life                              |                        |
|                                             |                        |
| -   We provide inpatient multidisciplinary  |                        |
|     rehabilitation in a prescribed,         |                        |
|     organized program in a plan facility or |                        |
|     skilled nursing facility for up to two  |                        |
|     consecutive months for all covered      |                        |
|     rehabilitation services and supplies    |                        |
|     you may receive at different sites for  |                        |
|     the same condition                      |                        |
|                                             |                        |
| > Note: This \$100 charge is waived if you  |                        |
| > have been admitted directly from a        |                        |
| > hospital inpatient stay.                  |                        |
+---------------------------------------------+------------------------+
| Outpatient physical and occupational        | > \$20 per visit in a  |
| therapy                                     | > specialty care       |
|                                             | > department           |
| -   We cover up to 30 office visits or 60   |                        |
|     days (whichever is greater) per         |                        |
|     condition of out-patient physical       |                        |
|     therapy services                        |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   We cover up to 90 days per condition of |                        |
|     out-patient occupational therapy        |                        |
|     services                                |                        |
|                                             |                        |
| > Habilitative services for children --     |                        |
| > from birth to age 19 for the treatment of |                        |
| > congenital and generic birth defects      |                        |
|                                             |                        |
| -   We cover services to help a child       |                        |
|     function age-appropriately within his   |                        |
|     or her environment and enhance his or   |                        |
|     her functional ability without an       |                        |
|     effective cure                          |                        |
|                                             |                        |
| > Cardiac Rehabilitation provided or        |                        |
| > coordinated by a hospital or other        |                        |
| > facility which is approved by a physician |                        |
| > and includes exercise stress testing,     |                        |
| > rehabilitative exercises, education and   |                        |
| > counseling                                |                        |
|                                             |                        |
| -   We cover services for up to 12 weeks or |                        |
|     36 sessions following coronary surgery  |                        |
|     or a myocardial infarction              |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| > **Physical and occupational therapies**   | > **You pay**          |
| > *(continued)*                             |                        |
+---------------------------------------------+------------------------+
| *Not covered:*                              | > *All charges*        |
|                                             |                        |
| -   *Long-term rehabilitative therapy*      |                        |
|                                             |                        |
| -   *Exercise programs*                     |                        |
|                                             |                        |
| -   *Cognitive rehabilitation programs*     |                        |
|                                             |                        |
| -   *Vocational rehabilitation programs*    |                        |
|                                             |                        |
| -   *Therapies done primarily for education |                        |
|     purposes, except as may otherwise be    |                        |
|     covered above*                          |                        |
+---------------------------------------------+------------------------+
| > **Speech therapy**                        |                        |
+---------------------------------------------+------------------------+
| > Inpatient Services -- up to 2 consecutive | > \$100 per admission  |
| > months of therapy per condition:          |                        |
|                                             |                        |
| -   Speech therapy by a Plan therapist in   |                        |
|     consultation with a Plan physician when |                        |
|     medically necessary                     |                        |
|                                             |                        |
| > Note: This \$100 charge is waived if you  |                        |
| > have been admitted directly from a        |                        |
| > hospital inpatient stay.                  |                        |
+---------------------------------------------+------------------------+
| > Outpatient Services --up to 90 days per   | > \$20 per visit in a  |
| > condition per year of outpatient speech   | > specialty care       |
| > therapy                                   | > department           |
| >                                           |                        |
| > Habilitative services for children --     |                        |
| > from birth to age 19 for the treatment of |                        |
| > congenital and generic birth defects      |                        |
|                                             |                        |
| -   We cover services to help a child       |                        |
|     function age-appropriately within his   |                        |
|     or her environment and enhance his or   |                        |
|     her functional ability without an       |                        |
|     effective cure                          |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges*        |
| >                                           |                        |
| > *Speech therapy that is not medically     |                        |
| > necessary such as:*                       |                        |
|                                             |                        |
| -   *Therapy for educational placement or   |                        |
|     other educational purposes*             |                        |
|                                             |                        |
| -   *Training or therapy to improve         |                        |
|     articulation in the absence of injury,  |                        |
|     illness, or medical condition affecting |                        |
|     articulation*                           |                        |
|                                             |                        |
| -   *Therapy for tongue thrust in the       |                        |
|     absence of swallowing problems*         |                        |
|                                             |                        |
| -   *Voice therapy for occupation or        |                        |
|     performing arts*                        |                        |
+---------------------------------------------+------------------------+
| > **Hearing services (testing, treatment,   |                        |
| > and supplies)**                           |                        |
+---------------------------------------------+------------------------+
| -   Hearing tests to determine the need for | \$10 per visit in a    |
|     hearing correction                      | primary care           |
|                                             | department             |
|                                             |                        |
|                                             | \$20 per visit in a    |
|                                             | specialty care         |
|                                             | department             |
+---------------------------------------------+------------------------+
| -   Hearing aids for children under age 18  | > All charges in       |
|                                             | > excess of \$1400 for |
|                                             | > each hearing         |
|                                             | > impaired ear every   |
|                                             | > 36 months            |
+---------------------------------------------+------------------------+
| > **Hearing services (testing, treatment,   | > **You pay**          |
| > and supplies)** *(continued)*             |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges*        |
|                                             |                        |
| -   *Hearing aids, tests to determine their |                        |
|     effectiveness, and examinations for     |                        |
|     them for all persons age 18 and over*   |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *All other hearing testing*             |                        |
+---------------------------------------------+------------------------+
| > **Vision services (testing, treatment,    |                        |
| > and supplies)**                           |                        |
+---------------------------------------------+------------------------+
| -   Eye exam in the Optometry Department    | > \$10 per visit       |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Eye refractions in the Optometry        |                        |
|     Department                              |                        |
|                                             |                        |
| > Note: Vision services performed outside   |                        |
| > the Optometry Department will be at the   |                        |
| > specialty copayment.                      |                        |
+---------------------------------------------+------------------------+
| -   Diagnosis and treatment of diseases of  | > \$20 per visit in a  |
|     the eye                                 | > specialty care       |
|                                             | > department           |
| Note: These services are performed in a     |                        |
| specialist department.                      |                        |
+---------------------------------------------+------------------------+
| -   Eyeglass frames purchased at Plan       | > 75% of our allowance |
|     Optical Shops                           |                        |
|                                             |                        |
| -   Eyeglass lenses purchased at Plan       |                        |
|     Optical Shops                           |                        |
+---------------------------------------------+------------------------+
| -   Initial fitting for contact lenses at a | > 85% of our allowance |
|     Plan facility                           |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Insertion and removal of contact lens   |                        |
|     training                                |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Three months of follow-up office visits |                        |
|                                             |                        |
| > Note: These services are provided only in |                        |
| > conjunction with obtaining your first set |                        |
| > of contact lenses at a Plan Optical Shop. |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges*        |
|                                             |                        |
| -   *Eye exercises and orthoptics*          |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Radial keratotomy and other refractive |                        |
|     surgery*                                |                        |
|                                             |                        |
| -   *Eye surgery solely for the purpose of  |                        |
|     correcting refractive defects of the    |                        |
|     eye, such as near-sightedness (myopia), |                        |
|     far-sightedness (hyperopia), and        |                        |
|     astigmatism*                            |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Cosmetic contact lenses*               |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Cost of eyewear not purchased at Plan  |                        |
|     facilities*                             |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Sunglasses without corrective lenses*  |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| ######## Foot care                          | > **You pay**          |
+---------------------------------------------+------------------------+
| -   Routine foot care when you are under    | \$10 per visit in a    |
|     active treatment for a metabolic or     | primary care           |
|     peripheral vascular disease             | department             |
|                                             |                        |
| > Note: See orthopedic and prosthetic       | \$20 per visit in a    |
| > devices for information on podiatric shoe | specialty care         |
| > inserts.                                  | department             |
+---------------------------------------------+------------------------+
| *Not covered:*                              | *All charges*          |
|                                             |                        |
| -   *Cutting, trimming, or removal of       |                        |
|     corns, calluses, or the free edge of    |                        |
|     toenails, and similar routine treatment |                        |
|     for conditions of the foot, except as   |                        |
|     stated above*                           |                        |
|                                             |                        |
| -   *Treatment of weak, strained, or flat   |                        |
|     feet or bunions or spurs; and of any    |                        |
|     instability, imbalance, or subluxation  |                        |
|     of the foot (unless the treatment is by |                        |
|     open cutting surgery)*                  |                        |
+---------------------------------------------+------------------------+
| > **Orthopedic and prosthetic devices**     |                        |
+---------------------------------------------+------------------------+
| -   Externally worn breast prostheses and   | 20% of our allowance   |
|     surgical bras including necessary       |                        |
|     replacements following a mastectomy     |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Internal prosthetic devices, such as    |                        |
|     artificial joints, pacemakers, cochlear |                        |
|     implants, and surgically implanted      |                        |
|     breast implants following mastectomy.   |                        |
|     Note: See Section 5(b) for coverage of  |                        |
|     the surgery to insert the device.       |                        |
+---------------------------------------------+------------------------+
| > One hair prosthesis if your hair loss     | All charges in excess  |
| > results from chemotherapy or radiation    | of \$350               |
| > treatment for cancer                      |                        |
+---------------------------------------------+------------------------+
| *Not covered:*                              | *All charges*          |
|                                             |                        |
| -   *Comfort, convenience, or luxury        |                        |
|     equipment or features*                  |                        |
|                                             |                        |
| -   *External prosthetics and orthotics,    |                        |
|     such as braces, foot orthotics,         |                        |
|     artificial limbs, and lenses following  |                        |
|     cataract removal*                       |                        |
|                                             |                        |
| -   *Devices, equipment, supplies, and      |                        |
|     prosthetics related to sexual           |                        |
|     dysfunction*                            |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Orthopedic and corrective shoes*       |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Arch supports*                         |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Foot orthotics*                        |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Heel pads and heel cups*               |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Lumbosacral supports*                  |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Corsets, trusses, elastic stockings,   |                        |
|     support hose and other supportive       |                        |
|     devices*                                |                        |
+---------------------------------------------+------------------------+
| ######## Durable medical equipment (DME)    | > **You pay**          |
+---------------------------------------------+------------------------+
| > We cover prescribed DME for home use for  | 20% of our allowance   |
| > up to three months from the date of       |                        |
| > discharge following:                      |                        |
|                                             |                        |
| -   An authorized hospital admission        |                        |
|                                             |                        |
| -   An authorized skilled nursing facility  |                        |
|     admission                               |                        |
|                                             |                        |
| -   An authorized rehabilitation facility   |                        |
|     admission                               |                        |
|                                             |                        |
| -   An authorized outpatient surgical       |                        |
|     procedure                               |                        |
|                                             |                        |
| Covered items include:                      |                        |
|                                             |                        |
| -   Hospital beds                           |                        |
|                                             |                        |
| -   Wheelchairs                             |                        |
|                                             |                        |
| -   Canes                                   |                        |
|                                             |                        |
| -   Walkers                                 |                        |
|                                             |                        |
| -   Portable commodes                       |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Crutches                                |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Insulin pumps and supplies              |                        |
|                                             |                        |
| -   Bilirubin lights and apnea monitors for |                        |
|     infants up to age 3 for a period not to |                        |
|     exceed 6 months                         |                        |
|                                             |                        |
| > Note: We decide whether to rent or        |                        |
| > purchase the equipment, and we select the |                        |
| > vendor. We will repair the equipment      |                        |
| > without charge, unless the repair is due  |                        |
| > to loss or misuse. You must return the    |                        |
| > equipment to us or pay us the fair market |                        |
| > price of the equipment when it is no      |                        |
| > longer prescribed.                        |                        |
+---------------------------------------------+------------------------+
| -   Continuous Positive Airway Pressure     | 20% of our allowance   |
|     (CPAP) and Bilevel Pressure device      | for the first three    |
|     (BIPAP) equipment                       | months; 50% of our     |
|                                             | allowance for every 30 |
| -   Oxygen and equipment for home use       | days thereafter        |
|                                             |                        |
| > Note: Your Plan physician must recertify  |                        |
| > your medical need for oxygen and          |                        |
| > equipment every 30 days.                  |                        |
+---------------------------------------------+------------------------+
| -   Asthmatic equipment (spacers, peak-flow | Spacers: \$5 per       |
|     meters, and nebulizers) for adults and  | spacer                 |
|     children, when purchased at a Plan      |                        |
|     pharmacy.                               | Peak-Flow Meters: \$10 |
|                                             | per meter              |
|                                             |                        |
|                                             | Nebulizers: \$30 per   |
|                                             | nebulizer              |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| > **Durable medical equipment (DME)**       | **You pay**            |
| > *(continued)*                             |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | *All charges*          |
|                                             |                        |
| -   *Oxygen tents*                          |                        |
|                                             |                        |
| -   *Motorized wheelchairs*                 |                        |
|                                             |                        |
| -   *Comfort, convenience, or luxury        |                        |
|     equipment or features*                  |                        |
|                                             |                        |
| -   *Exercise or hygiene equipment*         |                        |
|                                             |                        |
| -   *Non-medical items such as sauna baths  |                        |
|     or elevators*                           |                        |
|                                             |                        |
| -   *Modifications to your home or car*     |                        |
|                                             |                        |
| -   *Devices for testing blood or other     |                        |
|     body substances (glucose test strips    |                        |
|     are covered under your prescription     |                        |
|     drug benefits)*                         |                        |
|                                             |                        |
| -   *Electronic monitors of bodily          |                        |
|     functions, except apnea monitors and    |                        |
|     blood glucose monitors*                 |                        |
|                                             |                        |
| -   *Disposable supplies*                   |                        |
|                                             |                        |
| -   *Replacement of lost equipment*         |                        |
|                                             |                        |
| -   *Repairs, adjustments, or replacements  |                        |
|     necessitated by misuse*                 |                        |
|                                             |                        |
| -   *More than one piece of durable medical |                        |
|     equipment serving essentially the same  |                        |
|     function, except for replacements other |                        |
|     than those necessitated by misuse or    |                        |
|     loss*                                   |                        |
|                                             |                        |
| -   *Devices, equipment, supplies, and      |                        |
|     prosthetics for the treatment of sexual |                        |
|     dysfunction disorders*                  |                        |
|                                             |                        |
| -   *External and internally implanted      |                        |
|     hearing aids for all persons age 18 and |                        |
|     over*                                   |                        |
|                                             |                        |
| -   *Experimental or research equipment*    |                        |
|                                             |                        |
| -   *Dental appliances*                     |                        |
+---------------------------------------------+------------------------+
| ######## Home health services               |                        |
+---------------------------------------------+------------------------+
| > If you are homebound and reside in the    | Nothing                |
| > service area, we cover home health care   |                        |
| > ordered by a Plan physician and provided  |                        |
| > by a registered nurse, licensed practical |                        |
| > nurse, licensed vocational nurse,         |                        |
| > physical therapist, occupational          |                        |
| > therapist, speech and language            |                        |
| > pathologist, or home health aide          |                        |
|                                             |                        |
| -   Services include oxygen therapy,        |                        |
|     intravenous therapy, and medications    |                        |
|                                             |                        |
| > Note: Your Plan physician will            |                        |
| > periodically review the home health       |                        |
| > program for continuing appropriateness    |                        |
| > and medical need.                         |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| > **Home health services** *(continued)*    | **You pay**            |
+---------------------------------------------+------------------------+
| *Not covered:*                              | > *All charges*        |
|                                             |                        |
| -   *Nursing care requested by, or for the  |                        |
|     convenience of, the patient or the      |                        |
|     patient's family*                       |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Custodial care*                        |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Homemaker services*                    |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Services outside the service area*     |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Home care primarily for personal       |                        |
|     assistance that does not include a      |                        |
|     medical component and is not            |                        |
|     diagnostic, therapeutic, or             |                        |
|     rehabilitative*                         |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *General maintenance care of colostomy, |                        |
|     ileostomy, and ureterostomy*            |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Medical supplies or dressings applied  |                        |
|     by you or a family caregiver*           |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Care that a Plan physician determines  |                        |
|     may be provided in a Plan facility or   |                        |
|     skilled nursing facility if we provide  |                        |
|     or offer to provide that care in one of |                        |
|     those facilities*                       |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Transportation and delivery service    |                        |
|     costs of durable medical equipment,     |                        |
|     medications, drugs, medical supplies,   |                        |
|     and supplements to the home*            |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Personal care items*                   |                        |
+---------------------------------------------+------------------------+
| ######## Chiropractic                       |                        |
+---------------------------------------------+------------------------+
| > Chiropractic services, including spinal   | > \$15 per office      |
| > manipulation of the neck and back, up to  | > visit                |
| > 20 visits per calendar year, for the      |                        |
| > following services:                       |                        |
|                                             |                        |
| -   Evaluation and management               |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Routine chiropractic x-rays provided in |                        |
|     the chiropractor\'s office              |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Chiropractic adjustments                |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Adjunctive therapies (e.g., hot and     |                        |
|     cold packs)                             |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Educational materials                   |                        |
|                                             |                        |
| > Note: You receive these services when     |                        |
| > your Plan physician, in consultation with |                        |
| > the Complementary and Alternative         |                        |
| > Medicine Department, determines that such |                        |
| > care will result in improvement in your   |                        |
| > condition.                                |                        |
+---------------------------------------------+------------------------+
| ######## Chiropractic *(continued)*         | > **You pay**          |
+---------------------------------------------+------------------------+
| ## Not covered:                             | > *All charges*        |
|                                             |                        |
| ## Structural supports                      |                        |
|                                             |                        |
| -   *Nutritional supplements*               |                        |
+---------------------------------------------+------------------------+
| ######## Alternative treatments             |                        |
+---------------------------------------------+------------------------+
| > Acupuncture services up to 20 visits per  | \$15 per office visit  |
| > calendar year, for the following          |                        |
| > services:                                 |                        |
|                                             |                        |
| -   Evaluation and management               |                        |
|                                             |                        |
| > Note: You receive these services when     |                        |
| > your Plan physician, in consultation with |                        |
| > the Complementary and Alternative         |                        |
| > Medicine Department, determines that such |                        |
| > care will result in improvement in your   |                        |
| > condition.                                |                        |
+---------------------------------------------+------------------------+
| ## Not covered:                             | > *All charges*        |
|                                             |                        |
| -   *Herbal and nutritional supplements*    |                        |
+---------------------------------------------+------------------------+
| #### **Educational classes and programs**   |                        |
+---------------------------------------------+------------------------+
| #### Healt                                  | \$10 per visit in a    |
| h education for conditions such as diabetes | primary care           |
| , post-coronary, and nutritional counseling | department             |
|                                             |                        |
|                                             | > \$20 per visit in a  |
|                                             | > specialty care       |
|                                             | > department           |
+---------------------------------------------+------------------------+
| -   General health education classes such   | > Nominal fees ranging |
|     > as child birth, weight control,       | > from \$10 to \$50    |
|     > smoking cessation, and stress         | > per class            |
|     > management.                           |                        |
+---------------------------------------------+------------------------+
| *Not covered:*                              | > *All charges*        |
|                                             |                        |
| -   *Educational classes and programs not   |                        |
|     offered through this Plan*              |                        |
+---------------------------------------------+------------------------+

+---+---+-------------------------------------+----------------+---+---+
| > |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
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| > |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
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| a |   |                                     |                |   |   |
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| s |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
| > |   |                                     |                |   |   |
| > |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
| a |   |                                     |                |   |   |
| n |   |                                     |                |   |   |
| d |   |                                     |                |   |   |
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|   |   |                                     |                |   |   |
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| t |   |                                     |                |   |   |
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| > |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
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| a |   |                                     |                |   |   |
| l |   |                                     |                |   |   |
| t |   |                                     |                |   |   |
| h |   |                                     |                |   |   |
| > |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
| c |   |                                     |                |   |   |
| a |   |                                     |                |   |   |
| r |   |                                     |                |   |   |
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| > |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
| p |   |                                     |                |   |   |
| r |   |                                     |                |   |   |
| o |   |                                     |                |   |   |
| f |   |                                     |                |   |   |
| e |   |                                     |                |   |   |
| s |   |                                     |                |   |   |
| s |   |                                     |                |   |   |
| i |   |                                     |                |   |   |
| o |   |                                     |                |   |   |
| n |   |                                     |                |   |   |
| a |   |                                     |                |   |   |
| l |   |                                     |                |   |   |
| s |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
+---+---+-------------------------------------+----------------+---+---+
|   | * | > **Here are some important things  |                | * |   |
|   | * | > to keep in mind about these       |                | * |   |
|   | I | > benefits:**                       |                | I |   |
|   | * |                                     |                | * |   |
|   | * | -   Please remember that all        |                | * |   |
|   |   |     benefits are subject to the     |                |   |   |
|   | * |     definitions, limitations, and   |                | * |   |
|   | * |     exclusions in this brochure and |                | * |   |
|   | M |     are payable only when we        |                | M |   |
|   | * |     determine they are medically    |                | * |   |
|   | * |     necessary.                      |                | * |   |
|   |   |                                     |                |   |   |
|   | * | -   Plan physicians must provide or |                | * |   |
|   | * |     arrange your care.              |                | * |   |
|   | P |                                     |                | P |   |
|   | * | ```{=html}                          |                | * |   |
|   | * | <!-- -->                            |                | * |   |
|   |   | ```                                 |                |   |   |
|   | * | -   Be sure to read Section 4,      |                | * |   |
|   | * |     *Your costs for covered         |                | * |   |
|   | O |     services,* for valuable         |                | O |   |
|   | * |     information about how cost      |                | * |   |
|   | * |     sharing works. Also read        |                | * |   |
|   |   |     Section 9 about coordinating    |                |   |   |
|   | * |     benefits with other coverage,   |                | * |   |
|   | * |     including with Medicare.        |                | * |   |
|   | R |                                     |                | R |   |
|   | * | ```{=html}                          |                | * |   |
|   | * | <!-- -->                            |                | * |   |
|   |   | ```                                 |                |   |   |
|   | * | -   We have no calendar year        |                | * |   |
|   | * |     deductible.                     |                | * |   |
|   | T |                                     |                | T |   |
|   | * | -   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  |                | * |   |
|   | A |     charges associated with the     |                | A |   |
|   | * |     facility (i.e. hospital,        |                | * |   |
|   | * |     surgical center, etc.).         |                | * |   |
|   |   |                                     |                |   |   |
|   | * | ```{=html}                          |                | * |   |
|   | * | <!-- -->                            |                | * |   |
|   | N | ```                                 |                | N |   |
|   | * | -   YOUR PHYSICIAN MUST GET         |                | * |   |
|   | * |     PRECERTIFICATION OF SOME        |                | * |   |
|   |   |     SURGICAL PROCEDURES. Please     |                |   |   |
|   | * |     refer to the precertification   |                | * |   |
|   | * |     information shown in Section 3  |                | * |   |
|   | T |     to be sure which services       |                | T |   |
|   | * |     require precertification and    |                | * |   |
|   | * |     identify which surgeries        |                | * |   |
|   |   |     require precertification.       |                |   |   |
+---+---+-------------------------------------+----------------+---+---+
| # |   |                                     | **You Pay**    |   |   |
| # |   |                                     |                |   |   |
| # |   |                                     |                |   |   |
| # |   |                                     |                |   |   |
| # |   |                                     |                |   |   |
| # |   |                                     |                |   |   |
| # |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
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| f |   |                                     |                |   |   |
| i |   |                                     |                |   |   |
| t |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
| D |   |                                     |                |   |   |
| e |   |                                     |                |   |   |
| s |   |                                     |                |   |   |
| c |   |                                     |                |   |   |
| r |   |                                     |                |   |   |
| i |   |                                     |                |   |   |
| p |   |                                     |                |   |   |
| t |   |                                     |                |   |   |
| i |   |                                     |                |   |   |
| o |   |                                     |                |   |   |
| n |   |                                     |                |   |   |
+---+---+-------------------------------------+----------------+---+---+
| > |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
| S |   |                                     |                |   |   |
| u |   |                                     |                |   |   |
| r |   |                                     |                |   |   |
| g |   |                                     |                |   |   |
| i |   |                                     |                |   |   |
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| a |   |                                     |                |   |   |
| l |   |                                     |                |   |   |
| > |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
| p |   |                                     |                |   |   |
| r |   |                                     |                |   |   |
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| r |   |                                     |                |   |   |
| e |   |                                     |                |   |   |
| s |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
+---+---+-------------------------------------+----------------+---+---+
| > |   |                                     | > \$20 per     |   |   |
|   |   |                                     | > visit in a   |   |   |
| A |   |                                     | > specialty    |   |   |
| > |   |                                     | > care         |   |   |
|   |   |                                     | > department   |   |   |
| c |   |                                     | >              |   |   |
| o |   |                                     | > \$50 per     |   |   |
| m |   |                                     | > outpatient   |   |   |
| p |   |                                     | > surgery, or  |   |   |
| r |   |                                     | > \$100 per    |   |   |
| e |   |                                     | > inpatient    |   |   |
| h |   |                                     | > admission    |   |   |
| e |   |                                     |                |   |   |
| n |   |                                     |                |   |   |
| s |   |                                     |                |   |   |
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| * |   |                                     |                |   |   |
| S |   |                                     |                |   |   |
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| d |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
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|   |   |                                     |                |   |   |
| t |   |                                     |                |   |   |
| o |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
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|   |   |                                     |                |   |   |
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|   |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
| t |   |                                     |                |   |   |
| r |   |                                     |                |   |   |
| a |   |                                     |                |   |   |
| n |   |                                     |                |   |   |
| s |   |                                     |                |   |   |
| f |   |                                     |                |   |   |
| o |   |                                     |                |   |   |
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| m |   |                                     |                |   |   |
| a |   |                                     |                |   |   |
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| o |   |                                     |                |   |   |
| n |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
+---+---+-------------------------------------+----------------+---+---+

+---------------------------------------------+------------------------+
| > **Oral and maxillofacial surgery**        | > **You pay**          |
+---------------------------------------------+------------------------+
| Oral surgical procedures, limited to:       | > \$20 per visit in a  |
|                                             | > specialty care       |
| -   Reduction of fractures of the jaws or   | > department           |
|     facial bones                            | >                      |
|                                             | > \$50 per outpatient  |
| ```{=html}                                  | > surgery or           |
| <!-- -->                                    | >                      |
| ```                                         | > \$100 per inpatient  |
| -   Surgical correction of cleft lip, cleft | > admission            |
|     palate, or severe functional            |                        |
|     malocclusion                            |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Removal of stones from salivary ducts   |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Excision of leukoplakia or malignancies |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Excision of cysts and incision of       |                        |
|     abscesses when done as independent      |                        |
|     procedures                              |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Other surgical procedures that do not   |                        |
|     involve the teeth or their supporting   |                        |
|     structures                              |                        |
+---------------------------------------------+------------------------+
| *Not covered:*                              | > *All charges*        |
|                                             |                        |
| -   *Oral implants and transplants*         |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Procedures that involve the teeth or   |                        |
|     their supporting structures (such as    |                        |
|     the periodontal membrane, gingiva, and  |                        |
|     alveolar bone) except as covered under  |                        |
|     the accidental dental benefit.*         |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Shortening of the mandible or maxillae |                        |
|     for cosmetic purposes and correction of |                        |
|     malocclusion.*                          |                        |
+---------------------------------------------+------------------------+
| > **Organ/tissue transplants**              |                        |
+---------------------------------------------+------------------------+
| > Limited to:                               | > \$20 per visit in a  |
|                                             | > specialty care       |
| -   Cornea                                  | > department           |
|                                             | >                      |
| -   Heart                                   | > \$50 per outpatient  |
|                                             | > surgery or           |
| -   Heart/Lung                              | >                      |
|                                             | > \$100 per inpatient  |
| -   Kidney                                  | > admission            |
|                                             |                        |
| -   Kidney/Pancreas                         |                        |
|                                             |                        |
| -   Liver                                   |                        |
|                                             |                        |
| -   Lung: Single - Double                   |                        |
|                                             |                        |
| -   Pancreas                                |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Allogeneic (donor) bone marrow          |                        |
|     transplants                             |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Autologous bone marrow transplants      |                        |
|     (autologous stem cell and peripheral    |                        |
|     stem cell support) for the following    |                        |
|     conditions: acute lymphocytic or        |                        |
|     non-lymphocytic leukemia, advanced      |                        |
|     Hodgkin's lymphoma, advanced            |                        |
|     non-Hodgkin's lymphoma, advanced        |                        |
|     neuroblastoma, testicular, mediastinal, |                        |
|     retroperitoneal and ovarian germ cell   |                        |
|     tumors, breast cancer, multiple myeloma |                        |
|     and epithelial ovarian cancer           |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| > **Organ/tissue transplants**              | > **You pay**          |
| > *(continued)*                             |                        |
+---------------------------------------------+------------------------+
| -   Intestinal transplants (small           |                        |
|     intestine) and the small intestine with |                        |
|     the liver or small intestine with       |                        |
|     multiple organs such as the liver,      |                        |
|     stomach, and pancreas                   |                        |
|                                             |                        |
| > Unless otherwise authorized by your       |                        |
| > physician, transplants are covered only   |                        |
| > at institutions that we designate as      |                        |
| > "Centers of Excellence" for that specific |                        |
| > transplant. If your physician or the      |                        |
| > transplant facility determines that you   |                        |
| > do not satisfy the criteria for receiving |                        |
| > the transplant, we will pay only for the  |                        |
| > covered services and supplies you receive |                        |
| > before you are notified of that           |                        |
| > determination.                            |                        |
| >                                           |                        |
| > Limited Benefits: Treatment for breast    |                        |
| > cancer, multiple myeloma, and epithelial  |                        |
| > ovarian cancer may be provided in a       |                        |
| > National Cancer Institute (NCI)- or       |                        |
| > National Institutes of Health             |                        |
| > (NIH)-approved clinical trial at a        |                        |
| > Plan-designated center of excellence and  |                        |
| > if approved by the Plan's medical         |                        |
| > director in accordance with the Plan's    |                        |
| > protocols.                                |                        |
| >                                           |                        |
| > Note: We cover related medical and        |                        |
| > hospital expenses for a living donor when |                        |
| > those expenses are directly related to    |                        |
| > your covered transplant.                  |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges*        |
|                                             |                        |
| -   *Donor screening tests and donor search |                        |
|     expenses, except screening blood tests  |                        |
|     and advanced testing performed for the  |                        |
|     actual donor*                           |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Implants of non-human or artificial    |                        |
|     organs*                                 |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Transplants not listed as covered      |                        |
|     except when approved by the Clinical    |                        |
|     Management Committee of the National    |                        |
|     Transplant Network*                     |                        |
+---------------------------------------------+------------------------+
| > **Anesthesia**                            |                        |
+---------------------------------------------+------------------------+
| Professional services provided in:          | > Nothing              |
|                                             |                        |
| -   Hospital (inpatient)                    |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Hospital outpatient department          |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Ambulatory surgical center              |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Office                                  |                        |
+---------------------------------------------+------------------------+

+----+---+-----------------------------------+-------------+---+-----+---+---+
| *  |   |                                   |             |   |     |   |   |
| *S |   |                                   |             |   |     |   |   |
| ec |   |                                   |             |   |     |   |   |
| ti |   |                                   |             |   |     |   |   |
| on |   |                                   |             |   |     |   |   |
| 5  |   |                                   |             |   |     |   |   |
| (c |   |                                   |             |   |     |   |   |
| ). |   |                                   |             |   |     |   |   |
| Se |   |                                   |             |   |     |   |   |
| rv |   |                                   |             |   |     |   |   |
| ic |   |                                   |             |   |     |   |   |
| es |   |                                   |             |   |     |   |   |
| pr |   |                                   |             |   |     |   |   |
| ov |   |                                   |             |   |     |   |   |
| id |   |                                   |             |   |     |   |   |
| ed |   |                                   |             |   |     |   |   |
| by |   |                                   |             |   |     |   |   |
| a  |   |                                   |             |   |     |   |   |
| ho |   |                                   |             |   |     |   |   |
| sp |   |                                   |             |   |     |   |   |
| it |   |                                   |             |   |     |   |   |
| al |   |                                   |             |   |     |   |   |
| or |   |                                   |             |   |     |   |   |
| o  |   |                                   |             |   |     |   |   |
| th |   |                                   |             |   |     |   |   |
| er |   |                                   |             |   |     |   |   |
| f  |   |                                   |             |   |     |   |   |
| ac |   |                                   |             |   |     |   |   |
| il |   |                                   |             |   |     |   |   |
| it |   |                                   |             |   |     |   |   |
| y, |   |                                   |             |   |     |   |   |
| ** |   |                                   |             |   |     |   |   |
|    |   |                                   |             |   |     |   |   |
| *  |   |                                   |             |   |     |   |   |
| *a |   |                                   |             |   |     |   |   |
| nd |   |                                   |             |   |     |   |   |
| a  |   |                                   |             |   |     |   |   |
| mb |   |                                   |             |   |     |   |   |
| ul |   |                                   |             |   |     |   |   |
| an |   |                                   |             |   |     |   |   |
| ce |   |                                   |             |   |     |   |   |
| se |   |                                   |             |   |     |   |   |
| rv |   |                                   |             |   |     |   |   |
| ic |   |                                   |             |   |     |   |   |
| es |   |                                   |             |   |     |   |   |
| ** |   |                                   |             |   |     |   |   |
+----+---+-----------------------------------+-------------+---+-----+---+---+
|    | * | > **Here are some important       |             | * |     |   |   |
|    | * | > things to remember about these  |             | * |     |   |   |
|    | I | > benefits:**                     |             | I |     |   |   |
|    | * |                                   |             | * |     |   |   |
|    | * | -   Please remember that all      |             | * |     |   |   |
|    |   |     benefits are subject to the   |             |   |     |   |   |
|    | * |     definitions, limitations, and |             | * |     |   |   |
|    | * |     exclusions in this brochure   |             | * |     |   |   |
|    | M |     and are payable only when we  |             | M |     |   |   |
|    | * |     determine they are medically  |             | * |     |   |   |
|    | * |     necessary.                    |             | * |     |   |   |
|    |   |                                   |             |   |     |   |   |
|    | * | -   Plan physicians must provide  |             | * |     |   |   |
|    | * |     or arrange your care and you  |             | * |     |   |   |
|    | P |     must be hospitalized in a     |             | P |     |   |   |
|    | * |     Plan facility.                |             | * |     |   |   |
|    | * |                                   |             | * |     |   |   |
|    |   | -   Be sure to read Section 4,    |             |   |     |   |   |
|    | * |     *Your costs for covered       |             | * |     |   |   |
|    | * |     services,* for valuable       |             | * |     |   |   |
|    | O |     information about how cost    |             | O |     |   |   |
|    | * |     sharing works. Also read      |             | * |     |   |   |
|    | * |     Section 9 about coordinating  |             | * |     |   |   |
|    |   |     benefits with other coverage, |             |   |     |   |   |
|    | * |     including with Medicare.      |             | * |     |   |   |
|    | * |                                   |             | * |     |   |   |
|    | R | -   The amounts listed below are  |             | R |     |   |   |
|    | * |     for the charges billed by the |             | * |     |   |   |
|    | * |     facility (i.e., hospital or   |             | * |     |   |   |
|    |   |     surgical center) or ambulance |             |   |     |   |   |
|    | * |     service for your surgery or   |             | * |     |   |   |
|    | * |     care. Any costs associated    |             | * |     |   |   |
|    | T |     with the professional charge  |             | T |     |   |   |
|    | * |     (i.e., physicians, etc.) are  |             | * |     |   |   |
|    | * |     covered in Sections 5(a) or   |             | * |     |   |   |
|    |   |     (b).                          |             |   |     |   |   |
|    | * |                                   |             | * |     |   |   |
|    | * | ```{=html}                        |             | * |     |   |   |
|    | A | <!-- -->                          |             | A |     |   |   |
|    | * | ```                               |             | * |     |   |   |
|    | * | -   **YOUR PHYSICIAN MUST GET     |             | * |     |   |   |
|    |   |     PRECERTIFICATION OF HOSPITAL  |             |   |     |   |   |
|    | * |     STAYS (except for Maternity   |             | * |     |   |   |
|    | * |     stays).** Please refer to     |             | * |     |   |   |
|    | N |     Section 3 to be sure which    |             | N |     |   |   |
|    | * |     services require              |             | * |     |   |   |
|    | * |     precertification.             |             | * |     |   |   |
|    |   |                                   |             |   |     |   |   |
|    | * |                                   |             | * |     |   |   |
|    | * |                                   |             | * |     |   |   |
|    | T |                                   |             | T |     |   |   |
|    | * |                                   |             | * |     |   |   |
|    | * |                                   |             | * |     |   |   |
+----+---+-----------------------------------+-------------+---+-----+---+---+
| >  |   |                                   | **You Pay** |   |     |   |   |
|  * |   |                                   |             |   |     |   |   |
| *B |   |                                   |             |   |     |   |   |
| en |   |                                   |             |   |     |   |   |
| ef |   |                                   |             |   |     |   |   |
| it |   |                                   |             |   |     |   |   |
| >  |   |                                   |             |   |     |   |   |
|  D |   |                                   |             |   |     |   |   |
| es |   |                                   |             |   |     |   |   |
| cr |   |                                   |             |   |     |   |   |
| ip |   |                                   |             |   |     |   |   |
| ti |   |                                   |             |   |     |   |   |
| on |   |                                   |             |   |     |   |   |
| ** |   |                                   |             |   |     |   |   |
+----+---+-----------------------------------+-------------+---+-----+---+---+
| #  |   |                                   | ########    |   |     |   |   |
| ## |   |                                   |             |   |     |   |   |
| ## |   |                                   |             |   |     |   |   |
| ## |   |                                   |             |   |     |   |   |
| #  |   |                                   |             |   |     |   |   |
| In |   |                                   |             |   |     |   |   |
| pa |   |                                   |             |   |     |   |   |
| ti |   |                                   |             |   |     |   |   |
| en |   |                                   |             |   |     |   |   |
| t  |   |                                   |             |   |     |   |   |
| ho |   |                                   |             |   |     |   |   |
| sp |   |                                   |             |   |     |   |   |
| it |   |                                   |             |   |     |   |   |
| al |   |                                   |             |   |     |   |   |
+----+---+-----------------------------------+-------------+---+-----+---+---+
| Ro |   |                                   | > \$100 per |   |     |   |   |
| om |   |                                   | > admission |   |     |   |   |
| a  |   |                                   |             |   |     |   |   |
| nd |   |                                   |             |   |     |   |   |
| bo |   |                                   |             |   |     |   |   |
| ar |   |                                   |             |   |     |   |   |
| d, |   |                                   |             |   |     |   |   |
| su |   |                                   |             |   |     |   |   |
| ch |   |                                   |             |   |     |   |   |
| a  |   |                                   |             |   |     |   |   |
| s: |   |                                   |             |   |     |   |   |
|    |   |                                   |             |   |     |   |   |
| -  |   |                                   |             |   |     |   |   |
|    |   |                                   |             |   |     |   |   |
|  W |   |                                   |             |   |     |   |   |
| ar |   |                                   |             |   |     |   |   |
| d, |   |                                   |             |   |     |   |   |
|    |   |                                   |             |   |     |   |   |
|    |   |                                   |             |   |     |   |   |
| se |   |                                   |             |   |     |   |   |
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| pr |   |                                   |             |   |     |   |   |
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| at |   |                                   |             |   |     |   |   |
| e, |   |                                   |             |   |     |   |   |
|    |   |                                   |             |   |     |   |   |
|    |   |                                   |             |   |     |   |   |
| or |   |                                   |             |   |     |   |   |
|    |   |                                   |             |   |     |   |   |
|    |   |                                   |             |   |     |   |   |
|  i |   |                                   |             |   |     |   |   |
| nt |   |                                   |             |   |     |   |   |
| en |   |                                   |             |   |     |   |   |
| si |   |                                   |             |   |     |   |   |
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|    |   |                                   |             |   |     |   |   |
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| od |   |                                   |             |   |     |   |   |
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| ns |   |                                   |             |   |     |   |   |
|    |   |                                   |             |   |     |   |   |
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| =h |   |                                   |             |   |     |   |   |
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| -> |   |                                   |             |   |     |   |   |
| `  |   |                                   |             |   |     |   |   |
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|    |   |                                   |             |   |     |   |   |
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|    |   |                                   |             |   |     |   |   |
|    |   |                                   |             |   |     |   |   |
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| al |   |                                   |             |   |     |   |   |
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|    |   |                                   |             |   |     |   |   |
|    |   |                                   |             |   |     |   |   |
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| sa |   |                                   |             |   |     |   |   |
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| nd |   |                                   |             |   |     |   |   |
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| ed |   |                                   |             |   |     |   |   |
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| ce |   |                                   |             |   |     |   |   |
| ss |   |                                   |             |   |     |   |   |
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| >  |   |                                   |             |   |     |   |   |
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| ay |   |                                   |             |   |     |   |   |
| >  |   |                                   |             |   |     |   |   |
|  t |   |                                   |             |   |     |   |   |
| he |   |                                   |             |   |     |   |   |
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| ad |   |                                   |             |   |     |   |   |
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| ti |   |                                   |             |   |     |   |   |
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| ar |   |                                   |             |   |     |   |   |
| ge |   |                                   |             |   |     |   |   |
| >  |   |                                   |             |   |     |   |   |
|  a |   |                                   |             |   |     |   |   |
| bo |   |                                   |             |   |     |   |   |
| ve |   |                                   |             |   |     |   |   |
| >  |   |                                   |             |   |     |   |   |
|  t |   |                                   |             |   |     |   |   |
| he |   |                                   |             |   |     |   |   |
| >  |   |                                   |             |   |     |   |   |
|  s |   |                                   |             |   |     |   |   |
| em |   |                                   |             |   |     |   |   |
| ip |   |                                   |             |   |     |   |   |
| ri |   |                                   |             |   |     |   |   |
| va |   |                                   |             |   |     |   |   |
| te |   |                                   |             |   |     |   |   |
| >  |   |                                   |             |   |     |   |   |
| ro |   |                                   |             |   |     |   |   |
| om |   |                                   |             |   |     |   |   |
| >  |   |                                   |             |   |     |   |   |
|  r |   |                                   |             |   |     |   |   |
| at |   |                                   |             |   |     |   |   |
| e. |   |                                   |             |   |     |   |   |
+----+---+-----------------------------------+-------------+---+-----+---+---+

+---------------------------------------------+------------------------+
| ######## Inpatient hospital *(continued)*   | ######## You pay       |
+---------------------------------------------+------------------------+
| > Other hospital services and supplies,     | > \$100 per admission  |
| > such as:                                  |                        |
|                                             |                        |
| -   Operating, recovery, maternity, and     |                        |
|     other treatment rooms                   |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Prescribed drugs and medicines          |                        |
|                                             |                        |
| -   Diagnostic laboratory tests, X-rays,    |                        |
|     and pathology services                  |                        |
|                                             |                        |
| -   Procurement and storage for approved    |                        |
|     medically necessary cord blood for a    |                        |
|     designated recipient                    |                        |
|                                             |                        |
| -   Administration of blood and blood       |                        |
|     products                                |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Blood or blood plasma, if donated or    |                        |
|     replaced                                |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Dressings, splints, plaster casts, and  |                        |
|     sterile tray services                   |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Medical supplies and equipment,         |                        |
|     including oxygen                        |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Anesthetics and anesthesia services     |                        |
|                                             |                        |
| -   Take home items                         |                        |
|                                             |                        |
| -   Hospitalization for inpatient foot      |                        |
|     treatment                               |                        |
|                                             |                        |
| > Note: You may receive covered medical     |                        |
| > hospital services for certain dental      |                        |
| > procedures if a Plan physician determines |                        |
| > that you need to be hospitalized for      |                        |
| > reasons unrelated to the dental           |                        |
| > procedure. The conditions for which we    |                        |
| > will provide hospitalization include      |                        |
| > hemophilia and heart disease. The need    |                        |
| > for anesthesia, by itself, is not such a  |                        |
| > condition.                                |                        |
+---------------------------------------------+------------------------+
| *Not covered:*                              | > *All charges*        |
|                                             |                        |
| -   *Custodial care*                        |                        |
|                                             |                        |
| -   *Non-covered facilities*                |                        |
|                                             |                        |
| -   *Personal comfort items, such as        |                        |
|     telephone, television, barber services, |                        |
|     guest meals, and beds*                  |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Private nursing care*                  |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Whole blood and packed red blood cells |                        |
|     not replaced by member*                 |                        |
|                                             |                        |
| -   *Procurement and storage for possible   |                        |
|     future need or for yet to be determined |                        |
|     Member recipient*                       |                        |
|                                             |                        |
| -   *Any inpatient dental procedures*       |                        |
+---------------------------------------------+------------------------+
| #### **Outpatie                             | ####                   |
| nt hospital or ambulatory surgical center** |                        |
+---------------------------------------------+------------------------+
| -   Operating, recovery, and other          | > \$50 per outpatient  |
|     treatment rooms                         | > surgery              |
|                                             |                        |
| -   Prescribed drugs and medicines          |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Diagnostic laboratory tests, X-rays,    |                        |
|     and pathology services                  |                        |
|                                             |                        |
| -   Procurement and storage of cord blood   |                        |
|     for approved medically necessary        |                        |
|     procedures requiring cord blood for a   |                        |
|     designated recipient                    |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Administration of blood and blood       |                        |
|     products                                |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Blood and blood plasma, if donated or   |                        |
|     replaced                                |                        |
|                                             |                        |
| -   Pre-surgical testing                    |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Dressings, casts, and sterile tray      |                        |
|     services                                |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Medical supplies, including oxygen      |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Anesthetics and anesthesia service      |                        |
+---------------------------------------------+------------------------+
| #### **Outpatient hospital or               | #### **You pay**       |
|  ambulatory surgical center** *(continued)* |                        |
+---------------------------------------------+------------------------+
| # Not covered:                              | *All charges*          |
|                                             |                        |
| # Whole blood and packed                    |                        |
|  red blood cells not replaced by the member |                        |
|                                             |                        |
| -   *Procurement and storage for possible   |                        |
|     future need or for yet to be determined |                        |
|     Member recipient*                       |                        |
+---------------------------------------------+------------------------+
| ######## Skilled nursing care benefits      | ########               |
+---------------------------------------------+------------------------+
| > Up to 100 days per calendar year when     | > \$100 per admission  |
| > full-time skilled nursing care is         |                        |
| > necessary and confinement in a skilled    |                        |
| > nursing facility is medically             |                        |
| > appropriate. We cover the following:      |                        |
|                                             |                        |
| -   Physician and nursing services          |                        |
|                                             |                        |
| -   Room and board                          |                        |
|                                             |                        |
| -   Medical social services                 |                        |
|                                             |                        |
| -   Administration of blood, blood          |                        |
|     products, and derivatives               |                        |
|                                             |                        |
| -   Durable medical equipment ordinarily    |                        |
|     furnished by a skilled nursing          |                        |
|     facility, including oxygen-dispensing   |                        |
|     equipment and oxygen                    |                        |
|                                             |                        |
| -   Respiratory therapy                     |                        |
|                                             |                        |
| -   Biological supplies                     |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Medical supplies                        |                        |
|                                             |                        |
| > Note: We waive the additional \$100       |                        |
| > charge if you are admitted to an extended |                        |
| > care or skilled nursing facility directly |                        |
| > from a hospital inpatient stay.           |                        |
+---------------------------------------------+------------------------+
| ######## *Not covered:*                     | ######## *All charges* |
|                                             |                        |
| -   *Custodial care*                        |                        |
|                                             |                        |
| -   *Care in an intermediate facility*      |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| #### **Hospice care**                       | ######## You pay       |
+---------------------------------------------+------------------------+
| Supportive and palliative care for a        | > Nothing              |
| terminally ill member                       |                        |
|                                             |                        |
| -   You must reside in the service area     |                        |
|                                             |                        |
| -   Services are provided in your home, or  |                        |
|                                             |                        |
| -   Services are provided in a Plan         |                        |
|     approved hospice facility               |                        |
|                                             |                        |
| > Services include inpatient care,          |                        |
| > outpatient care, and family counseling. A |                        |
| > Plan physician must certify that you have |                        |
| > a terminal illness, with a life           |                        |
| > expectancy of approximately six months or |                        |
| > less.                                     |                        |
| >                                           |                        |
| > Note: Hospice is a program for caring for |                        |
| > the terminally ill that emphasizes        |                        |
| > supportive services, such as home care    |                        |
| > and pain control, rather than curative    |                        |
| > care of the terminal illness. A person    |                        |
| > who is terminally ill may elect to        |                        |
| > receive hospice benefits. These           |                        |
| > palliative and supportive services        |                        |
| > include nursing care, medical social      |                        |
| > services, physician services, and         |                        |
| > short-term inpatient care for pain        |                        |
| > control and acute and chronic symptom     |                        |
| > management. We also provide counseling    |                        |
| > and bereavement services for the          |                        |
| > individual and family members, and        |                        |
| > therapy for purposes of symptom control   |                        |
| > to enable the person to continue life     |                        |
| > with as little disruption as possible. If |                        |
| > you make a hospice election, you are not  |                        |
| > entitled to receive other health care     |                        |
| > services that are related to the terminal |                        |
| > illness. If you have made a hospice       |                        |
| > election, you may revoke that election at |                        |
| > any time, and your standard health        |                        |
| > benefits will be covered.                 |                        |
+---------------------------------------------+------------------------+
| > *Not covered*                             | > *All charges*        |
|                                             |                        |
| -   *Private duty nursing (independent      |                        |
|     nursing)*                               |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Homemaker services*                    |                        |
+---------------------------------------------+------------------------+
| ######## Ambulance                          | ########               |
+---------------------------------------------+------------------------+
| -   Local professional ambulance service    | > Nothing              |
|     when medically appropriate              |                        |
+---------------------------------------------+------------------------+

+---+---+-------------------------------------+---------------+---+----+
| # |   |                                     |               |   |    |
| # |   |                                     |               |   |    |
| # |   |                                     |               |   |    |
| # |   |                                     |               |   |    |
| # |   |                                     |               |   |    |
|   |   |                                     |               |   |    |
| S |   |                                     |               |   |    |
| e |   |                                     |               |   |    |
| c |   |                                     |               |   |    |
| t |   |                                     |               |   |    |
| i |   |                                     |               |   |    |
| o |   |                                     |               |   |    |
| 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 to |               | * | ## |
|   | * | > keep in mind about these          |               | * | ## |
|   | I | > benefits:                         |               | I | #  |
|   | * |                                     |               | * |    |
|   | * | -   Please remember that all        |               | * |    |
|   |   |     benefits are subject to the     |               |   |    |
|   | * |     definitions, limitations, and   |               | * |    |
|   | * |     exclusions in this brochure and |               | * |    |
|   | M |     we cover them only when we      |               | M |    |
|   | * |     determine they are medically    |               | * |    |
|   | * |     necessary.                      |               | * |    |
|   |   |                                     |               |   |    |
|   | * | -   We have no calendar year        |               | * |    |
|   | * |     deductible.                     |               | * |    |
|   | P |                                     |               | P |    |
|   | * | ```{=html}                          |               | * |    |
|   | * | <!-- -->                            |               | * |    |
|   |   | ```                                 |               |   |    |
|   | * | -   Be sure to read Section 4,      |               | * |    |
|   | * |     *Your costs for covered         |               | * |    |
|   | O |     services,* for valuable         |               | O |    |
|   | * |     information about how cost      |               | * |    |
|   | * |     sharing works. Also read        |               | * |    |
|   |   |     Section 9 about coordinating    |               |   |    |
|   | * |     benefits with other coverage,   |               | * |    |
|   | * |     including with Medicare.        |               | * |    |
|   | R |                                     |               | R |    |
|   | * | #####                               |               | * |    |
|   | * |                                     |               | * |    |
|   |   |                                     |               |   |    |
|   | * |                                     |               | * |    |
|   | * |                                     |               | * |    |
|   | T |                                     |               | T |    |
|   | * |                                     |               | * |    |
|   | * |                                     |               | * |    |
|   |   |                                     |               |   |    |
|   | * |                                     |               | * |    |
|   | * |                                     |               | * |    |
|   | A |                                     |               | A |    |
|   | * |                                     |               | * |    |
|   | * |                                     |               | * |    |
|   |   |                                     |               |   |    |
|   | * |                                     |               | * |    |
|   | * |                                     |               | * |    |
|   | N |                                     |               | N |    |
|   | * |                                     |               | * |    |
|   | * |                                     |               | * |    |
|   |   |                                     |               |   |    |
|   | * |                                     |               | * |    |
|   | * |                                     |               | * |    |
|   | T |                                     |               | T |    |
|   | * |                                     |               | * |    |
|   | * |                                     |               | * |    |
+---+---+-------------------------------------+---------------+---+----+
| > |   |                                     |               |   |    |
|   |   |                                     |               |   |    |
| * |   |                                     |               |   |    |
| * |   |                                     |               |   |    |
| W |   |                                     |               |   |    |
| h |   |                                     |               |   |    |
| a |   |                                     |               |   |    |
| t |   |                                     |               |   |    |
| > |   |                                     |               |   |    |
|   |   |                                     |               |   |    |
| i |   |                                     |               |   |    |
| s |   |                                     |               |   |    |
| > |   |                                     |               |   |    |
|   |   |                                     |               |   |    |
| a |   |                                     |               |   |    |
| > |   |                                     |               |   |    |
|   |   |                                     |               |   |    |
| m |   |                                     |               |   |    |
| e |   |                                     |               |   |    |
| d |   |                                     |               |   |    |
| i |   |                                     |               |   |    |
| c |   |                                     |               |   |    |
| a |   |                                     |               |   |    |
| l |   |                                     |               |   |    |
| > |   |                                     |               |   |    |
|   |   |                                     |               |   |    |
| e |   |                                     |               |   |    |
| m |   |                                     |               |   |    |
| e |   |                                     |               |   |    |
| r |   |                                     |               |   |    |
| g |   |                                     |               |   |    |
| e |   |                                     |               |   |    |
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| - |   |                                     | \$20 per      |   |    |
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+---+---+---------------------------------------+--------------+---+---+
|   | * | > When you get our approval for       |              | * | # |
|   | * | > services and follow a treatment     |              | * | # |
|   | I | > plan we approve, cost-sharing and   |              | I | # |
|   | * | > limitations for Plan mental health  |              | * | # |
|   | * | > and substance abuse benefits will   |              | * | # |
|   |   | > be no greater than for similar      |              |   |   |
|   | * | > benefits for other illnesses and    |              | * |   |
|   | * | > conditions.                         |              | * |   |
|   | M |                                       |              | M |   |
|   | * | **Here are some important things to   |              | * |   |
|   | * | keep in mind about these benefits:**  |              | * |   |
|   |   |                                       |              |   |   |
|   | * | • Please remember that all benefits   |              | * |   |
|   | * | are subject to the definitions,       |              | * |   |
|   | P | limitations, and exclusions in this   |              | P |   |
|   | * | brochure and are payable only when we |              | * |   |
|   | * | determine they are clinically         |              | * |   |
|   |   | appropriate to treat your condition.  |              |   |   |
|   | * |                                       |              | * |   |
|   | * | -   Plan physicians must provide or   |              | * |   |
|   | O |     arrange your care.                |              | O |   |
|   | * |                                       |              | * |   |
|   | * | • We have no calendar year            |              | * |   |
|   |   | deductible.                           |              |   |   |
|   | * |                                       |              | * |   |
|   | * | > • Be sure to read Section 4, *Your  |              | * |   |
|   | R | > costs for covered services,* for    |              | R |   |
|   | * | > valuable information about how cost |              | * |   |
|   | * | > sharing works. Also read Section 9  |              | * |   |
|   |   | > about coordinating benefits with    |              |   |   |
|   | * | > other coverage, including with      |              | * |   |
|   | * | > Medicare.                           |              | * |   |
|   | T |                                       |              | T |   |
|   | * |                                       |              | * |   |
|   | * |                                       |              | * |   |
|   |   |                                       |              |   |   |
|   | * |                                       |              | * |   |
|   | * |                                       |              | * |   |
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|   | * |                                       |              | * |   |
|   | * |                                       |              | * |   |
|   |   |                                       |              |   |   |
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|   | * |                                       |              | * |   |
|   |   |                                       |              |   |   |
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|   | * |                                       |              | * |   |
|   | T |                                       |              | T |   |
|   | * |                                       |              | * |   |
|   | * |                                       |              | * |   |
+---+---+---------------------------------------+--------------+---+---+
| * |   |                                       | **You Pay**  |   |   |
| * |   |                                       |              |   |   |
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| n |   |                                       |              |   |   |
| * |   |                                       |              |   |   |
| * |   |                                       |              |   |   |
+---+---+---------------------------------------+--------------+---+---+
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+---+---+---------------------------------------+--------------+---+---+
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| - |   |                                       | #            |   |   |
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|   |   |                                       |              |   |   |
| p |   |                                       |              |   |   |
| l |   |                                       |              |   |   |
| a |   |                                       |              |   |   |
| n |   |                                       |              |   |   |
| . |   |                                       |              |   |   |
+---+---+---------------------------------------+--------------+---+---+

+-----+---+------------------------------------------------+---+------+---+
| ##  |   |                                                |   |      |   |
| ### |   |                                                |   |      |   |
|  Se |   |                                                |   |      |   |
| cti |   |                                                |   |      |   |
| on  |   |                                                |   |      |   |
| 5 ( |   |                                                |   |      |   |
| f). |   |                                                |   |      |   |
|  Pr |   |                                                |   |      |   |
| esc |   |                                                |   |      |   |
| rip |   |                                                |   |      |   |
| tio |   |                                                |   |      |   |
| n d |   |                                                |   |      |   |
| rug |   |                                                |   |      |   |
|  be |   |                                                |   |      |   |
| nef |   |                                                |   |      |   |
| its |   |                                                |   |      |   |
+-----+---+------------------------------------------------+---+------+---+
|     | * | **Here are some important things to keep in    | * |      |   |
|     | * | mind about these benefits:**                   | * |      |   |
|     | I |                                                | I |      |   |
|     | * | -   We cover prescribed drugs and medications, | * |      |   |
|     | * |     as described in the chart beginning on     | * |      |   |
|     |   |     page 45.                                   |   |      |   |
|     | * |                                                | * |      |   |
|     | * | -   Please remember that all benefits are      | * |      |   |
|     | M |     subject to the definitions, limitations,   | M |      |   |
|     | * |     and exclusions in this brochure and we     | * |      |   |
|     | * |     cover them only when we determine they are | * |      |   |
|     |   |     medically necessary.                       |   |      |   |
|     | * |                                                | * |      |   |
|     | * | -   We have no calendar year deductible.       | * |      |   |
|     | P |                                                | P |      |   |
|     | * | -   Be sure to read Section 4, *Your costs for | * |      |   |
|     | * |     covered services,* for valuable            | * |      |   |
|     |   |     information about how cost sharing works.  |   |      |   |
|     | * |     Also read Section 9 about coordinating     | * |      |   |
|     | * |     benefits with other coverage, including    | * |      |   |
|     | O |     with Medicare.                             | O |      |   |
|     | * |                                                | * |      |   |
|     | * |                                                | * |      |   |
|     |   |                                                |   |      |   |
|     | * |                                                | * |      |   |
|     | * |                                                | * |      |   |
|     | R |                                                | R |      |   |
|     | * |                                                | * |      |   |
|     | * |                                                | * |      |   |
|     |   |                                                |   |      |   |
|     | * |                                                | * |      |   |
|     | * |                                                | * |      |   |
|     | T |                                                | T |      |   |
|     | * |                                                | * |      |   |
|     | * |                                                | * |      |   |
|     |   |                                                |   |      |   |
|     | * |                                                | * |      |   |
|     | * |                                                | * |      |   |
|     | A |                                                | A |      |   |
|     | * |                                                | * |      |   |
|     | * |                                                | * |      |   |
|     |   |                                                |   |      |   |
|     | * |                                                | * |      |   |
|     | * |                                                | * |      |   |
|     | N |                                                | N |      |   |
|     | * |                                                | * |      |   |
|     | * |                                                | * |      |   |
|     |   |                                                |   |      |   |
|     | * |                                                | * |      |   |
|     | * |                                                | * |      |   |
|     | T |                                                | T |      |   |
|     | * |                                                | * |      |   |
|     | * |                                                | * |      |   |
+-----+---+------------------------------------------------+---+------+---+

> **There are important features you should be aware of. These
> include:**

-   **Who can write your prescription.** A Plan physician, authorized
    provider or licensed contracted dentist must write the prescription.

```{=html}
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```
-   **Where you can obtain them.** You must fill the prescription at a
    Plan pharmacy, an affiliated network pharmacy, or by the Plan mail
    order delivery service for a maintenance medication. We will pay for
    prescriptions written by a non-Plan physician and filled at a
    non-Plan pharmacy only when the prescription was given during a
    hospital emergency room visit or an urgent care visit outside the
    service area.

```{=html}
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```
-   **We use a formulary.** Our drug formulary is a list of prescribed
    drugs and accessories that have been approved by our Pharmacy and
    Therapeutics Committee for our Members. Unless otherwise specified
    by your Plan physician or dentist, generic drugs may be used to fill
    prescriptions.

> Our Pharmacy and Therapeutics Committee, which is comprised of Plan
> physicians, Plan providers, and our pharmacists, selects prescription
> drugs and accessories for the drug formulary based on a number of
> factors, including safety and effectiveness as determined from a
> review of medical literature and research. In addition, the Committee
> sets dispensing limitations in accord with therapeutic guidelines
> based on the medical literature and research. The Pharmacy and
> Therapeutics' Committee meets periodically to consider adding and
> removing prescribed drugs and accessories on the formulary.
>
> If you request a non-formulary drug -- when your physician feels there
> is an acceptable formulary alternative -- you will be responsible for
> the full cost of that drug.
>
> However, if your Plan physician believes that a non-formulary drug
> best treats your medical condition; a formulary drug has been
> ineffective in the treatment of your medical condition; or a formulary
> drug causes or is reasonably expected to cause a harmful reaction,
> then an exception process is available to your Plan physician. In that
> case, your standard brand or generic prescription drug copayment would
> apply.
>
> If you would like information about whether a particular drug or
> accessory is included in our drug formulary, please visit us on line
> at
> [http://members.kaiserpermanente.org](http://members.kaiserpermanente.org/),
> or call our Member Services Department at 301/468-6000 inside the
> Washington, DC metropolitan area or at 800/777-7902 outside the
> Washington, DC metropolitan area. Our TTY telephone number is
> 301/879-6380.

-   **These are the dispensing limitations.** We provide up to a 60-day
    supply for one brand or generic copayment at a Plan or affiliated
    network pharmacy based upon (a) the prescribed quantity, (b) the
    standard manufacturer's package size, and (c) specified dispensing
    limits. Maintenance drugs may be obtained for up to a 90-day supply
    for one brand or generic copayment when ordered through our Plan's
    mail order program. Maintenance drug means a drug anticipated to be
    required for 6 months or more to treat a chronic condition.
    Injectable drugs that are self-administered and dispensed from the
    pharmacy are limited to a 30 day supply. Plan members called to
    active military duty (or members in time of national emergency) who
    need to obtain prescribed medications should call our Member
    Services Department at 301/468-6000.

```{=html}
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```
-   **Why use generic drugs?** Kaiser Permanente providers have
    successfully included the use of generic drugs as part of patient
    care without compromising quality. Generic drugs offer a safe and
    economic way to meet your medication needs. They are less expensive
    than brand name drugs - therefore you may reduce your out-of-pocket
    costs by choosing to use a generic drug. Generic drugs must contain
    the same active ingredients and be equivalent in strength and dosage
    to the original brand name product. The U.S. Food and Drug
    Administration and also Kaiser Permanente set criteria for the use
    of generic drugs to ensure that they meet the same standards of
    purity, strength and quality as brand-name drugs. They are expected
    to have the same therapeutic effect as the brand name product. Not
    all drugs have a generic equivalent. If a generic drug is
    unavailable, the standard brand copayment will apply.

```{=html}
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```
-   **When you have to file a claim.** When you receive drugs from a
    Plan pharmacy, you do not have to file a claim. For a covered
    out-of-area emergency, you will need to file a claim when you
    receive drugs from a non-Plan pharmacy. To file a claim, you should
    contact the Plan's Member Services Department at 301/468-6000 inside
    the Washington, DC metropolitan area or at 800/777-7902 outside the
    Washington, DC metropolitan area and obtain a claim form. Our TTY is
    301/879-6380. A claim for reimbursement must be submitted to the
    Plan within 12 months after you purchased the prescribed drugs.
    Members must pay full price for the drug and then submit a claim for
    reimbursement subject to the terms and conditions of the Plan.

*Prescription drug benefits begin on the next page*

+---------------------------------------------+------------------------+
| > **Benefit Description**                   | > **You Pay**          |
+---------------------------------------------+------------------------+
| > **Covered medications and supplies**      |                        |
+---------------------------------------------+------------------------+
| > We cover the following medications and    | > \$10 per             |
| > supplies prescribed by a Plan physician   | > prescription or      |
| > and obtained from a Plan pharmacy, an     | > refill for generic   |
| > affiliated network pharmacy or through    | > drugs or \$20 per    |
| > our mail order program:                   | > prescription or      |
|                                             | > refill for           |
| -   Drugs for which a physician's           | > brand-name drugs if  |
|     prescription is required by law         | > you get your         |
|                                             | > prescription filled  |
| -   Insulin (up to six (6) vials)           | > at a Plan medical    |
|                                             | > center pharmacy      |
| -   Disposable needles and syringes for the | >                      |
|     administration of covered medications   | > \$8 per prescription |
|                                             | > or refill for        |
| -   Contraceptive drugs                     | > generic drugs or     |
|                                             | > \$18 per             |
| -   Intrauterine devices (IUDs) and         | > prescription or      |
|     diaphragms                              | > refill for           |
|                                             | > brand-name drugs if  |
| -   Implanted time-release contraceptive    | > you get your         |
|     drugs                                   | > prescription filled  |
|                                             | > through our mail     |
| ```{=html}                                  | > order delivery       |
| <!-- -->                                    | > system               |
| ```                                         | >                      |
| -   Other implanted time-release drugs      | > \$20 per             |
|                                             | > prescription or      |
| -   Injectable contraceptive drugs          | > refill for generic   |
|                                             | > drugs or \$40 per    |
| ```{=html}                                  | > prescription or      |
| <!-- -->                                    | > refill for           |
| ```                                         | > brand-name drugs if  |
| -   Self-injectable drugs, other than       | > you get your         |
|     ovulation stimulants                    | > prescription filled  |
|                                             | > at an affiliated     |
| -   Self-administered chemotherapeutic      | > network pharmacy     |
|     drugs and oral chemotherapeutic agents  |                        |
|                                             |                        |
| -   Growth hormone therapy (GHT) - for      |                        |
|     treatment of children with growth       |                        |
|     hormone deficiency                      |                        |
|                                             |                        |
| > Note: Compounded preparations must        |                        |
| > contain at least one ingredient requiring |                        |
| > a prescription.                           |                        |
+---------------------------------------------+------------------------+
| -   Post-surgical immunosuppressant         | > Nothing              |
|     outpatient drugs required as a result   |                        |
|     of a covered transplant                 |                        |
|                                             |                        |
| -   Intravenous fluids and medications for  |                        |
|     home use                                |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Clinically administered chemotherapy    |                        |
|     drugs                                   |                        |
+---------------------------------------------+------------------------+
| -   Amino acid modified products used to    | > 25% of our allowance |
|     treat congenital errors of amino acid   |                        |
|     metabolism (PKU)                        |                        |
+---------------------------------------------+------------------------+
| > Diabetic supplies when purchased at a     |                        |
| > Plan pharmacy                             |                        |
+---------------------------------------------+------------------------+
| -   Glucose meter                           | > \$10 per meter       |
+---------------------------------------------+------------------------+
| -   Replacement batteries                   | \$5 per package        |
|                                             |                        |
| -   Control solutions                       | \$8 per package        |
|                                             |                        |
| -   Lancets                                 | \$8 per package        |
|                                             |                        |
| -   Disposable needles and syringes (up to  | 20% of our allowance   |
|     3 boxes)                                |                        |
|                                             | 20% of our allowance   |
| -   Glucose test strips (up to six (6)      |                        |
|     boxes of 50 count)                      |                        |
|                                             |                        |
| > Note: Lancets, disposable needles and     |                        |
| > syringes, and glucose test strips are     |                        |
| > available by mail order or through Plan   |                        |
| > Pharmacies. Other diabetic supplies in    |                        |
| > this section are available only at Plan   |                        |
| > pharmacies.                               |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| > **Covered medications and supplies**      | > **You pay**          |
| > *(continued)*                             |                        |
+---------------------------------------------+------------------------+
| -   Smoking cessation products are provided | 50% of our allowance   |
|     for one course of therapy per calendar  |                        |
|     year, when prescribed by Plan provider  |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Weight management drugs for morbid      |                        |
|     obesity                                 |                        |
|                                             |                        |
| -   Drugs for covered infertility           |                        |
|     treatments                              |                        |
|                                             |                        |
| -   Drugs for sexual dysfunction            |                        |
|                                             |                        |
| > Note: Drugs to treat sexual dysfunction   |                        |
| > have dispensing limitations. Please       |                        |
| > contact the Plan for details.             |                        |
+---------------------------------------------+------------------------+
| > *Not covered*:                            | *All charges*          |
|                                             |                        |
| -   *Drugs obtained at either a non-Plan    |                        |
|     pharmacy or non-affiliated network      |                        |
|     pharmacy except for emergencies inside  |                        |
|     and outside the service area*           |                        |
|                                             |                        |
| -   *Drugs or supplies for cosmetic         |                        |
|     purposes*                               |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Vitamins and nutritional supplements   |                        |
|     that can be purchased without a         |                        |
|     prescription*                           |                        |
|                                             |                        |
| -   *Nonprescription drugs*                 |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Prescription drugs for which there is  |                        |
|     a nonprescription equivalent available* |                        |
|                                             |                        |
| -   *Medical supplies such as dressings and |                        |
|     antiseptics*                            |                        |
|                                             |                        |
| -   *Drugs to enhance athletic performance* |                        |
|                                             |                        |
| -   *Drugs related to non-covered           |                        |
|     infertility services*                   |                        |
|                                             |                        |
| -   *Drugs for non-covered services*        |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Dental prescriptions other than those  |                        |
|     prescribed for pain relief or           |                        |
|     antibiotics*                            |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Replacement prescriptions necessitated |                        |
|     by theft, loss, or damage*              |                        |
|                                             |                        |
| -   *Drugs to shorten the duration of the   |                        |
|     common cold*                            |                        |
+---------------------------------------------+------------------------+

+----------------------+-----------------------------------------------+
| > Section 5 (g).     |                                               |
| > Special features   |                                               |
+----------------------+-----------------------------------------------+
| > **Feature**        | > **Description**                             |
+----------------------+-----------------------------------------------+
| **Flexible benefits  | Under the flexible benefits option, we        |
| option**             | determine the most effective way to provide   |
|                      | services.                                     |
|                      |                                               |
|                      | -   We may identify medically appropriate     |
|                      |     alternatives to traditional care and      |
|                      |     coordinate other treatments as a less     |
|                      |     costly alternative benefit.               |
|                      |                                               |
|                      | -   Alternative treatments are subject to our |
|                      |     ongoing review.                           |
|                      |                                               |
|                      | -   By approving an alternative treatment, we |
|                      |     cannot guarantee you will get it in the   |
|                      |     future.                                   |
|                      |                                               |
|                      | -   The decision to offer an alternative      |
|                      |     treatment is solely ours, and we may      |
|                      |     withdraw it at any time and resume        |
|                      |     regular contract benefits.                |
|                      |                                               |
|                      | ```{=html}                                    |
|                      | <!-- -->                                      |
|                      | ```                                           |
|                      | -   Our decision to offer or withdraw         |
|                      |     alternative treatments is not subject to  |
|                      |     OPM review under the disputed claims      |
|                      |     process.                                  |
+----------------------+-----------------------------------------------+
| > **24 hour nurse    | For any of your health concerns, 24 hours a   |
| > line**             | day, 7 days a week, you may call 703/359/7878 |
|                      | inside the Washington, DC metropolitan area   |
|                      | or 800/777-7904 outside the Washington, DC    |
|                      | metropolitan area or call our TTY at          |
|                      | 703/359-7616 or 800/700-4901 and talk with a  |
|                      | registered nurse who will discuss treatment   |
|                      | options and answer your health questions.     |
+----------------------+-----------------------------------------------+
| > **Services for     | For any of your health concerns, 24 hours a   |
| > deaf and hearing   | day, 7 days a week, you may call 703/359-7616 |
| > impaired**         | inside the Washington, DC metropolitan area   |
|                      | or 800/700-4901 outside the Washington, DC    |
|                      | metropolitan area and talk with a registered  |
|                      | nurse who will discuss treatment options and  |
|                      | answer your health questions.                 |
|                      |                                               |
|                      | During regular business hours Monday through  |
|                      | Friday, you may contact our Member Services   |
|                      | Department with any questions concerning the  |
|                      | Plan and how to obtain services by calling    |
|                      | 301/879-6380.                                 |
+----------------------+-----------------------------------------------+
| > **Centers of       | The Centers of Excellence program began in    |
| > Excellence**       | Fall 1987. As new technologies proliferate    |
|                      | and become the standard of care, Kaiser       |
|                      | Permanente refers members to contracted       |
|                      | "Centers of Excellence" for certain           |
|                      | specialized medical procedures.               |
|                      |                                               |
|                      | We have developed a national contract network |
|                      | of Centers of Excellence for organ            |
|                      | transplantation, which consists of medical    |
|                      | facilities that have met stringent criteria   |
|                      | for quality care in specific procedures. A    |
|                      | national clinical and administrative team has |
|                      | developed guidelines for site selection, site |
|                      | visit protocol, volume and survival criteria  |
|                      | for evaluation and selection of facilities.   |
|                      | The institutions have a record of positive    |
|                      | outcomes and exceptional standards of         |
|                      | quality.                                      |
+----------------------+-----------------------------------------------+
| > **Travel benefit** | Kaiser Permanente's travel benefits for       |
|                      | Federal employees provide you with outpatient |
|                      | follow-up or continuing medical care when you |
|                      | are temporarily outside your home service     |
|                      | area by more than 100 miles or outside of any |
|                      | other Kaiser Permanente service area. These   |
|                      | benefits are in addition to your emergency    |
|                      | and urgent care benefits and include:         |
|                      |                                               |
|                      | -   Outpatient follow-up care necessary to    |
|                      |     complete a course of treatment after a    |
|                      |     covered emergency. Services include       |
|                      |     removal of stitches, a catheter, or a     |
|                      |     cast.                                     |
|                      |                                               |
|                      | ```{=html}                                    |
|                      | <!-- -->                                      |
|                      | ```                                           |
|                      | -   Outpatient continuing care for covered    |
|                      |     services for conditions diagnosed and     |
|                      |     treated within the previous 90 days by a  |
|                      |     Kaiser Permanente health care provider or |
|                      |     affiliated Plan provider. Services        |
|                      |     include dialysis and prescription drug    |
|                      |     monitoring.                               |
|                      |                                               |
|                      | ```{=html}                                    |
|                      | <!-- -->                                      |
|                      | ```                                           |
|                      | -   You pay \$25 for each follow-up or        |
|                      |     continuing care office visit. This amount |
|                      |     will be deducted from the payment we make |
|                      |     to you.                                   |
|                      |                                               |
|                      | ```{=html}                                    |
|                      | <!-- -->                                      |
|                      | ```                                           |
|                      | -   Your benefit is limited to \$1200 each    |
|                      |     calendar year.                            |
|                      |                                               |
|                      | ```{=html}                                    |
|                      | <!-- -->                                      |
|                      | ```                                           |
|                      | -   For more information about this benefit   |
|                      |     you should contact the Plan's Member      |
|                      |     Services Department at 301/468-6000       |
|                      |     inside the Washington, DC metropolitan    |
|                      |     area or at 800/777-7902 outside the       |
|                      |     Washington, DC metropolitan area. Our TTY |
|                      |     is 301/879-6380.                          |
|                      |                                               |
|                      | ```{=html}                                    |
|                      | <!-- -->                                      |
|                      | ```                                           |
|                      | -   File claims as shown on page 61.          |
|                      |                                               |
|                      | *The following are not included in your       |
|                      | travel benefits coverage:*                    |
|                      |                                               |
|                      | -   *Non-emergency hospitalization*           |
|                      |                                               |
|                      | ```{=html}                                    |
|                      | <!-- -->                                      |
|                      | ```                                           |
|                      | -   *Infertility treatments*                  |
|                      |                                               |
|                      | ```{=html}                                    |
|                      | <!-- -->                                      |
|                      | ```                                           |
|                      | -   *Medical and hospital costs resulting     |
|                      |     from a normal full-term delivery of a     |
|                      |     baby outside the service area*            |
|                      |                                               |
|                      | ```{=html}                                    |
|                      | <!-- -->                                      |
|                      | ```                                           |
|                      | -   *Transplants*                             |
|                      |                                               |
|                      | -   *DME*                                     |
|                      |                                               |
|                      | ```{=html}                                    |
|                      | <!-- -->                                      |
|                      | ```                                           |
|                      | -   *Prescription drugs*                      |
|                      |                                               |
|                      | -   *Home health services*                    |
+----------------------+-----------------------------------------------+
| > **Services from    | When you are visiting in the service area of  |
| > other Kaiser       | another Kaiser Permanente plan, you are       |
| > Permanente plans** | entitled to receive virtually all the         |
|                      | benefits described in this brochure           |
|                      | (including our mail order prescription        |
|                      | program) at any Kaiser Permanente medical     |
|                      | office or medical center. You must pay the    |
|                      | charges or copayments imposed by the Kaiser   |
|                      | Permanente Plan you are visiting, with the    |
|                      | exception of mail order prescriptions which   |
|                      | are administered by your home Plan. You will  |
|                      | have to pay the charges imposed by the Plan   |
|                      | you are visiting. If the Plan you are         |
|                      | visiting has a benefit that is different from |
|                      | the benefits of this Plan, you are not        |
|                      | entitled to receive that benefit.             |
|                      |                                               |
|                      | > Some services covered by this Plan, such as |
|                      | > artificial reproductive services and the    |
|                      | > services of specialized rehabilitation      |
|                      | > facilities, will not be available in other  |
|                      | > Kaiser Permanente service areas. If a       |
|                      | > benefit is limited to a specific number of  |
|                      | > visits or days, you are entitled to receive |
|                      | > only the number of visits or days covered   |
|                      | > by the Plan in which you are enrolled.      |
|                      | >                                             |
|                      | > If you are seeking routine, non-emergent,   |
|                      | > or non-urgent services, you should call the |
|                      | > Kaiser Permanente Membership Services       |
|                      | > Department in that service area and request |
|                      | > an appointment. You may obtain routine      |
|                      | > follow-up or continuing care from these     |
|                      | > Plans, even when you have obtained the      |
|                      | > original services in the service area of    |
|                      | > this Plan. If you require emergency         |
|                      | > services as the result of unexpected or     |
|                      | > unforeseen illness that requires immediate  |
|                      | > attention, you should go directly to the    |
|                      | > nearest Kaiser Permanente facility to       |
|                      | > receive care.                               |
|                      |                                               |
|                      | At the time you register for services, you    |
|                      | will be asked to pay the charges required by  |
|                      | the local Plan.                               |
|                      |                                               |
|                      | If you plan to travel to an area with another |
|                      | Kaiser Permanente plan, and wish to obtain    |
|                      | more information about the benefits available |
|                      | to you from the Kaiser Permanente plan,       |
|                      | please call Membership Services at            |
|                      | 301/468-6000 inside the Washington, DC        |
|                      | metropolitan area or at 800/777-7902 outside  |
|                      | the Washington, DC metropolitan area. Our TTY |
|                      | is 301/879-6380.                              |
+----------------------+-----------------------------------------------+

+---+---+----------------------------+--------------------------+---+---+
| > |   |                            |                          |   |   |
|   |   |                            |                          |   |   |
| S |   |                            |                          |   |   |
| e |   |                            |                          |   |   |
| c |   |                            |                          |   |   |
| t |   |                            |                          |   |   |
| i |   |                            |                          |   |   |
| o |   |                            |                          |   |   |
| n |   |                            |                          |   |   |
| > |   |                            |                          |   |   |
|   |   |                            |                          |   |   |
| 5 |   |                            |                          |   |   |
| > |   |                            |                          |   |   |
|   |   |                            |                          |   |   |
| ( |   |                            |                          |   |   |
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| i |   |                            |                          |   |   |
| t |   |                            |                          |   |   |
| s |   |                            |                          |   |   |
+---+---+----------------------------+--------------------------+---+---+
|   | * | > **Here are some          |                          | * |   |
|   | * | > important things to keep |                          | * |   |
|   | I | > in mind about these      |                          | I |   |
|   | * | > benefits:**              |                          | * |   |
|   | * |                            |                          | * |   |
|   |   | -   Please remember that   |                          |   |   |
|   | * |     all benefits are       |                          | * |   |
|   | * |     subject to the         |                          | * |   |
|   | M |     definitions,           |                          | M |   |
|   | * |     limitations, and       |                          | * |   |
|   | * |     exclusions in this     |                          | * |   |
|   |   |     brochure and are       |                          |   |   |
|   | * |     payable only when we   |                          | * |   |
|   | * |     determine they are     |                          | * |   |
|   | P |     medically necessary.   |                          | P |   |
|   | * |                            |                          | * |   |
|   | * | ```{=html}                 |                          | * |   |
|   |   | <!-- -->                   |                          |   |   |
|   | * | ```                        |                          | * |   |
|   | * | -   Plan dentists must     |                          | * |   |
|   | O |     provide or arrange     |                          | O |   |
|   | * |     your care.             |                          | * |   |
|   | * |                            |                          | * |   |
|   |   | ```{=html}                 |                          |   |   |
|   | * | <!-- -->                   |                          | * |   |
|   | * | ```                        |                          | * |   |
|   | R | -   We have no calendar    |                          | R |   |
|   | * |     year deductible.       |                          | * |   |
|   | * |                            |                          | * |   |
|   |   | ```{=html}                 |                          |   |   |
|   | * | <!-- -->                   |                          | * |   |
|   | * | ```                        |                          | * |   |
|   | T | -   We cover               |                          | T |   |
|   | * |     hospitalization for    |                          | * |   |
|   | * |     dental procedures only |                          | * |   |
|   |   |     when a nondental       |                          |   |   |
|   | * |     physical impairment    |                          | * |   |
|   | * |     exists which makes     |                          | * |   |
|   | A |     hospitalization        |                          | A |   |
|   | * |     necessary to safeguard |                          | * |   |
|   | * |     the health of the      |                          | * |   |
|   |   |     patient. See Section   |                          |   |   |
|   | * |     5(c) for inpatient     |                          | * |   |
|   | * |     hospital benefits. We  |                          | * |   |
|   | N |     do not cover the       |                          | N |   |
|   | * |     dental procedure       |                          | * |   |
|   | * |     except as described    |                          | * |   |
|   |   |     below.                 |                          |   |   |
|   | * |                            |                          | * |   |
|   | * | -   Be sure to read        |                          | * |   |
|   | T |     Section 4, *Your costs |                          | T |   |
|   | * |     for covered services,* |                          | * |   |
|   | * |     for valuable           |                          | * |   |
|   |   |     information about how  |                          |   |   |
|   |   |     cost sharing works.    |                          |   |   |
|   |   |     Also read Section 9    |                          |   |   |
|   |   |     about coordinating     |                          |   |   |
|   |   |     benefits with other    |                          |   |   |
|   |   |     coverage, including    |                          |   |   |
|   |   |     with Medicare.         |                          |   |   |
+---+---+----------------------------+--------------------------+---+---+
| # |   |                            | **You pay**              |   |   |
| # |   |                            |                          |   |   |
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+---+---+----------------------------+--------------------------+---+---+
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+---+---+----------------------------+--------------------------+---+---+
| > |   |                            | \$10 per visit in a      |   |   |
|   |   |                            | primary care department  |   |   |
| W |   |                            |                          |   |   |
| e |   |                            | \$20 per visit in a      |   |   |
| > |   |                            | specialty care           |   |   |
|   |   |                            | department               |   |   |
| c |   |                            |                          |   |   |
| o |   |                            | All charges in excess of |   |   |
| v |   |                            | \$2,000 per member per   |   |   |
| e |   |                            | accident                 |   |   |
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| > |   |                            | \$100 per inpatient      |   |   |
|   |   |                            | admission                |   |   |
| W |   |                            |                          |   |   |
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|   |   |                            |                          |   |   |
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| r |   |                            | \$50 per outpatient      |   |   |
| > |   |                            | surgery                  |   |   |
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| d |   |                            |                          |   |   |
| i |   |                            |                          |   |   |
| b |   |                            |                          |   |   |
| u |   |                            |                          |   |   |
| l |   |                            |                          |   |   |
| a |   |                            |                          |   |   |
| r |   |                            |                          |   |   |
|   |   |                            |                          |   |   |
|   |   |                            |                          |   |   |
|   |   |                            |                          |   |   |
|   |   |                            |                          |   |   |
| j |   |                            |                          |   |   |
| o |   |                            |                          |   |   |
| i |   |                            |                          |   |   |
| n |   |                            |                          |   |   |
| t |   |                            |                          |   |   |
|   |   |                            |                          |   |   |
|   |   |                            |                          |   |   |
|   |   |                            |                          |   |   |
|   |   |                            |                          |   |   |
| ( |   |                            |                          |   |   |
| T |   |                            |                          |   |   |
| M |   |                            |                          |   |   |
| J |   |                            |                          |   |   |
| ) |   |                            |                          |   |   |
|   |   |                            |                          |   |   |
|   |   |                            |                          |   |   |
|   |   |                            |                          |   |   |
|   |   |                            |                          |   |   |
| d |   |                            |                          |   |   |
| i |   |                            |                          |   |   |
| s |   |                            |                          |   |   |
| o |   |                            |                          |   |   |
| r |   |                            |                          |   |   |
| d |   |                            |                          |   |   |
| e |   |                            |                          |   |   |
| r |   |                            |                          |   |   |
| s |   |                            |                          |   |   |
| * |   |                            |                          |   |   |
+---+---+----------------------------+--------------------------+---+---+

+-----------------------------------------------------------------------+
| > **Discounted Fee - Dental Benefits**                                |
+-----------------------------------------------------------------------+
| > Kaiser Permanente has entered into an Agreement with Dental Benefit |
| > Providers, Inc. ("DBP"), under which DBP will provide or arrange    |
| > for the administration of covered dental services to you through    |
| > Participating Dental Providers.                                     |
|                                                                       |
| -   All procedures listed in the following schedule of dental         |
|     services and fees are covered dental services. When you receive   |
|     any of the listed procedures from a Participating Dental          |
|     Provider, you will pay the fee listed next to the procedure       |
|     description for that service. The Participating Dental Provider   |
|     has agreed to accept that fee as payment in full for that         |
|     procedure. Neither Kaiser Permanente nor DBP are liable for       |
|     payment of these fees or for any fees incurred as the result of   |
|     receipt of non-covered dental services.                           |
|                                                                       |
| -   You will pay a fixed rate of \$30 per office visit for procedures |
|     with an "FC30" fee indication in the schedule below. We waive the |
|     \$5 sterilization fee for any office visit in which FC30 applies. |
|     "NB" indicates there is no benefit available and you must pay the |
|     full cost of these services.                                      |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   You may select a Participating Dental Provider, who is a "general |
|     dentist," from whom you will receive covered dental services.     |
|     With a large network of general dentists in our service area, you |
|     may select a general dentist from our Dental Provider Directory   |
|     for yourself and your family. You can obtain a Dental Provider    |
|     Directory by calling our Member Services Department at            |
|     301/468-6000 inside the Washington, DC metropolitan area or at    |
|     800/777-7902 outside the Washington, DC metropolitan area. Our    |
|     TTY is 301/879-6380.                                              |
|                                                                       |
| -   Specialty care is also available should further covered services  |
|     be necessary; however, you must be referred to a Participating    |
|     Dental Provider who is a specialist by your general dentist. Your |
|     discounted fees are slightly higher for care received by a        |
|     Participating Dental Provider who is a specialist. Please refer   |
|     to the following schedule of dental services and fees for those   |
|     discounted fees.                                                  |
|                                                                       |
| -   When a dental emergency occurs outside our service area, Kaiser   |
|     Permanente will reimburse you for the reasonable charges, less    |
|     any discounted fee, upon proof of payment, not to exceed \$50 per |
|     incident. We cover emergency dental treatment required to         |
|     alleviate pain, bleeding, or swelling. If post-emergency care is  |
|     required, you must receive all post-emergency care from your      |
|     Participating Dental Provider.                                    |
+-----------------------------------------------------------------------+

The schedule for dental services and fees are:

+--------+-------------------------------------+----------+-----------+
| **     |                                     | **You    |           |
| Dental |                                     | Pay**    |           |
| Bene   |                                     |          |           |
| fits** |                                     |          |           |
+--------+-------------------------------------+----------+-----------+
| *      | **PROCEDURE NAME**                  | **TO**   | **TO      |
| *ADA** |                                     |          | SPE       |
|        |                                     | **D      | CIALIST** |
| **     |                                     | ENTIST** |           |
| CODE** |                                     |          |           |
+--------+-------------------------------------+----------+-----------+
| **Diag |                                     |          |           |
| nostic |                                     |          |           |
| Serv   |                                     |          |           |
| ices** |                                     |          |           |
+--------+-------------------------------------+----------+-----------+
| 00120  | Periodic Oral Exam (every 6 months) | FC30     | NB        |
+--------+-------------------------------------+----------+-----------+
| 00140  | Ltd Oral Evaluation -- Problem      | FC30     | NB        |
|        | Focused                             |          |           |
+--------+-------------------------------------+----------+-----------+
| 00150  | Comprehensive Oral Examination      | FC30     | NB        |
+--------+-------------------------------------+----------+-----------+
| 00210  | Intraoral-Complete Series Including | \$34     | \$37      |
|        | Bitewings                           |          |           |
+--------+-------------------------------------+----------+-----------+
| 00220  | Intraoral-Periapical-First Film     | FC30     | \$9       |
+--------+-------------------------------------+----------+-----------+
| 00230  | Intraoral-Periapical-Each           | FC30     | \$9       |
|        | Additional Film                     |          |           |
+--------+-------------------------------------+----------+-----------+
| 00240  | Intraoral Occlusal Film             | FC30     | \$9       |
+--------+-------------------------------------+----------+-----------+
| 00270  | Bitewing-Single Film                | FC30     | \$9       |
+--------+-------------------------------------+----------+-----------+
| 00272  | Bitewing- Two Films                 | FC30     | \$9       |
+--------+-------------------------------------+----------+-----------+
| 00273  | Bitewing -- Three Films             | FC30     | \$16      |
+--------+-------------------------------------+----------+-----------+
| 00274  | Bitewing -- Four Films              | FC30     | \$25      |
+--------+-------------------------------------+----------+-----------+
| 00330  | Panoramic Film                      | \$28     | \$31      |
+--------+-------------------------------------+----------+-----------+
| 00460  | Pulp Vitality Tests                 | FC30     | \$16      |
+--------+-------------------------------------+----------+-----------+
| 00470  | Diagnostic Casts                    | FC30     | NB        |
+--------+-------------------------------------+----------+-----------+
| **Prev |                                     |          |           |
| entive |                                     |          |           |
| Serv   |                                     |          |           |
| ices** |                                     |          |           |
+--------+-------------------------------------+----------+-----------+
| 01110  | Prophylaxis Adults (Every six       | FC30     | NB        |
|        | months)                             |          |           |
+--------+-------------------------------------+----------+-----------+
| 01120  | Prophylaxis Child (Every six        | FC30     | NB        |
|        | months)                             |          |           |
+--------+-------------------------------------+----------+-----------+
| 01201  | Topical Fluoride Incl Proph \<16    | FC30     | NB        |
|        | yrs every 6 mos                     |          |           |
+--------+-------------------------------------+----------+-----------+
| 01203  | Topical Fluoride Excl Proph \<16    | FC30     | NB        |
|        | yrs every 6 mos                     |          |           |
+--------+-------------------------------------+----------+-----------+

+-------+------------------------------------+----------+-----------+---+
| **D   |                                    | **You    |           |   |
| ental |                                    | Pay**    |           |   |
| Benef |                                    |          |           |   |
| its** |                                    |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| **    | **PROCEDURE NAME**                 | **TO**   | **TO      |   |
| ADA** |                                    |          | SPE       |   |
|       |                                    | **D      | CIALIST** |   |
| **C   |                                    | ENTIST** |           |   |
| ODE** |                                    |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 01330 | Oral Hygiene Instruction           | FC30     | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| 01351 | Sealant --Per Tooth -- To age 16   | \$17     | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| 01510 | Space Maintainer -- Fixed          | \$184    | NB        |   |
|       | Unilateral                         |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 01515 | Space Maintainer -- Fixed          | \$184    | NB        |   |
|       | Bilateral                          |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 01520 | Space Maintainer -- Removable      | \$226    | NB        |   |
|       | Unilateral                         |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 01525 | Space Maintainer -- Removable      | \$141    | NB        |   |
|       | Bilateral                          |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 01550 | Recementation of Space Maintainer  | \$21     | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| **R   |                                    |          |           |   |
| estor |                                    |          |           |   |
| ative |                                    |          |           |   |
| Servi |                                    |          |           |   |
| ces** |                                    |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 02110 | Amalgam -- One Surface Primary     | \$27     | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| 02120 | Amalgam -- Two Surfaces Primary    | \$35     | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| 02130 | Amalgam -- Three Surfaces Primary  | \$39     | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| 02131 | Amalgam -- Four or More Surfaces   | \$50     | NB        |   |
|       | Primary                            |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 02140 | Amalgam -- One Surface Permanent   | \$30     | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| 02150 | Amalgam -- Two Surfaces Permanent  | \$41     | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| 02160 | Amalgam -- Three Surface Permanent | \$51     | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| 02161 | Amalgam -- Four or More Surfaces   | \$60     | NB        |   |
|       | Permanent                          |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 02330 | Resin -- One Surface Anterior      | \$37     | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| 02331 | Resin -- Two Surfaces Anterior     | \$51     | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| 02332 | Resin --Three Surfaces Anterior    | \$52     | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| 02335 | Resin \>3 Sur or Inv Incisal Angle | \$66     | NB        |   |
|       | Ant                                |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 02385 | Resin - One Surface, Posterior     | \$35     | NB        |   |
|       | Permanent                          |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 02386 | Resin - Two Surfaces, Posterior    | \$56     | NB        |   |
|       | Permanent                          |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 02387 | Resin - 3 or More Surfaces,        | \$70     | NB        |   |
|       | Posterior Permanent                |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 02510 | Inlay-Metallic-One Surface         | \$307    | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| 02520 | Inlay-Metallic-Two Surfaces        | \$334    | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| 02530 | Inlay-Metallic-Three Surfaces      | \$371    | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| 02540 | Onlay-Metallic-Per T In Add to     | \$408    | NB        |   |
|       | Inlay                              |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 02610 | Inlay-Porcelain/Ceramic-One        | \$498    | NB        |   |
|       | Surface                            |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 02620 | Inlay-Porcelain/Ceramic -- Two     | \$498    | NB        |   |
|       | Surfaces                           |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 02630 | Inlay-Porcelain/Ceramic -- Three   | \$498    | NB        |   |
|       | Surfaces                           |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 02640 | Onlay-Porc/Ceramic-Per Tooth +     | \$498    | NB        |   |
|       | Inlay                              |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 02650 | Inlay-Compos/Resin-1 Surf (Lab     | \$498    | NB        |   |
|       | Proc)                              |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 02651 | Inlay-Compos/Resin-2 Surf (Lab     | \$498    | NB        |   |
|       | Proc)                              |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 02652 | Inlay-Compos/Resin-3 or More Surf  | \$498    | NB        |   |
|       | (Lab)                              |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 02710 | Crown-Resin-Laboratory             | \$235    | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| 02740 | Crown-Porcelain/Ceramic Substrate  | \$526    | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| 02750 | Crown-Porcelain Fused to Hi Noble  | \$531    | NB        |   |
|       | Metal                              |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 02751 | Crown-Porcelain Fused to Predom    | \$472    | NB        |   |
|       | Base Mental                        |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 02752 | Crown-Porcelain Fused to Noble     | \$502    | NB        |   |
|       | Metal                              |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 02790 | Crown-Full Cast High Noble Metal   | \$510    | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| 02791 | Crown-Full Cast Predom Base Metal  | \$442    | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| 02792 | Crown-Full Cast Noble Metal        | \$465    | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| 02810 | Crown-3/4 Cast Metallic            | \$521    | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| 02910 | Recement Inlay                     | \$34     | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| 02920 | Recement Crown                     | \$34     | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| 02930 | Prefab Stainl Stl Crown-Prim Tooth | \$101    | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| 02931 | Prefab Stainl Stl Crown-Perm Tooth | \$106    | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| 02932 | Prefabricated Resin Crown          | \$157    | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| 02940 | Sedative Fillings                  | \$34     | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| 02950 | Crown Buildup (Substructure)       | \$101    | NB        |   |
|       | w/pins                             |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 02951 | Pin Reten-Per Tooth in Add to Rest | \$22     | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| 02952 | Cast Post & Core In Add to Crown   | \$146    | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| 02954 | Prefab Post & Core in Add to Crown | \$129    | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| **D   |                                    | **You    |           |   |
| ental |                                    | Pay**    |           |   |
| Benef |                                    |          |           |   |
| its** |                                    |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| **    | **PROCEDURE NAME**                 | **TO**   | **TO      |   |
| ADA** |                                    |          | SPE       |   |
|       |                                    | **D      | CIALIST** |   |
| **C   |                                    | ENTIST** |           |   |
| ODE** |                                    |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 02970 | Temporary Crown (Fractured Tooth)  | \$84     | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| 02980 | Crown Repair                       | \$84     | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| **    |                                    |          |           |   |
| Endod |                                    |          |           |   |
| ontic |                                    |          |           |   |
| Servi |                                    |          |           |   |
| ces** |                                    |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 03110 | Pulp Cap-Direct Excl Final Rest    | \$22     | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| 03120 | Pulp Cap-Indirect Excl Final Rest  | \$22     | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| 03220 | Therapeutic Pulpotomy Exc Fin Rest | \$62     | \$67      |   |
+-------+------------------------------------+----------+-----------+---+
| 03310 | RC Ther -- Ant Exc Final           | \$253    | \$319     |   |
|       | Restoration                        |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 03320 | RC Ther-Bicuspid Exc Final         | \$294    | \$496     |   |
|       | Restoration                        |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 03330 | RC Ther -- Molar Exc Final         | \$313    | \$614     |   |
|       | Restoration                        |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 03346 | Retreatment of Prev RC Ther -      | NB       | \$378     |   |
|       | Anterior                           |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 03347 | Retreatment of Prev RC Ther -      | NB       | \$584     |   |
|       | Bicuspid                           |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 03348 | Retreatment of Prev RC Ther -      | NB       | \$732     |   |
|       | Molar                              |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 03350 | Apexification/Recalc Per Trmt      | \$118    | \$164     |   |
|       | Visit                              |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 03410 | Apicoectomy/Periradicular Surg-Ant | \$148    | \$381     |   |
+-------+------------------------------------+----------+-----------+---+
| 03421 | Apico/perirad Surg-Bicus First     | \$148    | \$465     |   |
|       | Root                               |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 03425 | Apico/Perirad Srg-Molar First Root | \$148    | \$487     |   |
+-------+------------------------------------+----------+-----------+---+
| 03426 | Apico/Perirad Srg-Molar Ea Add     | \$49     | \$185     |   |
|       | Root                               |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 06430 | Retrograde Filling Per Root        | \$104    | \$196     |   |
+-------+------------------------------------+----------+-----------+---+
| 03450 | Root Amputation-Per Root           | \$104    | \$252     |   |
+-------+------------------------------------+----------+-----------+---+
| 03920 | Hemisect W Rt Rem-Wo Root Canal    | \$125    | \$224     |   |
|       | Therapy                            |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| **P   |                                    |          |           |   |
| eriod |                                    |          |           |   |
| ontic |                                    |          |           |   |
| Servi |                                    |          |           |   |
| ces** |                                    |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 04210 | Gingivectomy/Gingivoplasty-Per     | \$222    | \$297     |   |
|       | Quad                               |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 04211 | Gingivectomy/Gingivoplasty-Per     | \$59     | \$90      |   |
|       | Tooth                              |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 04220 | Ging Curettage Surg/Quad-By Report | \$67     | \$140     |   |
+-------+------------------------------------+----------+-----------+---+
| 04240 | Gingival Flap Incl Rt Health       | \$222    | \$381     |   |
|       | Plan-Per Quad                      |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 04249 | Crn Lengthn-Hard/Soft Tissue by    | \$260    | \$358     |   |
|       | Rep                                |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 04250 | Muco-Gingival Surgery-Per Qdrant   | \$260    | \$370     |   |
+-------+------------------------------------+----------+-----------+---+
| 04260 | Oss Surg Inc Flap Ent, Grafts &    | \$371    | \$661     |   |
|       | Clos                               |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 04261 | Osseous Graft                      | \$185    | \$330     |   |
+-------+------------------------------------+----------+-----------+---+
| 04262 | Osseous Graft Multiple             | \$185    | \$330     |   |
+-------+------------------------------------+----------+-----------+---+
| 04268 | Guid Tis Rgen Inc Sur Re-Ent by    | \$358    | \$358     |   |
|       | Rep                                |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 04270 | Pedicle Soft Tissue Graft          | \$178    | \$420     |   |
|       | Procedure                          |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 04271 | Free Soft Tissue Graft & Donor     | \$260    | \$510     |   |
|       | Site                               |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 04320 | Provisional Splinting --           | \$106    | \$130     |   |
|       | Intracoronal                       |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 04321 | Provisional Splinting --           | \$74     | \$134     |   |
|       | Extracoronal                       |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 04341 | Perio Scaling/Root Health          | \$71     | \$140     |   |
|       | Planing-Per Quad                   |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 04355 | FM Debridmt before Comp Trmt       | \$67     | \$140     |   |
+-------+------------------------------------+----------+-----------+---+
| 04910 | Perio Maint After Active Ther      | \$45     | \$67      |   |
+-------+------------------------------------+----------+-----------+---+
| **Pro |                                    |          |           |   |
| sthet |                                    |          |           |   |
| ics - |                                    |          |           |   |
| R     |                                    |          |           |   |
| emova |                                    |          |           |   |
| ble** |                                    |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 05110 | Complete Denture -- Upper          | \$525    | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| 05120 | Complete Denture -- Lower          | \$525    | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| 05130 | Immediate Denture -- Upper         | \$525    | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| 05140 | Immediate Denture -- Lower         | \$525    | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| 05211 | Upper Part Dent-Resin Base Incl    | \$381    | NB        |   |
|       | Clsp                               |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 05212 | Lower Part Dent-Resin Base Incl    | \$470    | NB        |   |
|       | Clsp                               |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 05213 | Up Part Dent-Met Base, Res SDL     | \$567    | NB        |   |
|       | Incl Clsp                          |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 05214 | Lo Part Dent-Met Base, Res SDL     | \$567    | NB        |   |
|       | Incl Clsp                          |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 05281 | Uni Part Dent-Met Base, Cast Clsp  | \$269    | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| 05410 | Adjust Dent-Comp or Part, Upr or   | \$73     | NB        |   |
|       | Lwr                                |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 05510 | Repair Broken Complete Denture     | \$56     | NB        |   |
|       | Base                               |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 05520 | Repl Miss/Brkn T-Compl Den-Ea T    | \$45     | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| 05610 | Repair Acrylic Saddle or Base      | \$56     | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| 05620 | Repair Cast Framework              | \$62     | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| **D   |                                    | **You    |           |   |
| ental |                                    | Pay**    |           |   |
| Benef |                                    |          |           |   |
| its** |                                    |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| **    | **PROCEDURE NAME**                 | **TO**   | **TO      |   |
| ADA** |                                    |          | SPE       |   |
|       |                                    | **D      | CIALIST** |   |
| **C   |                                    | ENTIST** |           |   |
| ODE** |                                    |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 05630 | Repair or Replace Broken Clasp     | \$50     | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| 05640 | Replace Broken Teeth-Per Tooth     | \$50     | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| 05650 | Add Tooth to Existing Part Denture | \$73     | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| 05660 | Add Clasp to Existing Part Denture | \$101    | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| 05710 | Rebase Dnt-Comp or Par, Upr or     | \$196    | NB        |   |
|       | Lower                              |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 05730 | Reline Dnt-Comp or Part, Chair     | \$134    | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| 05750 | Reline Dent-Comp or Part, Lab      | \$148    | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| 05820 | Temp Part Stayplate-Upper or Lower | \$207    | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| 05850 | Tissue Conditioning Upper --       | \$50     | NB        |   |
|       | Denture                            |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 05851 | Tissue Conditioning Lower          | \$56     | NB        |   |
|       | --Denture                          |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| **Pro |                                    |          |           |   |
| sthet |                                    |          |           |   |
| ics - |                                    |          |           |   |
| Fi    |                                    |          |           |   |
| xed** |                                    |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 06210 | Pontic-Cast High Noble Metal       | \$525    | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| 06211 | Pontic-Cast Predom Base Metal      | \$484    | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| 06212 | Pontic-Cast Noble Metal            | \$459    | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| 06240 | Pontic-Porc Fused to Hi Noble      | \$493    | NB        |   |
|       | Metal                              |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 06241 | Pontic-Porc Fused to Predom Base   | \$431    | NB        |   |
|       | Metal                              |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 06242 | Pontic-Porc Fused to Noble Metal   | \$465    | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| 06520 | Inlay-Metallic-Two Surfaces        | \$353    | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| 06530 | Inlay-Metallic -- 3 or More        | \$392    | NB        |   |
|       | Surfaces                           |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 06540 | Only -- Metallic Per Tooth + Inlay | \$431    | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| 06545 | Rtain-Cast Mtl For Acide Etch Brdg | \$224    | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| 06750 | Crown-Porc Fused to Hi Noble Metal | \$504    | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| 06751 | Crown-Porc Fused to Predom Bse     | \$420    | NB        |   |
|       | Metal                              |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 06752 | Crown-Porc Fused to Nobel Metal    | \$454    | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| 06780 | Crown-3/4 Cast High Noble Metal    | \$476    | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| 06790 | Crown-Full Cast High Noble Metal   | \$537    | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| 06791 | Crown-Full Cast Predom Base Metal  | \$478    | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| 06792 | Crown-Full Cast Noble Metal0       | \$465    | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| 06930 | Recement Bridge                    | \$39     | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| *     |                                    |          |           |   |
| *Oral |                                    |          |           |   |
| Surg  |                                    |          |           |   |
| ery** |                                    |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 07110 | Single Tooth                       | \$47     | \$53      |   |
+-------+------------------------------------+----------+-----------+---+
| 07120 | Each Additional Tooth              | \$41     | \$47      |   |
+-------+------------------------------------+----------+-----------+---+
| 07130 | Root Removal -- Exposed Roots      | \$28     | \$39      |   |
+-------+------------------------------------+----------+-----------+---+
| 07210 | Surgical Removal of Erupted Tooth  | \$59     | \$106     |   |
+-------+------------------------------------+----------+-----------+---+
| 07220 | Rem Impacted Tooth-Soft Tissue     | \$52     | \$129     |   |
+-------+------------------------------------+----------+-----------+---+
| 07230 | Rem Impacted Tooth-Part Bony       | \$67     | \$162     |   |
+-------+------------------------------------+----------+-----------+---+
| 07240 | Rem Impacted Tooth -- Compl Bony   | \$111    | \$190     |   |
+-------+------------------------------------+----------+-----------+---+
| 07250 | Surg Rem Resid T Roots-Cutting     | \$59     | \$106     |   |
|       | Proc                               |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 07260 | Oroantral Fistula Closure          | \$170    | \$213     |   |
+-------+------------------------------------+----------+-----------+---+
| 07270 | Tooth Reimplantation               | \$104    | \$241     |   |
+-------+------------------------------------+----------+-----------+---+
| 07280 | Surg Expos Imp/Unerup T-Ortho      | \$125    | \$207     |   |
+-------+------------------------------------+----------+-----------+---+
| 07281 | Surg Expos Imp/Unerup T-Aid Erup   | \$88     | \$168     |   |
+-------+------------------------------------+----------+-----------+---+
| 07285 | Biopsy of Oral Tissue-Hard\*\*     | \$74     | \$129     |   |
+-------+------------------------------------+----------+-----------+---+
| 07286 | Biopsy of Oral Tissue-Soft\*\*     | \$74     | \$112     |   |
+-------+------------------------------------+----------+-----------+---+
| 07291 | Transseptal Fiberotomy             | \$34     | \$34      |   |
+-------+------------------------------------+----------+-----------+---+
| 07310 | Alveolopl In Conj w Extrac-Per     | \$59     | \$118     |   |
|       | Quad                               |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 07320 | Alveolopl No Extract-Per Quad      | \$74     | \$134     |   |
+-------+------------------------------------+----------+-----------+---+
| 07410 | Rad Exc-Lesion to 1.25cm\*\*       | \$88     | \$168     |   |
+-------+------------------------------------+----------+-----------+---+
| 07420 | Rad Exc-Lesion over 1.25cm\*\*     | \$141    | \$286     |   |
+-------+------------------------------------+----------+-----------+---+
| 07430 | Exc Benign Tumor-Lesion to         | \$111    | \$179     |   |
|       | 1.25cm\*\*                         |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 07431 | Exc Benign Tumor-Lesion over       | \$140    | \$281     |   |
|       | 1.25cm\*\*                         |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 07450 | Rem Odont Cyc/Tum-Les to 1.25cm    | \$105    | \$170     |   |
+-------+------------------------------------+----------+-----------+---+
| 07451 | Rem Odont Cyst/Tum-Les over 1.25cm | \$140    | \$281     |   |
+-------+------------------------------------+----------+-----------+---+
| **D   |                                    | **You    |           |   |
| ental |                                    | Pay**    |           |   |
| Benef |                                    |          |           |   |
| its** |                                    |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| **    | **PROCEDURE NAME**                 | **TO**   | **TO      |   |
| ADA** |                                    |          | SPE       |   |
|       |                                    | **D      | CIALIST** |   |
| **C   |                                    | ENTIST** |           |   |
| ODE** |                                    |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 07460 | Rem NonOdont Cyst/Tum-Les to       | \$111    | \$179     |   |
|       | 1.25cm                             |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 07461 | Rem NonOdont Cyst/Tum-Les over     | \$148    | \$297     |   |
|       | 1.25cm                             |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 07470 | Rem Exostosis-Maxilla or Mandible  | \$193    | \$280     |   |
+-------+------------------------------------+----------+-----------+---+
| 07480 | Part Ostectomy Gutter or Sauceriz  | \$281    | \$281     |   |
+-------+------------------------------------+----------+-----------+---+
| 07510 | I&D Abscess-Intraoral Soft Tissue  | \$59     | \$78      |   |
+-------+------------------------------------+----------+-----------+---+
| 07520 | I&D Abscess-Extraoral Soft-Tissue  | \$59     | \$78      |   |
+-------+------------------------------------+----------+-----------+---+
| 07530 | Rem Foreign Body/Skn/Subcut Areo   | \$120    | \$179     |   |
|       | Tissue                             |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 07550 | Sequestrectomy for Osteomyelitis   | \$162    | \$162     |   |
+-------+------------------------------------+----------+-----------+---+
| 07910 | Suture Simple Wounds up to 5cm     | \$39     | \$39      |   |
+-------+------------------------------------+----------+-----------+---+
| 07911 | Suture of Complex Wounds up to 5cm | \$78     | \$78      |   |
+-------+------------------------------------+----------+-----------+---+
| 07960 | Frenectomy Frenec/Frenot-Sep Proc  | \$91     | \$196     |   |
+-------+------------------------------------+----------+-----------+---+
| 07970 | Exc of Hyperplastic Tissue-Per     | \$56     | \$148     |   |
|       | Arch                               |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 07971 | Excision of Periocoronal Gingiva   | \$67     | \$95      |   |
+-------+------------------------------------+----------+-----------+---+
| **    |                                    |          |           |   |
| Addit |                                    |          |           |   |
| ional |                                    |          |           |   |
| Pr    |                                    |          |           |   |
| ocedu |                                    |          |           |   |
| res** |                                    |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 09110 | Palliative Treatment               | \$28     | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| 09210 | Local Anesthesia                   | \$0      | NB        |   |
+-------+------------------------------------+----------+-----------+---+
| 09220 | General Anesthesia-First 30        | \$74     | \$185     |   |
|       | Minutes                            |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 09221 | General Anesthesia-Each Add'l 15   | \$37     | \$123     |   |
|       | Minutes                            |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 09230 | Analgesia (per 30 Minutes)         | \$17     | \$22      |   |
+-------+------------------------------------+----------+-----------+---+
| 09240 | IV Sedation (per ½ hour)           | \$111    | \$179     |   |
+-------+------------------------------------+----------+-----------+---+
| 09310 | Consult (No Add'l Procs Indicated) | \$45     | \$49      |   |
+-------+------------------------------------+----------+-----------+---+
| 09910 | Appl Of Desensitizing Med          | \$28     | \$28      |   |
+-------+------------------------------------+----------+-----------+---+
| 09940 | Occlusal Guards by Report          | \$162    | \$269     |   |
+-------+------------------------------------+----------+-----------+---+
| 09951 | Occlusal Adjustment -- Limited     | \$37     | \$57      |   |
+-------+------------------------------------+----------+-----------+---+
| 09952 | Occlusal Adjustment-Complete       | \$148    | \$244     |   |
+-------+------------------------------------+----------+-----------+---+
| 09980 | Sterilization Surcharge (per       | \$5      | \$5       |   |
|       | visit)                             |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 09990 | After Hours Surcharge              | \$25     | \$25      |   |
+-------+------------------------------------+----------+-----------+---+
| 09999 | Broken Appointment Fee -- Per ½    | \$15     | \$15      |   |
|       | Hour                               |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| **Or  |                                    |          |           |   |
| thodo |                                    |          |           |   |
| ntics |                                    |          |           |   |
| --    |                                    |          |           |   |
| Per   |                                    |          |           |   |
| C     |                                    |          |           |   |
| ase** |                                    |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 08070 | Orthodontic -- Fully Banded 2 Yr.  | NB       | \$2,375   |   |
|       | Case - Transitional                |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| 08080 | Orthodontic -- Fully Banded 2 Yr.  | NB       | \$2,375   |   |
|       | Case - Adolescent                  |          |           |   |
+-------+------------------------------------+----------+-----------+---+
| *L    |                                    |          |           |   |
| imita |                                    |          |           |   |
| tions |                                    |          |           |   |
| to    |                                    |          |           |   |
| d     |                                    |          |           |   |
| ental |                                    |          |           |   |
| servi |                                    |          |           |   |
| ces:* |                                    |          |           |   |
|       |                                    |          |           |   |
| -     |                                    |          |           |   |
| *Full |                                    |          |           |   |
|       |                                    |          |           |   |
| mouth |                                    |          |           |   |
|     X |                                    |          |           |   |
| -rays |                                    |          |           |   |
|       |                                    |          |           |   |
|   and |                                    |          |           |   |
|       |                                    |          |           |   |
|  pano |                                    |          |           |   |
| ramic |                                    |          |           |   |
|     X |                                    |          |           |   |
| -rays |                                    |          |           |   |
|       |                                    |          |           |   |
|   are |                                    |          |           |   |
|       |                                    |          |           |   |
|    co |                                    |          |           |   |
| vered |                                    |          |           |   |
|       |                                    |          |           |   |
|  once |                                    |          |           |   |
|       |                                    |          |           |   |
| every |                                    |          |           |   |
|       |                                    |          |           |   |
| thirt |                                    |          |           |   |
| y-six |                                    |          |           |   |
|  (36) |                                    |          |           |   |
|       |                                    |          |           |   |
|    mo |                                    |          |           |   |
| nths, |                                    |          |           |   |
|     e |                                    |          |           |   |
| xcept |                                    |          |           |   |
|       |                                    |          |           |   |
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|       |                                    |          |           |   |
| taken |                                    |          |           |   |
|       |                                    |          |           |   |
|   for |                                    |          |           |   |
|       |                                    |          |           |   |
|  diag |                                    |          |           |   |
| nosis |                                    |          |           |   |
|       |                                    |          |           |   |
|    of |                                    |          |           |   |
|       |                                    |          |           |   |
| third |                                    |          |           |   |
|       |                                    |          |           |   |
|    mo |                                    |          |           |   |
| lars, |                                    |          |           |   |
|     c |                                    |          |           |   |
| ysts, |                                    |          |           |   |
|       |                                    |          |           |   |
|    or |                                    |          |           |   |
|       |                                    |          |           |   |
| neopl |                                    |          |           |   |
| asms* |                                    |          |           |   |
|       |                                    |          |           |   |
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| html} |                                    |          |           |   |
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| *Full |                                    |          |           |   |
|       |                                    |          |           |   |
| mouth |                                    |          |           |   |
|     d |                                    |          |           |   |
| ebrid |                                    |          |           |   |
| ement |                                    |          |           |   |
|       |                                    |          |           |   |
|  (ADA |                                    |          |           |   |
|       |                                    |          |           |   |
| Code  |                                    |          |           |   |
| 4355) |                                    |          |           |   |
|       |                                    |          |           |   |
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|       |                                    |          |           |   |
| thirt |                                    |          |           |   |
| y-six |                                    |          |           |   |
|  (36) |                                    |          |           |   |
|       |                                    |          |           |   |
|    mo |                                    |          |           |   |
| nths* |                                    |          |           |   |
|       |                                    |          |           |   |
| ```{= |                                    |          |           |   |
| html} |                                    |          |           |   |
| <!-   |                                    |          |           |   |
| - --> |                                    |          |           |   |
| ```   |                                    |          |           |   |
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| Perio |                                    |          |           |   |
|     M |                                    |          |           |   |
| ainte |                                    |          |           |   |
| nance |                                    |          |           |   |
|       |                                    |          |           |   |
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| ctive |                                    |          |           |   |
|       |                                    |          |           |   |
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| erapy |                                    |          |           |   |
|       |                                    |          |           |   |
|  (ADA |                                    |          |           |   |
|     C |                                    |          |           |   |
| ode 0 |                                    |          |           |   |
| 4910) |                                    |          |           |   |
|       |                                    |          |           |   |
|    is |                                    |          |           |   |
|       |                                    |          |           |   |
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| mited |                                    |          |           |   |
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|    to |                                    |          |           |   |
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| twice |                                    |          |           |   |
|     w |                                    |          |           |   |
| ithin |                                    |          |           |   |
|     t |                                    |          |           |   |
| welve |                                    |          |           |   |
|  (12) |                                    |          |           |   |
|     m |                                    |          |           |   |
| onths |                                    |          |           |   |
|       |                                    |          |           |   |
| after |                                    |          |           |   |
|       |                                    |          |           |   |
|    Os |                                    |          |           |   |
| seous |                                    |          |           |   |
|       |                                    |          |           |   |
|   Sur |                                    |          |           |   |
| gery* |                                    |          |           |   |
|       |                                    |          |           |   |
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| nture |                                    |          |           |   |
|       |                                    |          |           |   |
|    re |                                    |          |           |   |
| lines |                                    |          |           |   |
|       |                                    |          |           |   |
|   for |                                    |          |           |   |
|       |                                    |          |           |   |
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| plete |                                    |          |           |   |
|       |                                    |          |           |   |
|    or |                                    |          |           |   |
|       |                                    |          |           |   |
|    pa |                                    |          |           |   |
| rtial |                                    |          |           |   |
|       |                                    |          |           |   |
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| nvent |                                    |          |           |   |
| ional |                                    |          |           |   |
|       |                                    |          |           |   |
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| tures |                                    |          |           |   |
|       |                                    |          |           |   |
|   are |                                    |          |           |   |
|       |                                    |          |           |   |
|   inc |                                    |          |           |   |
| luded |                                    |          |           |   |
|       |                                    |          |           |   |
|    in |                                    |          |           |   |
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|   the |                                    |          |           |   |
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|       |                                    |          |           |   |
|   fee |                                    |          |           |   |
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|       |                                    |          |           |   |
|   the |                                    |          |           |   |
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| x (6) |                                    |          |           |   |
|       |                                    |          |           |   |
| month |                                    |          |           |   |
|     p |                                    |          |           |   |
| eriod |                                    |          |           |   |
|       |                                    |          |           |   |
|  foll |                                    |          |           |   |
| owing |                                    |          |           |   |
|       |                                    |          |           |   |
| inser |                                    |          |           |   |
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|       |                                    |          |           |   |
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| lines |                                    |          |           |   |
|       |                                    |          |           |   |
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| vered |                                    |          |           |   |
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|  (12) |                                    |          |           |   |
|       |                                    |          |           |   |
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| ths.* |                                    |          |           |   |
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|       |                                    |          |           |   |
|  (ADA |                                    |          |           |   |
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| ode 0 |                                    |          |           |   |
| 1351) |                                    |          |           |   |
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|    to |                                    |          |           |   |
|       |                                    |          |           |   |
|   the |                                    |          |           |   |
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| first |                                    |          |           |   |
|       |                                    |          |           |   |
|   and |                                    |          |           |   |
|     s |                                    |          |           |   |
| econd |                                    |          |           |   |
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| diffi |                                    |          |           |   |
| culty |                                    |          |           |   |
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|   che |                                    |          |           |   |
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|     s |                                    |          |           |   |
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|    tw |                                    |          |           |   |
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| years |                                    |          |           |   |
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| aling |                                    |          |           |   |
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|  (ADA |                                    |          |           |   |
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| Code  |                                    |          |           |   |
| 4341) |                                    |          |           |   |
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| ement |                                    |          |           |   |
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| idges |                                    |          |           |   |
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|   and |                                    |          |           |   |
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+-------+------------------------------------+----------+-----------+---+

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

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

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

**Medicare Prepaid Plan Enrollment\
**We offer Medicare recipients the opportunity to enroll in our Plan
through Medicare. Annuitants and former spouses with FEHB coverage and
Medicare Parts A and B or Part B only may elect to either drop their
FEHB coverage and enroll in a Medicare prepaid plan or remain enrolled
in the FEHB Program and simultaneously enroll in the Medicare prepaid
plan when one is available in their area. If you choose to disenroll
from the FEHB Program you may then later re-enroll in the FEHB Program.
Before you drop your FEHB coverage and apply for coverage in the
Medicare prepaid plan, please contact us at 301/816-5690 or
301/816-6143.

**Expanded Dental Benefits\
**We are pleased to offer you an additional choice of dental coverage to
supplement what is currently available to you through the FEHB program.
This dental program is designed to enhance the level of dental benefits
that you currently receive. Your basic discounted dental coverage
through the Plan is not affected by this enhanced product offering. This
supplemental coverage is through Delta Dental, a national dental
provider, and is only available to members of Kaiser Permanente.

Delta Premier, a table of allowances program, allows you to choose any
licensed dentist; however, discounted pricing is available only through
Delta's provider network. After you satisfy a deductible, Delta will pay
a predetermined amount toward each covered service. You will not need to
satisfy a deductible toward covered preventive services you receive.
Delta Premier offers a full range of covered services: diagnostic,
preventive, restorative, endodontics, periodontics, oral surgery, and
both fixed and removable prosthodontics. Orthodontic coverage is not
available. Covered services will be phased in over a three (3) year
period.

Delta Premier is only available to you if you are enrolled in Kaiser
Permanente's Plan for the FEHB. You do not need to purchase this program
to receive the basic dental coverage included in the Plan. Premium
payments should be made directly to Delta Dental. Payroll deduction is
not available for this program.

How to Enroll: An enrollment form for Delta Premier is included in your
Kaiser Permanente enrollment kit. If you would wish more information on
Delta Premier, please call Delta Dental at 800/932-0783.

Monthly Premiums:

Self \$18.45

Self and One Party \$33.45

Family \$52.45

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

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

-   Care by non-Plan providers except for authorized referrals or
    emergencies (see Section 5(d)), services under the Travel Benefit
    (see Section 5(g)), and services received from other Kaiser
    Permanente plans (see Section 5(g));

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

-   Services, drugs, or supplies that are not medically necessary;

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

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

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

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

-   Services, drugs, or supplies related to sex transformations; or

```{=html}
<!-- -->
```
-   Services, drugs, or supplies you receive from a provider or facility
    barred from the FEHB Program.

  -----------------------------------------------------------------------
  Section 7. Filing a claim for covered services

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

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

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

**Medical, hospital, and drug** In most cases, providers and facilities
file claims for you. Physicians

**benefits** must file on the form HCFA-1500, Health Insurance Claim
Form. Facilities will file on the UB-92 form. For claims questions and
assistance, call us at 301/468-6000 inside the Washington, DC
metropolitan area or at 800/777-7902 outside the Washington, DC
metropolitan area. Our TTY telephone number is 301/879-6380.

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

-   Covered member's name and ID number;

-   Name and address of the physician or facility that provided the
    service or supply;

-   Dates you received the services or supplies;

-   Diagnosis;

-   Type of each service or supply;

-   The charge for each service or supply;

-   Follow up services rendered out-of-area

```{=html}
<!-- -->
```
-   A copy of the explanation of benefits, payments, or denial from any
    primary payer -- such as the Medicare Summary Notice (MSN); and

-   Receipts, if you paid for your services.

**Submit your claims to:**

Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.

> Attention: Claims Department
>
> P. O. Box 6233
>
> Rockville, Maryland 20849-6233
>
> **Deadline for filing your claim** Send us all of the documents for
> your claim as soon as possible. You must submit the claim by December
> 31 of the year after the year you received the service, unless timely
> filing was prevented by administrative operations of Government or
> legal incapacity, provided the claim was submitted as soon as
> reasonably possible.

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

  -----------------------------------------------------------------------
  Section 8. The disputed claims process

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

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

+---+---+-----------------------------------------------------------------+
| * |   | **Description**                                                 |
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| * |   |                                                                 |
+---+---+-----------------------------------------------------------------+
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|   | . |                                                                 |
+---+---+-----------------------------------------------------------------+
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|   | . |                                                                 |
+---+---+-----------------------------------------------------------------+

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

(a) We haven\'t responded yet to your initial request for care or
    preauthorization/prior approval, then call us Monday through Friday
    at 301/468-6000 inside the Washington, DC metropolitan area or
    800/777-7902 outside the Washington, DC metropolitan area. Our TTY
    is 301/879-6380. Weekends and holidays, please call 703/359-7878
    inside the Washington, DC metropolitan area or 800/777-7904 outside
    the Washington, DC metropolitan area. Our weekend TDD numbers are
    703/359-7616 or toll free at 800/700-4901. We will expedite our
    review; or

(b) We denied your initial request for care or pre-authorization/prior
    approval, then:

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

```{=html}
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```
-   You may call OPM\'s Health Insurance Group 3 at 202/606-0755 between
    8 a.m. and 5 p.m. eastern time.

  -----------------------------------------------------------------------
  Section 9. Coordinating benefits with other coverage

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

**When you have other health** You must tell us if you or a covered
family member have coverage

**coverage** under another group 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 is the primary payer; it pays
benefits first. The other plan pays a reduced benefit as the secondary
payer. We, like other insurers, determine which coverage is primary
according to the National Association of Insurance Commissioners\'
Guidelines.

When we are the primary payer, we will pay the benefits described in
this brochure.

When we are the secondary payer, we will determine our allowance. After
the primary plan pays, we will pay what is left of our allowance, up to
our regular benefit. We will not pay more than our allowance. If we are
the secondary payer, and you received your services from Plan providers,
we may bill the primary carrier.

-   **What is Medicare?** Medicare is a Health Insurance Program for:

```{=html}
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```
-   People 65 years of age and older.

```{=html}
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```
-   Some people with disabilities, under 65 years of age.

```{=html}
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```
-   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.

```{=html}
<!-- -->
```
-   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. The information in the next few pages shows how we
> coordinate benefits with Medicare, depending on the type of Medicare
> managed care plan you have.

-   **Should I enroll in Medicare?** The decision to enroll in Medicare
    is yours. 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**. When you don't have to pay premiums
> for Medicare Part A, it makes good sense to obtain the coverage. It
> can reduce your out-of-pocket expenses as well as costs to the FEHB,
> which can help keep FEHB premiums down.
>
> Everyone is charged a premium for Medicare Part B coverage. The Social
> Security Administration can provide you with premium and benefit
> information. Review the information and decide if it makes sense for
> you to buy the Medicare Part B coverage.

**• If you do enroll in** If you enroll in Medicare Part B, we require
you to assign your Medicare

**Medicare Part B** Part B benefits to the Plan for its services.

-   **The Original Medicare Plan** The Original Medicare Plan (Original
    Medicare) is available everywhere

> **(Part A or Part B)** in the United States. It is the way everyone
> used to get Medicare benefits
>
> and is the way most people get their Medicare Part A and Part B
> benefits now. You may go to any doctor, specialist, or hospital that
> accepts Medicare. The Original Medicare Plan pays its share and you
> pay your share. Some things are not covered under Original Medicare,
> like prescription drugs.
>
> 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. We will not waive any of our copayments.
>
> **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.

```{=html}
<!-- -->
```
-   When Original Medicare is the primary payer, Medicare processes your
    claim first. In most cases, your claim will be coordinated
    automatically and we will then provide secondary benefits for
    covered charges. You will not need to do anything. To find out if
    you need to do something to file your claim, please call
    301/468-6000 or 800/777-7902 or TTY 301/879-6380.

**(Primary payer chart begins on next page.)**

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 your  |     |  for  |
|     employment status                                | for  | other  |
|                                                      | Part | se     |
|                                                      | B    | rvices |
|                                                      | 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...**        |      |        |
+------------------------------------------------------+------+--------+
| ###### Have Medicare solel                           |      |       |
| y 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                             |      |        |
+------------------------------------------------------+------+--------+
| 1)  Become eligible for Medicare due to ESRD while   |      | for   |
|     already a Medicare beneficiary and...            |      | 30     |
|                                                      |      | -month |
| -   This Plan was the primary payer before           |      | coordi |
|     eligibility due to ESRD                          |      | nation |
|                                                      |      | period |
+------------------------------------------------------+------+--------+
| -   Medicare was the primary payer before            |     |        |
|     eligibility due to ESRD                          |      |        |
+------------------------------------------------------+------+--------+
| **C. When either you or 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**...**                      |     | []{    |
|                                                      |      | .mark} |
|     -   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. 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 managed care plan** If you are eligible for Medicare, you
    may choose to enroll in and get your Medicare benefits from another
    plan \-- a Medicare managed care plan. This is a health care choice
    (like HMOs) in some areas of the country. In most Medicare managed
    care plans, you can only go to doctors, specialists, or hospitals
    that are part of the plan. Medicare managed care plans provide all
    the benefits that Original Medicare covers. Some cover extras, like
    prescription drugs. To learn more about enrolling in a Medicare
    managed care plan, contact Medicare at 1-800-MEDICARE\
    (1-800-633-4227) or at [www.medicare.gov](http://www.medicare.gov/).

> If you enroll in a Medicare managed care plan, the following options
> are available to you:

**This Plan and our Medicare managed care plan:** You may enroll in our
Medicare managed care plan, known as Kaiser Permanente Medicare Plus (an
1876 Medicare Cost plan), and also remain enrolled in our FEHB Plan. To
be eligible for Kaiser Permanente Medicare Plus, you must have Medicare
Parts A and B or Medicare Part B only.

You may enroll in Medicare Plus at no additional monthly premium cost to
you. This plan offers you enhanced benefits and additional flexibility
in how you receive your medical care. If you enroll in Medicare Plus,
you still receive all of your in-network care through Kaiser Permanente
contracted Plan Providers. When you use Plan Providers, some of your
copayments and coinsurance will be lowered.

You can always choose to go to a doctor outside our network. We may not
pay for the services you receive outside of our network. If you go to a
provider outside of Kaiser Permanente Medicare Plus who accepts Medicare
patients, your coverage would be the same as Original Medicare. Original
Medicare deductibles and coinsurance apply and are your responsibility
to pay.

Under Kaiser Permanente Medicare Plus, when you receive your medical
care through Plan Providers, the following copayments or coinsurance
have been lowered:

+-----------------------------------------------------------------------+
| -   **Physician Office Visits (preventive and non-preventive):** \$5  |
|                                                                       |
| -   **Dialysis:** \$0                                                 |
|                                                                       |
| -   **Voluntary sterilizations and family planning:** \$5             |
|                                                                       |
| -   **Rehabilitative and Other Therapies:** \$5; unlimited number of  |
|     visits as medically necessary                                     |
|                                                                       |
| -   **Cardiac Rehabilitation:** \$5                                   |
|                                                                       |
| -   **Comprehensive Outpatient Rehabilitation Facility Services:**    |
|     \$5                                                               |
|                                                                       |
| -   **Chiropractic Services and Acupuncture beyond what is covered by |
|     Medicare:** \$5 up to 20 visits per modality per calendar year    |
|                                                                       |
| -   **Urgent Care Services:** \$5                                     |
|                                                                       |
| -   **Outpatient Substance Abuse Rehabilitation:** \$5                |
|                                                                       |
| -   **Outpatient Mental Health Services:** \$5                        |
|                                                                       |
| -   **Vision Services:** \$5 for eye examinations and refractions;    |
|     covered up to the Medicare-allowable amount for glasses after     |
|     cataract surgery; 25% discount on eyeglass lenses and frames; 15% |
|     discount on initial purchase of contact lenses                    |
|                                                                       |
| -   **Hearing exams:** \$5 for routine and Medicare-covered hearing   |
|     tests                                                             |
|                                                                       |
| -   **Podiatry (medically necessary):** \$5                           |
|                                                                       |
| -   **Blood transfusions:** \$5                                       |
|                                                                       |
| -   **Blood and blood components:** \$0 if the blood is replaced;     |
|     otherwise you must replace the first three (3) pints or pay       |
|     non-replacement fees for whole blood; \$0 for all blood products, |
|     except for hemophiliac factors that are covered under the         |
|     Prescription Drug benefit                                         |
|                                                                       |
| -   **Health Education Classes:** \$10-\$20 for health education      |
|     classes                                                           |
+-----------------------------------------------------------------------+

If you would like information about Kaiser Permanente Medicare Plus,
please call 301/468-6000 or 800/777-7902 or TTY 301/879-6380.

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

**Suspended FEHB coverage to enroll in a Medicare+Choice care plan:** If
you are an annuitant or former spouse, you can suspend your FEHB
coverage to enroll in a Medicare+Choice care plan, eliminating your FEHB
premium. (OPM does not contribute to your Medicare+Choice care plan
premium.) For information on suspending your FEHB enrollment, contact
your retirement office. If you later want to re-enroll in the FEHB
Program, generally you may do so only at the next open season unless you
involuntarily lose coverage or move out of the Medicare+Choice care
service area.

**TRICARE and CHAMPVA** TRICARE is the health care program for 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 re-enroll in the FEHB Program,
> generally you may do so only at the next Open Season unless you
> involuntarily lose coverage under the program.

**Workers' Compensation** We do not cover services that:

> • you need because of a workplace-related illness or injury that the
> Office of Workers' Compensation Programs (OWCP) or a similar Federal
> or State agency determines they must provide; or
>
> • OWCP or a similar agency pays for through a third party injury
> settlement or other similar proceeding that is based on a claim you
> filed under OWCP or similar laws.

Once OWCP or similar agency pays its maximum benefits for your
treatment, we will cover your care. You must use our providers.

**Medicaid** When you have this Plan and Medicaid, we pay first.

**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 Government agencies** We do not cover services and supplies
when a local, State,

**are responsible for your care** or Federal Government agency directly
or indirectly pays for them.

**When others are responsible** When you receive money to compensate you
for medical or

**for injuries** hospital care for injuries or illness caused by another
person, you must reimburse us for any expenses we paid. However, we will
cover the cost of treatment that exceeds the amount you received in the
settlement.

If you do not seek damages you must agree to let us try. This is called
subrogation. If you need more information, contact us for our
subrogation procedures.

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

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

**Calendar year** January 1 through December 31 of the same year. For
new enrollees, the calendar year begins on the effective date of their
enrollment and ends on December 31 of the same year.

**Coinsurance** Coinsurance is the percentage of our allowance that you
must pay for your care.

**Copayment** A copayment is a fixed amount of money you pay when you
receive covered services.

**Covered services** Care we provide benefits for, as described in this
brochure.

**Custodial care** (1) Assistance with activities of daily living, for
example, walking, getting in and out of bed, dressing, feeding,
toileting, and taking medicine. (2) Care that can be performed safely
and effectively by people who, in order to provide the care, do not
require medical licenses or certificates or the presence of a
supervising licensed nurse. Custodial care that lasts 90 days or more is
sometimes known as Long term care.

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

**Durable medical equipment** Durable medical equipment (DME) is
equipment that is intended for repeated use, medically necessary,
primarily and customarily used to serve a medical purpose, generally not
useful to a person who is not ill or injured, designed for prolonged
use, appropriate for use in the home, and serving a specific therapeutic
purpose in the treatment of an illness or injury.

+---------------------+------------------------------------------------+
| **Experimental or   | A service, supply, item or drug that:          |
| investigational     |                                                |
| services**          | > \(1\) has not been approved by the FDA; or   |
|                     | >                                              |
|                     | > \(2\) is the subject of a new drug or new    |
|                     | > device application on file with the FDA; or  |
|                     | >                                              |
|                     | > \(3\) is available as the result of a        |
|                     | > written protocol that evaluates the          |
|                     | > service's safety, toxicity, or efficacy; or  |
|                     | >                                              |
|                     | > \(4\) is subject to the approval or review   |
|                     | > of an Institutional Review Board; or         |
|                     | >                                              |
|                     | > \(5\) requires an informed consent that      |
|                     | > describes the service as experimental or     |
|                     | > investigational.                             |
+---------------------+------------------------------------------------+

**Group health coverage** Health care benefits that are available as a
result of your employment, or the employment of your spouse, and that
are offered by an employer or through membership in an employee
organization. Health care coverage may be insured or indemnity coverage,
self-insured or self-funded coverage, or coverage through health
maintenance organizations or other managed care plans. Health care
coverage purchased through membership in an organization is also "group
health coverage."

**Medically necessary** All benefits need to be medically necessary in
order for them to be covered benefits. Generally, if your Plan physician
provides the service in accord with the terms of this brochure, it will
be considered medically necessary. However, some services are reviewed
in advance of your receiving them to determine if they are medically
necessary. When we review a service to determine if it is medically
necessary, a Plan physician will evaluate what would happen to you if
you do not receive the service. If not receiving the service would
adversely affect your health, it will be considered medically necessary.
The services must be a medically appropriate course of treatment for
your condition. If they are not medically necessary, we will not cover
the services. In case of emergency services, the services that you
received will be evaluated to determine if they were medically
necessary.

**Our allowance** The amount we use to determine your coinsurance. When
you receive services or supplies from Plan providers, it is the amount
that we set for the services or supplies if we were to charge for them.
When you receive services from non-Plan providers, we determine the
amount that we believe is usual and customary for the service or supply,
and compare it to the charges. Our allowance is based upon the
reasonableness of the charges. If the charges exceed what we believe is
reasonable, you may be responsible for the excess over our allowance in
addition to your coinsurance.

**Your Primary care copayment** The copayment for your primary care
department visit is \$10 for the following areas: internal medicine,
obstetrics and gynecology, pediatrics and, family practice services.

**Your Specialty care copayment** The copayment for your specialty care
department visit is \$20. This copayment applies when you receive
services from areas other than primary care (as defined above).

**Us/We** Us and we refer to Kaiser Foundation Health Plan of the
Mid-Atlantic States, Inc.

**You** You refers to the enrollee and each covered family member.

  -----------------------------------------------------------------------
  Section 11. FEHB facts

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

**Coverage information**

**No pre-existing condition** We will not refuse to cover the treatment
of a condition that you had

**limitation** before you enrolled in this Plan solely because you had
the condition before you enrolled.

**Where you can get information** See [www.opm.gov/insure]{.underline}.
Also, your employing or retirement office

**about enrolling in the** can answer your questions, and give you a
*Guide to Federal Employees*

**FEHB Program** *Health Benefits Plans,* brochures for other plans, and
other materials you need to make an informed decision about your FEHB
coverage. These materials tell you:

-   When you may change your enrollment;

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-   How you can cover your family members;

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-   What happens when you transfer to another Federal agency, go on
    leave without pay, enter military service, or retire;

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-   When your enrollment ends; and

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-   When the next open season for enrollment begins.

We don't determine who is eligible for coverage and, in most cases,
cannot change your enrollment status without information from your
employing or retirement office.

**Types of coverage available** Self Only coverage is for you alone.
Self and Family coverage is for

**for you and your family** you, your spouse, and your unmarried
dependent children under age 22, including any foster children or
stepchildren your employing or retirement office authorizes coverage
for. Under certain circumstances, you may also continue coverage for a
disabled child 22 years of age or older who is incapable of
self-support.

If you have a Self Only enrollment, you may change to a Self and Family
enrollment if you marry, give birth, or add a child to your family. You
may change your enrollment 31 days before to 60 days after that event.
The Self and Family enrollment begins on the first day of the pay period
in which the child is born or becomes an eligible family member. When
you change to Self and Family because you marry, the change is effective
on the first day of the pay period that begins after your employing
office receives your enrollment form; benefits will not be available to
your spouse until you marry.

Your employing or retirement office will **not** notify you when a
family member is no longer eligible to receive health benefits, nor will
we. Please tell us immediately when you add or remove family members
from your coverage for any reason, including divorce, or when your child
under age 22 marries or turns 22.

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

**Children's Equity Act** OPM has implemented the Federal Employees
Health Benefits Children\'s Equity Act of 2000. This law mandates that
you be enrolled for Self and Family coverage in the Federal Employees
Health Benefits (FEHB) Program, if you are an employee subject to a
court or administrative order requiring you to provide health benefits
for your child(ren).

> If this law applies to you, you must enroll for Self and Family
> coverage in a health plan that provides full benefits in the area
> where your children live or provide documentation to your employing
> office that you have obtained other health benefits coverage for your
> children. If you do not do so, your employing office will enroll you
> involuntarily as follows:

-   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,

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-   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 and** The benefits in this brochure are effective on
January 1. If you joined

**premiums start** this Plan during Open Season, your coverage begins on
the first day of your first pay period that starts on or after
January 1. 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.

**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) (TCC), or a conversion policy
(a non-FEHB individual policy).

**When you lose benefits**

**• When FEHB coverage ends** You will receive an additional 31 days of
coverage, for no additional premium, when:

-   Your enrollment ends, unless you cancel your enrollment, or

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-   You are a family member no longer eligible for coverage.

You may be eligible for spouse equity coverage or Temporary Continuation
of Coverage.

**• Spouse equity coverage** If you are divorced from a Federal employee
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 supply
health coverage to you. But you may be eligible for your own FEHB
coverage under the spouse equity law or Temporary Continuation of
Coverage (TCC). If you are recently divorced or are anticipating a
divorce, contact your ex-spouse's employing or retirement office to get
RI 70-5, the *Guide to Federal Employees Health Benefits Plans for
Temporary Continuation of Coverage and Former Spouse Enrollees*, or
other information about your coverage choices. You can download the
guide from OPM\'s website, www.opm.gov/insure.

**• Temporary continuation** If you leave Federal service, or if you
lose coverage because you no

**of coverage (TCC)** longer qualify as a family member, you may be
eligible for Temporary Continuation of Coverage (TCC). For example, you
can receive TCC if you are not able to continue your FEHB enrollment
after you retire, if you lose your job, if you are a covered dependent
child and you turn 22 or marry, etc.

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

**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);

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-   You decided not to receive coverage under TCC or the spouse equity
    law; or

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```
-   You are not eligible for coverage under TCC or the spouse equity
    law.

If you leave Federal service, your employing office will notify you of
your right to convert. You must apply in writing to us within 31 days
after you receive this notice. However, if you are a family member who
is losing coverage, the employing or retirement office will **not**
notify you. You must apply in writing to us within 31 days after you are
no longer eligible for coverage.

Your benefits and rates will differ from those under the FEHB Program;
however, you will not have to answer questions about your health, and we
will not impose a waiting period or limit your coverage due to
pre-existing conditions.

**• Getting a Certificate of** The Health Insurance Portability and
Accountability Act of 1996

**Group Health Plan Coverage** (HIPAA) is a Federal law that offers
limited Federal protections for health coverage availability and
continuity to people who lose employer group coverage. If you leave the
FEHB Program, we will give you a Certificate of Group Health Plan
Coverage that indicates how long you have been enrolled with us. You can
use this certificate when getting health insurance or other health care
coverage. Your new plan must reduce or eliminate waiting periods,
limitations, or exclusions for health related conditions based on the
information in the certificate, as long as you enroll within 63 days of
losing coverage under this Plan. If you have been enrolled with us for
less than 12 months, but were previously enrolled in other FEHB plans,
you may also request a certificate from those plans. For more
information, get OPM pamphlet RI 79-27, Temporary Continuation of
Coverage (TCC) under the FEHB Program. See also the FEHB website
([www.opm.gov/insure/health]{.underline}); 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 Federal Programs complement FEHB benefits

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

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

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

-   **What is an FSA?** It is a tax-favored benefit that allows you to
    set aside pre-tax

> money from your paychecks to pay for a variety of eligible expenses.
> *By using an FSA,* *you can reduce your taxes while paying for
> services you would have to pay for anyway, producing a discount that
> can be over 40%!!*

There are two types of FSAs offered by the FSAFEDS Program:

-   Covers eligible health care expenses not reimbursed by this Plan, or
    any other medical, dental, or vision care plan you or your
    dependents may have

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```
-   Eligible dependents for this account include anyone you claim on
    your Federal income tax return as a qualified dependent under the
    U.S. Internal Revenue Service (IRS) definition and/or with whom you
    jointly file your Federal income tax return, even if you don't have
    self and family health benefits coverage*. **Note:*** The IRS has a
    broader definition than that of a "family member" than is used under
    the FEHB Program to provide benefits by your FEHB Plan.

```{=html}
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```
-   The maximum amount that can be allotted for the HCFSA is \$3,000
    annually. The minimum amount is \$250 annually.

```{=html}
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```
-   Covers eligible dependent care expenses incurred so you can work, or
    if you are married, so you and your spouse can work, or your spouse
    can look for work or attend school full-time.

-   Eligible dependents for this account include anyone you claim on
    your Federal income tax return as a qualified IRS dependent and/or
    with whom you jointly file your Federal income tax return.

-   The maximum that can be allotted for the DCFSA is \$5,000 annually.
    The minimum amount is \$250 annually. ***Note:*** The IRS limits
    contributions to a Dependent Care FSA. For single taxpayers and
    taxpayers filing a joint return, the maximum is \$5,000 per year.
    For taxpayers who file their taxes separately with a spouse, the
    maximum is \$2,500 per year. The limit includes any child care
    subsidy you may receive

```{=html}
<!-- -->
```
-   **Enroll during Open Season** You **must make an election** to
    enroll in an FSA during the

> FEHB Open Season. Even if you enrolled during the initial Open Season
> for 2003, you must make a new election to continue participating in
> 2004. Enrollment is easy!

-   Enroll online anytime during Open Season (November 10 through
    December 8, 2003) at [**www.fsafeds.com**](http://www.fsafeds.com/).

-   Call the toll --free number 1-877-FSAFEDS (372-3337) Monday through
    Friday, from 9 a.m. until 9 p.m. eastern time and a FSAFEDS Benefit
    Counselor will help you enroll.

> **What is SHPS?** SHPS is a third-party administrator hired by OPM to
> manage
>
> the FSAFEDS Program. SHPS is the largest FSA administrator in the
> nation and will be responsible for enrollment, claims processing,
> customer service, and day-to-day operations of FSAFEDS.
>
> **Who is eligible to enroll?** If you are a Federal employee eligible
> for FEHB -- even if you're not enrolled in FEHB--you can choose to
> participate in either, or both, of the flexible spending accounts. If
> you are not eligible for FEHB, you are not eligible to enroll for a
> Health Care FSA. However, almost all Federal employees are eligible to
> enroll for the Dependent Care FSA. The only exception is intermittent
> (also called when actually employed \[WAE\]) employees expected to
> work less than 180 days during the year.
>
> *Note:* FSAFEDS is the FSA Program established for all Executive
> Branch employees and Legislative Branch employees whose employers
> signed on. Under IRS law, FSAs are not available to annuitants. In
> addition, the U.S. Postal Service and the Judicial Branch, among
> others, are Federal agencies that have their own plans with slightly
> different rules, but the advantages of having an FSA are the same no
> matter what agency you work for.

-   **How much should I** Plan carefully when deciding how much to
    contribute to an

> **contribute to my FSA?** FSA. Because of the tax benefits of an FSA,
> the IRS places strict guidelines on them. You need to estimate how
> much you want to allocate to an FSA because current IRS regulations
> require you forfeit any funds remaining in your account(s) at the end
> of the FSA plan year. This is referred to as the "use-it-or-lose-it"
> rule. You will have until April 29, 2004 to submit claims for your
> eligible expenses incurred during 2003 if you enrolled in FSAFEDS when
> it was initially offered. You will have until April 30, 2005 to submit
> claims for your eligible expenses incurred from January 1 through
> December 31, 2004 if you elect FSAFEDS during this Open Season.
>
> The **FSAFEDS Calculator** at
> [www.fsafeds.com](http://www.fsafeds.com/) will help you plan your FSA
> allocations and provide an estimate of your tax savings based on your
> individual situation.

-   **What can my HCFSA** Every FEHB health plan includes cost sharing
    features, such as

> **pay for?** deductibles you must meet before the Plan provides
> benefits, coinsurance or copayments that you pay when you and the Plan
> share costs, and medical services and supplies that are not covered by
> the Plan and for which you must pay. These out-of-pocket costs are
> summarized on page 82 and detailed throughout this brochure. Your
> HCFSA will reimburse you for such costs when they are for tax
> deductible medical care for you and your dependents that is NOT
> covered by this FEHB Plan or any other coverage that you have.
>
> Under this Plan, typical out-of-pocket expenses include: office visit
> copayments, prescription drug copayments, and durable medical
> equipment coinsurance.
>
> The IRS governs expenses reimbursable by a HCFSA. See Publication 502
> for a comprehensive list of tax-deductible medical expenses. \
> **Note: While you will see insurance premiums listed in Publication
> 502, they are NOT a reimbursable expense for FSA purposes**.
> Publication 502 can be found on the IRS website at
> <http://www.irs.gov/pub/irs-pdf/p502.pdf>. If you do not see your
> service or expense listed in Publication 502, please call a FSAFEDS
> Benefit Counselor at 1-877-FSAFEDS (372-3337), who will be able to
> answer your specific questions.

-   **Tax savings with an FSA** An FSA lets you allot money for eligible
    expenses ***before*** your

> agency deducts taxes from your paycheck. This means the amount of
> income that your taxes are based on will be lower, so your tax
> liability will also be lower. Without an FSA, you would still pay for
> these expenses, but you would do so using money remaining in your
> paycheck after Federal (and often state and local) taxes are deducted.
> The following chart illustrates a typical tax savings example:

  --------------------------------------- -------------- -----------------
  **Annual Tax Savings Example**          **With FSA**   **Without FSA**

  If your taxable income is:              \$50,000       \$50,000

  And you deposit this amount into a FSA: \$ 2,000       -\$0-

  Your taxable income is now:             \$48,000       \$50,000

  Subtract Federal & Social Security      \$13,807       \$14,383
  taxes:                                                 

  If you spend after-tax dollars for      -\$0-          \$ 2,000
  expenses:                                              

  Your real spendable income is:          \$34,193       \$33,617

  **Your tax savings:**                   **\$576**      **-\$0-**
  --------------------------------------- -------------- -----------------

> **Note:** This example is intended to demonstrate a typical tax
> savings based on 27% Federal and 7.65% FICA taxes. Actual savings will
> vary based upon in which retirement system you are enrolled (CSRS or
> FERS), as well as your individual tax situation. In this example, the
> individual received \$2,000 in services for \$1,424, a discount of
> almost 36%! You may also wish to consult a tax professional for more
> information on the tax implications of an FSA.

-   **Tax credits and** You *cannot* claim expenses on your Federal
    income tax return

> **deductions** if you receive reimbursement for them from your HCFSA
> or DCFSA. Below are some guidelines that may help you decide whether
> to participate in FSAFEDS.
>
> **Health care expenses** The HCFSA is tax-free from the first dollar.
> In addition, you may be reimbursed from the HCFSA at any time during
> year for expenses up to the annual amount you\'ve elected to
> contribute.
>
> Only health care expenses exceeding 7.5% of your adjusted gross income
> are eligible to be deducted on your Federal income tax return. Using
> the example listed in the above chart, only health care expenses
> exceeding \$3,750 (7.5% of \$50,000) would be eligible to be deducted
> on your Federal income tax return. In addition, money set aside
> through a HCFSA is also exempt from FICA taxes. This exception is not
> available on your Federal income tax return.
>
> **Dependent care expenses** The DCFSA generally allows many families
> to save more than they would with the Federal tax credit for dependent
> care expenses. Note that you may only be reimbursed from the DCFSA up
> to your current account balance. If you file a claim for more than
> your current balance, it will be held until additional payroll
> allotments have been added to your account.
>
> Visit [www.fsafeds.com](http://www.fsafeds.com/) and download the
> Dependent Care Tax Credit Worksheet from the Quick Links box to help
> you determine what is best for your situation. You may also wish to
> consult a tax professional for more details.

-   **Does it cost me anything** Probably not. While there is an
    administrative fee of \$4.00 per month

> **to participate in FSAFEDS?** for an HCFSA and 1.5% of the annual
> election for a DCFSA, most agencies have elected to pay these fees out
> of their share of employment tax savings. To be sure, check the
> FSAFEDS.com website or call 1-877-FSAFEDS (372-3337). Also, remember
> that participating in FSAFEDS can cost you money if don't spend your
> entire account balance by the end of the plan year and wind up
> forfeiting your end of year account balance, per the IRS
> "use-it-or-lose-it" rule.

-   **Contact us** To find out more or to enroll, please visit the
    **FSAFEDS website** at

> [**www.fsafeds.com**](http://www.fsafeds.com/), or contact SHPS by
> email or by phone**.** SHPS Benefit Counselors are available from 9:00
> a.m. until 9:00 p.m. eastern time, Monday through Friday.

-   E-mail: <fsafeds@shps.net>

-   Telephone: 1-877-FSAFEDS (372-3337)

-   TTY: 1-800-952-0450 (for hearing impaired individuals that would
    like to utilize a text messaging service)

**The Federal Long Term Care Insurance Program**

**It's important protection** Here's why you should consider enrolling
in the Federal Long

> Term Care Insurance Program:

-   **FEHB plans do not cover the cost of long term care.** Also called
    "custodial care," long term care is help you receive when you need
    assistance performing activities of daily living -- such as bathing
    or dressing yourself. This need can strike anyone at any age and the
    cost of care can be substantial.

-   **The Federal Long Term Care Insurance Program can help protect you
    from the potentially high cost of long term care**. This coverage
    gives you control over the type of care you receive and where you
    receive it. It can also help you remain independent, so you won't
    have to worry about being a burden to your loved ones.

-   **It's to your advantage to apply sooner rather than later**. Long
    term care insurance is something you must apply for, and pass a
    medical screening (called underwriting) in order to be enrolled.
    Certain medical conditions will prevent some people from being
    approved for coverage. By applying while you're in good health, you
    could avoid the risk of having a change in health disqualify you
    from obtaining coverage. Also, the younger you are when you apply,
    the lower your premiums.

-   **You don't have to wait for an open season to apply**. The Federal
    Long Term Care Insurance Program accepts applications from eligible
    persons at any time. You will have to complete a full underwriting
    application, which asks a number of questions about your health.
    However, if you are a new or newly eligible employee, you (and your
    spouse, if applicable) have a limited opportunity to apply using the
    abbreviated underwriting application, which asks fewer questions. If
    you marry, your new spouse will also have a limited opportunity to
    apply using abbreviated underwriting. Qualified relatives are also
    eligible to apply with full underwriting.

**To find out more and** Call 1-800-LTC-FEDS (1-800-582-3337) (TTY
1-800-843-3557)

**to request an application** or visit
[www.ltcfeds.com](http://www.ltcfeds.com/).

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

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

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

**A**ccidental injury to sound

natural teeth 50

Allergy tests 21

Alternative treatment 29

Ambulance 37, 39

Anesthesia 33

Autologous bone marrow transplant 32

**B**iopsies 30

Blood and blood plasma 35

Breast cancer screening 17

**C**asts 35

Centers of Excellence 47

Changes for 2004 10

Chemotherapy 21

Chiropractic 28

Cholesterol tests 18

Coinsurance 15

Colorectal cancer screening 18

Congenital anomalies 30

Contraceptive devices and drugs 45

Coordination of benefits 64

Covered providers 11

Crutches 26

**D**eaf and hearing impaired

service 47

Deductible 15

Definitions 71

Dental care 50

Diagnostic services 17

Disputed claims review 62

Donor expenses (transplants) 33

Dressings 35

Durable medical equipment (DME) 26

**E**ducational classes and programs 29

Effective date of enrollment 13

Emergency 38

Experimental or investigational 60

Eyeglasses 24

**F**amily planning 20

Fecal occult blood test 18

Flexible benefits options 47

**G**eneral Exclusions 60

**H**earing services 19, 23

Home health services 27

Hospice care 37

Hospital 13

**I**mmunizations 19

Infertility 20

Inpatient Hospital Benefits 34

Insulin 45

**L**aboratory and pathological services 17

**M**agnetic Resonance Imagings (MRIs) 17

Mail Order Prescription Drugs 45

Mammograms 18

Maternity Benefits 19

Medicaid 69

Medically necessary 71

Medicare 64

Mental Conditions/Substance Abuse Benefits 40

**N**eurological testing 17

Newborn care 19

Non-FEHB Benefits 59

Nurse 27

-   Licensed Practical Nurse 27

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```
-   Nurse Anesthetist 30

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<!-- -->
```
-   Nurse Practitioner 27

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<!-- -->
```
-   Registered Nurse 27

    Nursery charges 19

    **O**bstetrical care 19

    Ocular Injury 24

    Occupational therapy 22

    Oral and maxillofacial surgery 32

    Orthopedic devices 25

    Ostomy and catheter supplies 28

    Out-of-pocket expenses 15

    Oxygen 26

    **P**ap test 18

    Physical examination 18

    Physical therapy 22

    Precertification 13

    Preventive care, adult 18

    Preventive care, children 19

    Preventive services 52

Primary care 12, 71

Prior approval 13

Prostate cancer screening 18

Prosthetic devices 25

Psychotherapy 42

**R**adiation therapy 21

Refractions 24

Renal dialysis 21

Room and board 34

**S**econd surgical opinion 17

Services from other Kaiser

> Permanente Plans 49

Skilled nursing care benefits 36

Smoking cessation 46

Specialty care 12, 71

Speech therapy 23

Splints 35

Sterilization procedures 30

Subrogation 69

Substance abuse 40

Surgery 30

-   Anesthesia 33

```{=html}
<!-- -->
```
-   Oral 32

-   Outpatient 35

-   Reconstructive 31

    Syringes 45

    **T**emporary continuation of coverage 74

    Transplants 32

Travel benefit 48

Treatment therapies 21

TRICARE and\
CHAMPVA 68

**V**ision services 19, 24

**W**ell child care 19

Wheelchairs 26

Workers' compensation 68

**X**-rays 17

**24** hour nurse line 47

  -----------------------------------------------------------------------
  **Summary of benefits for Kaiser Foundation Health Plan of the
  Mid-Atlantic States, Inc. -- 2004**

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

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

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

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

+-------------------------------------------+----------------------+---+
| **Benefits**                              | **You Pay**          | * |
|                                           |                      | * |
|                                           |                      | P |
|                                           |                      | a |
|                                           |                      | g |
|                                           |                      | e |
|                                           |                      | * |
|                                           |                      | * |
+-------------------------------------------+----------------------+---+
| Medical services provided by physicians:  | \$10 per visit in a  | 1 |
|                                           | primary care         | 7 |
| -   Diagnostic and treatment services     | department (except   |   |
|     provided in the office                | nothing for children |   |
|                                           | from infancy through |   |
|                                           | age 4)               |   |
|                                           |                      |   |
|                                           | > \$20 per visit in  |   |
|                                           | > a specialty care   |   |
|                                           | > department         |   |
+-------------------------------------------+----------------------+---+
| Services provided by a hospital:          | > \$100 per          | 3 |
|                                           | > admission          | 4 |
| -   Inpatient                             | >                    |   |
|                                           | > \$ 50 per          | 3 |
| -   Outpatient                            | > outpatient surgery | 5 |
+-------------------------------------------+----------------------+---+
| Emergency benefits:                       | > \$50 per visit     | 3 |
|                                           | >                    | 9 |
| -   In-area                               | > \$50 per visit     |   |
|                                           |                      | 3 |
| -   Out-of-area                           |                      | 9 |
+-------------------------------------------+----------------------+---+
| Mental health and substance abuse         | > Regular cost       | 4 |
| treatment:                                | > sharing            | 1 |
+-------------------------------------------+----------------------+---+
| Prescription drugs                        | > \$10 per           | 4 |
|                                           | > prescription or    | 5 |
|                                           | > refill for generic |   |
|                                           | > drugs or \$20 per  |   |
|                                           | > prescription or    |   |
|                                           | > refill for         |   |
|                                           | > brand-name drugs   |   |
|                                           | > if you get your    |   |
|                                           | > prescription       |   |
|                                           | > filled at a Plan   |   |
|                                           | > medical center     |   |
|                                           | > pharmacy           |   |
|                                           | >                    |   |
|                                           | > \$8 per            |   |
|                                           | > prescription or    |   |
|                                           | > refill for generic |   |
|                                           | > drugs or \$18 per  |   |
|                                           | > prescription or    |   |
|                                           | > refill for         |   |
|                                           | > brand-name drugs   |   |
|                                           | > if you get your    |   |
|                                           | > prescription       |   |
|                                           | > filled through our |   |
|                                           | > mail order         |   |
|                                           | > delivery system    |   |
|                                           | >                    |   |
|                                           | > \$20 per           |   |
|                                           | > prescription or    |   |
|                                           | > refill for generic |   |
|                                           | > drugs or \$40 per  |   |
|                                           | > prescription or    |   |
|                                           | > refill for         |   |
|                                           | > brand-name drugs   |   |
|                                           | > if you get your    |   |
|                                           | > prescription       |   |
|                                           | > filled at an       |   |
|                                           | > affiliated network |   |
|                                           | > pharmacy           |   |
+-------------------------------------------+----------------------+---+
| Dental Care                               | > Various copayments | 5 |
|                                           | > based on procedure | 0 |
|                                           | > rendered           |   |
+-------------------------------------------+----------------------+---+
| Vision Care                               | > Refractions in     | 2 |
|                                           | > Optometry; \$10    | 4 |
|                                           | > per office visit   |   |
+-------------------------------------------+----------------------+---+
| Special features: Flexible benefits       |                      | 4 |
| option; 24 hour nurse line; Services for  |                      | 7 |
| deaf and hearing impaired; Centers of     |                      |   |
| Excellence; Travel benefit; Services from |                      |   |
| other Kaiser Permanente Plans.            |                      |   |
+-------------------------------------------+----------------------+---+
| Protection against catastrophic costs     | Nothing after        | 1 |
|                                           | \$1,500/Self Only or | 5 |
| (your catastrophic protection             | \$3,000/Family       |   |
| out-of-pocket maximum)                    | enrollment per year  |   |
|                                           |                      |   |
|                                           | > Some costs do not  |   |
|                                           | > count toward this  |   |
|                                           | > protection         |   |
+-------------------------------------------+----------------------+---+

  -----------------------------------------------------------------------
  **Notes**

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

**2004 Rate Information for**

**Kaiser Foundation Health Plan of the**

**Mid-Atlantic States, Inc.**

**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**  | **  | **Go  | **Y   | **Go  | **Y   | **U   | **Y   |
|              | Cod | v't** | our** | v't** | our** | SPS** | our** |
| **           | e** |       |       |       |       |       |       |
| Enrollment** |     | **Sh  | **Sh  | **Sh  | **Sh  | **Sh  | **Sh  |
|              |     | are** | are** | are** | are** | are** | are** |
+--------------+-----+-------+-------+-------+-------+-------+-------+

  --------------- --------- -------------- ------------- -------------- -------------- -------------- -------------
  **Self Only**   **E31**   **\$109.49**   **\$36.49**   **\$237.22**   **\$79.07**    **\$129.56**   **\$16.42**

  **Self and      **E32**   **\$260.59**   **\$86.86**   **\$564.61**   **\$188.20**   **\$308.36**   **\$39.09**
  Family**                                                                                            
  --------------- --------- -------------- ------------- -------------- -------------- -------------- -------------