**OSF HealthPlans**

[http://www.osfhealthplans.com](http://www.planAddress.org/)

**2004**

**A Health Maintenance Organization**

**Serving:** Central Illinois and Central-Northwestern Illinois

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

**Geographic service area to enroll. See page 8 for requirements.**

**Enrollment codes for this Plan:**

**9F1 Self Only**

**9F2 Self and Family**

![](media/image4.png){width="1.1888888888888889in"
height="0.8888888888888888in"}

![](media/image5.png) **RI 73-762**

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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

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

# [Notice of the Office of Personnel Management's]{.underline}

# [Privacy Practices]{.underline}

### [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.]{.underline}

[By law, the 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.]{.underline}

[OPM **will** use and give out your personal medical
information:]{.underline}

-   [To you or someone who has the legal right to act for you (your
    personal representative),]{.underline}

-   [To the Secretary of the Department of Health and Human Services, if
    necessary, to make sure your privacy is protected,]{.underline}

-   [To law enforcement officials when investigating and/or prosecuting
    alleged or civil or criminal actions, and]{.underline}

-   [Where required by law.]{.underline}

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

-   [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.]{.underline}

-   [To review, make a decision, or litigate your disputed
    claim.]{.underline}

-   [For OPM and the General Accounting Office when conducting
    audits.]{.underline}

[OPM **may** use or give out your personal medical information for the
following purposes under limited circumstances:]{.underline}

-   [For Government healthcare oversight activities (such as fraud and
    abuse investigations),]{.underline}

-   [For research studies that meet all privacy law requirements (such
    as for medical research or education), and]{.underline}

-   [To avoid a serious and imminent threat to health or
    safety.]{.underline}

[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.]{.underline}

[By law, you **have the right** to:]{.underline}

-   [See and get a copy of your personal medical information held by
    OPM.]{.underline}

-   [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.]{.underline}

-   [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.]{.underline}

-   [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).]{.underline}

-   [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.]{.underline}

-   [Get a separate paper copy of this notice.]{.underline}

[For more information on exercising your rights set out in this notice,
look at]{.underline}
[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.]{.underline}

[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:]{.underline}

[Privacy Complaints]{.underline}

[Office of Personnel Management]{.underline}

[P.O. Box 707]{.underline}

[Washington, DC 20004-0707]{.underline}

[Filing a complaint will not affect your benefits under the FEHB
Program. You also may file a complaint with the Secretary of the
Department of Health and Human Services.]{.underline}

[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.]{.underline} The privacy practices
listed in this notice will be effective April 14, 2003.

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  Table of Contents
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Introduction............................................................................
4

Plain
Language........................................................................
4

Stop Health Care Fraud! 5

Preventing medical mistakes 5

Section 1. Facts about this HMO plan 7

How we pay providers 7

Who provides my health care? 7

Your Rights 7

Service Area 8

Section 2. How we change for
2004............................................... 9

Program-wide changes 9

Changes to this Plan 9

Section 3. How you get care ............\... 10

Identification cards 10

Where you get covered care 10

Plan providers 10

Plan facilities 10

What you must do to get covered care 10

Primary care 10

Specialty care 11

Hospital care 11

Circumstances beyond our control 12

Services requiring our prior approval 12

Section 4. Your costs for covered services 13

Copayments 13

Deductible 13

Coinsurance 13

Your catastrophic protection out-of-pocket maximum 13

Section 5.
Benefits..................................................................
14

Overview 14

(a) Medical services and supplies provided by physicians and other
    health care professionals 15

(b) Surgical and anesthesia services provided by physicians and other
    health care professionals 23

(c) Services provided by a hospital or other facility, and ambulance
    services 26

(d) Emergency services/accidents 28

(e) Mental health and substance abuse benefits 30

(f) Prescription drug benefits 32

(g) Special features 36

-   Services for deaf and hearing impaired

-   Centers of excellence for transplants

(h) Dental benefits 37

Section 6. General exclusions \-- things we don\'t cover 38

Section 7. Filing a claim for covered services 39

Section 8. The disputed claims process 40

Section 9. Coordinating benefits with other coverage 42

When you have other health coverage 42

What is Medicare 42

Medicare + Choice plan 45

TRICARE and CHAMPVA 45

-   Workers' Compensation 46

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-   Medicaid 46

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-   Other Government agencies 46

-   When others are responsible for injuries 46

Section 10. Definitions of terms we use in this brochure 47

Section 11. FEHB facts 48

Coverage information 48

No pre-existing condition limitation 48

Where you get information about enrolling in the FEHB Program 48

Types of coverage available for you and your family 48

-   Children's Equity Act 49

When benefits and premiums start 49

When you retire 49

When you lose benefits 50

When FEHB coverage ends 50

Spouse equity coverage 50

Temporary Continuation of Coverage (TCC) 50

Converting to individual coverage 50

Getting a Certificate of Group Health Plan Coverage 51

Two new Federal Programs complement FEHB benefits 52

The Federal Flexible Spending Account Program -- *FSAFEDS* 52

The Federal Long Term Care Insurance Program 55

Index 56

Summary of benefits 57

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

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  Introduction

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This brochure describes the benefits of OSF HealthPlans under our
contract (CS 2829) with the Office of Personnel Management (OPM), as
authorized by the Federal Employees Health Benefits law. The address for
OSF HealthPlans administrative offices is:

OSF HealthPlans

7915 N. Hale Ave., Suite D

Peoria, IL 61615-2047

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 9. Rates are shown at the end of this brochure.

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  Plain Language

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

-   Except for necessary technical terms, we use common words. For
    instance, "you" means the enrollee or family member; "we" means OSF
    HealthPlans.

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

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

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

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  **Stop Health Care Fraud!**

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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.

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

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

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

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

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

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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 800/OSF-5222
    and explain the situation.

-   If we do not resolve the issue:

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

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

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

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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.

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-   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.

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  Preventing Medical Mistakes

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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.

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

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

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

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

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

How we pay providers

We contract with individual physicians, medical groups, and hospitals to
provide the benefits in this brochure. These Plan providers accept a
negotiated payment from us, and you will only be responsible for your
copayments or coinsurance.

**Who provides my health care?**

OSF HealthPlans, Inc. is a Mixed Model Prepayment (MMP) plan. The Plan
contracts with hospitals, group physician practices, individual
physician practices, and other health care providers that provide
medical care to members in central Illinois and central-northwestern
Illinois.

**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.

-   We were awarded an Excellent status for our commercial HMO/POS
    combined plans for all 28 Illinois service area counties by the
    National Committee for Quality Assurance (NCQA).

-   We have been in existence for 8 years

-   We are a for profit entity

-   We scored above the 90^th^ percentile nationwide in the rating
    categories of Health Plan Overall, Health Care Overall and Personal
    Physician in our HEDIS 2002 Member Satisfaction Survey. We were also
    above the 90^th^ percentile nationwide for Customer Service, Getting
    Care Quickly, How Well Doctors Communicate, Claims Processing and
    Courteous and Helpful Office Staff. We scored above the 75^th^
    percentile nationwide for Getting Needed Care.

If you want more information about us, call 800/OSF-5222, or write to
OSF HealthPlans, 7915 N. Hale Ave., Peoria, IL, 61615-2047. You may also
contact us by fax at 309/677-8259 or visit our website at
[www.osfhealthplans.com](http://www.osfhealthplans.com/).

**Service Area**

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

**Central Illinois:** Dewitt, Fulton, Knox, Livingston, Marshall,
McLean, Peoria, Tazewell, and Woodford Counties.

**Central-Northwestern Illinois:** Boone, Bureau, DeKalb, Henderson,
Henry, Kane, LaSalle, Lee, McDonough, McHenry, Mercer, Ogle, Putnam,
Stark, Stephenson, Warren, Whiteside, and Winnebago Counties.

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

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

  -----------------------------------------------------------------------
  **Section 2. How we change for 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
    Program -- *FSAFEDS* and the Federal Long Term Care Insurance
    Program. See page 52.

-   We added information regarding Preventing medical mistakes. See page
    5.

-   We added information regarding enrolling in Medicare. See page 42

-   We revised the Medicare Primary Payer Chart. See page 44

**Changes to this Plan**

-   Your share of the non-Postal premium will increase by 15.1% for Self
    Only or 15.1% for Self and Family.

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  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), or your Employee
Express confirmation letter.

If you do not receive your ID card within 30 days after the effective
date of your enrollment, or if you need replacement cards, call us at
800/OSF-5222 or write to us at OSF HealthPlans, 7915 N. Hale Avenue,
Suite D, Peoria, IL 61615.

**Where you get covered care** You get care from "Plan providers" and
"Plan facilities." You will only pay copayments, and/or coinsurance, and
you will not have to file claims.

**Plan providers** Plan providers are physicians and other health care
professionals in our service area that we contract with to provide
covered services to our members. To make sure we provide high value
health care services and products, we do have guidelines and policies
for providers that request to participate in our network. In addition,
the National Committee for Quality Assurance (NCQA) has developed
standards and guidelines that we also follow.

We list Plan providers in the provider directory, which we update
periodically. The list is also on our website. You may also call us at
800/OSF-5222 to receive information about our providers.

**Plan facilities** Plan facilities are hospitals and other facilities
in our service area that we contract with to provide covered services to
our members. We list these in the provider directory, which we update
periodically.

**What you must do** It depends on the type of care you need. First, you
and each family

**to get covered care** 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. You should try to choose a
primary care physician that is familiar with your medical history. If
you must choose a new physician, we encourage you to schedule an
appointment as soon as possible so he/she can become familiar with you
and you can become familiar with him/her. If you need help choosing a
primary care physician, please call 800/OSF-5222 and we will assist you.

**Primary care** Your primary care physician can be a pediatrician,
family practitioner or internist. 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.
You may change two (2) times a year with a thirty (30) day interval
between changes. If you contact us by the fifteenth (15^th^) of the
month, your change will be effective the first of the following month.
If you contact us after the fifteenth (15^th^), there will be a month
between changes. This allows enough time for offices to schedule
appointments and to notify Primary Care Physicians of new patients.

**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. However, female members may see network OB/GYNs without
a referral.

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
develop a treatment plan that allows you to see your specialist for a
certain number of visits without additional referrals. Your primary care
physician and specialist will work together with you and the Plan when
creating your treatment plan. Your primary care physician will use our
criteria when creating your treatment plan (the physician may have to
get an authorization or approval beforehand).

If you are seeing a specialist when you enroll in our Plan, talk to your
primary care physician. 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.

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.

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

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-   drop out of the Federal Employees Health Benefits (FEHB) Program and
    you enroll in another FEHB Plan; or

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-   reduce our service area and you enroll in another FEHB Plan,

you may be able to continue seeing your specialist for up to 90 days
after you receive notice of the change. Contact us or, if we drop out of
the Program, contact your new plan.

If you are in the second or third trimester of pregnancy and you lose
access to your specialist based on the above circumstances, you can
continue to see your specialist until the end of your postpartum care,
even if it is beyond the 90 days.

**Hospital care** Your Plan 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 customer service department immediately at 800/OSF-5222. 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 our control** Under certain extraordinary
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 to
refer you for most services.

**prior approval** 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 the referral process. Your
physician must obtain a referral for the following services (this list
is intended as an example only): Inpatient hospitalization, outpatient
surgery, certain outpatient diagnostic procedures, specialty physician
office visits, durable medical equipment, home health care, growth
hormone therapy (GHT), physical therapy, occupational therapy, and
speech therapy. It is also your responsibility to notify us within 48
hours of any Emergency room visit. If you are unsure a service needs a
referral, call us at 800/OSF-5222.

Except in a medical emergency, you must contact your primary care
physician for a referral before seeing any other doctor or obtaining
special services. Referral to a participating specialist is given at the
primary care physician's discretion; if specialists or consultants are
required beyond those who are Plan doctors, the primary care physician
will make arrangements for appropriate referrals.

On referrals, the primary care physician will give specific instructions
to the consultant as to what services are authorized. Authorizations
will be for an adequate number of direct visits under an approved
treatment plan. If additional services or visits are suggested by the
consultant, over and above the approved treatment plan, you must first
check with your primary care physician. Do not go to the specialist
unless your primary care physician has arranged for, and the Plan has
issued an authorization for, the referral.

  -----------------------------------------------------------------------
  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 you see your primary care physician you pay a copayment of
\$20 per office visit and when you go in the hospital, you pay \$500 per
admission.

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

Note: If you change plans during open season, you do not have to start a
new deductible under your old plan between January 1 and the effective
date of your new plan. If you change plans at another time during the
year, you must begin a new deductible under your new plan.

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

Example: In our Plan, you pay 20% of our allowance for durable medical
equipment, prosthetic devices, and orthopedic devices.

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

**out-of-pocket maximum for** \$3,000 per family enrollment in any
calendar year, you do not have to

**coinsurance and copayments** pay any more for covered services.
However, copayments or

> coinsurance for the following services do not count toward your
> out-of-pocket maximum, and you must continue to pay copayments or
> coinsurance for these services:

-   Durable medical equipment;

-   Prosthetic devices;

-   Orthopedic devices; and

-   Prescription drugs

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

+-----------------------------------------------------------------------+
| ####### Section 5. Benefits \-- OVERVIEW                              |
|                                                                       |
| ***(See page 9 for how our benefits changed this year and page 57 for |
| a benefits summary.)***                                               |
+-----------------------------------------------------------------------+

**NOTE**: This benefits section is divided into subsections. Please read
the important things you should keep in mind at the beginning of each
subsection. Also read the General Exclusions in Section 6; they apply to
the benefits in the following subsections. To obtain claim forms, claims
filing advice, or more information about our benefits, contact us at
800/OSF-5222 or at our website at [www.osfhealthplans.com]()*.*

(a) Medical services and supplies provided by physicians and other
    health care professionals 15-22

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

(b) Surgical and anesthesia services provided by physicians and other
    health care professionals 23-25

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

(c) Services provided by a hospital or other facility, and ambulance
    services 26-27

+---------------------------------+------------------------------------+
| Inpatient hospital              | Extended care benefits/skilled     |
|                                 | nursing care facility benefits     |
| Outpatient hospital or          |                                    |
| ambulatory surgical center      | Hospice care                       |
|                                 |                                    |
|                                 | Ambulance                          |
+---------------------------------+------------------------------------+

(d) Emergency services/accidents 28-29

> Medical emergency Ambulance

(e) Mental health and substance abuse benefits 30-31

(f) Prescription drug benefits 32-35

(g) Special features 36

  ---------------------------------- ------------------------------------
  Services for deaf and hearing      Centers of excellence for
  impaired                           transplants

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

(h) Dental benefits 37

Summary of benefits 57

+---+---+-------------------------------------+----------------+---+----+
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| * |   |                                     |                |   |    |
+---+---+-------------------------------------+----------------+---+----+
|   | * | **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 |    |
|   | * | -   We have no calendar year        |                | * |    |
|   | * |     deductible*.*                   |                | * |    |
|   |   |                                     |                |   |    |
|   | * | ```{=html}                          |                | * |    |
|   | * | <!-- -->                            |                | * |    |
|   | O | ```                                 |                | O |    |
|   | * | -   Be sure to read Section 4,      |                | * |    |
|   | * |     *Your costs for covered         |                | * |    |
|   |   |     services,* for valuable         |                |   |    |
|   | * |     information about how cost      |                | * |    |
|   | * |     sharing works. Also read        |                | * |    |
|   | R |     Section 9 about coordinating    |                | R |    |
|   | * |     benefits with other coverage,   |                | * |    |
|   | * |     including with Medicare.        |                | * |    |
|   |   |                                     |                |   |    |
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|   | * |                                     |                | * |    |
|   | * |                                     |                | * |    |
+---+---+-------------------------------------+----------------+---+----+
| > |   |                                     | **You pay**    |   |    |
|   |   |                                     |                |   |    |
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+---+---+-------------------------------------+----------------+---+----+
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+---+---+-------------------------------------+----------------+---+----+
| > |   |                                     | > \$20 per     |   |    |
|   |   |                                     | > office visit |   |    |
| P |   |                                     | > to your      |   |    |
| r |   |                                     | > primary care |   |    |
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| f |   |                                     | > a specialist |   |    |
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+---+---+-------------------------------------+----------------+---+----+
| # |   |                                     | **You pay**    |   |    |
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+---+---+-------------------------------------+----------------+---+----+
| > |   |                                     | > \$20 per     |   |    |
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+---+---+-------------------------------------+----------------+---+----+
| # |   |                                     | **You pay**    |   |    |
| # |   |                                     |                |   |    |
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| > |   |                                     | > \$100 per    |   |    |
|   |   |                                     | > delivery     |   |    |
| C |   |                                     |                |   |    |
| o |   |                                     | Note: \$500    |   |    |
| m |   |                                     | per admission  |   |    |
| p |   |                                     | copay is       |   |    |
| l |   |                                     | applicable.    |   |    |
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+---+---+-------------------------------------+----------------+---+----+
| > |   |                                     | > *All         |   |    |
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| # |   |                                     | **You pay**    |   |    |
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+---+---+-------------------------------------+----------------+---+----+
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+---+---+-------------------------------------+----------------+---+----+
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| 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 |   |
|   | * | -   We have no calendar year        |                | * |   |
|   | * |     deductible.                     |                | * |   |
|   |   |                                     |                |   |   |
|   | * | -   Be sure to read Section 4,      |                | * |   |
|   | * |     *Your costs for covered         |                | * |   |
|   | O |     services,* for valuable         |                | O |   |
|   | * |     information about how cost      |                | * |   |
|   | * |     sharing works. Also read        |                | * |   |
|   |   |     Section 9 about coordinating    |                |   |   |
|   | * |     benefits with other coverage,   |                | * |   |
|   | * |     including with Medicare.        |                | * |   |
|   | R |                                     |                | R |   |
|   | * | -   The amounts listed below are    |                | * |   |
|   | * |     for the charges billed by a     |                | * |   |
|   |   |     physician or other health care  |                |   |   |
|   | * |     professional for your surgical  |                | * |   |
|   | * |     care. Look in Section 5(c) for  |                | * |   |
|   | T |     charges associated with the     |                | T |   |
|   | * |     facility (i.e., hospital,       |                | * |   |
|   | * |     surgical center, etc.) .        |                | * |   |
|   |   |                                     |                |   |   |
|   | * | ```{=html}                          |                | * |   |
|   | * | <!-- -->                            |                | * |   |
|   | A | ```                                 |                | A |   |
|   | * | -   YOUR PHYSICIAN MUST GET         |                | * |   |
|   | * |     PRECERTIFICATION OF SOME        |                | * |   |
|   |   |     SURGICAL PROCEDURES. Please     |                |   |   |
|   | * |     refer to the precertification   |                | * |   |
|   | * |     information shown in Section 3  |                | * |   |
|   | N |     to be sure which services       |                | N |   |
|   | * |     require precertification and    |                | * |   |
|   | * |     identify which surgeries        |                | * |   |
|   |   |     require precertification.       |                |   |   |
|   | * |                                     |                | * |   |
|   | * |                                     |                | * |   |
|   | T |                                     |                | T |   |
|   | * |                                     |                | * |   |
|   | * |                                     |                | * |   |
+---+---+-------------------------------------+----------------+---+---+
| > |   |                                     | **You pay**    |   |   |
|   |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
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+---+---+-------------------------------------+----------------+---+---+
| > |   |                                     |                |   |   |
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+---+---+-------------------------------------+----------------+---+---+
| > |   |                                     | > \$20 per     |   |   |
|   |   |                                     | > office visit |   |   |
| A |   |                                     | > to a primary |   |   |
| > |   |                                     | > care         |   |   |
|   |   |                                     | > physician or |   |   |
| c |   |                                     | > a specialist |   |   |
| o |   |                                     | >              |   |   |
| m |   |                                     | > Nothing for  |   |   |
| p |   |                                     | > hospital     |   |   |
| r |   |                                     | > visits       |   |   |
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|   |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
| s |   |                                     |                |   |   |
| e |   |                                     |                |   |   |
| e |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
| F |   |                                     |                |   |   |
| o |   |                                     |                |   |   |
| o |   |                                     |                |   |   |
| t |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
| c |   |                                     |                |   |   |
| a |   |                                     |                |   |   |
| r |   |                                     |                |   |   |
| e |   |                                     |                |   |   |
| . |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
+---+---+-------------------------------------+----------------+---+---+

+---------------------------------------------+------------------------+
| > **Reconstructive surgery**                | **You pay**            |
+---------------------------------------------+------------------------+
| -   Surgery to correct a functional defect  | > Nothing              |
|                                             |                        |
| -   Surgery to correct a condition caused   |                        |
|     by injury or illness if:                |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   the condition produced a major effect   |                        |
|     on the member's appearance and          |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   the condition can reasonably be         |                        |
|     expected to be corrected by such        |                        |
|     surgery                                 |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Surgery to correct a condition that     |                        |
|     existed at or from birth and is a       |                        |
|     significant deviation from the common   |                        |
|     form or norm. Examples of congenital    |                        |
|     anomalies are: protruding ear           |                        |
|     deformities; cleft lip; cleft palate;   |                        |
|     birth marks; webbed fingers; and webbed |                        |
|     toes.                                   |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   All stages of breast reconstruction     |                        |
|     surgery following a mastectomy, such    |                        |
|     as:                                     |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   surgery to produce a symmetrical        |                        |
|     appearance on the other breast;         |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   treatment of any physical               |                        |
|     complications, such as lymphedemas;     |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   breast prostheses and surgical bras and |                        |
|     replacements (see Prosthetic devices)   |                        |
|                                             |                        |
| > Note: If you need a mastectomy, you may   |                        |
| > choose to have the procedure performed on |                        |
| > an inpatient basis and remain in the      |                        |
| > hospital up to 48 hours after the         |                        |
| > procedure.                                |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges*        |
|                                             |                        |
| -   *Cosmetic surgery -- any surgical       |                        |
|     procedure (or any portion of a          |                        |
|     procedure) performed primarily to       |                        |
|     improve physical appearance through     |                        |
|     change in bodily form, except repair of |                        |
|     accidental injury*                      |                        |
|                                             |                        |
| -   *Surgeries related to sex               |                        |
|     transformation*                         |                        |
+---------------------------------------------+------------------------+
| > **Oral and maxillofacial surgery**        |                        |
+---------------------------------------------+------------------------+
| > Oral surgical procedures, limited to:     | > Nothing              |
|                                             |                        |
| -   Reduction of fractures of the jaws or   |                        |
|     facial bones;                           |                        |
|                                             |                        |
| -   Surgical correction of cleft lip, cleft |                        |
|     palate or severe functional             |                        |
|     malocclusion;                           |                        |
|                                             |                        |
| -   Removal of stones from salivary ducts;  |                        |
|                                             |                        |
| -   Excision of leukoplakia or              |                        |
|     malignancies;                           |                        |
|                                             |                        |
| -   Excision of cysts and incision of       |                        |
|     abscesses when done as independent      |                        |
|     procedures; and                         |                        |
|                                             |                        |
| -   Other surgical procedures that do not   |                        |
|     involve the teeth or their supporting   |                        |
|     structures.                             |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges.*       |
|                                             |                        |
| -   *Oral implants and transplants*         |                        |
|                                             |                        |
| -   *Procedures that involve the teeth or   |                        |
|     their supporting structures (such as    |                        |
|     the periodontal membrane, gingiva, and  |                        |
|     alveolar bone)*                         |                        |
+---------------------------------------------+------------------------+
| > **Organ/tissue transplants**              | > **You pay**          |
+---------------------------------------------+------------------------+
| > Limited to:                               | > Nothing              |
|                                             |                        |
| -   Cornea                                  |                        |
|                                             |                        |
| -   Heart                                   |                        |
|                                             |                        |
| -   Heart/lung                              |                        |
|                                             |                        |
| -   Kidney                                  |                        |
|                                             |                        |
| -   Kidney/Pancreas                         |                        |
|                                             |                        |
| -   Liver                                   |                        |
|                                             |                        |
| -   Lung: Single --Double                   |                        |
|                                             |                        |
| -   Pancreas                                |                        |
|                                             |                        |
| -   Allogeneic (donor) bone marrow          |                        |
|     transplants                             |                        |
|                                             |                        |
| -   Autologous bone marrow transplants      |                        |
|     (autologous stem cell and peripheral    |                        |
|     stem cell support) for the following    |                        |
|     conditions: acute lymphocytic or        |                        |
|     non-lymphocytic leukemia; advanced      |                        |
|     Hodgkin\'s lymphoma; advanced           |                        |
|     non-Hodgkin\'s lymphoma; advanced       |                        |
|     neuroblastoma; breast cancer; multiple  |                        |
|     myeloma; epithelial ovarian cancer; and |                        |
|     testicular, mediastinal,                |                        |
|     retroperitoneal and ovarian germ cell   |                        |
|     tumors.                                 |                        |
|                                             |                        |
| -   Intestinal transplants (small           |                        |
|     intestine) and the small intestine with |                        |
|     the liver or small intestine with       |                        |
|     multiple organs such as the liver,      |                        |
|     stomach, and pancreas                   |                        |
|                                             |                        |
| -   The transplant must be performed at a   |                        |
|     Plan approved facility.                 |                        |
|                                             |                        |
| > Limited Benefits - Treatment for breast   |                        |
| > cancer, multiple myeloma, and epithelial  |                        |
| > ovarian cancer may be provided in an NCI- |                        |
| > or NIH-approved clinical trial at a       |                        |
| > Plan-designated center of excellence and  |                        |
| > if approved by the Plan's medical         |                        |
| > director in accordance with the Plan's    |                        |
| > protocols.                                |                        |
|                                             |                        |
| Note: We cover related medical and hospital |                        |
| expenses of the donor when we cover the     |                        |
| recipient.                                  |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges.*       |
|                                             |                        |
| -   *Donor screening tests and donor search |                        |
|     expenses, except those performed for    |                        |
|     the actual donor*                       |                        |
|                                             |                        |
| -   *Implants of artificial organs*         |                        |
|                                             |                        |
| -   *Transplants performed at a             |                        |
|     non-approved facility*                  |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Transplants not listed as covered*     |                        |
+---------------------------------------------+------------------------+
| > **Anesthesia**                            |                        |
+---------------------------------------------+------------------------+
| > Professional services provided in --      | > Nothing              |
|                                             |                        |
| -   Hospital (inpatient)                    |                        |
|                                             |                        |
| -   Hospital outpatient department          |                        |
|                                             |                        |
| -   Skilled nursing facility                |                        |
|                                             |                        |
| -   Ambulatory surgical center              |                        |
|                                             |                        |
| -   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.                |              | * |     |
|    | * |                                   |              | * |     |
|    |   | -   We have no calendar year      |              |   |     |
|    | * |     deductible.                   |              | * |     |
|    | * |                                   |              | * |     |
|    | O | -   Be sure to read Section 4,    |              | O |     |
|    | * |     *Your costs for covered       |              | * |     |
|    | * |     services,* for valuable       |              | * |     |
|    |   |     information about how cost    |              |   |     |
|    | * |     sharing works. Also read      |              | * |     |
|    | * |     Section 9 about coordinating  |              | * |     |
|    | R |     benefits with other coverage, |              | R |     |
|    | * |     including with Medicare.      |              | * |     |
|    | * |                                   |              | * |     |
|    |   | -   The amounts listed below are  |              |   |     |
|    | * |     for the charges billed by the |              | * |     |
|    | * |     facility (i.e., hospital or   |              | * |     |
|    | T |     surgical center) or ambulance |              | T |     |
|    | * |     service for your surgery or   |              | * |     |
|    | * |     care. Any costs associated    |              | * |     |
|    |   |     with the professional charge  |              |   |     |
|    | * |     (i.e., physicians, etc.) are  |              | * |     |
|    | * |     covered in Sections 5(a) or   |              | * |     |
|    | A |     (b).                          |              | A |     |
|    | * |                                   |              | * |     |
|    | * | ```{=html}                        |              | * |     |
|    |   | <!-- -->                          |              |   |     |
|    | * | ```                               |              | * |     |
|    | * | -   **YOUR PHYSICIAN MUST GET     |              | * |     |
|    | N |     PRECERTIFICATION OF HOSPITAL  |              | N |     |
|    | * |     STAYS.** Please refer to      |              | * |     |
|    | * |     Section 3 to be sure which    |              | * |     |
|    |   |     services require              |              |   |     |
|    | * |     precertification.             |              | * |     |
|    | * |                                   |              | * |     |
|    | T |                                   |              | T |     |
|    | * |                                   |              | * |     |
|    | * |                                   |              | * |     |
+----+---+-----------------------------------+--------------+---+-----+
| >  |   |                                   | **You pay**  |   |     |
|  * |   |                                   |              |   |     |
| *B |   |                                   |              |   |     |
| en |   |                                   |              |   |     |
| ef |   |                                   |              |   |     |
| it |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  D |   |                                   |              |   |     |
| es |   |                                   |              |   |     |
| cr |   |                                   |              |   |     |
| ip |   |                                   |              |   |     |
| ti |   |                                   |              |   |     |
| on |   |                                   |              |   |     |
| ** |   |                                   |              |   |     |
+----+---+-----------------------------------+--------------+---+-----+
| #  |   |                                   | ########     |   |     |
| ## |   |                                   |              |   |     |
| ## |   |                                   |              |   |     |
| ## |   |                                   |              |   |     |
| #  |   |                                   |              |   |     |
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| sp |   |                                   |              |   |     |
| it |   |                                   |              |   |     |
| al |   |                                   |              |   |     |
+----+---+-----------------------------------+--------------+---+-----+
| >  |   |                                   | > > \$500    |   |     |
| Ro |   |                                   | > > per      |   |     |
| om |   |                                   | >            |   |     |
| >  |   |                                   |  > admission |   |     |
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| >  |   |                                   |              |   |     |
|  s |   |                                   |              |   |     |
| em |   |                                   |              |   |     |
| ip |   |                                   |              |   |     |
| ri |   |                                   |              |   |     |
| va |   |                                   |              |   |     |
| te |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| ro |   |                                   |              |   |     |
| om |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  r |   |                                   |              |   |     |
| at |   |                                   |              |   |     |
| e. |   |                                   |              |   |     |
+----+---+-----------------------------------+--------------+---+-----+
| #  |   |                                   | > Nothing    |   |     |
| ## |   |                                   |              |   |     |
| #  |   |                                   |              |   |     |
| Ot |   |                                   |              |   |     |
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| r  |   |                                   |              |   |     |
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| it |   |                                   |              |   |     |
| al |   |                                   |              |   |     |
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| vi |   |                                   |              |   |     |
| ce |   |                                   |              |   |     |
| s  |   |                                   |              |   |     |
| an |   |                                   |              |   |     |
| d  |   |                                   |              |   |     |
| su |   |                                   |              |   |     |
| pp |   |                                   |              |   |     |
| li |   |                                   |              |   |     |
| es |   |                                   |              |   |     |
| ,  |   |                                   |              |   |     |
| su |   |                                   |              |   |     |
| ch |   |                                   |              |   |     |
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| s: |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| -  |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
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| er |   |                                   |              |   |     |
| at |   |                                   |              |   |     |
| in |   |                                   |              |   |     |
| g, |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
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| ec |   |                                   |              |   |     |
| ov |   |                                   |              |   |     |
| er |   |                                   |              |   |     |
| y, |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
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| rn |   |                                   |              |   |     |
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|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
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| nd |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
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| th |   |                                   |              |   |     |
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|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
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| nt |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
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| ms |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| -  |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
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| es |   |                                   |              |   |     |
| cr |   |                                   |              |   |     |
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|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
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| gs |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
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| nd |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
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| ed |   |                                   |              |   |     |
| ic |   |                                   |              |   |     |
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|    |   |                                   |              |   |     |
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| no |   |                                   |              |   |     |
| st |   |                                   |              |   |     |
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|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
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|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
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|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
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| nd |   |                                   |              |   |     |
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| ni |   |                                   |              |   |     |
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|    |   |                                   |              |   |     |
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|    |   |                                   |              |   |     |
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|    |   |                                   |              |   |     |
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|    |   |                                   |              |   |     |
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|    |   |                                   |              |   |     |
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|    |   |                                   |              |   |     |
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|    |   |                                   |              |   |     |
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|    |   |                                   |              |   |     |
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|    |   |                                   |              |   |     |
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| s, |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
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|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
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|    |   |                                   |              |   |     |
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| s, |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
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|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
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|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
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| st |   |                                   |              |   |     |
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|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
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| rv |   |                                   |              |   |     |
| ic |   |                                   |              |   |     |
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| e- |   |                                   |              |   |     |
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|    |   |                                   |              |   |     |
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| <! |   |                                   |              |   |     |
| -- |   |                                   |              |   |     |
|  - |   |                                   |              |   |     |
| -> |   |                                   |              |   |     |
| `  |   |                                   |              |   |     |
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| -  |   |                                   |              |   |     |
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|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
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| pl |   |                                   |              |   |     |
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|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
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|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
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| ov |   |                                   |              |   |     |
| er |   |                                   |              |   |     |
| ed |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
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| ms |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| bi |   |                                   |              |   |     |
| ll |   |                                   |              |   |     |
| ed |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| by |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  a |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| ho |   |                                   |              |   |     |
| sp |   |                                   |              |   |     |
| it |   |                                   |              |   |     |
| al |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  f |   |                                   |              |   |     |
| or |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  u |   |                                   |              |   |     |
| se |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| at |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| ho |   |                                   |              |   |     |
| me |   |                                   |              |   |     |
+----+---+-----------------------------------+--------------+---+-----+
| >  |   |                                   | > *All       |   |     |
| *N |   |                                   | > charges.*  |   |     |
| ot |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  c |   |                                   |              |   |     |
| ov |   |                                   |              |   |     |
| er |   |                                   |              |   |     |
| ed |   |                                   |              |   |     |
| :* |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| -  |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| *C |   |                                   |              |   |     |
| us |   |                                   |              |   |     |
| to |   |                                   |              |   |     |
| di |   |                                   |              |   |     |
| al |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  c |   |                                   |              |   |     |
| ar |   |                                   |              |   |     |
| e* |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| -  |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| *N |   |                                   |              |   |     |
| on |   |                                   |              |   |     |
| -c |   |                                   |              |   |     |
| ov |   |                                   |              |   |     |
| er |   |                                   |              |   |     |
| ed |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  f |   |                                   |              |   |     |
| ac |   |                                   |              |   |     |
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| ie |   |                                   |              |   |     |
| s, |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
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|    |   |                                   |              |   |     |
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|    |   |                                   |              |   |     |
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|  n |   |                                   |              |   |     |
| ur |   |                                   |              |   |     |
| si |   |                                   |              |   |     |
| ng |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| ho |   |                                   |              |   |     |
| me |   |                                   |              |   |     |
| s, |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| sc |   |                                   |              |   |     |
| ho |   |                                   |              |   |     |
| ol |   |                                   |              |   |     |
| s* |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| -  |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  * |   |                                   |              |   |     |
| Pe |   |                                   |              |   |     |
| rs |   |                                   |              |   |     |
| on |   |                                   |              |   |     |
| al |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  c |   |                                   |              |   |     |
| om |   |                                   |              |   |     |
| fo |   |                                   |              |   |     |
| rt |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| it |   |                                   |              |   |     |
| em |   |                                   |              |   |     |
| s, |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| su |   |                                   |              |   |     |
| ch |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| as |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| te |   |                                   |              |   |     |
| le |   |                                   |              |   |     |
| ph |   |                                   |              |   |     |
| on |   |                                   |              |   |     |
| e, |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  t |   |                                   |              |   |     |
| el |   |                                   |              |   |     |
| ev |   |                                   |              |   |     |
| is |   |                                   |              |   |     |
| io |   |                                   |              |   |     |
| n, |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| ba |   |                                   |              |   |     |
| rb |   |                                   |              |   |     |
| er |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  s |   |                                   |              |   |     |
| er |   |                                   |              |   |     |
| vi |   |                                   |              |   |     |
| ce |   |                                   |              |   |     |
| s, |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  g |   |                                   |              |   |     |
| ue |   |                                   |              |   |     |
| st |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  m |   |                                   |              |   |     |
| ea |   |                                   |              |   |     |
| ls |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  a |   |                                   |              |   |     |
| nd |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  b |   |                                   |              |   |     |
| ed |   |                                   |              |   |     |
| s* |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| -  |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| *P |   |                                   |              |   |     |
| ri |   |                                   |              |   |     |
| va |   |                                   |              |   |     |
| te |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  n |   |                                   |              |   |     |
| ur |   |                                   |              |   |     |
| si |   |                                   |              |   |     |
| ng |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  c |   |                                   |              |   |     |
| ar |   |                                   |              |   |     |
| e* |   |                                   |              |   |     |
+----+---+-----------------------------------+--------------+---+-----+
| ## |   |                                   | > **You      |   |     |
| ## |   |                                   | > pay**      |   |     |
|  O |   |                                   |              |   |     |
| ut |   |                                   |              |   |     |
| pa |   |                                   |              |   |     |
| ti |   |                                   |              |   |     |
| en |   |                                   |              |   |     |
| t  |   |                                   |              |   |     |
| ho |   |                                   |              |   |     |
| sp |   |                                   |              |   |     |
| it |   |                                   |              |   |     |
| al |   |                                   |              |   |     |
|  o |   |                                   |              |   |     |
| r  |   |                                   |              |   |     |
| am |   |                                   |              |   |     |
| bu |   |                                   |              |   |     |
| la |   |                                   |              |   |     |
| to |   |                                   |              |   |     |
| ry |   |                                   |              |   |     |
|  s |   |                                   |              |   |     |
| ur |   |                                   |              |   |     |
| gi |   |                                   |              |   |     |
| ca |   |                                   |              |   |     |
| l  |   |                                   |              |   |     |
| ce |   |                                   |              |   |     |
| nt |   |                                   |              |   |     |
| er |   |                                   |              |   |     |
+----+---+-----------------------------------+--------------+---+-----+
| -  |   |                                   | > \$150 per  |   |     |
|    |   |                                   | > surgery    |   |     |
| Op |   |                                   |              |   |     |
| er |   |                                   |              |   |     |
| at |   |                                   |              |   |     |
| in |   |                                   |              |   |     |
| g, |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  r |   |                                   |              |   |     |
| ec |   |                                   |              |   |     |
| ov |   |                                   |              |   |     |
| er |   |                                   |              |   |     |
| y, |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  a |   |                                   |              |   |     |
| nd |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  o |   |                                   |              |   |     |
| th |   |                                   |              |   |     |
| er |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  t |   |                                   |              |   |     |
| re |   |                                   |              |   |     |
| at |   |                                   |              |   |     |
| me |   |                                   |              |   |     |
| nt |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  r |   |                                   |              |   |     |
| oo |   |                                   |              |   |     |
| ms |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| `` |   |                                   |              |   |     |
| `{ |   |                                   |              |   |     |
| =h |   |                                   |              |   |     |
| tm |   |                                   |              |   |     |
| l} |   |                                   |              |   |     |
| <! |   |                                   |              |   |     |
| -- |   |                                   |              |   |     |
|  - |   |                                   |              |   |     |
| -> |   |                                   |              |   |     |
| `  |   |                                   |              |   |     |
| `` |   |                                   |              |   |     |
| -  |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| Pr |   |                                   |              |   |     |
| es |   |                                   |              |   |     |
| cr |   |                                   |              |   |     |
| ib |   |                                   |              |   |     |
| ed |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  d |   |                                   |              |   |     |
| ru |   |                                   |              |   |     |
| gs |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  a |   |                                   |              |   |     |
| nd |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  m |   |                                   |              |   |     |
| ed |   |                                   |              |   |     |
| ic |   |                                   |              |   |     |
| in |   |                                   |              |   |     |
| es |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| `` |   |                                   |              |   |     |
| `{ |   |                                   |              |   |     |
| =h |   |                                   |              |   |     |
| tm |   |                                   |              |   |     |
| l} |   |                                   |              |   |     |
| <! |   |                                   |              |   |     |
| -- |   |                                   |              |   |     |
|  - |   |                                   |              |   |     |
| -> |   |                                   |              |   |     |
| `  |   |                                   |              |   |     |
| `` |   |                                   |              |   |     |
| -  |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| Di |   |                                   |              |   |     |
| ag |   |                                   |              |   |     |
| no |   |                                   |              |   |     |
| st |   |                                   |              |   |     |
| ic |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| la |   |                                   |              |   |     |
| bo |   |                                   |              |   |     |
| ra |   |                                   |              |   |     |
| to |   |                                   |              |   |     |
| ry |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| te |   |                                   |              |   |     |
| st |   |                                   |              |   |     |
| s, |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  X |   |                                   |              |   |     |
| -r |   |                                   |              |   |     |
| ay |   |                                   |              |   |     |
| s, |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  a |   |                                   |              |   |     |
| nd |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  p |   |                                   |              |   |     |
| at |   |                                   |              |   |     |
| ho |   |                                   |              |   |     |
| lo |   |                                   |              |   |     |
| gy |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| se |   |                                   |              |   |     |
| rv |   |                                   |              |   |     |
| ic |   |                                   |              |   |     |
| es |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| -  |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| Ad |   |                                   |              |   |     |
| mi |   |                                   |              |   |     |
| ni |   |                                   |              |   |     |
| st |   |                                   |              |   |     |
| ra |   |                                   |              |   |     |
| ti |   |                                   |              |   |     |
| on |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| of |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| bl |   |                                   |              |   |     |
| oo |   |                                   |              |   |     |
| d, |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  b |   |                                   |              |   |     |
| lo |   |                                   |              |   |     |
| od |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  p |   |                                   |              |   |     |
| la |   |                                   |              |   |     |
| sm |   |                                   |              |   |     |
| a, |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  a |   |                                   |              |   |     |
| nd |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  o |   |                                   |              |   |     |
| th |   |                                   |              |   |     |
| er |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  b |   |                                   |              |   |     |
| io |   |                                   |              |   |     |
| lo |   |                                   |              |   |     |
| gi |   |                                   |              |   |     |
| ca |   |                                   |              |   |     |
| ls |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| -  |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  B |   |                                   |              |   |     |
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| od |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  a |   |                                   |              |   |     |
| nd |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  b |   |                                   |              |   |     |
| lo |   |                                   |              |   |     |
| od |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  p |   |                                   |              |   |     |
| la |   |                                   |              |   |     |
| sm |   |                                   |              |   |     |
| a, |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| if |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  n |   |                                   |              |   |     |
| ot |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  d |   |                                   |              |   |     |
| on |   |                                   |              |   |     |
| at |   |                                   |              |   |     |
| ed |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
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|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
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| pl |   |                                   |              |   |     |
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|    |   |                                   |              |   |     |
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| e- |   |                                   |              |   |     |
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| rg |   |                                   |              |   |     |
| ic |   |                                   |              |   |     |
| al |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  t |   |                                   |              |   |     |
| es |   |                                   |              |   |     |
| ti |   |                                   |              |   |     |
| ng |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| -  |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| Dr |   |                                   |              |   |     |
| es |   |                                   |              |   |     |
| si |   |                                   |              |   |     |
| ng |   |                                   |              |   |     |
| s, |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| ca |   |                                   |              |   |     |
| st |   |                                   |              |   |     |
| s, |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  a |   |                                   |              |   |     |
| nd |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  s |   |                                   |              |   |     |
| te |   |                                   |              |   |     |
| ri |   |                                   |              |   |     |
| le |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| tr |   |                                   |              |   |     |
| ay |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| se |   |                                   |              |   |     |
| rv |   |                                   |              |   |     |
| ic |   |                                   |              |   |     |
| es |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| -  |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  M |   |                                   |              |   |     |
| ed |   |                                   |              |   |     |
| ic |   |                                   |              |   |     |
| al |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  s |   |                                   |              |   |     |
| up |   |                                   |              |   |     |
| pl |   |                                   |              |   |     |
| ie |   |                                   |              |   |     |
| s, |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  i |   |                                   |              |   |     |
| nc |   |                                   |              |   |     |
| lu |   |                                   |              |   |     |
| di |   |                                   |              |   |     |
| ng |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| ox |   |                                   |              |   |     |
| yg |   |                                   |              |   |     |
| en |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
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| ne |   |                                   |              |   |     |
| st |   |                                   |              |   |     |
| he |   |                                   |              |   |     |
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| cs |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
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|    |   |                                   |              |   |     |
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| an |   |                                   |              |   |     |
| es |   |                                   |              |   |     |
| th |   |                                   |              |   |     |
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| ia |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
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|  s |   |                                   |              |   |     |
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|    |   |                                   |              |   |     |
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|  N |   |                                   |              |   |     |
| OT |   |                                   |              |   |     |
| E: |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| -- |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
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| >  |   |                                   |              |   |     |
|  c |   |                                   |              |   |     |
| ov |   |                                   |              |   |     |
| er |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| ho |   |                                   |              |   |     |
| sp |   |                                   |              |   |     |
| it |   |                                   |              |   |     |
| al |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| se |   |                                   |              |   |     |
| rv |   |                                   |              |   |     |
| ic |   |                                   |              |   |     |
| es |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  a |   |                                   |              |   |     |
| nd |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| su |   |                                   |              |   |     |
| pp |   |                                   |              |   |     |
| li |   |                                   |              |   |     |
| es |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  r |   |                                   |              |   |     |
| el |   |                                   |              |   |     |
| at |   |                                   |              |   |     |
| ed |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| to |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| de |   |                                   |              |   |     |
| nt |   |                                   |              |   |     |
| al |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| pr |   |                                   |              |   |     |
| oc |   |                                   |              |   |     |
| ed |   |                                   |              |   |     |
| ur |   |                                   |              |   |     |
| es |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| wh |   |                                   |              |   |     |
| en |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| ne |   |                                   |              |   |     |
| ce |   |                                   |              |   |     |
| ss |   |                                   |              |   |     |
| it |   |                                   |              |   |     |
| at |   |                                   |              |   |     |
| ed |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| by |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  a |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| no |   |                                   |              |   |     |
| n- |   |                                   |              |   |     |
| de |   |                                   |              |   |     |
| nt |   |                                   |              |   |     |
| al |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| ph |   |                                   |              |   |     |
| ys |   |                                   |              |   |     |
| ic |   |                                   |              |   |     |
| al |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  i |   |                                   |              |   |     |
| mp |   |                                   |              |   |     |
| ai |   |                                   |              |   |     |
| rm |   |                                   |              |   |     |
| en |   |                                   |              |   |     |
| t. |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| We |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| do |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  n |   |                                   |              |   |     |
| ot |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  c |   |                                   |              |   |     |
| ov |   |                                   |              |   |     |
| er |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  t |   |                                   |              |   |     |
| he |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| de |   |                                   |              |   |     |
| nt |   |                                   |              |   |     |
| al |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  p |   |                                   |              |   |     |
| ro |   |                                   |              |   |     |
| ce |   |                                   |              |   |     |
| du |   |                                   |              |   |     |
| re |   |                                   |              |   |     |
| s. |   |                                   |              |   |     |
+----+---+-----------------------------------+--------------+---+-----+
| #  |   |                                   | > *All       |   |     |
|  * |   |                                   | > charges.*  |   |     |
| No |   |                                   |              |   |     |
| t  |   |                                   |              |   |     |
| co |   |                                   |              |   |     |
| ve |   |                                   |              |   |     |
| re |   |                                   |              |   |     |
| d: |   |                                   |              |   |     |
|  b |   |                                   |              |   |     |
| lo |   |                                   |              |   |     |
| od |   |                                   |              |   |     |
|  a |   |                                   |              |   |     |
| nd |   |                                   |              |   |     |
|  b |   |                                   |              |   |     |
| lo |   |                                   |              |   |     |
| od |   |                                   |              |   |     |
|  d |   |                                   |              |   |     |
| er |   |                                   |              |   |     |
| iv |   |                                   |              |   |     |
| at |   |                                   |              |   |     |
| iv |   |                                   |              |   |     |
| es |   |                                   |              |   |     |
|  n |   |                                   |              |   |     |
| ot |   |                                   |              |   |     |
|  r |   |                                   |              |   |     |
| ep |   |                                   |              |   |     |
| la |   |                                   |              |   |     |
| ce |   |                                   |              |   |     |
| d  |   |                                   |              |   |     |
| by |   |                                   |              |   |     |
|  t |   |                                   |              |   |     |
| he |   |                                   |              |   |     |
|  m |   |                                   |              |   |     |
| em |   |                                   |              |   |     |
| be |   |                                   |              |   |     |
| r* |   |                                   |              |   |     |
+----+---+-----------------------------------+--------------+---+-----+
| ## |   |                                   | ########     |   |     |
| ## |   |                                   |              |   |     |
| ## |   |                                   |              |   |     |
| ## |   |                                   |              |   |     |
|  E |   |                                   |              |   |     |
| xt |   |                                   |              |   |     |
| en |   |                                   |              |   |     |
| de |   |                                   |              |   |     |
| d  |   |                                   |              |   |     |
| ca |   |                                   |              |   |     |
| re |   |                                   |              |   |     |
|  b |   |                                   |              |   |     |
| en |   |                                   |              |   |     |
| ef |   |                                   |              |   |     |
| it |   |                                   |              |   |     |
| s/ |   |                                   |              |   |     |
| sk |   |                                   |              |   |     |
| il |   |                                   |              |   |     |
| le |   |                                   |              |   |     |
| d  |   |                                   |              |   |     |
| nu |   |                                   |              |   |     |
| rs |   |                                   |              |   |     |
| in |   |                                   |              |   |     |
| g  |   |                                   |              |   |     |
| ca |   |                                   |              |   |     |
| re |   |                                   |              |   |     |
|  f |   |                                   |              |   |     |
| ac |   |                                   |              |   |     |
| il |   |                                   |              |   |     |
| it |   |                                   |              |   |     |
| y  |   |                                   |              |   |     |
| be |   |                                   |              |   |     |
| ne |   |                                   |              |   |     |
| fi |   |                                   |              |   |     |
| ts |   |                                   |              |   |     |
+----+---+-----------------------------------+--------------+---+-----+
| >  |   |                                   | > Nothing    |   |     |
|  * |   |                                   |              |   |     |
| Ex |   |                                   |              |   |     |
| te |   |                                   |              |   |     |
| nd |   |                                   |              |   |     |
| ed |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| ca |   |                                   |              |   |     |
| re |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| be |   |                                   |              |   |     |
| ne |   |                                   |              |   |     |
| fi |   |                                   |              |   |     |
| t: |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| We |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  c |   |                                   |              |   |     |
| ov |   |                                   |              |   |     |
| er |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  a |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| fu |   |                                   |              |   |     |
| ll |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  r |   |                                   |              |   |     |
| an |   |                                   |              |   |     |
| ge |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| of |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| be |   |                                   |              |   |     |
| ne |   |                                   |              |   |     |
| fi |   |                                   |              |   |     |
| ts |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| up |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| to |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| 45 |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| da |   |                                   |              |   |     |
| ys |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  p |   |                                   |              |   |     |
| er |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| ca |   |                                   |              |   |     |
| le |   |                                   |              |   |     |
| nd |   |                                   |              |   |     |
| ar |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| ye |   |                                   |              |   |     |
| ar |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  f |   |                                   |              |   |     |
| or |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  f |   |                                   |              |   |     |
| ul |   |                                   |              |   |     |
| l- |   |                                   |              |   |     |
| ti |   |                                   |              |   |     |
| me |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  s |   |                                   |              |   |     |
| ki |   |                                   |              |   |     |
| ll |   |                                   |              |   |     |
| ed |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  n |   |                                   |              |   |     |
| ur |   |                                   |              |   |     |
| si |   |                                   |              |   |     |
| ng |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| ca |   |                                   |              |   |     |
| re |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| in |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  a |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  s |   |                                   |              |   |     |
| ki |   |                                   |              |   |     |
| ll |   |                                   |              |   |     |
| ed |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  n |   |                                   |              |   |     |
| ur |   |                                   |              |   |     |
| si |   |                                   |              |   |     |
| ng |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  f |   |                                   |              |   |     |
| ac |   |                                   |              |   |     |
| il |   |                                   |              |   |     |
| it |   |                                   |              |   |     |
| y. |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  A |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| Pl |   |                                   |              |   |     |
| an |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| do |   |                                   |              |   |     |
| ct |   |                                   |              |   |     |
| or |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| mu |   |                                   |              |   |     |
| st |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  d |   |                                   |              |   |     |
| et |   |                                   |              |   |     |
| er |   |                                   |              |   |     |
| mi |   |                                   |              |   |     |
| ne |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| th |   |                                   |              |   |     |
| at |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  c |   |                                   |              |   |     |
| on |   |                                   |              |   |     |
| fi |   |                                   |              |   |     |
| ne |   |                                   |              |   |     |
| me |   |                                   |              |   |     |
| nt |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| is |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  m |   |                                   |              |   |     |
| ed |   |                                   |              |   |     |
| ic |   |                                   |              |   |     |
| al |   |                                   |              |   |     |
| ly |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  n |   |                                   |              |   |     |
| ec |   |                                   |              |   |     |
| es |   |                                   |              |   |     |
| sa |   |                                   |              |   |     |
| ry |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  a |   |                                   |              |   |     |
| nd |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| it |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| mu |   |                                   |              |   |     |
| st |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| be |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| ap |   |                                   |              |   |     |
| pr |   |                                   |              |   |     |
| ov |   |                                   |              |   |     |
| ed |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| by |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  t |   |                                   |              |   |     |
| he |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  P |   |                                   |              |   |     |
| la |   |                                   |              |   |     |
| n. |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  A |   |                                   |              |   |     |
| ll |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  n |   |                                   |              |   |     |
| ec |   |                                   |              |   |     |
| es |   |                                   |              |   |     |
| sa |   |                                   |              |   |     |
| ry |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| se |   |                                   |              |   |     |
| rv |   |                                   |              |   |     |
| ic |   |                                   |              |   |     |
| es |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  a |   |                                   |              |   |     |
| re |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| co |   |                                   |              |   |     |
| ve |   |                                   |              |   |     |
| re |   |                                   |              |   |     |
| d, |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  i |   |                                   |              |   |     |
| nc |   |                                   |              |   |     |
| lu |   |                                   |              |   |     |
| di |   |                                   |              |   |     |
| ng |   |                                   |              |   |     |
| :* |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| -  |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  * |   |                                   |              |   |     |
| Be |   |                                   |              |   |     |
| d, |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  b |   |                                   |              |   |     |
| oa |   |                                   |              |   |     |
| rd |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  a |   |                                   |              |   |     |
| nd |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  g |   |                                   |              |   |     |
| en |   |                                   |              |   |     |
| er |   |                                   |              |   |     |
| al |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  n |   |                                   |              |   |     |
| ur |   |                                   |              |   |     |
| si |   |                                   |              |   |     |
| ng |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  c |   |                                   |              |   |     |
| ar |   |                                   |              |   |     |
| e* |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| -  |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  * |   |                                   |              |   |     |
| Dr |   |                                   |              |   |     |
| ug |   |                                   |              |   |     |
| s, |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| bi |   |                                   |              |   |     |
| ol |   |                                   |              |   |     |
| og |   |                                   |              |   |     |
| ic |   |                                   |              |   |     |
| al |   |                                   |              |   |     |
| s, |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  s |   |                                   |              |   |     |
| up |   |                                   |              |   |     |
| pl |   |                                   |              |   |     |
| ie |   |                                   |              |   |     |
| s, |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  a |   |                                   |              |   |     |
| nd |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  e |   |                                   |              |   |     |
| qu |   |                                   |              |   |     |
| ip |   |                                   |              |   |     |
| me |   |                                   |              |   |     |
| nt |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| or |   |                                   |              |   |     |
| di |   |                                   |              |   |     |
| na |   |                                   |              |   |     |
| ri |   |                                   |              |   |     |
| ly |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| pr |   |                                   |              |   |     |
| ov |   |                                   |              |   |     |
| id |   |                                   |              |   |     |
| ed |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| or |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| ar |   |                                   |              |   |     |
| ra |   |                                   |              |   |     |
| ng |   |                                   |              |   |     |
| ed |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| by |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  t |   |                                   |              |   |     |
| he |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  s |   |                                   |              |   |     |
| ki |   |                                   |              |   |     |
| ll |   |                                   |              |   |     |
| ed |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  n |   |                                   |              |   |     |
| ur |   |                                   |              |   |     |
| si |   |                                   |              |   |     |
| ng |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| fa |   |                                   |              |   |     |
| ci |   |                                   |              |   |     |
| li |   |                                   |              |   |     |
| ty |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| wh |   |                                   |              |   |     |
| en |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| pr |   |                                   |              |   |     |
| es |   |                                   |              |   |     |
| cr |   |                                   |              |   |     |
| ib |   |                                   |              |   |     |
| ed |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| by |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  a |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| Pl |   |                                   |              |   |     |
| an |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| do |   |                                   |              |   |     |
| ct |   |                                   |              |   |     |
| or |   |                                   |              |   |     |
| .* |   |                                   |              |   |     |
+----+---+-----------------------------------+--------------+---+-----+
| >  |   |                                   | > *All       |   |     |
|  N |   |                                   | > charges.*  |   |     |
| ot |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| co |   |                                   |              |   |     |
| ve |   |                                   |              |   |     |
| re |   |                                   |              |   |     |
| d: |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  c |   |                                   |              |   |     |
| us |   |                                   |              |   |     |
| to |   |                                   |              |   |     |
| di |   |                                   |              |   |     |
| al |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| ca |   |                                   |              |   |     |
| re |   |                                   |              |   |     |
+----+---+-----------------------------------+--------------+---+-----+
| #  |   |                                   | ####         |   |     |
| ## |   |                                   |              |   |     |
| #  |   |                                   |              |   |     |
| Ho |   |                                   |              |   |     |
| sp |   |                                   |              |   |     |
| ic |   |                                   |              |   |     |
| e  |   |                                   |              |   |     |
| ca |   |                                   |              |   |     |
| re |   |                                   |              |   |     |
+----+---+-----------------------------------+--------------+---+-----+
| >  |   |                                   | > Nothing    |   |     |
| Ca |   |                                   |              |   |     |
| re |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  f |   |                                   |              |   |     |
| or |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  a |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| te |   |                                   |              |   |     |
| rm |   |                                   |              |   |     |
| in |   |                                   |              |   |     |
| al |   |                                   |              |   |     |
| ly |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  i |   |                                   |              |   |     |
| ll |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| me |   |                                   |              |   |     |
| mb |   |                                   |              |   |     |
| er |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| is |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  c |   |                                   |              |   |     |
| ov |   |                                   |              |   |     |
| er |   |                                   |              |   |     |
| ed |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| in |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  t |   |                                   |              |   |     |
| he |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| ho |   |                                   |              |   |     |
| me |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| or |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  a |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  h |   |                                   |              |   |     |
| os |   |                                   |              |   |     |
| pi |   |                                   |              |   |     |
| ce |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  f |   |                                   |              |   |     |
| ac |   |                                   |              |   |     |
| il |   |                                   |              |   |     |
| it |   |                                   |              |   |     |
| y. |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| Se |   |                                   |              |   |     |
| rv |   |                                   |              |   |     |
| ic |   |                                   |              |   |     |
| es |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  i |   |                                   |              |   |     |
| nc |   |                                   |              |   |     |
| lu |   |                                   |              |   |     |
| de |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  i |   |                                   |              |   |     |
| np |   |                                   |              |   |     |
| at |   |                                   |              |   |     |
| ie |   |                                   |              |   |     |
| nt |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  a |   |                                   |              |   |     |
| nd |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| ou |   |                                   |              |   |     |
| tp |   |                                   |              |   |     |
| at |   |                                   |              |   |     |
| ie |   |                                   |              |   |     |
| nt |   |                                   |              |   |     |
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| re |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  a |   |                                   |              |   |     |
| nd |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| fa |   |                                   |              |   |     |
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| ly |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
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| ou |   |                                   |              |   |     |
| ns |   |                                   |              |   |     |
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| g. |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  A |   |                                   |              |   |     |
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| do |   |                                   |              |   |     |
| ct |   |                                   |              |   |     |
| or |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| mu |   |                                   |              |   |     |
| st |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| di |   |                                   |              |   |     |
| re |   |                                   |              |   |     |
| ct |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
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| he |   |                                   |              |   |     |
| se |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| se |   |                                   |              |   |     |
| rv |   |                                   |              |   |     |
| ic |   |                                   |              |   |     |
| es |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  a |   |                                   |              |   |     |
| nd |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  c |   |                                   |              |   |     |
| er |   |                                   |              |   |     |
| ti |   |                                   |              |   |     |
| fy |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  t |   |                                   |              |   |     |
| he |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  p |   |                                   |              |   |     |
| at |   |                                   |              |   |     |
| ie |   |                                   |              |   |     |
| nt |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| is |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| te |   |                                   |              |   |     |
| rm |   |                                   |              |   |     |
| in |   |                                   |              |   |     |
| al |   |                                   |              |   |     |
| ly |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  i |   |                                   |              |   |     |
| ll |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| wi |   |                                   |              |   |     |
| th |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  a |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| li |   |                                   |              |   |     |
| fe |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| ex |   |                                   |              |   |     |
| pe |   |                                   |              |   |     |
| ct |   |                                   |              |   |     |
| an |   |                                   |              |   |     |
| cy |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| of |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  s |   |                                   |              |   |     |
| ix |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| mo |   |                                   |              |   |     |
| nt |   |                                   |              |   |     |
| hs |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| or |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  l |   |                                   |              |   |     |
| es |   |                                   |              |   |     |
| s. |   |                                   |              |   |     |
+----+---+-----------------------------------+--------------+---+-----+
| >  |   |                                   | > *All       |   |     |
| *N |   |                                   | > charges.*  |   |     |
| ot |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| co |   |                                   |              |   |     |
| ve |   |                                   |              |   |     |
| re |   |                                   |              |   |     |
| d: |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  I |   |                                   |              |   |     |
| nd |   |                                   |              |   |     |
| ep |   |                                   |              |   |     |
| en |   |                                   |              |   |     |
| de |   |                                   |              |   |     |
| nt |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| nu |   |                                   |              |   |     |
| rs |   |                                   |              |   |     |
| in |   |                                   |              |   |     |
| g, |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  h |   |                                   |              |   |     |
| om |   |                                   |              |   |     |
| em |   |                                   |              |   |     |
| ak |   |                                   |              |   |     |
| er |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  s |   |                                   |              |   |     |
| er |   |                                   |              |   |     |
| vi |   |                                   |              |   |     |
| ce |   |                                   |              |   |     |
| s* |   |                                   |              |   |     |
+----+---+-----------------------------------+--------------+---+-----+
| ## |   |                                   | ########     |   |     |
| ## |   |                                   |              |   |     |
| ## |   |                                   |              |   |     |
| ## |   |                                   |              |   |     |
|  A |   |                                   |              |   |     |
| mb |   |                                   |              |   |     |
| ul |   |                                   |              |   |     |
| an |   |                                   |              |   |     |
| ce |   |                                   |              |   |     |
+----+---+-----------------------------------+--------------+---+-----+
| -  |   |                                   | > Nothing    |   |     |
|    |   |                                   |              |   |     |
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|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| pr |   |                                   |              |   |     |
| of |   |                                   |              |   |     |
| es |   |                                   |              |   |     |
| si |   |                                   |              |   |     |
| on |   |                                   |              |   |     |
| al |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
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| mb |   |                                   |              |   |     |
| ul |   |                                   |              |   |     |
| an |   |                                   |              |   |     |
| ce |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  s |   |                                   |              |   |     |
| er |   |                                   |              |   |     |
| vi |   |                                   |              |   |     |
| ce |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| wh |   |                                   |              |   |     |
| en |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  m |   |                                   |              |   |     |
| ed |   |                                   |              |   |     |
| ic |   |                                   |              |   |     |
| al |   |                                   |              |   |     |
| ly |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| ap |   |                                   |              |   |     |
| pr |   |                                   |              |   |     |
| op |   |                                   |              |   |     |
| ri |   |                                   |              |   |     |
| at |   |                                   |              |   |     |
| e. |   |                                   |              |   |     |
+----+---+-----------------------------------+--------------+---+-----+

+---+---+-------------------------------------+----------------+---+----+
| # |   |                                     |                |   |    |
| # |   |                                     |                |   |    |
| # |   |                                     |                |   |    |
| # |   |                                     |                |   |    |
| # |   |                                     |                |   |    |
|   |   |                                     |                |   |    |
|   |   |                                     |                |   |    |
| 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.    |                | * |    |
|   | M |                                     |                | M |    |
|   | * | -   We have no calendar year        |                | * |    |
|   | * |     deductible.                     |                | * |    |
|   |   |                                     |                |   |    |
|   | * | -   Be sure to read Section 4,      |                | * |    |
|   | * |     *Your costs for covered         |                | * |    |
|   | P |     services,* for valuable         |                | P |    |
|   | * |     information about how cost      |                | * |    |
|   | * |     sharing works. Also read        |                | * |    |
|   |   |     Section 9 about coordinating    |                |   |    |
|   | * |     benefits with other coverage,   |                | * |    |
|   | * |     including with Medicare.        |                | * |    |
|   | O |                                     |                | O |    |
|   | * | #####                               |                | * |    |
|   | * |                                     |                | * |    |
|   |   |                                     |                |   |    |
|   | * |                                     |                | * |    |
|   | * |                                     |                | * |    |
|   | R |                                     |                | R |    |
|   | * |                                     |                | * |    |
|   | * |                                     |                | * |    |
|   |   |                                     |                |   |    |
|   | * |                                     |                | * |    |
|   | * |                                     |                | * |    |
|   | T |                                     |                | T |    |
|   | * |                                     |                | * |    |
|   | * |                                     |                | * |    |
|   |   |                                     |                |   |    |
|   | * |                                     |                | * |    |
|   | * |                                     |                | * |    |
|   | A |                                     |                | A |    |
|   | * |                                     |                | * |    |
|   | * |                                     |                | * |    |
|   |   |                                     |                |   |    |
|   | * |                                     |                | * |    |
|   | * |                                     |                | * |    |
|   | N |                                     |                | N |    |
|   | * |                                     |                | * |    |
|   | * |                                     |                | * |    |
|   |   |                                     |                |   |    |
|   | * |                                     |                | * |    |
|   | * |                                     |                | * |    |
|   | T |                                     |                | T |    |
|   | * |                                     |                | * |    |
|   | * |                                     |                | * |    |
+---+---+-------------------------------------+----------------+---+----+
| > |   |                                     |                |   |    |
|   |   |                                     |                |   |    |
| * |   |                                     |                |   |    |
| * |   |                                     |                |   |    |
| W |   |                                     |                |   |    |
| h |   |                                     |                |   |    |
| a |   |                                     |                |   |    |
| t |   |                                     |                |   |    |
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| > |   |                                     |                |   |    |
|   |   |                                     |                |   |    |
| m |   |                                     |                |   |    |
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| d |   |                                     |                |   |    |
| i |   |                                     |                |   |    |
| c |   |                                     |                |   |    |
| a |   |                                     |                |   |    |
| l |   |                                     |                |   |    |
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+---+---+-------------------------------------+----------------+---+----+
| > |   |                                     | **You pay**    |   |    |
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| > |   |                                     |                |   |    |
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+---+---+-------------------------------------+----------------+---+----+
| - |   |                                     | > \$20 per     |   |    |
|   |   |                                     | > office visit |   |    |
|   |   |                                     | > to your      |   |    |
|   |   |                                     | > primary care |   |    |
| E |   |                                     | > physician or |   |    |
| m |   |                                     | > a specialist |   |    |
| e |   |                                     | >              |   |    |
| r |   |                                     | > \$20 per     |   |    |
| g |   |                                     | > visit to an  |   |    |
| e |   |                                     | > urgent care  |   |    |
| n |   |                                     | > center       |   |    |
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+---+---+-------------------------------------+----------------+---+----+
| - |   |                                     | > \$100 per    |   |    |
|   |   |                                     | > visit,       |   |    |
|   |   |                                     | > waived if    |   |    |
|   |   |                                     | > admitted     |   |    |
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+---+---+-------------------------------------+----------------+---+----+
| > |   |                                     | > *All         |   |    |
|   |   |                                     | > charges.*    |   |    |
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| c |   |                                     |                |   |    |
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|   |   |                                     |                |   |    |
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| - |   |                                     |                |   |    |
| e |   |                                     |                |   |    |
| m |   |                                     |                |   |    |
| e |   |                                     |                |   |    |
| r |   |                                     |                |   |    |
| g |   |                                     |                |   |    |
| e |   |                                     |                |   |    |
| n |   |                                     |                |   |    |
| c |   |                                     |                |   |    |
| y |   |                                     |                |   |    |
| > |   |                                     |                |   |    |
|   |   |                                     |                |   |    |
| c |   |                                     |                |   |    |
| a |   |                                     |                |   |    |
| r |   |                                     |                |   |    |
| e |   |                                     |                |   |    |
| * |   |                                     |                |   |    |
+---+---+-------------------------------------+----------------+---+----+

+---------------------------------------------+------------------------+
| ######## Emergency outside our service area | ######## You pay       |
+---------------------------------------------+------------------------+
| -   Emergency care at a doctor\'s office    | > \$20 per office      |
|                                             | > visit to your        |
| -   Emergency care at an urgent care center | > primary\             |
|                                             | > care physician or a  |
|                                             | > specialist.          |
|                                             | >                      |
|                                             | > \$20 per visit to an |
|                                             | > urgent care center   |
+---------------------------------------------+------------------------+
| -   Emergency care as an outpatient or      | > \$100 per visit,     |
|     inpatient at a hospital, including      | > waived if admitted   |
|     doctors\' services                      |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges.*       |
|                                             |                        |
| -   *Elective care or non-emergency care*   |                        |
|                                             |                        |
| -   *Emergency care provided outside the    |                        |
|     service area if the need for care could |                        |
|     have been foreseen before leaving the   |                        |
|     service area*                           |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Medical and hospital costs resulting   |                        |
|     from a normal full-term delivery of a   |                        |
|     baby outside the service area*          |                        |
+---------------------------------------------+------------------------+
| > **Ambulance**                             |                        |
+---------------------------------------------+------------------------+
| > Professional ambulance service, including | > Nothing              |
| > air ambulance, when medically             |                        |
| > appropriate.                              |                        |
| >                                           |                        |
| > See 5(c) for non-emergency service.       |                        |
+---------------------------------------------+------------------------+

+---+---+---------------------------------------+-------------------+---+---+
| * |   |                                       |                   |   |   |
| * |   |                                       |                   |   |   |
| S |   |                                       |                   |   |   |
| e |   |                                       |                   |   |   |
| c |   |                                       |                   |   |   |
| t |   |                                       |                   |   |   |
| i |   |                                       |                   |   |   |
| o |   |                                       |                   |   |   |
| n |   |                                       |                   |   |   |
| 5 |   |                                       |                   |   |   |
| ( |   |                                       |                   |   |   |
| e |   |                                       |                   |   |   |
| ) |   |                                       |                   |   |   |
| . |   |                                       |                   |   |   |
| M |   |                                       |                   |   |   |
| e |   |                                       |                   |   |   |
| n |   |                                       |                   |   |   |
| t |   |                                       |                   |   |   |
| a |   |                                       |                   |   |   |
| l |   |                                       |                   |   |   |
| h |   |                                       |                   |   |   |
| e |   |                                       |                   |   |   |
| a |   |                                       |                   |   |   |
| l |   |                                       |                   |   |   |
| t |   |                                       |                   |   |   |
| h |   |                                       |                   |   |   |
| a |   |                                       |                   |   |   |
| n |   |                                       |                   |   |   |
| d |   |                                       |                   |   |   |
| s |   |                                       |                   |   |   |
| u |   |                                       |                   |   |   |
| b |   |                                       |                   |   |   |
| s |   |                                       |                   |   |   |
| t |   |                                       |                   |   |   |
| a |   |                                       |                   |   |   |
| n |   |                                       |                   |   |   |
| c |   |                                       |                   |   |   |
| e |   |                                       |                   |   |   |
| a |   |                                       |                   |   |   |
| b |   |                                       |                   |   |   |
| u |   |                                       |                   |   |   |
| s |   |                                       |                   |   |   |
| e |   |                                       |                   |   |   |
| b |   |                                       |                   |   |   |
| e |   |                                       |                   |   |   |
| n |   |                                       |                   |   |   |
| e |   |                                       |                   |   |   |
| f |   |                                       |                   |   |   |
| i |   |                                       |                   |   |   |
| t |   |                                       |                   |   |   |
| s |   |                                       |                   |   |   |
| * |   |                                       |                   |   |   |
| * |   |                                       |                   |   |   |
+---+---+---------------------------------------+-------------------+---+---+
|   | * | > 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:**                         |                   |   |   |
|   | * | >                                     |                   | * |   |
|   | * | > All benefits are subject to the     |                   | * |   |
|   | P | > definitions, limitations, and       |                   | P |   |
|   | * | > exclusions in this brochure.        |                   | * |   |
|   | * | >                                     |                   | * |   |
|   |   | > Be sure to read Section 4, *Your    |                   |   |   |
|   | * | > costs for covered services,* for    |                   | * |   |
|   | * | > valuable information about how cost |                   | * |   |
|   | O | > sharing works. Also read Section 9  |                   | O |   |
|   | * | > about coordinating benefits with    |                   | * |   |
|   | * | > other coverage, including with      |                   | * |   |
|   |   | > Medicare.                           |                   |   |   |
|   | * | >                                     |                   | * |   |
|   | * | > **YOU MUST GET PREAUTHORIZATION OF  |                   | * |   |
|   | R | > THESE SERVICES.** See the           |                   | R |   |
|   | * | > instructions after the benefits     |                   | * |   |
|   | * | > description below.                  |                   | * |   |
|   |   |                                       |                   |   |   |
|   | * |                                       |                   | * |   |
|   | * |                                       |                   | * |   |
|   | T |                                       |                   | T |   |
|   | * |                                       |                   | * |   |
|   | * |                                       |                   | * |   |
|   |   |                                       |                   |   |   |
|   | * |                                       |                   | * |   |
|   | * |                                       |                   | * |   |
|   | A |                                       |                   | A |   |
|   | * |                                       |                   | * |   |
|   | * |                                       |                   | * |   |
|   |   |                                       |                   |   |   |
|   | * |                                       |                   | * |   |
|   | * |                                       |                   | * |   |
|   | N |                                       |                   | N |   |
|   | * |                                       |                   | * |   |
|   | * |                                       |                   | * |   |
|   |   |                                       |                   |   |   |
|   | * |                                       |                   | * |   |
|   | * |                                       |                   | * |   |
|   | T |                                       |                   | T |   |
|   | * |                                       |                   | * |   |
|   | * |                                       |                   | * |   |
+---+---+---------------------------------------+-------------------+---+---+
| > |   |                                       | **You pay**       |   |   |
|   |   |                                       |                   |   |   |
| * |   |                                       |                   |   |   |
| * |   |                                       |                   |   |   |
| B |   |                                       |                   |   |   |
| e |   |                                       |                   |   |   |
| n |   |                                       |                   |   |   |
| e |   |                                       |                   |   |   |
| f |   |                                       |                   |   |   |
| i |   |                                       |                   |   |   |
| t |   |                                       |                   |   |   |
| > |   |                                       |                   |   |   |
|   |   |                                       |                   |   |   |
| D |   |                                       |                   |   |   |
| e |   |                                       |                   |   |   |
| s |   |                                       |                   |   |   |
| c |   |                                       |                   |   |   |
| r |   |                                       |                   |   |   |
| i |   |                                       |                   |   |   |
| p |   |                                       |                   |   |   |
| t |   |                                       |                   |   |   |
| i |   |                                       |                   |   |   |
| o |   |                                       |                   |   |   |
| n |   |                                       |                   |   |   |
| * |   |                                       |                   |   |   |
| * |   |                                       |                   |   |   |
+---+---+---------------------------------------+-------------------+---+---+
| # |   |                                       | ###               |   |   |
| # |   |                                       |                   |   |   |
| # |   |                                       |                   |   |   |
|   |   |                                       |                   |   |   |
| * |   |                                       |                   |   |   |
| * |   |                                       |                   |   |   |
| M |   |                                       |                   |   |   |
| e |   |                                       |                   |   |   |
| n |   |                                       |                   |   |   |
| t |   |                                       |                   |   |   |
| a |   |                                       |                   |   |   |
| l |   |                                       |                   |   |   |
|   |   |                                       |                   |   |   |
| h |   |                                       |                   |   |   |
| e |   |                                       |                   |   |   |
| a |   |                                       |                   |   |   |
| l |   |                                       |                   |   |   |
| t |   |                                       |                   |   |   |
| h |   |                                       |                   |   |   |
|   |   |                                       |                   |   |   |
| a |   |                                       |                   |   |   |
| n |   |                                       |                   |   |   |
| d |   |                                       |                   |   |   |
|   |   |                                       |                   |   |   |
| s |   |                                       |                   |   |   |
| u |   |                                       |                   |   |   |
| b |   |                                       |                   |   |   |
| s |   |                                       |                   |   |   |
| t |   |                                       |                   |   |   |
| a |   |                                       |                   |   |   |
| n |   |                                       |                   |   |   |
| c |   |                                       |                   |   |   |
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|   |   |                                       |                   |   |   |
| a |   |                                       |                   |   |   |
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| u |   |                                       |                   |   |   |
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|   |   |                                       |                   |   |   |
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| s |   |                                       |                   |   |   |
| * |   |                                       |                   |   |   |
| * |   |                                       |                   |   |   |
+---+---+---------------------------------------+-------------------+---+---+
| > |   |                                       | > Your cost       |   |   |
|   |   |                                       | > sharing         |   |   |
| A |   |                                       | >                 |   |   |
| l |   |                                       |  responsibilities |   |   |
| l |   |                                       | > are no greater  |   |   |
| > |   |                                       | > than for other  |   |   |
|   |   |                                       | > illnesses or    |   |   |
| d |   |                                       | > conditions      |   |   |
| i |   |                                       |                   |   |   |
| a |   |                                       |                   |   |   |
| g |   |                                       |                   |   |   |
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+---+---+---------------------------------------+-------------------+---+---+
| - |   |                                       | > \$20 per office |   |   |
|   |   |                                       | > visit to a      |   |   |
|   |   |                                       | > specialist      |   |   |
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|   |   |                                       |                   |   |   |
|   |   |                                       |                   |   |   |
|   |   |                                       |                   |   |   |
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| e |   |                                       |                   |   |   |
| d |   |                                       |                   |   |   |
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|   |   |                                       |                   |   |   |
|   |   |                                       |                   |   |   |
|   |   |                                       |                   |   |   |
|   |   |                                       |                   |   |   |
| m |   |                                       |                   |   |   |
| a |   |                                       |                   |   |   |
| n |   |                                       |                   |   |   |
| a |   |                                       |                   |   |   |
| g |   |                                       |                   |   |   |
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| e |   |                                       |                   |   |   |
| n |   |                                       |                   |   |   |
| t |   |                                       |                   |   |   |
+---+---+---------------------------------------+-------------------+---+---+

Mental health and substance abuse benefits - Continued on next page

+----------------------------------------------+-----------------------+
| ### **Mental health a                        | ### **You pay**       |
| nd substance abuse benefits** *(Continued)*  |                       |
+----------------------------------------------+-----------------------+
| -   Diagnostic tests                         | > Nothing             |
+----------------------------------------------+-----------------------+
| -   Services provided by a hospital or other | > \$500 per admission |
|     facility                                 |                       |
|                                              |                       |
| -   Services in approved alternative care    |                       |
|     settings such as partial                 |                       |
|     hospitalization, full-day                |                       |
|     hospitalization, facility based          |                       |
|     intensive outpatient treatment           |                       |
+----------------------------------------------+-----------------------+
| ##                                           | > *All charges.*      |
|  Not covered: Services we have not approved. |                       |
|                                              |                       |
| ## Note: OP                                  |                       |
| M will base its review of disputes about tre |                       |
| atment plans on the treatment plan\'s clinic |                       |
| al appropriateness. OPM will generally not o |                       |
| rder us to pay or provide one clinically app |                       |
| ropriate treatment plan in favor of another. |                       |
+----------------------------------------------+-----------------------+
| **Preauthorization** To be eligible to       |                       |
| receive these benefits you must obtain a     |                       |
| treatment plan and follow all of the         |                       |
| following authorization processes:           |                       |
|                                              |                       |
| -   Call our mental health and substance     |                       |
|     abuse provider, United Behavioral Health |                       |
|     (UBH), at 800/420-5729. An intake        |                       |
|     coordinator will assist you with your    |                       |
|     needs. You may then be referred to a     |                       |
|     participating provider.                  |                       |
+----------------------------------------------+-----------------------+
| > **Limitation** We may limit your benefits  |                       |
| > if you do not obtain a treatment plan.     |                       |
+----------------------------------------------+-----------------------+

+-----+---+-------------------------------------------------+---+-------+
| **S |   |                                                 |   |       |
| ect |   |                                                 |   |       |
| ion |   |                                                 |   |       |
| 5   |   |                                                 |   |       |
| (   |   |                                                 |   |       |
| f). |   |                                                 |   |       |
| Pre |   |                                                 |   |       |
| scr |   |                                                 |   |       |
| ipt |   |                                                 |   |       |
| ion |   |                                                 |   |       |
| d   |   |                                                 |   |       |
| rug |   |                                                 |   |       |
| b   |   |                                                 |   |       |
| ene |   |                                                 |   |       |
| fit |   |                                                 |   |       |
| s** |   |                                                 |   |       |
+-----+---+-------------------------------------------------+---+-------+
|     | * | **Here are some important things to keep in     | * |       |
|     | * | mind about these benefits:**                    | * |       |
|     | I |                                                 | I |       |
|     | * | -   We cover prescribed drugs and medications,  | * |       |
|     | * |     as described in the chart beginning on the  | * |       |
|     |   |     next page.                                  |   |       |
|     | * |                                                 | * |       |
|     | * | -   All benefits are subject to the             | * |       |
|     | M |     definitions, limitations and exclusions in  | M |       |
|     | * |     this brochure and are payable only when we  | * |       |
|     | * |     determine they are medically necessary.     | * |       |
|     |   |                                                 |   |       |
|     | * | ```{=html}                                      | * |       |
|     | * | <!-- -->                                        | * |       |
|     | P | ```                                             | P |       |
|     | * | -   We have no calendar year deductible.        | * |       |
|     | * |                                                 | * |       |
|     |   | ```{=html}                                      |   |       |
|     | * | <!-- -->                                        | * |       |
|     | * | ```                                             | * |       |
|     | O | -   Be sure to read Section 4, *Your costs for  | O |       |
|     | * |     covered services,* for valuable information | * |       |
|     | * |     about how cost sharing works. Also read     | * |       |
|     |   |     Section 9 about coordinating benefits with  |   |       |
|     | * |     other coverage, including with Medicare.    | * |       |
|     | * |                                                 | * |       |
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|     | . |                                                 |   |       |
+-----+---+-------------------------------------------------+---+-------+

*Prescription drug benefits begin on the next page.*

+-----------------------------------------------+----------------------+
| > **Benefit Description**                     | **You pay**          |
+-----------------------------------------------+----------------------+
| > **Covered medications and supplies**        |                      |
+-----------------------------------------------+----------------------+
| > We cover the following medications and      | ### FOR U            |
| > supplies prescribed by a Plan physician and | P TO A 34-DAY SUPPLY |
| > obtained from a Plan pharmacy or through    |                      |
| > our mail order program:                     | -   A \$10 copay for |
|                                               |     a preferred      |
| -   Drugs and medicines that by Federal law   |     generic drug;    |
|     of the United States require a            |                      |
|     physician's prescription for their        | -   A \$20 copay for |
|     purchase, except as excluded below.       |     a preferred name |
|                                               |     brand drug when  |
| -   Insulin; a copay charge applies to each   |     no generic drug  |
|     vial                                      |     is available;    |
|                                               |                      |
| -   Disposable needles and syringes for the   | -   A \$40 copay for |
|     administration of covered medications; a  |     a non-preferred  |
|     copay charge applies to each 34-day       |     name brand drug  |
|     supply                                    |     when no generic  |
|                                               |     drug is          |
| -   Drugs for sexual dysfunction are subject  |     available; and   |
|     to dosage limits set by the Plan. Contact |                      |
|     the Plan for details.                     | -   A \$10 copay     |
|                                               |     plus the price   |
| -   Fertility drugs                           |     difference in    |
|                                               |     the cost of the  |
|                                               |     name brand drug  |
|                                               |     over the generic |
|                                               |     drug for a       |
|                                               |     preferred or     |
|                                               |     non-preferred    |
|                                               |     name brand drug  |
|                                               |     when you or your |
|                                               |     physician        |
|                                               |     requests a name  |
|                                               |     brand drug when  |
|                                               |     a generic drug   |
|                                               |     is available.    |
|                                               |                      |
|                                               | FOR A 35-90 DAY      |
|                                               | SUPPLY               |
|                                               |                      |
|                                               | -   A \$20 copay for |
|                                               |     a preferred      |
|                                               |     generic drug;    |
|                                               |                      |
|                                               | -   A \$40 copay for |
|                                               |     a preferred name |
|                                               |     brand drug when  |
|                                               |     no generic drug  |
|                                               |     is available;    |
|                                               |                      |
|                                               | -   A \$80 copay for |
|                                               |     a non-preferred  |
|                                               |     name brand drug  |
|                                               |     when no generic  |
|                                               |     drug is          |
|                                               |     available; and   |
|                                               |                      |
|                                               | -   A \$20 copay     |
|                                               |     plus the price   |
|                                               |     difference in    |
|                                               |     the cost of the  |
|                                               |     name brand drug  |
|                                               |     over the generic |
|                                               |     drug for a       |
|                                               |     preferred or     |
|                                               |     non-preferred    |
|                                               |     name brand drug  |
|                                               |     when you or your |
|                                               |     physician        |
|                                               |     requests a name  |
|                                               |     brand drug when  |
|                                               |     a generic drug   |
|                                               |     is available.    |
+-----------------------------------------------+----------------------+

*Covered medications and supplies - Continued on next page.*

+---------------------------------------------+------------------------+
| > **Covered medications and supplies**      | > **You pay**          |
| > *(continued)*                             |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All Charges.*       |
|                                             |                        |
| -   *Drugs and supplies for cosmetic        |                        |
|     purposes*                               |                        |
|                                             |                        |
| -   *Vitamins, and nutritional substances   |                        |
|     that can be purchased without a         |                        |
|     prescription*                           |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Nonprescription medicines*             |                        |
|                                             |                        |
| -   *Drugs obtained at a non-Plan pharmacy  |                        |
|     except for out-of-area emergencies*     |                        |
|                                             |                        |
| -   *Medical supplies such as dressings and |                        |
|     antiseptics*                            |                        |
|                                             |                        |
| -   *Drugs to enhance athletic performance* |                        |
|                                             |                        |
| -   *Diabetic supplies, except needles,     |                        |
|     syringes, and insulin (Additional       |                        |
|     equipment, i.e., blood glucose          |                        |
|     monitors, insulin pumps, and supplies,  |                        |
|     i.e., lancets and test strips, are      |                        |
|     covered under \"Durable medical         |                        |
|     equipment,\" see page 21)*              |                        |
|                                             |                        |
| -   *Smoking cessation drugs and            |                        |
|     medication*                             |                        |
|                                             |                        |
| -   *Drugs prescribed for weight loss and   |                        |
|     appetite suppressants, except for       |                        |
|     treatment of Morbid Obesity*            |                        |
+---------------------------------------------+------------------------+

+---------------------+------------------------------------------------+
| > Section 5 (g).    |                                                |
| > Special Features  |                                                |
+=====================+================================================+
| > **Feature**       | > **Description**                              |
+---------------------+------------------------------------------------+
| > **Services for    | > We offer a TDD line at 1-888/817-0139        |
| > deaf and hearing  |                                                |
| > impaired**        |                                                |
+---------------------+------------------------------------------------+
| > **Centers of      | > We utilize centers of excellence for         |
| > excellence**      | > transplants. It is a national organ and      |
|                     | > tissue network consisting of 48 transplant   |
|                     | > medical centers and 120 transplant programs. |
|                     | > In order to become a center of excellence,   |
|                     | > the program is strictly credentialed using   |
|                     | > program and physician experience, transplant |
|                     | > volume, outcomes, comprehensive services,    |
|                     | > quality assessment and complications rate.   |
+---------------------+------------------------------------------------+

+---+---+------------------------------------------+----------------+---+---+
| > |   |                                          |                |   |   |
|   |   |                                          |                |   |   |
| S |   |                                          |                |   |   |
| e |   |                                          |                |   |   |
| c |   |                                          |                |   |   |
| t |   |                                          |                |   |   |
| i |   |                                          |                |   |   |
| o |   |                                          |                |   |   |
| n |   |                                          |                |   |   |
| > |   |                                          |                |   |   |
|   |   |                                          |                |   |   |
| 5 |   |                                          |                |   |   |
| > |   |                                          |                |   |   |
|   |   |                                          |                |   |   |
| ( |   |                                          |                |   |   |
| h |   |                                          |                |   |   |
| ) |   |                                          |                |   |   |
| . |   |                                          |                |   |   |
| > |   |                                          |                |   |   |
|   |   |                                          |                |   |   |
| D |   |                                          |                |   |   |
| e |   |                                          |                |   |   |
| n |   |                                          |                |   |   |
| t |   |                                          |                |   |   |
| a |   |                                          |                |   |   |
| l |   |                                          |                |   |   |
| > |   |                                          |                |   |   |
|   |   |                                          |                |   |   |
| b |   |                                          |                |   |   |
| e |   |                                          |                |   |   |
| n |   |                                          |                |   |   |
| e |   |                                          |                |   |   |
| f |   |                                          |                |   |   |
| i |   |                                          |                |   |   |
| t |   |                                          |                |   |   |
| s |   |                                          |                |   |   |
+===+===+==========================================+================+===+===+
|   | * | **Here are some important things to keep |                | * |   |
|   | * | in mind about these benefits:**          |                | * |   |
|   | I |                                          |                | I |   |
|   | * | -   Please remember that all benefits    |                | * |   |
|   | * |     are subject to the definitions,      |                | * |   |
|   |   |     limitations, and exclusions in this  |                |   |   |
|   | * |     brochure and are payable only when   |                | * |   |
|   | * |     we determine they are medically      |                | * |   |
|   | M |     necessary.                           |                | M |   |
|   | * |                                          |                | * |   |
|   | * | -   We have no calendar year deductible. |                | * |   |
|   |   |                                          |                |   |   |
|   | * | -   We cover hospitalization for dental  |                | * |   |
|   | * |     procedures only when a nondental     |                | * |   |
|   | P |     physical impairment exists which     |                | P |   |
|   | * |     makes hospitalization necessary to   |                | * |   |
|   | * |     safeguard the health of the patient. |                | * |   |
|   |   |     See Section 5(c) for impatient       |                |   |   |
|   | * |     hospital benefits. We do not cover   |                | * |   |
|   | * |     the dental procedure unless it is    |                | * |   |
|   | O |     described below.                     |                | O |   |
|   | * |                                          |                | * |   |
|   | * | ```{=html}                               |                | * |   |
|   |   | <!-- -->                                 |                |   |   |
|   | * | ```                                      |                | * |   |
|   | * | -   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 |   |
|   | * |                                          |                | * |   |
|   | * |                                          |                | * |   |
|   |   |                                          |                |   |   |
|   | * |                                          |                | * |   |
|   | * |                                          |                | * |   |
|   | A |                                          |                | A |   |
|   | * |                                          |                | * |   |
|   | * |                                          |                | * |   |
|   |   |                                          |                |   |   |
|   | * |                                          |                | * |   |
|   | * |                                          |                | * |   |
|   | N |                                          |                | N |   |
|   | * |                                          |                | * |   |
|   | * |                                          |                | * |   |
|   |   |                                          |                |   |   |
|   | * |                                          |                | * |   |
|   | * |                                          |                | * |   |
|   | T |                                          |                | T |   |
|   | * |                                          |                | * |   |
|   | * |                                          |                | * |   |
+---+---+------------------------------------------+----------------+---+---+
| # |   |                                          | > **You pay**  |   |   |
| # |   |                                          |                |   |   |
| # |   |                                          |                |   |   |
|   |   |                                          |                |   |   |
| * |   |                                          |                |   |   |
| * |   |                                          |                |   |   |
| A |   |                                          |                |   |   |
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| n |   |                                          |                |   |   |
| j |   |                                          |                |   |   |
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| y |   |                                          |                |   |   |
|   |   |                                          |                |   |   |
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| f |   |                                          |                |   |   |
| i |   |                                          |                |   |   |
| t |   |                                          |                |   |   |
| * |   |                                          |                |   |   |
| * |   |                                          |                |   |   |
|   |   |                                          |                |   |   |
+---+---+------------------------------------------+----------------+---+---+
| > |   |                                          | > Nothing      |   |   |
|   |   |                                          |                |   |   |
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| . |   |                                          |                |   |   |
+---+---+------------------------------------------+----------------+---+---+
| > |   |                                          |                |   |   |
|   |   |                                          |                |   |   |
| * |   |                                          |                |   |   |
| * |   |                                          |                |   |   |
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| s |   |                                          |                |   |   |
| * |   |                                          |                |   |   |
| * |   |                                          |                |   |   |
+---+---+------------------------------------------+----------------+---+---+
| > |   |                                          |                |   |   |
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| f |   |                                          |                |   |   |
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| t |   |                                          |                |   |   |
| s |   |                                          |                |   |   |
| . |   |                                          |                |   |   |
+---+---+------------------------------------------+----------------+---+---+

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

> The exclusions in this section apply to all benefits. **Although we
> may list a specific service as a benefit, we will not cover it unless
> your Plan doctor determines it is medically necessary to prevent,
> diagnose, or treat your illness, disease, injury, or condition and we
> agree, as discussed under *Services requiring our prior approval* on
> page 12.**
>
> We do not cover the following:

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

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

-   Services, drugs, or supplies 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;

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

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

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

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

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

When you see Plan physicians, receive services at Plan hospitals and
facilities, or 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 and hospital benefits** In most cases, providers and
facilities file claims for you. Physicians 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
800/OSF-5222.

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;

```{=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: OSF HealthPlans, P.O. Box 5128, Peoria, IL
> 61601-5128.**

**Prescription drugs** In most cases, participating pharmacies file
claims for you. If you need to file a prescription drug claim directly
to AdvancePCS, call us at 800/OSF-5222 and we will provide you with a
form that must be completely filled out and sent to AdvancePCS.

**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
preauthorization:

+---+------------------------------------------------------------------+
| * | **Description**                                                  |
| * |                                                                  |
| S |                                                                  |
| t |                                                                  |
| e |                                                                  |
| p |                                                                  |
| * |                                                                  |
| * |                                                                  |
+---+------------------------------------------------------------------+
| * | Ask us in writing to reconsider our initial decision. You must:  |
| * |                                                                  |
| 1 | (a) Write to us within 6 months from the date of our decision;   |
| * |     and                                                          |
| * |                                                                  |
|   | (b) Send your request to us at: OSF HealthPlans, 7915 N. Hale    |
|   |     Ave., Suite D, Peoria, IL 61615; and                         |
|   |                                                                  |
|   | (c) Include a statement about why you believe our initial        |
|   |     decision was wrong, based on specific benefit provisions in  |
|   |     this brochure; and                                           |
|   |                                                                  |
|   | (d) Include copies of documents that support your claim, such as |
|   |     physicians\' letters, operative reports, bills, medical      |
|   |     records, and explanation of benefits (EOB) forms.            |
+---+------------------------------------------------------------------+
| * | We have 30 days from the date we receive your request to:        |
| * |                                                                  |
| 2 | (a) Pay the claim (or, if applicable, arrange for the health     |
| * |     care provider to give you the care); or                      |
| * |                                                                  |
|   | (b) Write to you and maintain our denial \-- go to step 4; or    |
|   |                                                                  |
|   | (c) Ask you or your medical provider for more information. If we |
|   |     ask your provider, we will send you a copy of our            |
|   |     request---go to step 3.                                      |
+---+------------------------------------------------------------------+
| * | You or your provider must send the information so that we        |
| * | receive it within 60 days of our request. We will then decide    |
| 3 | within 30 more days.                                             |
| * |                                                                  |
| * | If we do not receive the information within 60 days, we will     |
|   | decide within 30 days of the date the information was due. We    |
|   | will base our decision on the information we already have.       |
|   |                                                                  |
|   | We will write to you with our decision.                          |
+---+------------------------------------------------------------------+
| * | If you do not agree with our decision, you may ask OPM to review |
| * | it.                                                              |
| 4 |                                                                  |
| * |                                                                  |
| * |                                                                  |
+---+------------------------------------------------------------------+
|   | You must write to OPM within:                                    |
|   |                                                                  |
|   | -   90 days after the date of our letter upholding our initial   |
|   |     decision; or                                                 |
|   |                                                                  |
|   | -   120 days after you first wrote to us \-- if we did not       |
|   |     answer that request in some way within 30 days; or           |
|   |                                                                  |
|   | -   120 days after we asked for additional information.          |
+---+------------------------------------------------------------------+
|   | Write to OPM at: Office of Personnel Management, Insurance       |
|   | Services Programs, Health Insurance Group 3, 1900 E Street, NW,  |
|   | Washington, D.C. 20415-3630.                                     |
+---+------------------------------------------------------------------+
|   | Send OPM the following information:                              |
|   |                                                                  |
|   | -   A statement about why you believe our decision was wrong,    |
|   |     based on specific benefit provisions in this brochure;       |
|   |                                                                  |
|   | -   Copies of documents that support your claim, such as         |
|   |     physicians\' letters, operative reports, bills, medical      |
|   |     records, and explanation of benefits (EOB) forms;            |
|   |                                                                  |
|   | -   Copies of all letters you sent to us about the claim;        |
|   |                                                                  |
|   | -   Copies of all letters we sent to you about the claim; and    |
|   |                                                                  |
|   | -   Your daytime phone number and the best time to call.         |
|   |                                                                  |
|   | Note: If you want OPM to review more than one claim, you must    |
|   | clearly identify which documents apply to which claim.           |
+---+------------------------------------------------------------------+
|   | Note: You are the only person who has a right to file a disputed |
|   | claim with OPM. Parties acting as your representative, such as   |
|   | medical providers, must include a copy of your specific written  |
|   | consent with the review request.                                 |
|   |                                                                  |
|   | Note: The above deadlines may be extended if you show that you   |
|   | were unable to meet the deadline because of reasons beyond your  |
|   | control.                                                         |
+---+------------------------------------------------------------------+
| * | OPM will review your disputed claim request and will use the     |
| * | information it collects from you and us to decide whether our    |
| 5 | decision is correct. OPM will send you a final decision within   |
| * | 60 days. There are no other administrative appeals.              |
| * |                                                                  |
+---+------------------------------------------------------------------+
|   | If you do not agree with OPM's decision, your only recourse is   |
|   | to sue. If you decide to sue, you must file the suit against OPM |
|   | in Federal court by December 31 of the third year after the year |
|   | in which you received the disputed services, drugs, or supplies  |
|   | or from the year in which you were denied precertification or    |
|   | prior approval. This is the only deadline that may not be        |
|   | extended.                                                        |
|   |                                                                  |
|   | OPM may disclose the information it collects during the review   |
|   | process to support their disputed claim decision. This           |
|   | information will become part of the court record.                |
+---+------------------------------------------------------------------+
|   | You may not sue until you have completed the disputed claims     |
|   | process. Further, Federal law governs your lawsuit, benefits,    |
|   | and payment of benefits. The Federal court will base its review  |
|   | on the record that was before OPM when OPM decided to uphold or  |
|   | overturn our decision. You may recover only the amount of        |
|   | benefits in dispute.                                             |
+---+------------------------------------------------------------------+

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

(a) We haven\'t responded yet to your initial request for care or
    preauthorization/prior approval, then call us at 800/OSF-5222 and we
    will expedite our review; or

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

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

```{=html}
<!-- -->
```
-   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 coverage** You must tell us if you or a
covered family member have 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 normally pays its benefits in
full as the primary payer and the other plan pays a reduced benefit as
the secondary payer. We, like other insurers, determine which coverage
is primary according to the National Association of Insurance
Commissioners\' guidelines.

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

When we are the secondary payer, we will determine our allowance. After
the primary plan pays, we will pay what is left of our allowance, up to
our regular benefit. We will not pay more than our allowance.

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

-   People 65 years of age and older.

-   Some people with disabilities, under 65 years of age.

-   People with End-Stage Renal Disease (permanent kidney failure
    requiring dialysis or a transplant).

Medicare has two parts:

-   Part A (Hospital Insurance). Most people do not have to pay for
    Part A. If you or your spouse worked for at least 10 years in
    Medicare-covered employment, you should be able to qualify for
    premium-free Part A insurance. (Someone who was a Federal employee
    on January 1, 1983, or since automatically qualifies.) Otherwise, if
    you are age 65 or older, you may be able to buy it. Contact
    1-800-MEDICARE for more information.

-   Part B (Medical Insurance). Most people pay monthly for Part B.
    Generally, Part B premiums are withheld from your monthly Social
    Security check or your retirement check.

> 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 are eligible for Medicare, you may have choices in how you get
> your health care. Medicare+Choice is the term used to describe the
> various health plan choices available to Medicare beneficiaries. The
> information in the next few pages shows how we coordinate benefits
> with Medicare, depending on the type of Medicare + Choice plan you
> have.

The Original Medicare Plan (Original Medicare) is available everywhere
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.

**Claims process when you have the Original Medicare Plan \--** You
probably will never have to file a claim form when you have both our
Plan and the Original Medicare Plan.

-   When we are the primary payer, we process the claim first.

-   When Original Medicare is the primary payer, Medicare processes your
    claim first. In most cases, your claim will be coordinated
    automatically and we will then provide secondary benefits for
    covered charges. You will not need to do anything. To find out if
    you need to do something to file your claim, call us at
    309/677-8205, toll free 877/677-8205, or TDD 888/817-0139.

> We do not waive any costs if the Original Medicare Plan is your
> primary payer.

**(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     | for  |   | for      |
|     your employment status                         | Part |   | other    |
|                                                    | B    |   | services |
|                                                    | serv |   |          |
|                                                    | ices |   |          |
+----------------------------------------------------+------+---+----------+
| 7)  Are a former Federal employee receiving        | \*\* |   |          |
|     Workers' Compensation and the Office of        |      |   |          |
|     Workers' Compensation Programs has determined  |      |   |          |
|     that you are unable to return to duty)         |      |   |          |
+----------------------------------------------------+------+---+----------+
| **B. When you or a covered family member...**      |      |   |          |
+----------------------------------------------------+------+---+----------+
| ###### Have Medicare sol                           |      |   |          |
| ely based on end stage renal disease (ESRD) and... |      |   |          |
|                                                    |      |   |          |
| ###### It is within the firs                       |      |   |          |
| t 30 months of eligibility for or entitlement to M |      |   |          |
| edicare 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 |      | f |          |
|     already a Medicare beneficiary and**...**      |      | o |          |
|                                                    |      | r |          |
| -   This Plan was the primary payer before         |      | 3 |          |
|     eligibility due to ESRD                        |      | 0 |          |
|                                                    |      | - |          |
|                                                    |      | m |          |
|                                                    |      | o |          |
|                                                    |      | n |          |
|                                                    |      | t |          |
|                                                    |      | h |          |
|                                                    |      | c |          |
|                                                    |      | o |          |
|                                                    |      | o |          |
|                                                    |      | r |          |
|                                                    |      | d |          |
|                                                    |      | i |          |
|                                                    |      | n |          |
|                                                    |      | a |          |
|                                                    |      | t |          |
|                                                    |      | i |          |
|                                                    |      | o |          |
|                                                    |      | n |          |
|                                                    |      | p |          |
|                                                    |      | e |          |
|                                                    |      | r |          |
|                                                    |      | i |          |
|                                                    |      | o |          |
|                                                    |      | d |          |
+----------------------------------------------------+------+---+----------+
| -   Medicare was the primary payer before          |      |   |          |
|     eligibility due to ESRD                        |      |   |          |
+----------------------------------------------------+------+---+----------+
| **C. When either you or your spouse are eligible   |      |   |          |
| for Medicare solely due to disability and you**    |      |   |          |
+----------------------------------------------------+------+---+----------+
| 1)  Are an active employee with the Federal        |      |   |          |
|     government and**...**                          |      |   |          |
|                                                    |      |   |          |
|     -   You have FEHB coverage on your own or      |      |   |          |
|         through your spouse who is also an active  |      |   |          |
|         employee                                   |      |   |          |
+----------------------------------------------------+------+---+----------+
| -   You have FEHB coverage through your spouse who |      |   |          |
|     is an annuitant                                |      |   |          |
+----------------------------------------------------+------+---+----------+
| 2)  Are an annuitant and**...**                    |      | [ |          |
|                                                    |      | ] |          |
|     -   You have FEHB coverage on your own or      |      | { |          |
|         through your spouse who is also an         |      | . |          |
|         annuitant                                  |      | m |          |
|                                                    |      | a |          |
|                                                    |      | r |          |
|                                                    |      | k |          |
|                                                    |      | } |          |
+----------------------------------------------------+------+---+----------+
| -   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 + Choice plan** If you are eligible for Medicare, you may
choose to enroll in and get your Medicare benefits from a Medicare +
Choice plan. These are health care choices (like HMOs) in some areas of
the country. In most Medicare + Choice plans, you can only go to
doctors, specialists, or hospitals that are part of the plan. Medicare +
Choice plans provide all the benefits that Original Medicare covers.
Some cover extras, like prescription drugs. To learn more about
enrolling in a Medicare + Choice plan, contact Medicare at
1-800-MEDICARE (1-800-633-4227) or at
[www.medicare.gov](http://www.medicare.gov/).

If you enroll in a Medicare + Choice plan, the following options are
available to you:

**This Plan and our Medicare + Choice plan:** You may enroll in our
Medicare + Choice plan and also remain enrolled in our FEHB plan. In
this case, we do not waive cost-sharing for your FEHB coverage.

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

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

**If you do not enroll in** If you do not have one or both parts of
Medicare, you can still be covered

**Medicare Part A or Part B** under the FEHB Program. We will not
require you to enroll in Medicare Part B and, if you can't get
premium-free Part A, we will not ask you to enroll in it.

**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
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 hospital

**for injuries** 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. See page 13.

**Copayment** A copayment is a fixed amount of money you pay when you
receive covered services. See page 13.

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

**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. See page 13

The Plan uses a range of sources to decide if a new procedure, process,
or pharmaceutical is or is not experimental or investigational. These
sources include an independent third party evaluation where valid, an
agreement of specialists in the related field, the Food and Drug
Administration, Medicare Guidelines, Hayes Technology Assessment and
other available sources of medical information. All information is given
to the Plan's Utilization Management Committee by the Plan's Medical
Director for a decision. The Medical Director also uses the resources of
the Plan's Technology Assessment Committee.

**Us/We** Us and we refer to OSF HealthPlans.

**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;
>
> How you can cover your family members;
>
> What happens when you transfer to another Federal agency, go on leave
> without pay, enter military service, or retire;
>
> When your enrollment ends; and
>
> When the next open season for enrollment begins.

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

**Types of 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,

```{=html}
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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 this Plan

**premiums start** during Open Season, your coverage begins on the first
day of your 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).

**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
>
> You are a family member no longer eligible for coverage.

You may be eligible for spouse equity coverage or Temporary Continuation
of Coverage (TCC), or a conversion policy (a non-FEHB individual
policy).

**Spouse equity** If you are divorced from a Federal employee or
annuitant, you may not

**coverage** 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
also download the guide from OPM's website, www.opm.gov/insure.

**Temporary Continuation of** If you leave Federal service, or if you
lose coverage because you no

**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);

```{=html}
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```
-   You decided not to receive coverage under TCC or the spouse equity
    law; or

```{=html}
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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.

The Health Insurance Portability and Accountability Act of 1996 (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 web site
([www.opm.gov/insure/health):](http://www.opm.gov/insure/health):) refer
to the "TCC and HIPAA" frequently asked questions. These highlight HIPAA
rules, such as the requirement that Federal employees must exhaust any
TCC eligibility as one condition for guaranteed access to individual
health coverage under HIPAA, and 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.

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

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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.
>
> []{.mark}

**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 FSA. Because of the tax

**contribute to my FSA?** 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 deductibles you must **pay for?** 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 XX 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.
>
> TTTThis Plan's, typical out-of-pocket expenses include: *\$100 per
> delivery maternity copayment;\$500 per admission inpatient
> hospitalization copayment;\$150 per surgery outpatient surgery
> copayment; dental expenses except as noted on page 37; eyeglasses
> except as noted on page 20 and chiropractic expenses.*
>
> The IRS governs expenses reimbursable by a HCFSA. See Publication 502
> for a comprehensive list of tax-deductible medical expenses.  **Note:
> While you will see insurance premiums listed in Publication 502, they
> are NOT a reimbursable expense for FSA purposes**.  Publication 502
> can be found on the IRS Web site at
> <http://www.irs.gov/pub/irs-pdf/p502.pdf>.  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 taxes: \$13,807       \$14,383

  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 if you receive

**deductions** 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 the year for expenses up to the annual
> amount you\'ve
>
> elected to contribute.
>
> Only health care expenses exceeding 7.5% of your adjusted gross income
> are eligible to be deducted on your Federal income tax return. Using
> the example 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 exemption 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 for an HCFSA

> **to participate in FSAFEDS?** 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 web site
> or call 1-877-FSAFEDS (372-3337). Also, remember that participating in
> FSAFEDS can cost you money if you don't spend your entire account
> balance by the end of the plan year 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 Web site** 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 37

Allergy tests 18

Allogenetic (donor) bone marrow

transplant 25

Alternative treatment 22

Ambulance 29

Anesthesia 25

Autologous bone marrow transplant 25

**B**iopsies 23

Blood and blood plasma 26

Breast cancer screening 16

**C**asts 26

Catastrophic protection 13

Changes for 2004 9

Chemotherapy 19

Childbirth 17

Chiropractic 22

Cholesterol tests 16

Claims 39

Coinsurance 13

Colorectal cancer screening 16

Congenital anomalies 24

Coordination of benefits 42

Covered providers 7

Crutches 21

**D**eductible 13

Definitions 47

Dental care 37

Diagnostic services 15

Disputed claims review 40

Donor expenses (transplants) 25

Dressings 26

Durable medical equipment (DME) 21

**E**ducational classes and programs 22

Effective date of enrollment 48

Emergency 28

Experimental or investigational 38

Eyeglasses 20

**F**amily planning 17

Fecal occult blood test 16

**G**eneral Exclusions 38

**H**earing services 20

Home health services 22

Hospice care 27

Home nursing care 22

Hospital 26

**I**mmunizations 16

Infertility 18

Inhospital physician care 26

Inpatient Hospital Benefits 26

Insulin 34

**L**aboratory and pathological services 15 (After flow)

Magnetic Resonance Imagings (MRIs) 15

Mammograms 16

Maternity Benefits 17

Medicaid 46

Medicare 42

Mental Conditions/Substance Abuse Benefits 30

Newborn care 17

Nurse

Licensed Practical Nurse 22

Registered Nurse 22

Nursery charges 17

**O**bstetrical care 17

Occupational therapy 19

Office visits 15

Oral and maxillofacial surgery 24

Orthopedic devices 21

Out-of-pocket expenses 13

Outpatient facility care 27

**P**ap test 16

Physical examination 16

Physical therapy 19

Physician 10

Precertification 12

Preventive care, adult 16

Preventive care, children 16

Prescription drugs 32

Preventive services 16

Prior approval 12

Prostate cancer screening 16

Prosthetic devices 21

Psychologist 30

**R**adiation therapy 19

Room and board 26

**S**econd surgical opinion 15

Skilled nursing facility care 27

Smoking cessation 22,35

Speech therapy 19

Splints 26

Sterilization procedures 17

Subrogation 46

Substance abuse 30

Surgery 23

-   Anesthesia 25

```{=html}
<!-- -->
```
-   Oral 24

-   Outpatient 27

-   Reconstructive 24

    Syringes 34

    **T**emporary continuation of coverage 50

    Transplants 25

Treatment therapies 19

**V**ision services 20

**W**ell child care 16

Wheelchairs 21

Workers' compensation 46

**X**-rays 15

  -----------------------------------------------------------------------
  **Summary of benefits for OSF HealthPlans - 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.

```{=html}
<!-- -->
```
-   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.

```{=html}
<!-- -->
```
-   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:  | Office visit copay:  | > |
|                                           | \$20 primary care;   |   |
| -   Diagnostic and treatment services     | \$20 specialist      | 1 |
|     provided in the office                |                      | 5 |
+-------------------------------------------+----------------------+---+
| Services provided by a hospital:          | \$500 per admission  | 2 |
|                                           |                      | 6 |
| -   Inpatient                             | \$150 per outpatient |   |
|                                           | surgery              | 2 |
| -   Outpatient                            |                      | 7 |
+-------------------------------------------+----------------------+---+
| Emergency benefits:                       | \$100 per emergency  | 2 |
|                                           | room visit at a      | 8 |
| -   In-area                               | hospital (waived if  |   |
|                                           | admitted).\          | 2 |
| -   Out-of-area                           | \                    | 9 |
|                                           | \$100 per emergency  |   |
|                                           | room visit at a      |   |
|                                           | hospital (waived if  |   |
|                                           | admitted)            |   |
+-------------------------------------------+----------------------+---+
| > Mental health and substance abuse       | Regular cost sharing | > |
| > treatment                               |                      |   |
|                                           |                      | 3 |
|                                           |                      | 0 |
+-------------------------------------------+----------------------+---+
| Prescription drugs                        | > \$10/\$20 copay    | > |
|                                           | > for generic drugs; |   |
| For up to a 34-day supply or 35-90 day    | > \$20/\$40 copay    | 3 |
| supply per prescription unit or refill,   | > for preferred name | 2 |
| depending on where you fill your          | > brand drugs when   |   |
| prescription. The first copay is for up   | > no generic drug is |   |
| to a 34-day supply, and the second copay  | > available;         |   |
| is for a 35-90 day supply.                | > \$40/\$80 copay    |   |
|                                           | > for non-preferred  |   |
|                                           | > name brand drugs   |   |
|                                           | > when no generic    |   |
|                                           | > drug is available; |   |
|                                           | > and \$10/\$20      |   |
|                                           | > copay plus the     |   |
|                                           | > price difference   |   |
|                                           | > between the name   |   |
|                                           | > brand drug and the |   |
|                                           | > generic drug for   |   |
|                                           | > the preferred or   |   |
|                                           | > non-preferred name |   |
|                                           | > brand drug when    |   |
|                                           | > requested by you   |   |
|                                           | > or the physician   |   |
|                                           | > when a generic     |   |
|                                           | > drug is available. |   |
+-------------------------------------------+----------------------+---+
| Dental Care Accidental injury benefit     | > Nothing            | > |
| only                                      |                      |   |
|                                           |                      | 3 |
|                                           |                      | 7 |
+-------------------------------------------+----------------------+---+
| Vision Care One refraction every          | > \$20 per visit     | > |
| twenty-four (24) months                   |                      |   |
|                                           |                      | 2 |
|                                           |                      | 0 |
+-------------------------------------------+----------------------+---+
| > Special features: Services for deaf and |                      | > |
| > hearing impaired; and Centers of        |                      |   |
| > excellence for transplants.             |                      | 3 |
|                                           |                      | 6 |
+-------------------------------------------+----------------------+---+
| Protection against catastrophic costs     | Nothing after        | > |
|                                           | \$1,500/Self Only or |   |
| (your out-of-pocket maximum)              | \$3,000/Family       | 1 |
|                                           | enrollment per year  | 3 |
|                                           |                      |   |
|                                           | Some costs do not    |   |
|                                           | count toward this    |   |
|                                           | protection           |   |
+-------------------------------------------+----------------------+---+

**2004 Rate Information for**

**OSF HealthPlans, 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.
Refer to the applicable FEHB Guide.

+--------------+-----+-------+-------+-------+-------+-------+-------+
|              |     | **    |       |       |       | **P   |       |
|              |     | Non-P |       |       |       | ostal |       |
|              |     | ostal |       |       |       | Prem  |       |
|              |     | Prem  |       |       |       | ium** |       |
|              |     | ium** |       |       |       |       |       |
+--------------+-----+-------+-------+-------+-------+-------+-------+
|              |     | *     |       | **[Mo |       | *     |       |
|              |     | *[Biw |       | nthly |       | *[Biw |       |
|              |     | eekly |       | ]{.un |       | eekly |       |
|              |     | ]{.un |       | derli |       | ]{.un |       |
|              |     | derli |       | ne}** |       | derli |       |
|              |     | ne}** |       |       |       | ne}** |       |
+--------------+-----+-------+-------+-------+-------+-------+-------+
| **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** |
+--------------+-----+-------+-------+-------+-------+-------+-------+

**Location Information: Central Illinois and Central-Northwestern
Illinois**

  --------------- --------- -------------- ------------- -------------- -------------- -------------- -------------
  **Self Only**   **9F1**   **\$98.09**    **\$32.69**   **\$212.52**   **\$70.84**    **\$116.07**   **\$14.71**

  **Self and      **9F2**   **\$257.96**   **\$85.98**   **\$558.90**   **\$186.30**   **\$305.25**   **\$38.69**
  Family**                                                                                            
  --------------- --------- -------------- ------------- -------------- -------------- -------------- -------------