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Sioux Valley Health Plan

http://www.siouxvalley.org

**2004**

**Serving:** **Central, Eastern South Dakota and counties surrounding
the** ![](media/image2.png){width="1.4868055555555555in"
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**Rapid City area, and Northwestern Iowa**

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

**Geographic service area to enroll. See page 4 for requirements.**

Sioux Valley Health Plan and Sioux Valley Health Plan of Minnesota

Commercial HMO products received NCQA Commendable MCO Accreditation
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on July 15, 2003 effective through July 15, 2004.

NCQA\'s New Health Plan Accreditation Program applies to health

plans that are less than two years old. The program is distinct from

NCQA\'s MCO Accreditation Program.

**Enrollment codes for this Plan:**

**AU1 High Option Self Only**

**AU2 High Option Self and Family**

**AU4 Standard Option Self Only**

> **AU 5 Standard Option Self and Family**

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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!

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

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

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

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

# 

# ![](media/image8.png){width="1.225in" height="1.0611111111111111in"} ![](media/image9.png){width="1.1555555555555554in" height="0.9055555555555556in"}

# Notice of the Office of Personnel Management's

# Privacy Practices

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

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

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

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

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

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

4.  Where required by law.

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

1.  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.

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

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

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

1.  For Government healthcare oversight activities (such as fraud and
    abuse investigations),

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

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

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

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

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

2.  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.

3.  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.

4.  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).

5.  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.

6.  Get a separate paper copy of this notice.

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

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

Privacy Complaints

Office of Personnel Management

P.O. Box 707

Washington, DC 20004-0707

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

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

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  Table of Contents
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Introduction............................................................................
1

Plain Language 1

Stop Health Care Fraud! 1

Preventing Medical Mistakes 2

Section 1. Facts about this HMO plan 4

We also have point-of-service (POS) benefits 4

How we pay providers 4

Your Rights 4

Service Area 4

Section 2. How we changed for 2004 6

Program-wide changes 6

Changes to this Plan 6

Section 3. How you get care 7

Identification cards 7

Where you get covered care 7

-   Plan providers 7

-   Plan facilities 7

    What you must do to get covered care 7

-   Primary care 7

-   Specialty care 7

-   Hospital care 8

    Circumstances beyond our control 9

    Services requiring our prior approval 9

    Section 4. Your costs for covered services 10

-   Copayments 10

-   Deductible 10

-   Coinsurance 10

Your catastrophic protection out-of-pocket maximum 10

Section 5. Benefits 11

Overview 11

(a) Medical services and supplies provided by physicians and other
    health care professionals 12

(b) Surgical and anesthesia services provided by physicians and other
    health care professionals 20

(c) Services provided by a hospital or other facility, and ambulance
    services 23

(d) Emergency services/accidents 25

(e) Mental health and substance abuse benefits 27

(f) Prescription drug benefits 28

(g) Special features 30

-   24 Hour Nurse Line

-   Services for deaf and hearing impaired

-   Pregnancy Program

-   Centers of Excellence for transplants

    \(h\) Dental
    benefits........................................................................................................................31

    \(i\) Point of service product 32

    Section 6. General exclusions \-- things we don\'t cover 35

    Section 7. Filing a claim for covered services 36

    Section 8. The disputed claims process 37

    Section 9. Coordinating benefits with other coverage 39

    When you have other health
    coverage.................................................................................................
    39

-   What is Medicare 39

-   Medicare managed care plan 42

-   TRICARE and CHAMPVA 42

-   Workers' Compensation 42

-   Medicaid 43

-   Other Government agencies 43

-   When others are responsible for injuries 43

    Section 10. Definitions of terms we use in this brochure 44

    Section 11. FEHB facts 46

    Coverage information 46

-   No pre-existing condition limitation 46

-   Where you get information about enrolling in the FEHB Program 46

-   Types of coverage available for you and your family 46

-   Children's Equity Act 46

-   When benefits and premiums start 47

-   Your medical and claims records are confidential 47

-   When you retire 48

    When you lose benefits 48

-   When FEHB coverage ends 48

-   Spouse equity coverage 48

-   Temporary Continuation of Coverage (TCC) 48

-   Converting to individual coverage 48

-   Getting a Certificate of Group Health Plan Coverage 49

    Two new Federal Programs complement FEHB benefits 50

    The Federal Flexible Spending Account Program - FSAFEDS 50

    The Federal Long Term Care Insurance Program 53

    Index............ 54

    Summary of benefits 55

    Rates Back cover

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  Introduction

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This brochure describes the benefits of Sioux Valley Health Plan under
our contract (CS 2443) with the Office of Personnel Management (OPM), as
authorized by the Federal Employees Health Benefits law. This Plan is
underwritten by Sioux Valley Health Plan**.** The address for Sioux
Valley Health Plan's administrative offices is:

Sioux Valley Health Plan

1100 E. 21st St., Suite 600

Sioux Falls, SD 57105

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 6. 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
    Sioux Valley Health Plan*.*

-   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 or e-mail OPM at
    fehbwebcomments@opm.gov. You may also write to OPM at the Office of
    Personnel Management, Office of Insurance Planning and Evaluation
    Division, 1900 E Street, NW Washington, DC 20415-3650*.*

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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.

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

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

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

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

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

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

-   If the provider does not resolve the matter, call us at
    605/328328-6868 and explain the situation.

-   If we do not resolve the issue:

    **CALL \-- THE HEALTH CARE FRAUD HOTLINE**

    **202-418-3300**

    **OR WRITE TO:**

    The United States Office of Personnel Management

    Office of the Inspector General Fraud Hotline

    1900 E Street, NW, Room 6400

    Washington, DC 20415

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

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

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

-   If you have any questions about the eligibility of a dependent,
    check with your personnel office if you are employed or with OPM if
    you are retired.

-   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:

-   **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.

-   **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.

-   **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.

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-   Call your doctor and ask for your results.

-   Ask what the results mean for your care.

-   **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.

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

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

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

-   Ask your surgeon:

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

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

> Want more information on patient safety?

-   www.ahrq.gov/consumer/pathqpack.htm. 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. The National Patient Safety Foundation has information
    on how to ensure safer healthcare for you and your family.

-   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. The Leapfrog Group is active in promoting
    safe practices in hospital care.

-   www.ahqa.org. The American Health Quality Association represents
    organizations and healthcare professionals working to improve
    patient safety.

-   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). To receive
in-network benefit coverage, the Plan requires you to see specific
physicians, hospitals, and other providers that contract with us. These
Plan providers coordinate your health care services. You are encouraged
to select a Sioux Valley Health Plan participating Primary Care Provider
(PCP) to provide and coordinate your healthcare services. However, the
Plan does not require that you select a PCP or that a PCP refer you for
specialty care. You can self-refer yourself to a Sioux Valley Health
Plan participating specialty provider at any time. 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,
coinsurance, and deductibles described in this brochure. When you
receive emergency services from non-Plan providers, you may have to
submit claim forms.

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

**We also have Point-of-Service (POS) benefits:**

Our HMO offers Point-of-Service (POS) benefits. This means you can
receive covered services from a participating provider without a
required referral, or from a non-participating provider. These
out-of-network benefits have higher out-of-pocket costs than our
in-network benefits.

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 or deductible (if applicable).

**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) lists the
specific types of information that we must make available to you. Some
of the required information is listed below.

-   Years in existence

-   Profit status

    If you want more information about us, call 1-800/752-5863, or write
    to Sioux Valley Health Plan, PO Box 91110, Sioux Falls, SD
    57109-1110. You may also contact us by fax at 605/328-6812 or visit
    our website at www.siouxvalley.org.

    **Service Area**

    To enroll in this Plan, you must live in our Service Area. This is
    where our providers practice.

    In South Dakota our service area is: Aurora, Beadle, Bennett, Bon
    Homme, Brookings, Brown, Brule, Buffalo, Butte, Campbell, Charles
    Mix, Clark, Clay, Codington, Davison, Day , Deuel, Douglas, Edmunds,
    Faulk, Grant, Gregory, Hamlin, Hand, Hanson, Hughes, Hutchinson,
    Hyde, Jerauld, Kingsbury, Lake, Lawrence, Lincoln, Lyman, Marshall,
    McCook, McPherson, Meade, Miner, Minnehaha, Moody, Potter, Roberts,
    Sanborn, Spink, Stanley, Sully, Todd, Tripp, Turner, Union,
    Walworht, and Yankton.

    In Iowa our service area is: Clay, Dickinson, Emmet, Lyon, O'Brien,
    Ocseola, and Sioux.

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

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

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

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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** {#program-wide-changes .unnumbered}

-   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 50.

-   We added information regarding Preventing medical mistakes. See page
    2.

-   We added information regarding enrolling in Medicare. See page 39.

-   We revised the Medicare Primary Payer Chart. See page 41.

## **Changes to this Plan** {#changes-to-this-plan .unnumbered}

-   We are offering a new Standard Option Plan, AU4 and AU5 (High Option
    is now AU1 and AU2).

-   Your share of the non-Postal premium for High Option will increase
    by 59.6% for Self Only or 61% for Self and Family.

-   Your specialist office visit copayment increases from \$20 copay to
    \$30 copay per visit. (Section 5(a))

-   Your inpatient hospital copayment increases from \$100 copay per
    admission to \$100 copay per day up to \$500 per admission. (Section
    5 (c)).

-   Your ambulance services copayment is \$50. The copayment is waived
    if you are admitted. (Section 5 (c)).

-   Your prescription drugs copayment increase from:

    \$10 to \$15 for Generic Drugs

    \$20 to \$30 for formulary Band Name Drugs

    \$35 to \$50 for *non-formulary* Brand Name Drugs

    (See Section 5(f)).

-   Your copayment for diabetic supplies increased from \$10 to \$15
    (See Section 5(f)).

-   Your home health service copayment is \$20 per visit. (Section
    5(a)).

-   Your Out of Pocket Maximum will increase from \$1,500 to \$4,000 for
    Self Only and from \$3,000 to \$4,000 for Self and Family. (Section
    4).

-   Your maternity care benefit includes 2 routine sonograms per
    pregnancy to determine fetal age, size or sex. (Section 5(a)).

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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
1-800/752-5863 or write to us at PO Box 91110 Sioux Falls, SD
57109-1110. You may also request replacement cards through our website
at www.siouxvalley.org.

**Where you get covered care** You get care from "Plan providers" and
"Plan facilities." You will only pay copayments, deductibles, and/or
coinsurance, and you will not have to file claims. If you use our
point-of-service program, you can also get care from non-Plan providers,
or from participating providers without a required referral, but it will
cost you more. You may also have to file your own 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 you. We credential Plan providers according to the
NCQA national standards.

We list Plan providers in the provider directory, which we update
periodically. The list is also on our website.

**•Plan facilities** Plan facilities are hospitals and other facilities
in our service area that we contract with to provide covered services to
you. We list these in the provider directory, which we update
periodically. The list is also on our website.

It depends on the type of care you need. First, you and each family
member are encouraged, but not required, to select a primary care
physician. This decision is important since your primary care physician
provides or arranges for most of your health care. Primary care
physicians are included in our provider directory. You may choose the
physician who best meets your needs.

**• Primary care** Your primary care physician can be a family
practitioner, internist, pediatrician, general practitioner or OB/GYN.
Your primary care physician will provide most of your health care, or
give you a referral to see a specialist. Appropriate access for Primary
Care Physicians and Hospital Provider sites is within thirty (30) miles
of your city of residence. Appropriate access includes access to our
providers when you have traveled outside of the service area. If you are
traveling within the service area where other Plan providers are
available then you must use Plan providers.

If you want to change primary care physicians or if your primary care
physician leaves the Plan, call us. We will help you select a new one.

**• Specialty care** Your primary care physician may refer you to a
specialist for needed care. However, you may also self--refer to Plan
specialist providers. No referral is necessary. Appropriate access for
Specialty Physicians and Hospital Provider sites is within ninety (90)
miles of your city of residence. Appropriate access includes access to
Plan providers when you have traveled outside of the service area. If
you are traveling within the service area where other Plan providers are
available then you must use Plan providers.

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, you may directly access the
specialist for needed services.

• 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 at the in-network
benefit level if you choose 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

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

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

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

    If you are in the second or third trimester of pregnancy 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 Member Service department immediately at 605/328-6800 or
    1-800/752-5863 (TYY 605/328-6869). 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:

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

    **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.

##   {#section-2 .unnumbered}

You are ultimately responsible for obtaining prior authorization from
the Health Services Department in order to receive In-Network coverage.
However, information provided by the provider's office will also satisfy
this requirement. Primary care physicians and any Participating
Specialists have been given instructions on how to get the necessary
authorizations for surgical procedures or hospitalizations you may need.

We determine approval for prior authorization based on appropriateness
of care and service and existence of coverage.

**Services that Require Prior Authorization Include:**

-   Inpatient hospital admissions including admissions for medical,
    surgical, neonatal intensive care nursery, mental health and
    chemical dependency services;

-   Partial Hospital Program (PHP)/Day Treatment for mental health and
    chemical dependency services;

-   Selected Outpatient Surgeries;

-   Physician office site surgical center;

-   Home Health, Hospice and Home IV therapy services;

-   Durable Medical Equipment (rental or purchase over \$200);

-   Rehabilitative services; including speech, occupational and physical
    therapy and one to one water therapy;

-   Skilled nursing and sub-acute care;

-   Organ transplants;

-   Ambulance Services for non-emergency situations; and

-   Referrals to Non-Participating Providers which are recommended by
    Participating Providers. Prior authorization is required for the
    purposes of receiving In-Network coverage only. If prior
    authorization is not obtained for referrals to Non-Participating
    Providers, the services will be covered at the Out of Network
    coverage level. Prior authorization does not apply to services that
    are provided by Non-Participating Providers as a result of a lack of
    appropriate access to Participating Providers as described in Part
    III, Section A.

    **Prior approval Process** To receive detailed instructions on the
    prior authorization process for elective inpatient

    hospitalizations, non urgent care, pharmaceutical decisions,
    behavioral health, urgent/emergency conditions, concurrent review
    and retrospective review (post-service) contact our Health Services
    Department, available between the hours of 8:00a.m. and 5:00p.m.
    Central Standard Time, Monday through Friday, by calling our
    toll-free number 1-800-805-7938 or (650)328-6807. After hours you
    may leave a message on the confidential voice mail of the Health
    Services Department and someone will return your call. You are
    ultimately responsible for obtaining prior authorization from the
    Health Services Department. Failure to obtain prior authorization
    will result in a reduction to the Out of Network benefits level.
    However, information provided by the physician's office also
    satisfies this requirement.

  -----------------------------------------------------------------------
  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
provider, facility, pharmacy, etc., when you receive services.

Example: Under High Option, your office visit copayment per visit is
\$20 for primary care physicians and \$30 for Specialist. Under Standard
Option, office visit copayments are \$25 per visit.

**•Deductible** A deductible is a fixed expense you must incur for
certain covered services and supplies before we start paying benefits
for them.

Example: Under High Option, deductibles only apply when you use our
Point of Services (POS) benefits. There is a \$500 deductible for Self
enrollment and a \$1,000 deductible for Self and Family enrollment.
Under Standard Option, deductibles apply to both Participating providers
and POS benefits. The deductible for Participating provider benefits is
\$500 Self enrollment and \$1,000 Self and Family. The POS benefit
deductible is \$1,000 Self enrollment and \$3,000 Self and Family.

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.

And, if you change options in this Plan during the year, we will credit
the amount of covered expenses already applied toward the deductible of
your old option to the deductible of your new option.

**•Coinsurance** Coinsurance is the percentage of our negotiated fee
that you must pay for certain in-network and all out-of-network care.
Coinsurance doesn't begin until you meet your deductible (there is no
deductible for in-network care under the High Option).

Example: Under **High Option,** you pay 40% of our allowance for medical
office visits when you receive services from a Non-Participating
Provider or you pay 20% of our negotiated fee for durable medical
equipment and orthopedic appliances received by in-network providers.
Under **Standard Option,** you pay 20% of our allowance for office
visits when you receive services from Participating Providers or you pay
40% of our allowance for medical office visits when you receive services
from non-Participating Providers with POS benefits.

Under the **High Option,** after your in-network copayments total
\$4,000 Self enrollment or \$4,000 Self and Family enrollment in any
calendar year, you do not have to pay any more for covered services.
Under the **Standard Option**, after your in-network copayments and
coinsurances total \$3,000 Self enrollment or \$4,000 Self and Family
enrollment in any calendar year, you do not have to pay any more for
covered services. However, copayments for the following services do not
count toward your catastrophic protection out-of-pocket maximum, and you
must continue to pay copayments for these services:

-   Prescription drugs; and

-   Physician office visits.

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

+-----------------------------------------------------------------------+
| **Section 5. Benefits -- OVERVIEW**                                   |
|                                                                       |
| ***(See page 6 for how our benefits changed this year and pages 55-56 |
| 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
1-800/752-5863 (TYY at 605/328-6869).

(a) Medical services and supplies provided by physicians and other
    health care professionals ...16

+---------------------------------+------------------------------------+
| -   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      |
| -   Infertility services        |     (DME)                          |
|                                 |                                    |
| -   Allergy care                | -   Home health services           |
|                                 |                                    |
| -   Treatment therapies         | -   Chiropractic                   |
|                                 |                                    |
| -   Physical, cardiac and       | -   Alternative treatments         |
|     occupational therapies      |                                    |
|                                 | -   Educational classes and        |
|                                 |     programs                       |
+---------------------------------+------------------------------------+

(a) Surgical and anesthesia services provided by physicians and other
    health care professionals 20

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

(a) Services provided by a hospital or other facility, and ambulance
    services 23

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

(a) Emergency services/accidents 25

    •Medical emergency •Ambulance

(b) Mental health and substance abuse benefits 27

(c) Prescription drug benefits 28

(d) Special features 30

> • 24 Hour Nurse Line

-   Services for deaf and hearing impaired

-   Pregnancy Program

-   Centers of Excellence for transplants

    \(h\) Dental benefits 31

    \(i\) Point of service benefits .32

    Summary of benefits 55-56

+---+---+------------------------------------+---+-------------+---+------+---+---+
| * |   |                                    |   |             |   |      |   |   |
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| s |   |                                    |   |             |   |      |   |   |
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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    |   |             |   |      | * |   |
|   | M |     and are payable only when we   |   |             |   |      | M |   |
|   | * |     determine they are medically   |   |             |   |      | * |   |
|   | * |     necessary.                     |   |             |   |      | * |   |
|   |   |                                    |   |             |   |      |   |   |
|   | * | -   **Under High Option,** we have |   |             |   |      | * |   |
|   | * |     no calendar year deductible    |   |             |   |      | * |   |
|   | P |     for In Network services.       |   |             |   |      | P |   |
|   | * |                                    |   |             |   |      | * |   |
|   | * | -   **Under Standard Option,** the |   |             |   |      | * |   |
|   |   |     calendar year deductible for   |   |             |   |      |   |   |
|   | * |     In Network services is \$500   |   |             |   |      | * |   |
|   | * |     per person (\$1,000 per        |   |             |   |      | * |   |
|   | O |     family). The calendar year     |   |             |   |      | O |   |
|   | * |     deductible applies to almost   |   |             |   |      | * |   |
|   | * |     all benefits in this section.  |   |             |   |      | * |   |
|   |   |     We added "(No deductible)" to  |   |             |   |      |   |   |
|   | * |     show when the calendar year    |   |             |   |      | * |   |
|   | * |     deductible does not apply.     |   |             |   |      | * |   |
|   | R |                                    |   |             |   |      | R |   |
|   | * | -   **Under both High and Standard |   |             |   |      | * |   |
|   | * |     Options,** you must use Plan   |   |             |   |      | * |   |
|   |   |     Providers in order to receive  |   |             |   |      |   |   |
|   | * |     In Network benefit coverage.   |   |             |   |      | * |   |
|   | * |                                    |   |             |   |      | * |   |
|   | T | -   Be sure to read Section 4,     |   |             |   |      | T |   |
|   | * |     *Your costs for covered        |   |             |   |      | * |   |
|   | * |     services,* for valuable        |   |             |   |      | * |   |
|   |   |     information about how cost     |   |             |   |      |   |   |
|   | * |     sharing works. Also read       |   |             |   |      | * |   |
|   | * |     Section 9 about coordinating   |   |             |   |      | * |   |
|   | A |     benefits with other coverage,  |   |             |   |      | A |   |
|   | * |     including with Medicare.       |   |             |   |      | * |   |
|   | * |                                    |   |             |   |      | * |   |
|   |   |                                    |   |             |   |      |   |   |
|   | * |                                    |   |             |   |      | * |   |
|   | * |                                    |   |             |   |      | * |   |
|   | N |                                    |   |             |   |      | N |   |
|   | * |                                    |   |             |   |      | * |   |
|   | * |                                    |   |             |   |      | * |   |
|   |   |                                    |   |             |   |      |   |   |
|   | * |                                    |   |             |   |      | * |   |
|   | * |                                    |   |             |   |      | * |   |
|   | T |                                    |   |             |   |      | T |   |
|   | * |                                    |   |             |   |      | * |   |
|   | * |                                    |   |             |   |      | * |   |
+---+---+------------------------------------+---+-------------+---+------+---+---+
| * |   |                                    |   | **You pay   |   | *    |   |   |
| * |   |                                    |   | -**         |   | *You |   |   |
| B |   |                                    |   |             |   | pay  |   |   |
| e |   |                                    |   | **High      |   | -**  |   |   |
| n |   |                                    |   | Option**    |   |      |   |   |
| e |   |                                    |   |             |   | **   |   |   |
| f |   |                                    |   |             |   | Stan |   |   |
| i |   |                                    |   |             |   | dard |   |   |
| t |   |                                    |   |             |   | Opti |   |   |
| D |   |                                    |   |             |   | on** |   |   |
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| * |   |                                    |   |             |   |      |   |   |
| * |   |                                    |   |             |   |      |   |   |
+---+---+------------------------------------+---+-------------+---+------+---+---+
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| # |   |                                    |   |             |   |      |   |   |
| # |   |                                    |   |             |   |      |   |   |
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+---+---+------------------------------------+---+-------------+---+------+---+---+
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| r |   |                                    |   | per primary |   | c    |   |   |
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| f |   |                                    |   |             |   | pri  |   |   |
| e |   |                                    |   | \$30 copay  |   | mary |   |   |
| s |   |                                    |   | per         |   | or   |   |   |
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+---+---+------------------------------------+---+-------------+---+------+---+---+
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+---+---+------------------------------------+---+-------------+---+------+---+---+
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+---+---+------------------------------------+---+-------------+---+------+---+---+
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| d |   |                                    |   |             |   |      |   |   |
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|   |   |                                    |   |             |   |      |   |   |
|   |   |                                    |   |             |   |      |   |   |
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| r |   |                                    |   |             |   |      |   |   |
| s |   |                                    |   |             |   |      |   |   |
+---+---+------------------------------------+---+-------------+---+------+---+---+
| * |   |                                    |   | *All        |   | *All |   |   |
| N |   |                                    |   | charges.*   |   | char |   |   |
| o |   |                                    |   |             |   | ges* |   |   |
| t |   |                                    |   |             |   |      |   |   |
| c |   |                                    |   |             |   |      |   |   |
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| - |   |                                    |   | \$20 copay  |   | \$25 |   |   |
|   |   |                                    |   | per primary |   | c    |   |   |
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+---+---+------------------------------------+---+-------------+---+------+---+---+
| V |   |                                    |   | 20% of      |   | 20%  |   |   |
| o |   |                                    |   | charges per |   | of   |   |   |
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| u |   |                                    |   | admission,  |   | rges |   |   |
| n |   |                                    |   |             |   |      |   |   |
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+---+---+------------------------------------+---+-------------+---+------+---+---+
| * |   |                                    |   | *All        |   | *All |   |   |
| N |   |                                    |   | charges.*   |   | char |   |   |
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| t |   |                                    |   |             |   |      |   |   |
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| s |   |                                    |   |             |   |      |   |   |
| t |   |                                    |   |             |   |      |   |   |
| i |   |                                    |   |             |   |      |   |   |
| n |   |                                    |   |             |   |      |   |   |
| g |   |                                    |   |             |   |      |   |   |
| . |   |                                    |   |             |   |      |   |   |
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+---+---+------------------------------------+---+-------------+---+------+---+---+

#########  {#section-3 .unnumbered}

+------------------------------------------+-------------+-------------+
| **Infertility services**                 | **You pay   | **You pay   |
|                                          | -**         | -**         |
|                                          |             |             |
|                                          | **High      | **Standard  |
|                                          | Option**    | Option**    |
+------------------------------------------+-------------+-------------+
| Diagnosis and treatment of infertility,  | \$30 per    | 20% of      |
| such as:                                 | specialist  | charges     |
|                                          | visit       |             |
| Artificial insemination:                 |             |             |
|                                          | 20% of      |             |
| -   Intravaginal insemination (IVI)      | charges per |             |
|                                          | inpatient   |             |
| -   Intra­cervical insemination (ICI)     | admission   |             |
|                                          |             |             |
| -   Intrauterine insemina­tion (IUI)      | \$50 per    |             |
|                                          | outpatient  |             |
|                                          | surgery     |             |
+------------------------------------------+-------------+-------------+
| *Not covered:*                           | *All        | *All        |
|                                          | charges.*   | charges*    |
| -   *Assisted reproductive technology    |             |             |
|     (ART) procedures, such as:*          |             |             |
|                                          |             |             |
| -   *In vitro fertilization*             |             |             |
|                                          |             |             |
| -   *Embryo transfer, gamete GIFT and    |             |             |
|     zygote ZIFT*                         |             |             |
|                                          |             |             |
| -   *Zygote transfer*                    |             |             |
|                                          |             |             |
| -   *Services and supplies related to    |             |             |
|     excluded ART procedures*             |             |             |
|                                          |             |             |
| -   *Cost of donor sperm*                |             |             |
|                                          |             |             |
| -   *Cost of donor egg*                  |             |             |
|                                          |             |             |
| -   *Fertility drugs*                    |             |             |
|                                          |             |             |
| -   *Expenses related to surrogate       |             |             |
|     parenting*                           |             |             |
|                                          |             |             |
| -   *Other preservation techniques*      |             |             |
+------------------------------------------+-------------+-------------+
| #####                                    |             |             |
| Allergy care {#allergy-care .unnumbered} |             |             |
+------------------------------------------+-------------+-------------+
| -   Testing and treatment                | \$30 per    | \$25 copay  |
|                                          | specialist  | per visit   |
| -   Allergy injection                    | visit       | (No         |
|                                          |             | deductible) |
+------------------------------------------+-------------+-------------+
| Allergy serum                            | Nothing     | Nothing     |
+------------------------------------------+-------------+-------------+
| *Not covered: provocative food testing   | *All        | *All        |
| and sublingual allergy desensitization.* | charges.*   | charges*    |
+------------------------------------------+-------------+-------------+
| **Treatment therapies**                  |             |             |
+------------------------------------------+-------------+-------------+
| -   Chemotherapy and radiation therapy   | \$30 per    | 20% of      |
|                                          | specialist  | charges     |
|     NOTE: High dose chemotherapy in      | visit       |             |
|     association with autologous bone     |             |             |
|     marrow transplants are limited to    |             |             |
|     those transplants listed under       |             |             |
|     *Organ/Tissue Transplants in Section |             |             |
|     5(b).*                               |             |             |
|                                          |             |             |
| -   Respiratory and inhalation therapy   |             |             |
|                                          |             |             |
| -   Dialysis -- hemodialysis and         |             |             |
|     peritoneal dialysis                  |             |             |
|                                          |             |             |
| -   Intravenous (IV)/Infusion Therapy -- |             |             |
|     Home IV and antibiotic therapy       |             |             |
|                                          |             |             |
| -   Growth hormone therapy (GHT)         |             |             |
|                                          |             |             |
|     NOTE: Growth hormone is covered      |             |             |
|     under the medical benefit.           |             |             |
|                                          |             |             |
|     NOTE: We will only cover GHT when we |             |             |
|     pre-authorize the treatment. Call    |             |             |
|     1-800/805-7938 for prior approval.   |             |             |
|     We will ask you to submit            |             |             |
|     information that establishes that    |             |             |
|     the GHT is medically necessary. Ask  |             |             |
|     us to authorize GHT before you begin |             |             |
|     treatment; otherwise, we will only   |             |             |
|     cover GHT services from the date you |             |             |
|     submit the information. If you do    |             |             |
|     not ask or if we determine GHT is    |             |             |
|     not medically necessary, we will not |             |             |
|     cover the GHT or related services    |             |             |
|     and supplies. See *Services          |             |             |
|     requiring our prior approval* *in    |             |             |
|     Section 3.*                          |             |             |
+------------------------------------------+-------------+-------------+

+------------------------------------------+-------------+-------------+
| **Physical, cardiac and occupational     | **You pay   | **You pay   |
| therapies**                              | -**         | -**         |
|                                          |             |             |
|                                          | **High      | **Standard  |
|                                          | Option**    | Option**    |
+------------------------------------------+-------------+-------------+
| Coverage up to 2 consecutive months per  | \$30 per    | 20% of      |
| condition for the services of each of    | outpatient  | charges     |
| the following:                           | visit       |             |
|                                          |             |             |
| -   qualified physical therapists        | Nothing per |             |
|                                          | visit       |             |
| -   occupational therapists              | during      |             |
|                                          | covered     |             |
|     NOTE: We only cover therapy to       | inpatient   |             |
|     restore bodily function when there   | admission   |             |
|     has been a total or partial loss of  |             |             |
|     bodily function due to illness or    |             |             |
|     injury (see *Services requiring our  |             |             |
|     Prior Approval in Section 3).*       |             |             |
|                                          |             |             |
| -   Cardiac rehabilitation following a   |             |             |
|     heart transplant, bypass surgery or  |             |             |
|     a myocardial infarction.             |             |             |
+------------------------------------------+-------------+-------------+
| -   *Not covered:*                       | *All        | *All        |
|                                          | charges.*   | charges*    |
| -   *long-term rehabilitative therapy*   |             |             |
|                                          |             |             |
| -   *exercise programs*                  |             |             |
+------------------------------------------+-------------+-------------+
| **Speech therapy**                       |             |             |
+------------------------------------------+-------------+-------------+
| Coverage up to 2 consecutive months per  | \$30 per    | 20% of      |
| condition by                             | outpatient  | charges     |
|                                          | visit       |             |
| speech therapists (see *Services         |             |             |
| requiring our Prior Approval* on page    | Nothing per |             |
| 9).                                      | visit       |             |
|                                          | during      |             |
|                                          | covered     |             |
|                                          | inpatient   |             |
|                                          | admission   |             |
+------------------------------------------+-------------+-------------+
| *Not covered:*                           | *All        | *All        |
|                                          | charges.*   | charges*    |
| -   *long term therapy*                  |             |             |
+------------------------------------------+-------------+-------------+
| **Hearing services (testing, treatment,  |             |             |
| and supplies)**                          |             |             |
+------------------------------------------+-------------+-------------+
| -   First hearing aid(s) (unilateral or  | \$30 per    | \$25 copay  |
|     bilateral, one time only), and       | specialist  | per visit   |
|     testing and fitting of hearing       | visit       | (No         |
|     aid(s) when necessitated by          |             | deductible) |
|     accidental injury only.              |             |             |
|                                          |             |             |
|     NOTE: Hearing services must be       |             |             |
|     received within 6 months of injury.  |             |             |
|                                          |             |             |
| -   Hearing testing for children through |             |             |
|     age 17 (see *Preventive care,        |             |             |
|     children*)                           |             |             |
+------------------------------------------+-------------+-------------+
| *Not covered:*                           | *All        | *All        |
|                                          | charges.*   | charges*    |
| -   *all other hearing testing*          |             |             |
|                                          |             |             |
| -   *all other hearing aids*             |             |             |
|                                          |             |             |
| -   *all other hearing supplies and      |             |             |
|     services*                            |             |             |
+------------------------------------------+-------------+-------------+
| **Vision services (testing, treatment,   |             |             |
| and supplies)**                          |             |             |
+------------------------------------------+-------------+-------------+
| Eyeglasses or one pair of contact lenses | \$20 per    | \$25 copay  |
| to correct an impairment directly caused | primary     | per visit   |
| by accidental ocular injury or           | care visit  | (No         |
| intraocular surgery (such as for         |             | deductible) |
| cataracts)                               | \$30 per    |             |
|                                          | specialist  |             |
|                                          | visit       |             |
+------------------------------------------+-------------+-------------+
| Eye exam including refraction error to   | \$20 per    | \$25 copay  |
| determine the need for vision correction | primary     | per visit   |
| for children through age 17 (see         | care visit  | (No         |
| Preventive care, children)               |             | deductible) |
|                                          | \$30 per    |             |
|                                          | specialist  |             |
|                                          | visit       |             |
+------------------------------------------+-------------+-------------+
| *Not covered:*                           | *All        | *All        |
|                                          | charges*    | charges*    |
| -   *surgery for the purpose of          |             |             |
|     modifying or correcting myopia,      |             |             |
|     hyperopia or stigmatic error*        |             |             |
|                                          |             |             |
| -   *all other vision services except as |             |             |
|     described above.*                    |             |             |
+------------------------------------------+-------------+-------------+
| **Foot care**                            | **You pay   | **You pay   |
|                                          | -**         | -**         |
|                                          |             |             |
|                                          | **High      | **Standard  |
|                                          | Option**    | Option**    |
+------------------------------------------+-------------+-------------+
| Routine foot care when you are under     | \$20 per    | \$25 copay  |
| active treatment for a metabolic or      | primary     | per visit   |
| peripheral vascular disease, such as     | care visit  | (No         |
| diabetes.                                |             | deductible) |
|                                          | \$30 per    |             |
| See orthopedic and prosthetic devices    | specialist  |             |
| for information on podiatric shoe        |             |             |
| inserts.                                 |             |             |
+------------------------------------------+-------------+-------------+
| *Not covered:*                           | *All        | *All        |
|                                          | charges.*   | charges*    |
| -   *Cutting, trimming or removal of     |             |             |
|     corns, calluses, or the free edge of |             |             |
|     toenails, and similar routine        |             |             |
|     treatment of conditions of the foot, |             |             |
|     except as stated above*              |             |             |
|                                          |             |             |
| -   *Treatment of weak, strained or flat |             |             |
|     feet or bunions or spurs; and of any |             |             |
|     instability, imbalance or            |             |             |
|     subluxation of the foot (unless the  |             |             |
|     treatment is by open cutting         |             |             |
|     surgery).*                           |             |             |
+------------------------------------------+-------------+-------------+
| **Orthopedic and prosthetic devices**    |             |             |
+------------------------------------------+-------------+-------------+
| -   Artificial limbs and eyes; stump     | 20% of      | 20% of      |
|     hose                                 | charges     | charges     |
|                                          |             |             |
| -   Externally worn breast prostheses    |             |             |
|     and surgical bras, including         |             |             |
|     necessary replacements, following a  |             |             |
|     mastectomy                           |             |             |
|                                          |             |             |
| -   Internal prosthetic devices, such as |             |             |
|     artificial joints, pacemakers,       |             |             |
|     cochlear implants, and surgically    |             |             |
|     implanted breast implant following   |             |             |
|     mastectomy.                          |             |             |
|                                          |             |             |
|     NOTE: See 5(b) for coverage of the   |             |             |
|     surgery to insert the device.        |             |             |
|                                          |             |             |
| -   Corrective orthopedic appliances for |             |             |
|     *non-dental* treatment of            |             |             |
|     temporomandibular joint (TMJ) pain   |             |             |
|     dysfunction syndrome (See *Services  |             |             |
|     requiring our prior approval* *in    |             |             |
|     Section 3.)*                         |             |             |
+------------------------------------------+-------------+-------------+
| *Not covered:*                           | *All        | *All        |
|                                          | charges.*   | charges*    |
| -   *orthopedic and corrective shoes*    |             |             |
|                                          |             |             |
| -   *arch supports*                      |             |             |
|                                          |             |             |
| -   *foot orthotics*                     |             |             |
|                                          |             |             |
| -   *heel pads and heel cups*            |             |             |
|                                          |             |             |
| -   *lumbosacral supports*               |             |             |
|                                          |             |             |
| -   *corsets, trusses, elastic           |             |             |
|     stockings, support hose, and other   |             |             |
|     supportive devices*                  |             |             |
|                                          |             |             |
| -   *prosthetic replacements provided    |             |             |
|     less than 3 years after the last one |             |             |
|     we provided.*                        |             |             |
|                                          |             |             |
| -   *Dental appliances of any sort,      |             |             |
|     including but not limited to         |             |             |
|     bridges, braces, and retainers,      |             |             |
|     except those for non-dental          |             |             |
|     treatment of TMJ.*                   |             |             |
|                                          |             |             |
| -   *Wigs, scalp hair prosthesis or hair |             |             |
|     transplants*                         |             |             |
+------------------------------------------+-------------+-------------+

+------------------------------------------+-------------+-------------+
| **Durable medical equipment (DME)**      | **You pay   | **You pay   |
|                                          | -**         | -**         |
|                                          |             |             |
|                                          | **High      | **Standard  |
|                                          | Option**    | Option**    |
+------------------------------------------+-------------+-------------+
| Rental or purchase, at our option,       | 20% of      | 20% of      |
| including repairs (repairs are limited   | charges     | charges     |
| to \$750 allowable charges per year) and |             |             |
| adjustments, of durable medical          | NOTE: You   | NOTE: You   |
| equipment prescribed by your Plan        | must obtain | must obtain |
| physician, such as oxygen and dialysis   | prior       | prior       |
| equipment Under this benefit, we also    | au          | au          |
| cover:                                   | thorization | thorization |
|                                          | for         | for         |
| -   standard hospital beds;              | supplie     | supplie     |
|                                          | s/equipment | s/equipment |
| -   standard wheelchairs;                | with a      | with a      |
|                                          | retail      | retail      |
| -   crutches;                            | value of    | value of    |
|                                          | \$200 or    | \$200 or    |
| -   walkers;                             | more.       | more.       |
|                                          | Failure to  | Failure to  |
| -   canes;                               | obtain      | obtain      |
|                                          | prior       | prior       |
| -   diabetes supplies including blood    | au          | au          |
|     glucose monitors and insulin pumps;  | thorization | thorization |
|                                          | will result | will result |
| -   spacers                              | in benefits | in benefits |
|                                          | being paid  | being paid  |
| -   initial casts, braces, and/or slings | at the      | at the      |
|     provided on day of treatment;        | Point of    | Point of    |
|                                          | Service     | Service     |
| -   air compressor                       | benefit     | benefit     |
|                                          | level.      | level.      |
| -   pressure pads, mattresses, and       |             |             |
|     decubitus care equipment;            |             |             |
|                                          |             |             |
| -   apnea monitor;                       |             |             |
|                                          |             |             |
| -   sleeve compression;                  |             |             |
|                                          |             |             |
| -   home intravenous therapy supplies;   |             |             |
|                                          |             |             |
| -   commodes;                            |             |             |
|                                          |             |             |
| -   compression hose                     |             |             |
|                                          |             |             |
| NOTE: We will cover motorized            |             |             |
| wheelchairs and electric beds up to, but |             |             |
| not to exceed, the cost of standard      |             |             |
| wheelchairs or standard hospital beds.   |             |             |
| Call us at 605/328-6807 or toll free at  |             |             |
| 1-800/805-7938 as soon as your Plan      |             |             |
| physician prescribes this equipment. We  |             |             |
| will arrange with a health care provider |             |             |
| to rent or sell you durable medical      |             |             |
| equipment at discounted rates and will   |             |             |
| tell you more about this service when    |             |             |
| you call.                                |             |             |
+------------------------------------------+-------------+-------------+
| *Not covered:*                           | *All        | *All        |
|                                          | charges.*   | charges.*   |
| -   *Medical supplies/equipment that can |             |             |
|     be purchased over-the-counter*       |             |             |
|                                          |             |             |
| -   *Household equipment/fixtures, such  |             |             |
|     as air purifiers and ramps*          |             |             |
|                                          |             |             |
| -   *Convenience items*                  |             |             |
|                                          |             |             |
| -   *Self-help items*                    |             |             |
|                                          |             |             |
| -   *Educational equipment*              |             |             |
|                                          |             |             |
| -   *Communication aids or devices, such |             |             |
|     as speech processors*                |             |             |
|                                          |             |             |
| -   *Replacement or repair of items, if  |             |             |
|     the items are damaged or destroyed   |             |             |
|     by your misuse, abuse or             |             |             |
|     carelessness, lost, or stolen*       |             |             |
|                                          |             |             |
| -   *Duplicate or similar items*         |             |             |
|                                          |             |             |
| -   *Service call charges, labor         |             |             |
|     charges, charges for repair          |             |             |
|     estimates*                           |             |             |
|                                          |             |             |
| -   *Vehicle/car or van modifications    |             |             |
|     including, but not limited to, hand  |             |             |
|     brakes, hydraulic lifts and car      |             |             |
|     carrier*                             |             |             |
+------------------------------------------+-------------+-------------+
| **Home health services**                 |             |             |
+------------------------------------------+-------------+-------------+
| -   Home health care ordered by a Plan   | \$20 copay  | 20% of      |
|     physician and provided by a          | per visit   | charges     |
|     registered nurse (R.N.), licensed    |             |             |
|     practical nurse (L.P.N.), licensed   |             |             |
|     vocational nurse (L.V.N.), or home   |             |             |
|     health aide.                         |             |             |
|                                          |             |             |
| -   Services include oxygen therapy,     |             |             |
|     intravenous therapy and medications. |             |             |
|                                          |             |             |
|     NOTE: Prior Authorization is         |             |             |
|     required, failure to get prior       |             |             |
|     authorization will result in payment |             |             |
|     at the point of service level. See   |             |             |
|     *Services requiring our prior        |             |             |
|     approval* *in Section 3.*            |             |             |
+------------------------------------------+-------------+-------------+

#   {#section-4 .unnumbered}

#  {#section-5 .unnumbered}

+------------------------------------------+-------------+-------------+
| **Home health services (continued)**     | **You pay   | **You pay   |
|                                          | -**         | -**         |
|                                          |             |             |
|                                          | **High      | **Standard  |
|                                          | Option**    | Option**    |
+------------------------------------------+-------------+-------------+
| Not covered:                             | *All        | *All        |
|                                          | charges.*   | charges*    |
| -   Nursing care requested by, or for    |             |             |
|     the convenience of, the patient or   |             |             |
|     the patient's family;                |             |             |
|                                          |             |             |
| -   Home care primarily for personal     |             |             |
|     assistance that does not include a   |             |             |
|     medical component and is not         |             |             |
|     diagnostic, therapeutic, or          |             |             |
|     rehabilitative.                      |             |             |
+------------------------------------------+-------------+-------------+
| **Chiropractic**                         |             |             |
+------------------------------------------+-------------+-------------+
| -   Manipulation of the spine and        | \$20 per    | \$25 copay  |
|     extremities.                         | visit       | per visit   |
|                                          |             | (No         |
| -   Adjunctive procedures such as        |             | deductible) |
|     ultrasound, electrical muscle        |             |             |
|     stimulation and vibratory therapy.   |             |             |
|                                          |             |             |
|     NOTE: Office visits are limited to   |             |             |
|     20 visits per calendar year.         |             |             |
+------------------------------------------+-------------+-------------+
| *Not covered: Vitamins, minerals,        | *All        | *All        |
| therabands, cervical pillows, traction   | charges.*   | charges*    |
| services, and hot/cold pack              |             |             |
| application.*                            |             |             |
+------------------------------------------+-------------+-------------+
| **Alternative treatments**               |             |             |
+------------------------------------------+-------------+-------------+
| -   Acupuncture by a doctor of medicine  | \$30 per    | 20% of      |
|     or osteopathy for anesthesia pain    | specialist  | charges     |
|     relief.                              | visit       |             |
|                                          |             |             |
| -   Sleep therapy for central or         |             |             |
|     obstructive apnea when we have       |             |             |
|     approved it.                         |             |             |
+------------------------------------------+-------------+-------------+
| *Not covered:*                           | *All        | *All        |
|                                          | charges*    | charges*    |
| -   *biofeedback*                        |             |             |
|                                          |             |             |
| -   *all other homeopathic or            |             |             |
|     naturopathic services*               |             |             |
+------------------------------------------+-------------+-------------+
| **Educational classes and programs**     |             |             |
+------------------------------------------+-------------+-------------+
| Coverage is limited to:                  | Nothing     | Nothing     |
|                                          |             |             |
| -   Smoking Cessation -- Up to \$100 for |             |             |
|     one smoking cessation program per    |             |             |
|     member per lifetime, including all   |             |             |
|     related expenses such as             |             |             |
|     prescription drugs                   |             |             |
|                                          |             |             |
| -   Diabetes self-management from        |             |             |
|     qualified providers for persons who  |             |             |
|     meet plan criteria -- limited to no  |             |             |
|     more than two (2) comprehensive      |             |             |
|     education programs per lifetime and  |             |             |
|     up to eight (8) follow-up visits per |             |             |
|     year will be covered.                |             |             |
+------------------------------------------+-------------+-------------+

+---+---+-----------------------------------+-------------+-----+---+---+
| * |   |                                   |             |     |   |   |
| * |   |                                   |             |     |   |   |
| S |   |                                   |             |     |   |   |
| e |   |                                   |             |     |   |   |
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| 5 |   |                                   |             |     |   |   |
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| * |   |                                   |             |     |   |   |
| * |   |                                   |             |     |   |   |
|   |   |                                   |             |     |   |   |
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| a |   |                                   |             |     |   |   |
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| r |   |                                   |             |     |   |   |
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| a |   |                                   |             |     |   |   |
| l |   |                                   |             |     |   |   |
| t |   |                                   |             |     |   |   |
| h |   |                                   |             |     |   |   |
| c |   |                                   |             |     |   |   |
| a |   |                                   |             |     |   |   |
| r |   |                                   |             |     |   |   |
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| p |   |                                   |             |     |   |   |
| r |   |                                   |             |     |   |   |
| o |   |                                   |             |     |   |   |
| f |   |                                   |             |     |   |   |
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| s |   |                                   |             |     |   |   |
| s |   |                                   |             |     |   |   |
| i |   |                                   |             |     |   |   |
| o |   |                                   |             |     |   |   |
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| l |   |                                   |             |     |   |   |
| s |   |                                   |             |     |   |   |
| * |   |                                   |             |     |   |   |
| * |   |                                   |             |     |   |   |
+---+---+-----------------------------------+-------------+-----+---+---+
|   | * | **Here are some important things  |             |     | * |   |
|   | * | to keep in mind about these       |             |     | * |   |
|   | I | benefits:**                       |             |     | I |   |
|   | * |                                   |             |     | * |   |
|   | * | -   Please remember that all      |             |     | * |   |
|   |   |     benefits are subject to the   |             |     |   |   |
|   | * |     definitions, limitations, and |             |     | * |   |
|   | * |     exclusions in this brochure   |             |     | * |   |
|   | M |     and are payable only when we  |             |     | M |   |
|   | * |     determine they are medically  |             |     | * |   |
|   | * |     necessary.                    |             |     | * |   |
|   |   |                                   |             |     |   |   |
|   | * | -   **Under High Option,** we     |             |     | * |   |
|   | * |     have no calendar year         |             |     | * |   |
|   | P |     deductible for In Network     |             |     | P |   |
|   | * |     services.                     |             |     | * |   |
|   | * |                                   |             |     | * |   |
|   |   | -   **Under Standard Option,**    |             |     |   |   |
|   | * |     the calendar year deductible  |             |     | * |   |
|   | * |     for Participating Providers   |             |     | * |   |
|   | O |     is \$500 per person (\$1,000  |             |     | O |   |
|   | * |     per family). The calendar     |             |     | * |   |
|   | * |     year deductible applies to    |             |     | * |   |
|   |   |     almost all benefits in this   |             |     |   |   |
|   | * |     section. We added "(No        |             |     | * |   |
|   | * |     deductible)" to show when the |             |     | * |   |
|   | R |     calendar year deductible does |             |     | R |   |
|   | * |     not apply.                    |             |     | * |   |
|   | * |                                   |             |     | * |   |
|   |   | -   **Under both High and         |             |     |   |   |
|   | * |     Standard Options,** you must  |             |     | * |   |
|   | * |     use Plan Providers in order   |             |     | * |   |
|   | T |     to receive in-network benefit |             |     | T |   |
|   | * |     coverage.                     |             |     | * |   |
|   | * |                                   |             |     | * |   |
|   |   | -   Be sure to read Section 4,    |             |     |   |   |
|   | * |     *Your costs for covered       |             |     | * |   |
|   | * |     services* for valuable        |             |     | * |   |
|   | A |     information about how cost    |             |     | A |   |
|   | * |     sharing works. Also read      |             |     | * |   |
|   | * |     Section 9 about coordinating  |             |     | * |   |
|   |   |     benefits with other coverage, |             |     |   |   |
|   | * |     including with Medicare.      |             |     | * |   |
|   | * |                                   |             |     | * |   |
|   | N | -   The amounts listed below are  |             |     | N |   |
|   | * |     for the charges billed by a   |             |     | * |   |
|   | * |     physician or other health     |             |     | * |   |
|   |   |     care professional for your    |             |     |   |   |
|   | * |     surgical care. Look in        |             |     | * |   |
|   | * |     Section 5(c) for charges      |             |     | * |   |
|   | T |     associated with the facility  |             |     | T |   |
|   | * |     (i.e. hospital, surgical      |             |     | * |   |
|   | * |     center, etc.).                |             |     | * |   |
|   |   |                                   |             |     |   |   |
|   |   | -   YOU OR YOUR PHYSICIAN MUST    |             |     |   |   |
|   |   |     GET PRIOR AUTHORIZATION OF    |             |     |   |   |
|   |   |     SOME SURGICAL PROCEDURES.     |             |     |   |   |
|   |   |     Please refer to the prior     |             |     |   |   |
|   |   |     authorization information     |             |     |   |   |
|   |   |     shown in Section 3 to be sure |             |     |   |   |
|   |   |     which services require prior  |             |     |   |   |
|   |   |     authorization and identify    |             |     |   |   |
|   |   |     which surgeries require prior |             |     |   |   |
|   |   |     authorization.                |             |     |   |   |
+---+---+-----------------------------------+-------------+-----+---+---+
| * |   |                                   | **You pay   | **  |   |   |
| * |   |                                   | --**        | You |   |   |
| B |   |                                   |             | pay |   |   |
| e |   |                                   | **High      | -** |   |   |
| n |   |                                   | Option**    |     |   |   |
| e |   |                                   |             | *   |   |   |
| f |   |                                   |             | *St |   |   |
| i |   |                                   |             | and |   |   |
| t |   |                                   |             | ard |   |   |
| D |   |                                   |             | Op  |   |   |
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| s |   |                                   |             | n** |   |   |
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| n |   |                                   |             |     |   |   |
| * |   |                                   |             |     |   |   |
| * |   |                                   |             |     |   |   |
+---+---+-----------------------------------+-------------+-----+---+---+
| # |   |                                   |             |     |   |   |
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| p |   |                                   |             |     |   |   |
| r |   |                                   |             |     |   |   |
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| d |   |                                   |             |     |   |   |
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|   |   |                                   |             |     |   |   |
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+---+---+-----------------------------------+-------------+-----+---+---+
| A |   |                                   | \$30 per    | \   |   |   |
| c |   |                                   | specialist  | $25 |   |   |
| o |   |                                   | visit       | co  |   |   |
| m |   |                                   |             | pay |   |   |
| p |   |                                   | \$100 per   | per |   |   |
| r |   |                                   | day copay   | off |   |   |
| e |   |                                   | up to \$500 | ice |   |   |
| h |   |                                   | per         | vi  |   |   |
| e |   |                                   | inpatient   | sit |   |   |
| n |   |                                   | surgery or  | (No |   |   |
| s |   |                                   | service     | de  |   |   |
| i |   |                                   |             | duc |   |   |
| v |   |                                   | \$50 per    | tib |   |   |
| e |   |                                   | outpatient  | le) |   |   |
| r |   |                                   | surgery or  |     |   |   |
| a |   |                                   | service     | \$  |   |   |
| n |   |                                   |             | 100 |   |   |
| g |   |                                   |             | per |   |   |
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| s |   |                                   |             | up  |   |   |
| e |   |                                   |             | to  |   |   |
| r |   |                                   |             | \$  |   |   |
| v |   |                                   |             | 500 |   |   |
| i |   |                                   |             | per |   |   |
| c |   |                                   |             | inp |   |   |
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| : |   |                                   |             |     |   |   |
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+---+---+-----------------------------------+-------------+-----+---+---+
| * |   |                                   | *All        | *   |   |   |
| N |   |                                   | charges.*   | All |   |   |
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|   |   |                                   |             |     |   |   |
|   |   |                                   |             |     |   |   |
|   |   |                                   |             |     |   |   |
|   |   |                                   |             |     |   |   |
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|   |   |                                   |             |     |   |   |
|   |   |                                   |             |     |   |   |
|   |   |                                   |             |     |   |   |
|   |   |                                   |             |     |   |   |
| F |   |                                   |             |     |   |   |
| o |   |                                   |             |     |   |   |
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| t |   |                                   |             |     |   |   |
|   |   |                                   |             |     |   |   |
|   |   |                                   |             |     |   |   |
|   |   |                                   |             |     |   |   |
|   |   |                                   |             |     |   |   |
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| . |   |                                   |             |     |   |   |
| * |   |                                   |             |     |   |   |
+---+---+-----------------------------------+-------------+-----+---+---+

+------------------------------------------+-------------+-------------+
| **Reconstructive surgery**               | **You pay   | **You pay   |
|                                          | -**         | -**         |
|                                          |             |             |
|                                          | **High      | **Standard  |
|                                          | Option**    | Option**    |
+------------------------------------------+-------------+-------------+
| -   Surgery to correct a functional      | \$30 per    | \$25 copay  |
|     defect                               | specialist  | per office  |
|                                          | visit       | visit (No   |
| -   Surgery to correct a condition       |             | deductible) |
|     caused by injury or illness if:      | \$100 day   |             |
|                                          | copay up to | \$100 per   |
|     \- the condition produced a major    | \$500 per   | day copay   |
|     effect on your appearance and        | inpatient   | up to \$500 |
|                                          | surgery or  | per         |
|     \- the condition can reasonably be   | service     | inpatient   |
|     expected to be corrected by such     |             | surgery or  |
|     surgery                              | \$50 per    | service     |
|                                          | outpatient  |             |
| -   Surgery to correct a condition that  | surgery or  | 20% of      |
|     existed at or from birth and is a    | service     | outpatient  |
|     significant deviation from the       |             | charges     |
|     common form or norm. Examples of     |             |             |
|     congenital anomalies are: protruding |             |             |
|     ear deformities; cleft lip; cleft    |             |             |
|     palate; birth marks; webbed fingers; |             |             |
|     and webbed toes.                     |             |             |
|                                          |             |             |
| -   All stages of breast reconstruction  |             |             |
|     surgery following a mastectomy, such |             |             |
|     as:                                  |             |             |
|                                          |             |             |
|     \- surgery to produce a symmetrical  |             |             |
|     appearance on the other breast;      |             |             |
|                                          |             |             |
|     \- treatment of any physical         |             |             |
|     complications, such as lymphedemas;  |             |             |
|                                          |             |             |
|     \- breast prostheses and surgical    |             |             |
|     bras and replacements (see           |             |             |
|     *Prosthetic devices*)                |             |             |
|                                          |             |             |
|     NOTE: If you need a mastectomy, you  |             |             |
|     may choose to have the procedure     |             |             |
|     performed on an inpatient basis and  |             |             |
|     remain in the hospital up to 48      |             |             |
|     hours after the procedure.           |             |             |
+------------------------------------------+-------------+-------------+
| *Not covered:*                           | *All        | *All        |
|                                          | charges.*   | charges.*   |
| -   *Cosmetic surgery --any surgical     |             |             |
|     procedure (or any portion of a       |             |             |
|     procedure) performed primarily to    |             |             |
|     improve physical appearance through  |             |             |
|     change in bodily form, including     |             |             |
|     skin tag removal, except repair of   |             |             |
|     accidental injury.*                  |             |             |
|                                          |             |             |
| -   *Surgeries related to sex            |             |             |
|     transformation*                      |             |             |
+------------------------------------------+-------------+-------------+
| **Oral and maxillofacial surgery**       |             |             |
+------------------------------------------+-------------+-------------+
| Oral surgical procedures, limited to:    | \$30 per    | \$25 copay  |
|                                          | specialist  | per visit   |
| -   Reduction of fractures of the jaws   | visit       | (No         |
|     or facial bones;                     |             | deductible) |
|                                          | \$100 per   |             |
| -   Surgical correction of cleft lip,    | day copay   | \$100 per   |
|     cleft palate or severe functional    | up to \$500 | day copay   |
|     malocclusion;                        | per         | up to \$500 |
|                                          | inpatient   | per         |
| -   Removal of stones from salivary      | surgery or  | inpatient   |
|     ducts;                               | service     | surgery or  |
|                                          |             | service     |
| -   Excision of leukoplakia or           | \$50 per    |             |
|     malignancies;                        | outpatient  | 20% of      |
|                                          | surgery or  | outpatient  |
| -   Excision of cysts and incision of    | service     | charges     |
|     abscesses when done as independent   |             |             |
|     procedures; and                      |             |             |
|                                          |             |             |
| -   Other surgical procedures that do    |             |             |
|     not involve the teeth or their       |             |             |
|     supporting structures.               |             |             |
|                                          |             |             |
| -   Surgery to correct TMJ is covered    |             |             |
|     upon radiological determination of   |             |             |
|     pathology (See *Services requiring   |             |             |
|     our prior approval* *in Section 3)*  |             |             |
+------------------------------------------+-------------+-------------+
| *Not covered:*                           | *All        | *All        |
|                                          | charges.*   | 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   | **You pay   |
|                                          | -**         | -**         |
|                                          |             |             |
|                                          | **High      | **Standard  |
|                                          | Option**    | Option**    |
+------------------------------------------+-------------+-------------+
| Limited to:                              | Nothing     | Nothing     |
|                                          |             |             |
| -   Cornea                               |             |             |
|                                          |             |             |
| -   Heart                                |             |             |
|                                          |             |             |
| -   Heart/Lung                           |             |             |
|                                          |             |             |
| -   Kidney                               |             |             |
|                                          |             |             |
| -   Kidney/Pancreas                      |             |             |
|                                          |             |             |
| -   Liver                                |             |             |
|                                          |             |             |
| -   Intestinal transplants (small        |             |             |
|     intestine) and the small intestine   |             |             |
|     with the liver or small intestine    |             |             |
|     with multiple organs such as the     |             |             |
|     liver, stomach, and pancreas         |             |             |
+------------------------------------------+-------------+-------------+
| -   Lung: Single --Double                | Nothing     | 20% of      |
|                                          |             | charges     |
| -   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                          |             |             |
|                                          |             |             |
|     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 our medical director in           |             |             |
|     accordance with our protocols.       |             |             |
|                                          |             |             |
|     NOTE: We cover related medical and   |             |             |
|     hospital expenses of the donor when  |             |             |
|     we cover the recipient. All          |             |             |
|     transplants must be provided at Plan |             |             |
|     participating Center of Excellence   |             |             |
|     facilities.                          |             |             |
+------------------------------------------+-------------+-------------+
| *Not covered:*                           | *All        | *All        |
|                                          | charges.*   | charges.*   |
| -   *Donor screening tests and donor     |             |             |
|     search expenses, except those        |             |             |
|     performed for the actual donor*      |             |             |
|                                          |             |             |
| -   *Autologous tandem transplants*      |             |             |
|                                          |             |             |
| -   *Transplants not listed as covered*  |             |             |
+------------------------------------------+-------------+-------------+
| **Anesthesia**                           |             |             |
+------------------------------------------+-------------+-------------+
| Professional services provided in --     | Nothing     | 20% of      |
|                                          |             | charges     |
| -   Hospital (inpatient)                 |             |             |
+------------------------------------------+-------------+-------------+
| -   Hospital outpatient department       | Nothing     | 20% of      |
|                                          |             | charges     |
| -   Skilled nursing facility             |             |             |
|                                          |             |             |
| -   Ambulatory surgical center           |             |             |
|                                          |             |             |
| -   Office                               |             |             |
+------------------------------------------+-------------+-------------+
| *Not Covered: Hypnotic Anesthesia*       | *All        | *All        |
|                                          | Charges*    | charges.*   |
+------------------------------------------+-------------+-------------+

.

+---+---+-----------------------------------+-------------+-----+---+---+
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| * |   |                                   |             |     |   |   |
| * |   |                                   |             |     |   |   |
+---+---+-----------------------------------+-------------+-----+---+---+
|   | * | **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.                |             |     | * |   |
|   | * |                                   |             |     | * |   |
|   |   | -   **Under High Option,** we     |             |     |   |   |
|   | * |     have no calendar year         |             |     | * |   |
|   | * |     deductible for In Network     |             |     | * |   |
|   | O |     services.                     |             |     | O |   |
|   | * |                                   |             |     | * |   |
|   | * | -   **Under Standard Option,**    |             |     | * |   |
|   |   |     the calendar year deductible  |             |     |   |   |
|   | * |     for Participating Providers   |             |     | * |   |
|   | * |     is \$500 per person (\$1,000  |             |     | * |   |
|   | R |     per family). The calendar     |             |     | R |   |
|   | * |     year deductible applies to    |             |     | * |   |
|   | * |     almost all benefits in this   |             |     | * |   |
|   |   |     section. We added "(No        |             |     |   |   |
|   | * |     deductible)" to show when the |             |     | * |   |
|   | * |     calendar year deductible does |             |     | * |   |
|   | T |     not apply.                    |             |     | T |   |
|   | * |                                   |             |     | * |   |
|   | * | -   **Under both High and         |             |     | * |   |
|   |   |     Standard Options,** you must  |             |     |   |   |
|   | * |     use Plan Providers in order   |             |     | * |   |
|   | * |     to receive in-network benefit |             |     | * |   |
|   | A |     coverage.                     |             |     | A |   |
|   | * |                                   |             |     | * |   |
|   | * | -   Be sure to read Section 4,    |             |     | * |   |
|   |   |     *Your costs for covered       |             |     |   |   |
|   | * |     services,* for valuable       |             |     | * |   |
|   | * |     information about how cost    |             |     | * |   |
|   | N |     sharing works. Also read      |             |     | N |   |
|   | * |     Section 9 about coordinating  |             |     | * |   |
|   | * |     benefits with other coverage, |             |     | * |   |
|   |   |     including with Medicare.      |             |     |   |   |
|   | * |                                   |             |     | * |   |
|   | * | -   The amounts listed below are  |             |     | * |   |
|   | T |     for the charges billed by the |             |     | T |   |
|   | * |     facility (i.e., hospital or   |             |     | * |   |
|   | * |     surgical center) or ambulance |             |     | * |   |
|   |   |     service for your surgery or   |             |     |   |   |
|   |   |     care. Any costs associated    |             |     |   |   |
|   |   |     with the professional charge  |             |     |   |   |
|   |   |     (i.e., physicians, etc.) are  |             |     |   |   |
|   |   |     covered in Sections 5(a) or   |             |     |   |   |
|   |   |     (b).                          |             |     |   |   |
|   |   |                                   |             |     |   |   |
|   |   | -   **YOU OR YOUR PHYSICIAN MUST  |             |     |   |   |
|   |   |     GET PRIOR AUTHORIZATION OF    |             |     |   |   |
|   |   |     NON-EMERGENCY HOSPITAL        |             |     |   |   |
|   |   |     STAYS.** Please refer to      |             |     |   |   |
|   |   |     Section 3 to be sure which    |             |     |   |   |
|   |   |     services require prior        |             |     |   |   |
|   |   |     authorization.                |             |     |   |   |
+---+---+-----------------------------------+-------------+-----+---+---+
| * |   |                                   | **You pay   | **  |   |   |
| * |   |                                   | --**        | You |   |   |
| B |   |                                   |             | pay |   |   |
| e |   |                                   | **High      | -** |   |   |
| n |   |                                   | Option**    |     |   |   |
| e |   |                                   |             | *   |   |   |
| f |   |                                   |             | *St |   |   |
| i |   |                                   |             | and |   |   |
| t |   |                                   |             | ard |   |   |
| D |   |                                   |             | Op  |   |   |
| e |   |                                   |             | tio |   |   |
| s |   |                                   |             | n** |   |   |
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| n |   |                                   |             |     |   |   |
| * |   |                                   |             |     |   |   |
| * |   |                                   |             |     |   |   |
+---+---+-----------------------------------+-------------+-----+---+---+
| * |   |                                   |             |     |   |   |
| * |   |                                   |             |     |   |   |
| I |   |                                   |             |     |   |   |
| n |   |                                   |             |     |   |   |
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| * |   |                                   |             |     |   |   |
+---+---+-----------------------------------+-------------+-----+---+---+
| R |   |                                   | \$100 per   | \$  |   |   |
| o |   |                                   | day copay   | 100 |   |   |
| o |   |                                   | up to \$500 | per |   |   |
| m |   |                                   | per         | day |   |   |
| a |   |                                   | admission   | co  |   |   |
| n |   |                                   |             | pay |   |   |
| d |   |                                   |             | up  |   |   |
| b |   |                                   |             | to  |   |   |
| o |   |                                   |             | \$  |   |   |
| a |   |                                   |             | 500 |   |   |
| r |   |                                   |             | per |   |   |
| d |   |                                   |             | adm |   |   |
| , |   |                                   |             | iss |   |   |
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|   |   |                                   |             |     |   |   |
|   |   |                                   |             |     |   |   |
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| * |   |                                   |             |     |   |   |
+---+---+-----------------------------------+-------------+-----+---+---+

+------------------------------------------+-------------+-------------+
| **Outpatient hospital or ambulatory      | **You pay   | **You pay   |
| surgical center**                        | -**         | -**         |
|                                          |             |             |
|                                          | **High      | **Standard  |
|                                          | Option**    | Option**    |
+------------------------------------------+-------------+-------------+
| -   Operating, recovery, and other       | \$50 per    | 20% of      |
|     treatment rooms                      | visit       | charges     |
|                                          |             |             |
| -   Prescribed drugs and medicines       |             |             |
|                                          |             |             |
| -   Administration of blood, blood       |             |             |
|     plasma, and other biologicals        |             |             |
|                                          |             |             |
| -   Blood and blood plasma, if not       |             |             |
|     donated or replaced                  |             |             |
|                                          |             |             |
| -   Dressings, casts, and sterile tray   |             |             |
|     services                             |             |             |
|                                          |             |             |
| -   Medical supplies, including oxygen   |             |             |
|                                          |             |             |
| -   Anesthetics and anesthesia service   |             |             |
|                                          |             |             |
|     NOTE: We cover hospital services and |             |             |
|     supplies related to dental           |             |             |
|     procedures when necessitated by a    |             |             |
|     non-dental physical impairment. We   |             |             |
|     do not cover the dental procedures.  |             |             |
+------------------------------------------+-------------+-------------+
| Outpatient hospital services:            | Nothing     | 20% of      |
|                                          |             | charges     |
| -   Diagnostic laboratory tests, X-rays, |             |             |
|     and pathology services               |             |             |
|                                          |             |             |
| -   Pre-surgical testing                 |             |             |
+------------------------------------------+-------------+-------------+
| *Not covered: blood and blood            | *All        | *All        |
| derivatives not replaced by you.*        | charges.*   | charges.*   |
+------------------------------------------+-------------+-------------+
| **Extended care benefits/skilled nursing |             |             |
| care facility benefits**                 |             |             |
+------------------------------------------+-------------+-------------+
| All necessary services ordered by a Plan | \$100 per   | \$100 per   |
| doctor are covered, including:           | day copay   | day copay   |
|                                          | up to \$500 | up to \$500 |
| -   Unlimited days                       | per         | per         |
|                                          | admission   | admission   |
| -   bed, board, and general nursing care |             |             |
|                                          |             |             |
| -   drugs, biologicals, supplies, and    |             |             |
|     equipment ordinarily provided or     |             |             |
|     arranged by the skilled nursing      |             |             |
|     facility when prescribed by a Plan   |             |             |
|     doctor                               |             |             |
|                                          |             |             |
| -   Care must be received from a state   |             |             |
|     licensed nursing facility.           |             |             |
+------------------------------------------+-------------+-------------+
| *Not covered: custodial, convalescent,   | *All        | *All        |
| intermediate level or domiciliary care,  | charges.*   | charges.*   |
| residential care, rest cures or services |             |             |
| to assist in activities of daily         |             |             |
| living.*                                 |             |             |
+------------------------------------------+-------------+-------------+
| **Hospice care**                         |             |             |
+------------------------------------------+-------------+-------------+
| -   Admission to a hospice facility,     | Nothing     | 20% of      |
|     hospital, or skilled nursing         |             | charges     |
|     facility for room and board,         |             |             |
|     supplies and services for pain       |             |             |
|     management and other acute/chronic   |             |             |
|     symptom management                   |             |             |
|                                          |             |             |
| -   Part-time or intermittent nursing    |             |             |
|     care by an RN, LPN, LVN or home      |             |             |
|     health aide for patient care for up  |             |             |
|     to 8 hours a day                     |             |             |
|                                          |             |             |
| -   Social services                      |             |             |
|                                          |             |             |
| -   Psychological and dietary counseling |             |             |
|                                          |             |             |
| -   Physical or occupational therapy     |             |             |
|                                          |             |             |
| -   Consultation and case management     |             |             |
|     services by a participating          |             |             |
|     practitioner                         |             |             |
|                                          |             |             |
| -   Medical supplies and drugs           |             |             |
|     prescribed by a participating        |             |             |
|     practitioner                         |             |             |
+------------------------------------------+-------------+-------------+
| *Not covered: Independent nursing,       | *All        | *All        |
| homemaker services*                      | charges.*   | charges.*   |
+------------------------------------------+-------------+-------------+
| **Ambulance**                            |             |             |
+------------------------------------------+-------------+-------------+
| -   Local professional ground and/or air | \$50 copay  | 20% of      |
|     ambulance service when medically     |             | charges     |
|     necessary and plan approved hospital |             |             |
|     transfers.                           |             |             |
+------------------------------------------+-------------+-------------+
| *Not covered:*                           | *All        | *All        |
|                                          | charges.*   | charges.*   |
| -   *Transfers to hospitals performed    |             |             |
|     only for the convenience of the      |             |             |
|     member, the member's family or the   |             |             |
|     member's physician or other          |             |             |
|     provider.*                           |             |             |
|                                          |             |             |
| -   *Non-emergency services and/or       |             |             |
|     travel, unless pre-approved and      |             |             |
|     arranged by us.*                     |             |             |
+------------------------------------------+-------------+-------------+

+---+---+-------------------------------------+-------------+-------+---+---+
| * |   |                                     |             |       |   |   |
| * |   |                                     |             |       |   |   |
| S |   |                                     |             |       |   |   |
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| t |   |                                     |             |       |   |   |
| i |   |                                     |             |       |   |   |
| o |   |                                     |             |       |   |   |
| n |   |                                     |             |       |   |   |
| 5 |   |                                     |             |       |   |   |
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| n |   |                                     |             |       |   |   |
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| y |   |                                     |             |       |   |   |
| s |   |                                     |             |       |   |   |
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| v |   |                                     |             |       |   |   |
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| s |   |                                     |             |       |   |   |
| / |   |                                     |             |       |   |   |
| a |   |                                     |             |       |   |   |
| c |   |                                     |             |       |   |   |
| c |   |                                     |             |       |   |   |
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| d |   |                                     |             |       |   |   |
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| n |   |                                     |             |       |   |   |
| 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        |             |       | * |   |
|   | M |     determine they are medically    |             |       | M |   |
|   | * |     necessary.                      |             |       | * |   |
|   | * |                                     |             |       | * |   |
|   |   | -   **Under High Option,** we have  |             |       |   |   |
|   | * |     no calendar year deductible for |             |       | * |   |
|   | * |     In Network services.            |             |       | * |   |
|   | P |                                     |             |       | P |   |
|   | * | -   **Under Standard Option,** the  |             |       | * |   |
|   | * |     calendar year deductible for    |             |       | * |   |
|   |   |     Participating Providers is      |             |       |   |   |
|   | * |     \$500 per person (\$1,000 per   |             |       | * |   |
|   | * |     family). The calendar year      |             |       | * |   |
|   | O |     deductible applies to almost    |             |       | O |   |
|   | * |     all benefits in this section.   |             |       | * |   |
|   | * |     We added "(No deductible)" to   |             |       | * |   |
|   |   |     show when the calendar year     |             |       |   |   |
|   | * |     deductible does not apply.      |             |       | * |   |
|   | * |                                     |             |       | * |   |
|   | R | -   **Under both High and Standard  |             |       | R |   |
|   | * |     Options,** you must use Plan    |             |       | * |   |
|   | * |     Providers in order to receive   |             |       | * |   |
|   |   |     in-network benefit coverage.    |             |       |   |   |
|   | * |                                     |             |       | * |   |
|   | * | -   Be sure to read Section 4,      |             |       | * |   |
|   | T |     *Your costs for covered         |             |       | T |   |
|   | * |     services,* for valuable         |             |       | * |   |
|   | * |     information about how cost      |             |       | * |   |
|   |   |     sharing works. Also read        |             |       |   |   |
|   | * |     Section 9 about coordinating    |             |       | * |   |
|   | * |     benefits with other coverage,   |             |       | * |   |
|   | A |     including with Medicare.        |             |       | A |   |
|   | * |                                     |             |       | * |   |
|   | * |                                     |             |       | * |   |
|   |   |                                     |             |       |   |   |
|   | * |                                     |             |       | * |   |
|   | * |                                     |             |       | * |   |
|   | N |                                     |             |       | N |   |
|   | * |                                     |             |       | * |   |
|   | * |                                     |             |       | * |   |
|   |   |                                     |             |       |   |   |
|   | * |                                     |             |       | * |   |
|   | * |                                     |             |       | * |   |
|   | T |                                     |             |       | T |   |
|   | * |                                     |             |       | * |   |
|   | * |                                     |             |       | * |   |
+---+---+-------------------------------------+-------------+-------+---+---+
| * |   |                                     |             |       |   |   |
| * |   |                                     |             |       |   |   |
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| - |   |                                     | \$20 per    | \$25  |   |   |
|   |   |                                     | primary     | copay |   |   |
|   |   |                                     | care visit  | per   |   |   |
|   |   |                                     |             | pr    |   |   |
| E |   |                                     | \$30 per    | imary |   |   |
| m |   |                                     | specialist  | care  |   |   |
| e |   |                                     | visit       | or    |   |   |
| r |   |                                     |             | speci |   |   |
| g |   |                                     |             | alist |   |   |
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| n |   |                                     |             | (No   |   |   |
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| r |   |                                     |             |       |   |   |
| g |   |                                     |             |       |   |   |
| e |   |                                     |             |       |   |   |
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|   |   |                                     |             |       |   |   |
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| c |   |                                     |             |       |   |   |
| a |   |                                     |             |       |   |   |
| r |   |                                     |             |       |   |   |
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|   |   |                                     |             |       |   |   |
|   |   |                                     |             |       |   |   |
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| r |   |                                     |             |       |   |   |
+---+---+-------------------------------------+-------------+-------+---+---+
| - |   |                                     | \$100 per   | \$100 |   |   |
|   |   |                                     | visit,      | per   |   |   |
|   |   |                                     | waived if   | v     |   |   |
|   |   |                                     | admitted    | isit, |   |   |
| E |   |                                     |             | w     |   |   |
| m |   |                                     |             | aived |   |   |
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| r |   |                                     |             | adm   |   |   |
| g |   |                                     |             | itted |   |   |
| e |   |                                     |             | (No   |   |   |
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| c |   |                                     |             | ducti |   |   |
| y |   |                                     |             | ble). |   |   |
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| * |   |                                     | *All        | *All  |   |   |
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| - |   |                                     | \$20 per    | \$25  |   |   |
|   |   |                                     | primary     | copay |   |   |
|   |   |                                     | care visit  | per   |   |   |
|   |   |                                     |             | pr    |   |   |
| E |   |                                     | \$30 per    | imary |   |   |
| m |   |                                     | specialist  | care  |   |   |
| e |   |                                     | visit       | or    |   |   |
| r |   |                                     |             | speci |   |   |
| g |   |                                     |             | alist |   |   |
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| - |   |                                     | \$100 per , | \$100 |   |   |
|   |   |                                     | waived if   | per   |   |   |
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|   |   |                                     |             | isit, |   |   |
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| m |   |                                     |             | aived |   |   |
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+---+---+-------------------------------------+-------------+-------+---+---+

+---+---+-------------------------------------+-------------+-------+---+---+
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| * |   |                                     |             |       |   |   |
| * |   |                                     |             |       |   |   |
+---+---+-------------------------------------+-------------+-------+---+---+
|   | * | When you get our approval for       |             |       | * |   |
|   | * | services and follow a treatment     |             |       | * |   |
|   | I | plan we approve, cost-sharing and   |             |       | I |   |
|   | * | limitations for Plan mental health  |             |       | * |   |
|   | * | and substance abuse benefits will   |             |       | * |   |
|   |   | be no greater than for similar      |             |       |   |   |
|   | * | benefits for other illnesses and    |             |       | * |   |
|   | * | conditions.                         |             |       | * |   |
|   | M |                                     |             |       | M |   |
|   | * | **Here are some important things to |             |       | * |   |
|   | * | keep in mind about these            |             |       | * |   |
|   |   | benefits:**                         |             |       |   |   |
|   | * |                                     |             |       | * |   |
|   | * | -   All benefits are subject to the |             |       | * |   |
|   | P |     definitions, limitations, and   |             |       | P |   |
|   | * |     exclusions in this brochure and |             |       | * |   |
|   | * |     are payable only when we        |             |       | * |   |
|   |   |     determine they are medically    |             |       |   |   |
|   | * |     necessary.                      |             |       | * |   |
|   | * |                                     |             |       | * |   |
|   | O | -   **Under High Option,** we have  |             |       | O |   |
|   | * |     no calendar year deductible for |             |       | * |   |
|   | * |     In Network services.            |             |       | * |   |
|   |   |                                     |             |       |   |   |
|   | * | -   **Under Standard Option,** the  |             |       | * |   |
|   | * |     calendar year deductible for    |             |       | * |   |
|   | R |     Participating Providers is      |             |       | R |   |
|   | * |     \$500 per person (\$1,000 per   |             |       | * |   |
|   | * |     family). The calendar year      |             |       | * |   |
|   |   |     deductible applies to almost    |             |       |   |   |
|   | * |     all benefits in this section.   |             |       | * |   |
|   | * |     We added "(No deductible)" to   |             |       | * |   |
|   | T |     show when the calendar year     |             |       | T |   |
|   | * |     deductible does not apply.      |             |       | * |   |
|   | * |                                     |             |       | * |   |
|   |   | -   **Under both High and Standard  |             |       |   |   |
|   | * |     Options,** you must use Plan    |             |       | * |   |
|   | * |     Providers in order to receive   |             |       | * |   |
|   | A |     in-network benefit coverage.    |             |       | A |   |
|   | * |                                     |             |       | * |   |
|   | * | -   Be sure to read Section 4,      |             |       | * |   |
|   |   |     *Your costs for covered         |             |       |   |   |
|   | * |     services,* for valuable         |             |       | * |   |
|   | * |     information about how cost      |             |       | * |   |
|   | N |     sharing works. Also read        |             |       | N |   |
|   | * |     Section 9 about coordinating    |             |       | * |   |
|   | * |     benefits with other coverage,   |             |       | * |   |
|   |   |     including with Medicare.        |             |       |   |   |
|   | * |                                     |             |       | * |   |
|   | * | -   **YOU MUST GET PRIOR APPROVAL   |             |       | * |   |
|   | T |     OF THESE SERVICES.** See the    |             |       | T |   |
|   | * |     instructions after the benefits |             |       | * |   |
|   | * |     description below.              |             |       | * |   |
+---+---+-------------------------------------+-------------+-------+---+---+
| * |   |                                     | **You Pay   | **You |   |   |
| * |   |                                     | --**        | pay   |   |   |
| B |   |                                     |             | -**   |   |   |
| e |   |                                     | **High      |       |   |   |
| n |   |                                     | Option**    | **Sta |   |   |
| e |   |                                     |             | ndard |   |   |
| f |   |                                     |             | Opt   |   |   |
| i |   |                                     |             | ion** |   |   |
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| p |   |                                     |             |       |   |   |
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| n |   |                                     |             |       |   |   |
| * |   |                                     |             |       |   |   |
| * |   |                                     |             |       |   |   |
+---+---+-------------------------------------+-------------+-------+---+---+
| * |   |                                     |             |       |   |   |
| * |   |                                     |             |       |   |   |
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+---+---+-------------------------------------+-------------+-------+---+---+
| A |   |                                     | Your cost   | Your  |   |   |
| l |   |                                     | sharing     | cost  |   |   |
| l |   |                                     | respo       | sh    |   |   |
| d |   |                                     | nsibilities | aring |   |   |
| i |   |                                     | are no      | r     |   |   |
| a |   |                                     | greater     | espon |   |   |
| g |   |                                     | than for    | sibil |   |   |
| n |   |                                     | other       | ities |   |   |
| o |   |                                     | illness or  | are   |   |   |
| s |   |                                     | conditions. | no    |   |   |
| t |   |                                     |             | gr    |   |   |
| i |   |                                     |             | eater |   |   |
| c |   |                                     |             | than  |   |   |
| a |   |                                     |             | for   |   |   |
| n |   |                                     |             | other |   |   |
| d |   |                                     |             | il    |   |   |
| t |   |                                     |             | lness |   |   |
| r |   |                                     |             | or    |   |   |
| e |   |                                     |             | c     |   |   |
| a |   |                                     |             | ondit |   |   |
| t |   |                                     |             | ions. |   |   |
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| - |   |                                     | \$30 per    | \$25  |   |   |
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+---+---+-------------------------------------+-------------+-------+---+---+
| - |   |                                     | Nothing     | 20%   |   |   |
|   |   |                                     |             | of    |   |   |
|   |   |                                     |             | ch    |   |   |
|   |   |                                     |             | arges |   |   |
| D |   |                                     |             |       |   |   |
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| s |   |                                     |             |       |   |   |
+---+---+-------------------------------------+-------------+-------+---+---+
| - |   |                                     | \$100 per   | \$100 |   |   |
|   |   |                                     | day copay   | per   |   |   |
|   |   |                                     | up to \$500 | day   |   |   |
|   |   |                                     | per         | copay |   |   |
| S |   |                                     | inpatient   | up to |   |   |
| e |   |                                     | admission   | \$500 |   |   |
| r |   |                                     |             | per   |   |   |
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+---+---+-------------------------------------+-------------+-------+---+---+

+---+---+------------------------------------+-------------+------+---+---+---+
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| * |   |                                    |             |      |   |   |   |
+---+---+------------------------------------+-------------+------+---+---+---+
|   | * | **Here are some important things   |             |      | * |   |   |
|   | * | to keep in mind about these        |             |      | * |   |   |
|   | I | benefits:**                        |             |      | I |   |   |
|   | * |                                    |             |      | * |   |   |
|   | * | -   We cover prescribed drugs and  |             |      | * |   |   |
|   |   |     medications, as described in   |             |      |   |   |   |
|   | * |     the chart beginning on the     |             |      | * |   |   |
|   | * |     next page.                     |             |      | * |   |   |
|   | M |                                    |             |      | M |   |   |
|   | * | -   All benefits are subject to    |             |      | * |   |   |
|   | * |     the definitions, limitations   |             |      | * |   |   |
|   |   |     and exclusions in this         |             |      |   |   |   |
|   | * |     brochure and are payable only  |             |      | * |   |   |
|   | * |     when we determine they are     |             |      | * |   |   |
|   | P |     medically necessary.           |             |      | P |   |   |
|   | * |                                    |             |      | * |   |   |
|   | * | -   **Under High Option,** we have |             |      | * |   |   |
|   |   |     no calendar year deductible    |             |      |   |   |   |
|   | * |     for In Network services.       |             |      | * |   |   |
|   | * |                                    |             |      | * |   |   |
|   | O | -   **Under Standard Option,** the |             |      | O |   |   |
|   | * |     calendar year deductible for   |             |      | * |   |   |
|   | * |     Participating Providers is     |             |      | * |   |   |
|   |   |     \$500 per person (\$1,000 per  |             |      |   |   |   |
|   | * |     family). The calendar year     |             |      | * |   |   |
|   | * |     deductible applies to almost   |             |      | * |   |   |
|   | R |     all benefits in this section.  |             |      | R |   |   |
|   | * |     We added "(No deductible)" to  |             |      | * |   |   |
|   | * |     show when the calendar year    |             |      | * |   |   |
|   |   |     deductible does not apply.     |             |      |   |   |   |
|   | * |                                    |             |      | * |   |   |
|   | * | -   **Under both High and Standard |             |      | * |   |   |
|   | T |     Options,** you must use Plan   |             |      | T |   |   |
|   | * |     Providers, there are no Point  |             |      | * |   |   |
|   | * |     of Service (out-of-network)    |             |      | * |   |   |
|   |   |     benefits.                      |             |      |   |   |   |
|   | * |                                    |             |      | * |   |   |
|   | * | -   Be sure to read Section 4,     |             |      | * |   |   |
|   | A |     *Your costs for covered        |             |      | A |   |   |
|   | * |     services,* for valuable        |             |      | * |   |   |
|   | * |     information about how cost     |             |      | * |   |   |
|   |   |     sharing works. Also read       |             |      |   |   |   |
|   | * |     Section 9 about coordinating   |             |      | * |   |   |
|   | * |     benefits with other coverage,  |             |      | * |   |   |
|   | N |     including with Medicare.       |             |      | N |   |   |
|   | * |                                    |             |      | * |   |   |
|   | * |                                    |             |      | * |   |   |
|   |   |                                    |             |      |   |   |   |
|   | * |                                    |             |      | * |   |   |
|   | * |                                    |             |      | * |   |   |
|   | T |                                    |             |      | T |   |   |
|   | * |                                    |             |      | * |   |   |
|   | * |                                    |             |      | * |   |   |
+---+---+------------------------------------+-------------+------+---+---+---+
|   |   | **There are important features you |             |      |   |   |   |
|   |   | should be aware of.** These        |             |      |   |   |   |
|   |   | include:                           |             |      |   |   |   |
|   |   |                                    |             |      |   |   |   |
|   |   | -   **Who can write your           |             |      |   |   |   |
|   |   |     prescription.** A licensed     |             |      |   |   |   |
|   |   |     physician, Nurse Practitioner, |             |      |   |   |   |
|   |   |     or Physician's Assistant must  |             |      |   |   |   |
|   |   |     write the prescription.        |             |      |   |   |   |
|   |   |                                    |             |      |   |   |   |
|   |   | -   **Where you can obtain them.** |             |      |   |   |   |
|   |   |     You must fill the prescription |             |      |   |   |   |
|   |   |     at a network pharmacy. If you  |             |      |   |   |   |
|   |   |     choose to go to a non-network  |             |      |   |   |   |
|   |   |     pharmacy, you must pay 100% of |             |      |   |   |   |
|   |   |     the costs of the medication to |             |      |   |   |   |
|   |   |     the pharmacy (except in an     |             |      |   |   |   |
|   |   |     emergency). Some injectible    |             |      |   |   |   |
|   |   |     drugs are obtained through     |             |      |   |   |   |
|   |   |     mail order, For more           |             |      |   |   |   |
|   |   |     information call Member        |             |      |   |   |   |
|   |   |     Services at 605/328-6800 for a |             |      |   |   |   |
|   |   |     copy of the Prescription Drug  |             |      |   |   |   |
|   |   |     Brochure. To enroll and obtain |             |      |   |   |   |
|   |   |     prior-approval to join the     |             |      |   |   |   |
|   |   |     Injectible Drugs Program call  |             |      |   |   |   |
|   |   |     1-800/278-0980.                |             |      |   |   |   |
|   |   |                                    |             |      |   |   |   |
|   |   | -   **How you can obtain them.**   |             |      |   |   |   |
|   |   |     You must present your          |             |      |   |   |   |
|   |   |     prescription ID card to your   |             |      |   |   |   |
|   |   |     pharmacy, if you do not        |             |      |   |   |   |
|   |   |     present your prescription ID   |             |      |   |   |   |
|   |   |     card to your pharmacy, you     |             |      |   |   |   |
|   |   |     must pay 100% of the costs of  |             |      |   |   |   |
|   |   |     the medication to the pharmacy |             |      |   |   |   |
|   |   |     (except in an emergency).      |             |      |   |   |   |
|   |   |                                    |             |      |   |   |   |
|   |   | -   **We use a formulary.**        |             |      |   |   |   |
|   |   |     However, we have an open       |             |      |   |   |   |
|   |   |     3-tiered formulary. If your    |             |      |   |   |   |
|   |   |     physician believes a name      |             |      |   |   |   |
|   |   |     brand product is necessary or  |             |      |   |   |   |
|   |   |     there is no generic available, |             |      |   |   |   |
|   |   |     your physician may prescribe a |             |      |   |   |   |
|   |   |     name brand drug from a         |             |      |   |   |   |
|   |   |     formulary list. This list of   |             |      |   |   |   |
|   |   |     name brand drugs is a          |             |      |   |   |   |
|   |   |     preferred list of drugs that   |             |      |   |   |   |
|   |   |     we selected to meet patient    |             |      |   |   |   |
|   |   |     needs at a lower cost. To      |             |      |   |   |   |
|   |   |     order a prescription drug      |             |      |   |   |   |
|   |   |     brochure, call 605/328-6800 or |             |      |   |   |   |
|   |   |     1-800/752-5863 or go to the    |             |      |   |   |   |
|   |   |     Express Scripts website at     |             |      |   |   |   |
|   |   |                                    |             |      |   |   |   |
|   |   |    www.siouxvalley.org/HealthPlan. |             |      |   |   |   |
|   |   |                                    |             |      |   |   |   |
|   |   | -   **These are the dispensing     |             |      |   |   |   |
|   |   |     limitations.** Prescriptions   |             |      |   |   |   |
|   |   |     can be filled for up to a 30   |             |      |   |   |   |
|   |   |     day supply per copayment.      |             |      |   |   |   |
|   |   |     Those prescription drug        |             |      |   |   |   |
|   |   |     classes identified as          |             |      |   |   |   |
|   |   |     maintenance medications will   |             |      |   |   |   |
|   |   |     be made available for up to a  |             |      |   |   |   |
|   |   |     90-day supply. However, three  |             |      |   |   |   |
|   |   |     copayments will apply. A       |             |      |   |   |   |
|   |   |     generic equivalent will be     |             |      |   |   |   |
|   |   |     dispensed if it is available,  |             |      |   |   |   |
|   |   |     unless your physician          |             |      |   |   |   |
|   |   |     specifically requires a name   |             |      |   |   |   |
|   |   |     brand. If you receive a name   |             |      |   |   |   |
|   |   |     brand drug when a              |             |      |   |   |   |
|   |   |     Federally-approved generic     |             |      |   |   |   |
|   |   |     drug is available, and your    |             |      |   |   |   |
|   |   |     physician has not specified    |             |      |   |   |   |
|   |   |     Dispense as Written for the    |             |      |   |   |   |
|   |   |     name brand drug, you have to   |             |      |   |   |   |
|   |   |     pay the difference in cost     |             |      |   |   |   |
|   |   |     between the name brand drug    |             |      |   |   |   |
|   |   |     and the generic. Additionally, |             |      |   |   |   |
|   |   |     if there is no generic         |             |      |   |   |   |
|   |   |     equivalent, you will still be  |             |      |   |   |   |
|   |   |     required to pay the brand name |             |      |   |   |   |
|   |   |     copayment.                     |             |      |   |   |   |
|   |   |                                    |             |      |   |   |   |
|   |   | -   **Why use generic drugs?** To  |             |      |   |   |   |
|   |   |     reduce your out-of-pocket      |             |      |   |   |   |
|   |   |     expenses! A generic drug is    |             |      |   |   |   |
|   |   |     the chemical equivalent of a   |             |      |   |   |   |
|   |   |     corresponding brand name drug. |             |      |   |   |   |
|   |   |     Under federal law, generic and |             |      |   |   |   |
|   |   |     name brand drugs must meet the |             |      |   |   |   |
|   |   |     same standards for safety,     |             |      |   |   |   |
|   |   |     purity, strength, and          |             |      |   |   |   |
|   |   |     effectiveness. Generic drugs   |             |      |   |   |   |
|   |   |     are less expensive than brand  |             |      |   |   |   |
|   |   |     name drugs; therefore, you may |             |      |   |   |   |
|   |   |     reduce your out-of-pocket      |             |      |   |   |   |
|   |   |     costs by choosing to use a     |             |      |   |   |   |
|   |   |     generic drug.                  |             |      |   |   |   |
|   |   |                                    |             |      |   |   |   |
|   |   | -   **When you have to file a      |             |      |   |   |   |
|   |   |     claim.** Please submit all     |             |      |   |   |   |
|   |   |     claims directly to us at:      |             |      |   |   |   |
|   |   |     Sioux Valley Health Plan, PO   |             |      |   |   |   |
|   |   |     Box 91110, Sioux Falls, SD     |             |      |   |   |   |
|   |   |     57109-1110. Claim forms are    |             |      |   |   |   |
|   |   |     available at your request. You |             |      |   |   |   |
|   |   |     may, however, submit your      |             |      |   |   |   |
|   |   |     itemized prescription receipt  |             |      |   |   |   |
|   |   |     with date, supply, drug name,  |             |      |   |   |   |
|   |   |     and all necessary member       |             |      |   |   |   |
|   |   |     information in lieu of a claim |             |      |   |   |   |
|   |   |     form.                          |             |      |   |   |   |
|   |   |                                    |             |      |   |   |   |
|   |   |     *Prescription drugs continue   |             |      |   |   |   |
|   |   |     on the next page*              |             |      |   |   |   |
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| * |   |                                    | **You pay   | *    |   |   |   |
| * |   |                                    | --**        | *You |   |   |   |
| B |   |                                    |             | pay  |   |   |   |
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| n |   |                                    | Option**    |      |   |   |   |
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+---+---+------------------------------------+-------------+------+---+---+---+
| W |   |                                    | \$15 per    | \$15 |   |   |   |
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| o |   |                                    | drug        | ormu |   |   |   |
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| t |   |                                    | brand name  | drug |   |   |   |
| h |   |                                    | drug        |      |   |   |   |
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| D |   |                                    | \$15 copay  | \$15 |   |   |   |
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| f |   |                                    |             |      |   |   |   |
| i |   |                                    |             |      |   |   |   |
| v |   |                                    |             |      |   |   |   |
| e |   |                                    |             |      |   |   |   |
| * |   |                                    |             |      |   |   |   |
+---+---+------------------------------------+-------------+------+---+---+---+

  -----------------------------------------------------------------------
  **Section 5 (g).       
  Special Features**     
  ---------------------- ------------------------------------------------
  **Feature**            **Description**

  **24 hour nurse line** For any of your health concerns, 24 hours a day,
                         7 days a week, you may call Healthformation at
                         605/333-4444 and talk with a registered nurse
                         who will discuss treatment options and answer
                         your health questions.

  **Services for deaf    For individuals needing assistance, please
  and hearing impaired** contact our TTY line at 605/328-6869.

  **Pregnancy Program**  Individuals may contact the Healthy Pregnancy
                         Program at 1-800/752-5863 to enroll.

  **Centers of           We utilize the contracted Centers of Excellence
  Excellence**           Network for transplant services. Please contact
                         us at 605/328-6807 for any information needed.
  -----------------------------------------------------------------------

+---+---+------------------------------------+-------------+------+---+---+
| * |   |                                    |             |      |   |   |
| * |   |                                    |             |      |   |   |
| 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        |             |      | * |   |
|   | I | benefits:**                        |             |      | I |   |
|   | * |                                    |             |      | * |   |
|   | * | -   Please remember that all       |             |      | * |   |
|   |   |     benefits are subject to the    |             |      |   |   |
|   | * |     definitions, limitations, and  |             |      | * |   |
|   | * |     exclusions in this brochure    |             |      | * |   |
|   | M |     and are payable only when we   |             |      | M |   |
|   | * |     determine they are medically   |             |      | * |   |
|   | * |     necessary.                     |             |      | * |   |
|   |   |                                    |             |      |   |   |
|   | * | -   Plan dentists must provide or  |             |      | * |   |
|   | * |     arrange your care.             |             |      | * |   |
|   | P |                                    |             |      | P |   |
|   | * | -   **Under High Option,** we have |             |      | * |   |
|   | * |     no calendar year deductible    |             |      | * |   |
|   |   |     for In Network services.       |             |      |   |   |
|   | * |                                    |             |      | * |   |
|   | * | -   **Under Standard Option,** the |             |      | * |   |
|   | O |     calendar year deductible for   |             |      | O |   |
|   | * |     Participating Providers is     |             |      | * |   |
|   | * |     \$500 per person (\$1,000 per  |             |      | * |   |
|   |   |     family). The calendar year     |             |      |   |   |
|   | * |     deductible applies to almost   |             |      | * |   |
|   | * |     all benefits in this section.  |             |      | * |   |
|   | R |     We added "(No deductible)" to  |             |      | R |   |
|   | * |     show when the calendar year    |             |      | * |   |
|   | * |     deductible does not apply.     |             |      | * |   |
|   |   |                                    |             |      |   |   |
|   | * | -   **Under both High and Standard |             |      | * |   |
|   | * |     Options,** you must use Plan   |             |      | * |   |
|   | T |     Providers in order to receive  |             |      | T |   |
|   | * |     in-network benefit coverage.   |             |      | * |   |
|   | * |                                    |             |      | * |   |
|   |   | -   We cover hospitalization for   |             |      |   |   |
|   | * |     dental procedures only when a  |             |      | * |   |
|   | * |     non-dental physical impairment |             |      | * |   |
|   | A |     exists which makes             |             |      | A |   |
|   | * |     hospitalization necessary to   |             |      | * |   |
|   | * |     safeguard the health of the    |             |      | * |   |
|   |   |     patient. See Section 5 (c) for |             |      |   |   |
|   | * |     inpatient hospital benefits.   |             |      | * |   |
|   | * |     We do not cover the dental     |             |      | * |   |
|   | N |     procedure unless it is         |             |      | N |   |
|   | * |     described below.               |             |      | * |   |
|   | * |                                    |             |      | * |   |
|   |   | -   Be sure to read Section 4,     |             |      |   |   |
|   | * |     *Your costs for covered        |             |      | * |   |
|   | * |     services,* for valuable        |             |      | * |   |
|   | T |     information about how cost     |             |      | T |   |
|   | * |     sharing works. Also read       |             |      | * |   |
|   | * |     Section 9 about coordinating   |             |      | * |   |
|   |   |     benefits with other coverage,  |             |      |   |   |
|   |   |     including with Medicare.       |             |      |   |   |
+---+---+------------------------------------+-------------+------+---+---+
| * |   |                                    | **You pay   | *    |   |   |
| * |   |                                    | -**         | *You |   |   |
| A |   |                                    |             | pay  |   |   |
| c |   |                                    | **High      | -**  |   |   |
| c |   |                                    | Option**    |      |   |   |
| i |   |                                    |             | **   |   |   |
| d |   |                                    |             | Stan |   |   |
| e |   |                                    |             | dard |   |   |
| n |   |                                    |             | Opti |   |   |
| t |   |                                    |             | on** |   |   |
| a |   |                                    |             |      |   |   |
| l |   |                                    |             |      |   |   |
| i |   |                                    |             |      |   |   |
| n |   |                                    |             |      |   |   |
| j |   |                                    |             |      |   |   |
| u |   |                                    |             |      |   |   |
| r |   |                                    |             |      |   |   |
| y |   |                                    |             |      |   |   |
| b |   |                                    |             |      |   |   |
| e |   |                                    |             |      |   |   |
| n |   |                                    |             |      |   |   |
| e |   |                                    |             |      |   |   |
| f |   |                                    |             |      |   |   |
| i |   |                                    |             |      |   |   |
| t |   |                                    |             |      |   |   |
| * |   |                                    |             |      |   |   |
| * |   |                                    |             |      |   |   |
+---+---+------------------------------------+-------------+------+---+---+
| W |   |                                    | \$30 per    | 20%  |   |   |
| e |   |                                    | specialist  | of   |   |   |
| c |   |                                    | visit       | cha  |   |   |
| o |   |                                    |             | rges |   |   |
| v |   |                                    | \$50 per    | for  |   |   |
| e |   |                                    | outpatient  | sp   |   |   |
| r |   |                                    | surgery     | ecia |   |   |
| r |   |                                    |             | list |   |   |
| e |   |                                    | \$100 per   | v    |   |   |
| s |   |                                    | day copay   | isit |   |   |
| t |   |                                    | up to \$500 | or   |   |   |
| o |   |                                    | per         | ou   |   |   |
| r |   |                                    | inpatient   | tpat |   |   |
| a |   |                                    | admission   | ient |   |   |
| t |   |                                    |             | sur  |   |   |
| i |   |                                    |             | gery |   |   |
| v |   |                                    |             |      |   |   |
| e |   |                                    |             | \    |   |   |
| s |   |                                    |             | $100 |   |   |
| e |   |                                    |             | per  |   |   |
| r |   |                                    |             | day  |   |   |
| v |   |                                    |             | c    |   |   |
| i |   |                                    |             | opay |   |   |
| c |   |                                    |             | up   |   |   |
| e |   |                                    |             | to   |   |   |
| s |   |                                    |             | \    |   |   |
| a |   |                                    |             | $500 |   |   |
| n |   |                                    |             | per  |   |   |
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+---+---+------------------------------------+-------------+------+---+---+
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+---+---+------------------------------------+-------------+------+---+---+
| - |   |                                    | \$30 per    | 20%  |   |   |
|   |   |                                    | specialist  | of   |   |   |
|   |   |                                    | visit       | cha  |   |   |
|   |   |                                    |             | rges |   |   |
| D |   |                                    | \$50 per    | for  |   |   |
| e |   |                                    | outpatient  | sp   |   |   |
| n |   |                                    | surgery     | ecia |   |   |
| t |   |                                    |             | list |   |   |
| a |   |                                    | \$100 per   | v    |   |   |
| l |   |                                    | day copay   | isit |   |   |
|   |   |                                    | up to \$500 | or   |   |   |
|   |   |                                    | per         | ou   |   |   |
|   |   |                                    | inpatient   | tpat |   |   |
|   |   |                                    | admission   | ient |   |   |
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+---+---+------------------------------------+-------------+------+---+---+
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| s |   |                                    |             |      |   |   |
+---+---+------------------------------------+-------------+------+---+---+

+---+---+----------------------------------------------------------+---+---+
| S |   |                                                          |   |   |
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| 5 |   |                                                          |   |   |
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| r |   |                                                          |   |   |
| v |   |                                                          |   |   |
| i |   |                                                          |   |   |
| c |   |                                                          |   |   |
| e |   |                                                          |   |   |
| b |   |                                                          |   |   |
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| n |   |                                                          |   |   |
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| 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 necessary.                             | * |   |
|   | * |                                                          | * |   |
|   | M | -   **Under High Option,** the calendar year deductible  | M |   |
|   | * |     is \$500 per person and \$1,000 per family.          | * |   |
|   | * |                                                          | * |   |
|   |   | ```{=html}                                               |   |   |
|   | * | <!-- -->                                                 | * |   |
|   | * | ```                                                      | * |   |
|   | P | -   **Under Standard Option,** the calendar year         | P |   |
|   | * |     deductible for Non-Participating Providers is        | * |   |
|   | * |     \$1,000 per person and \$3,000 per family. The       | * |   |
|   |   |     calendar year deductible applies to almost all       |   |   |
|   | * |     benefits in this section. We added "(No deductible)" | * |   |
|   | * |     to show when the calendar year deductible does not   | * |   |
|   | O |     apply.                                               | O |   |
|   | * |                                                          | * |   |
|   | * | ```{=html}                                               | * |   |
|   |   | <!-- -->                                                 |   |   |
|   | * | ```                                                      | * |   |
|   | * | -   Be sure to read Section 4, *Your costs for covered   | * |   |
|   | R |     services,* for valuable information about how cost   | R |   |
|   | * |     sharing works. Also read Section 9 about             | * |   |
|   | * |     coordinating benefits with other coverage, including | * |   |
|   |   |     with Medicare.                                       |   |   |
|   | * |                                                          | * |   |
|   | * |                                                          | * |   |
|   | T |                                                          | T |   |
|   | * |                                                          | * |   |
|   | * |                                                          | * |   |
|   |   |                                                          |   |   |
|   | * |                                                          | * |   |
|   | * |                                                          | * |   |
|   | A |                                                          | A |   |
|   | * |                                                          | * |   |
|   | * |                                                          | * |   |
|   |   |                                                          |   |   |
|   | * |                                                          | * |   |
|   | * |                                                          | * |   |
|   | N |                                                          | N |   |
|   | * |                                                          | * |   |
|   | * |                                                          | * |   |
|   |   |                                                          |   |   |
|   | * |                                                          | * |   |
|   | * |                                                          | * |   |
|   | T |                                                          | T |   |
|   | * |                                                          | * |   |
|   | * |                                                          | * |   |
+---+---+----------------------------------------------------------+---+---+

**[Facts about this Plan\'s POS option]{.underline}**

You may choose to obtain benefits covered by our POS options from
non-Plan doctors and hospitals whenever you need care,
[except]{.underline} for the benefits listed below under \"What is not
covered.\" Benefits not covered under POS must be received by Plan
doctors to be covered. When you obtain covered non-emergency medical
treatment from a non-Plan doctor without authorization from us, you are
subject to the deductibles, coinsurance and maximum benefit stated
below.

**[What is covered]{.underline}**

-   Medical Office Visits

-   Preventive Health Services including Well Baby and Well Child Care
    (up to 6 years old), routine periodic preventive health exams,
    immunizations, allergy testing and treatment, and allergy serum

-   Emergency Services (No deductible)

-   X-Ray and Laboratory Services

-   Acute Inpatient Hospital Services

-   Maternity, Pregnancy and Newborn Care

-   Inpatient Physician Services and Consultations

-   Outpatient Hospital Services

-   Outpatient Surgery

-   Home Health Care

-   Skilled Nursing Facility Service

-   Mental Health Services

-   Inpatient Chemical Dependency Services

-   Inpatient Alcohol Treatment

-   Durable Medical Equipment and Prosthetic Devices (prior approval
    required for rentals or purchases over \$200).

-   Orthopedic Appliances

-   Outpatient Rehabilitative Therapy

-   Oral Surgery and Other Dental Services

    **[What is Not Covered]{.underline}**

-   Tobacco Treatment;

-   Services list as not covered at the in-network level in Section 5;

-   Chiropractic Services;

-   Transplants at Non-Participating Center of Excellence Facilities;

-   Custodial care; and

-   All other services not listed in the "What is covered" Section
    above.

    **Under High and Standard Options,** you pay 40% of the allowed
    benefit after paying the deductible and any charges greater than the
    allowed benefit.

    **All participating providers are paid at the In-Network Benefit
    level and only the out-of-network doctor and/or facility charges are
    paid at the Out-of-Network POS level. Services obtained within or
    outside of the service area by non-Plan Participating Providers are
    eligible for coverage under POS.**

    **[Outpatient substance abuse benefits]{.underline}**

    You pay 70% of our allowed benefit and any charges above the allowed
    \$30 benefit, after the deductible for all covered chemical
    dependency and alcohol treatment services.

    **[Ambulance and other transportation services]{.underline}**

    **Under High Option,** you pay 20% of our allowed benefit and any
    charges above the allowed benefit, after the deductible, for all
    covered services. Prior approval is only required for non-emergency
    transportation.

    **Under Standard Option,** you pay 40% of our allowed benefit and
    any charges above the allowed benefit, after the deductible, for all
    covered services. Prior approval is only required for non-emergency
    transportation.

    **[Deductible]{.underline}**

    The deductible is the amount that you must pay at the time services
    are received before we will pay for such services.

    **Under High Option,** the calendar year deductible is \$500 per
    person and \$1,000 per family for Non-Participating Providers.

    **Under Standard Option,** the calendar year deductible for
    Non-Participating Providers is \$1,000 per person and \$3,000 per
    family. The calendar year deductible applies to almost all benefits
    in this section. We added "(No deductible)" to show when the
    calendar year deductible does not apply.

    **[Coinsurance]{.underline}**

    Coinsurance is the percentage of charges to be paid by you for
    services at the time such services are rendered. Our coinsurance for
    Point of Service benefits is 60%; you pay 40%, except for ambulance
    and other transportation services and outpatient substance abuse
    services which have a different coinsurance. The fee schedule is set
    at the 90th percentile of the standard Usual and Customary Rate
    (UCR) allowance for our region. You will be liable for your
    coinsurance percentage plus any charges in excess of the UCR
    allowance.

    **[Maximum benefit]{.underline}**

    There is no lifetime maximum benefit under the POS plan.

    **[Catastrophic Protection Out-of-pocket maximum]{.underline}**

    The catastrophic limit on your out-of-pocket Point of Service
    expenses per calendar year is \$10,000 for the individual and
    \$10,000 for the family (this does not apply to transplant
    services). Your out-of-pocket expenses under POS qualify for our
    catastrophic protection out-of-pocket maximum.

    **[Hospital/extended care]{.underline}**

    We will pay a participating hospital in full even though the POS
    benefit (and non-Plan doctor) are being used. The hospital charge,
    sometimes called facility charge, does not cover any charges for
    doctors\' services.

    **[Emergency benefits]{.underline}**

    True emergency care is always payable as an in-Plan benefit; there
    is a \$100 per day copay up to \$500 per inpatient admission, but
    the copay is waived for true emergency admissions.

    **[Outpatient substance abuse benefits]{.underline}**

    For chemical dependency services, the POS benefit pays 30% of
    eligible reasonable and customary charges up to a \$30 limit; you
    pay 70%. Also, for alcohol treatment, the POS benefit pays 30% of
    eligible reasonable and customary charges up to a \$30 limit; you
    pay 70%.

    **[How to obtain benefits]{.underline}**

    To access POS benefits you may see the physician or obtain services
    at the facility of your choice. Benefits will be paid at 60% after
    the Out-of-Network deductible is met; you pay 40%, except for
    ambulance and other transportation services and outpatient substance
    abuse services which have a different coinsurance. We will need a
    claim from you, including a CPT code, date of service, diagnosis
    code, name of doctor or hospital, member\'s birthdate and
    identification number. Submit your claims to:

    Sioux Valley Health Plan

    PO Box 91110

######  Sioux Falls, SD 57109-1110 {#sioux-falls-sd-57109-1110 .unnumbered}

  -----------------------------------------------------------------------
  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 *What Services Require Our Prior Approval* in Section 3.

We do not cover the following:

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

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

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

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

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

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

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

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

-   Health Care Services performed by any Provider who is a Member of
    the enrollee's immediate family, including any person normally
    residing in the member's home. This exclusion does not apply in
    those areas in which the immediate family member is the only
    Provider in the area.

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

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

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

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

**Medical, hospital and drug 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 Member Services at 605/328-6800 or toll
free at 1-800/752-5863 (TYY 605/328-6869).

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

-   Covered member's name and ID number;

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

-   Dates you received the services or supplies;

-   Diagnosis;

-   Type of each service or supply;

-   The charge for each service or supply;

-   A copy of the explanation of benefits, payments, or denial from any
    primary payer \--such as the Medicare Summary Notice (MSN); and

-   Receipts, if you paid for your services.

**Submit your claims to:** Sioux Valley Health Plan

> PO Box 91110
>
> Sioux Falls, SD 57109-1110

**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 prior approval:

+---+------------------------------------------------------------------+
| * | **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: Sioux Valley Health Plan, PO Box |
|   |     91110, Sioux Falls, SD 57109-1110;                           |
|   |                                                                  |
|   | (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 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, Office of       |
|   | Insurance Programs, Contracts Division 3, 1900 E Street, NW,     |
|   | Washington, DC 20415-3630.                                       |
+---+------------------------------------------------------------------+
|   | **The Disputed Claims process *(Continued) ***                   |
|   |                                                                  |
|   | Send OPM the following information:                              |
|   |                                                                  |
|   | -   A statement about why you believe our decision was wrong,    |
|   |     based on specific benefit provisions in this brochure;       |
|   |                                                                  |
|   | -   Copies of documents that support your claim, such as         |
|   |     physicians\' letters, operative reports, bills, medical      |
|   |     records, and                                                 |
|   |                                                                  |
|   | explanation of benefits (EOB) forms;                             |
|   |                                                                  |
|   | -   Copies of all letters you sent to us about the claim;        |
|   |                                                                  |
|   | -   Copies of all letters we sent to you about the claim; and    |
|   |                                                                  |
|   | -   Your daytime phone number and the best time to call.         |
|   |                                                                  |
|   | Note: If you want OPM to review more than one claim, you must    |
|   | clearly identify which documents apply to which claim.           |
+---+------------------------------------------------------------------+
|   | Note: You are the only person who has a right to file a disputed |
|   | claim with OPM. Parties acting as your representative, such as   |
|   | medical providers, must include a copy of your specific written  |
|   | consent with the review request.                                 |
|   |                                                                  |
|   | Note: The above deadlines may be extended if you show that you   |
|   | were unable to meet the deadline because of reasons beyond your  |
|   | control.                                                         |
+---+------------------------------------------------------------------+
| * | OPM will review your disputed claim request and will use the     |
| * | information it collects from you and us to decide whether our    |
| 5 | decision is correct. OPM will 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 prior authorization.   |
|   | 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 prior
    approval/prior approval, then call us at 605/328-6807 and we will
    expedite our review; or

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

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

-   You may call OPM\'s Health Benefits Contracts Division 3 at
    202/606-0737 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. All plan
benefits and visit limitations are taken into consideration even if
benefits are coordinated. Visits and corresponding claims are denied
once they go beyond plan maximum limits.

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

-   People 65 years of age and older.

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

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

    Medicare has two parts:

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

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

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

1.  **Should I enroll in Medicare?** The decision to enroll in Medicare
    is yours. We encourage you to apply for

Medicare benefits 3 months before you turn age 65. It's easy. Just call
the Social Security Administration toll-free number 1-800-772-1213 to
set up an appointment to apply. If you do not apply for one or both
Parts of Medicare, you can still be covered under the FEHB Program.

> If you can get premium-free Part A coverage, we advise you to enroll
> in it. Most Federal employees and annuitants are entitled to Medicare
> Part A at age 65 **without cost**. When you don't have to pay premiums
> for Medicare Part A, it makes good sense to obtain the coverage. It
> can reduce your out-of-pocket expenses as well as costs to the FEHB,
> which can help keep FEHB premiums down.
>
> Everyone is charged a premium for Medicare Part B coverage. The Social
> Security Administration can provide you with premium and benefit
> information. Review the information and decide if it makes sense for
> you to buy the Medicare Part B coverage.

If you 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 managed care 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. We will not waive any of our copayments, coinsurance, and
deductibles*.* The following chart illustrates whether the Original
Medicare Plan 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.

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

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

```{=html}
<!-- -->
```
-   When Original Medicare is the primary payer, Medicare processes your
    claim first. In most cases, your claim will be coordinated
    automatically and we will then provide secondary benefits for the
    balance of covered charges. You will not need to do anything. To
    find out if you need to do something to file your claims, call us at
    605/328-6800 or 1-800/752-5863.

**We do not waive any costs when you have Medicare.** Medicare always
makes the final determination as to whether they are the primary payer.
The following chart illustrates whether Medicare or this Plan should be
the primary payer for you according to your employment status and other
factors determined by Medicare. It is critical that you tell us if you
or a covered family member has Medicare coverage so we can administer
these requirements correctly. *Please note, if your Plan physician does
not participate in Medicare, you will have to file a claim with
Medicare.*

+-------------------------------------------------------+-----+---+-------+
| > **Primary Payer Chart**                             |     |   |       |
+-------------------------------------------------------+-----+---+-------+
| **A. When you - or your covered spouse - are age 65   | **  |   |       |
| or over and have Medicare and you...**                | The |   |       |
|                                                       | p   |   |       |
|                                                       | rim |   |       |
|                                                       | ary |   |       |
|                                                       | pa  |   |       |
|                                                       | yer |   |       |
|                                                       | for |   |       |
|                                                       | the |   |       |
|                                                       | i   |   |       |
|                                                       | ndi |   |       |
|                                                       | vid |   |       |
|                                                       | ual |   |       |
|                                                       | w   |   |       |
|                                                       | ith |   |       |
|                                                       | Me  |   |       |
|                                                       | dic |   |       |
|                                                       | are |   |       |
|                                                       | i   |   |       |
|                                                       | s.. |   |       |
|                                                       | .** |   |       |
+-------------------------------------------------------+-----+---+-------+
|                                                       | **M | * |       |
|                                                       | edi | * |       |
|                                                       | car | T |       |
|                                                       | e** | h |       |
|                                                       |     | i |       |
|                                                       |     | s |       |
|                                                       |     | P |       |
|                                                       |     | l |       |
|                                                       |     | a |       |
|                                                       |     | n |       |
|                                                       |     | * |       |
|                                                       |     | * |       |
+-------------------------------------------------------+-----+---+-------+
| Are an active employee with the Federal government    |     |  |       |
| and**...**                                            |     |   |       |
|                                                       |     |   |       |
| 1.  You have FEHB coverage on your own or through     |     |   |       |
|     your spouse who is also an active employee        |     |   |       |
+-------------------------------------------------------+-----+---+-------+
| 2.  You have FEHB coverage through your spouse who is |    |   |       |
|     an annuitant                                      |     |   |       |
+-------------------------------------------------------+-----+---+-------+
| Are an annuitant and**...**                           |    |   |       |
|                                                       |     |   |       |
| 3.  You have FEHB coverage on your own or through     |     |   |       |
|     your spouse who is also an annuitant              |     |   |       |
+-------------------------------------------------------+-----+---+-------+
| 4.  You have FEHB coverage through your spouse who is |     |  |       |
|     an active employee                                |     |   |       |
+-------------------------------------------------------+-----+---+-------+
| 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)                                                 |     |   |       |
+-------------------------------------------------------+-----+---+-------+
| 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**...**                                      |     |   |       |
|                                                       |     |   |       |
| 5.  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                                             |     |   |       |
+-------------------------------------------------------+-----+---+-------+
| 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)                         | \*  |   |       |
|                                                       | {#s |   |       |
|                                                       | ect |   |       |
|                                                       | ion |   |       |
|                                                       | -8  |   |       |
|                                                       | .un |   |       |
|                                                       | num |   |       |
|                                                       | ber |   |       |
|                                                       | ed} |   |       |
+-------------------------------------------------------+-----+---+-------+
| Are enrolled in Part B only, regardless of your       |    |  |       |
| employment status                                     | for | f |       |
|                                                       | P   | o |       |
|                                                       | art | r |       |
|                                                       | B   | o |       |
|                                                       | se  | t |       |
|                                                       | rvi | h |       |
|                                                       | ces | e |       |
|                                                       |     | r |       |
|                                                       |     | s |       |
|                                                       |     | e |       |
|                                                       |     | r |       |
|                                                       |     | v |       |
|                                                       |     | i |       |
|                                                       |     | c |       |
|                                                       |     | e |       |
|                                                       |     | s |       |
+-------------------------------------------------------+-----+---+-------+
| 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 sole                             |     |   |      |
| ly based on end stage renal disease (ESRD) and**...** |     |   |       |
|                                                       |     |   |       |
| ###### It is within th                                |     |   |       |
| e first 30 months of eligibility for or entitlement t |     |   |       |
| o Medicare due to ESRD (30-month coordination period) |     |   |       |
+-------------------------------------------------------+-----+---+-------+
| It is beyond the 30-month coordination period and you |    |   |       |
| or a family member are still entitled to Medicare due |     |   |       |
| to ESRD                                               |     |   |       |
+-------------------------------------------------------+-----+---+-------+
| Become eligible for Medicare due to ESRD while        |     |   | for  |
| already a Medicare beneficiary and**...**             |     |   | 30-   |
|                                                       |     |   | month |
| 1.  This Plan was the primary payer before            |     |   | co    |
|     eligibility due to ESRD                           |     |   | ordin |
|                                                       |     |   | ation |
|                                                       |     |   | p     |
|                                                       |     |   | eriod |
+-------------------------------------------------------+-----+---+-------+
| 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**           |     |   |       |
+-------------------------------------------------------+-----+---+-------+
| Are an active employee with the Federal government    |     |   |      |
| and**...**                                            |     |   |       |
|                                                       |     |   |       |
| 1.  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                                        |     |   |       |
+-------------------------------------------------------+-----+---+-------+
| Are an annuitant and**...**                           |    |   | []{.  |
|                                                       |     |   | mark} |
| 2.  You have FEHB coverage on your own or through     |     |   |       |
|     your spouse who is also an annuitant              |     |   |       |
+-------------------------------------------------------+-----+---+-------+
| > You have FEHB coverage through your spouse who is   |     |   |      |
| > an active employee                                  |     |   |       |
+-------------------------------------------------------+-----+---+-------+
| **D. Are covered under the FEHB Spouse Equity         |    |   |       |
| provision as a former spouse**                        |     |   |       |
+-------------------------------------------------------+-----+---+-------+

\* Unless you have FEHB coverage through your spouse who is an active
employee. \*\* Workers' Compensation is primary for claims related to
your condition under Workers' Compensation.

**• Medicare managed care plan** If you are eligible for Medicare, you
may choose to enroll in and get your Medicare benefits from a Medicare
managed care plan. These are health care choices (like HMOs) in some
areas of the country. In most Medicare managed care plans, you can only
go to doctors, specialists, or hospitals that are part of the plan.
Medicare managed care plans provide all the benefits that Original
Medicare covers. Some cover extras, like prescription drugs. To learn
more about enrolling in a Medicare managed care plan, contact Medicare
at 1-800/MEDICARE (1-800/633-4227) or at www.medicare.gov.

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

**This Plan and another plan\'s Medicare managed care plan:** You may
enroll in another plan's Medicare managed care plan and also remain
enrolled in our FEHB plan. We will still provide benefits when your
Medicare managed care 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, coinsurance, or deductibles. If
you enroll in a Medicare managed care plan, tell us. We will need to
know whether you are in the Original Medicare Plan or in a Medicare
managed care plan so we can correctly coordinate benefits with Medicare.

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

If you do not have one or both Parts of Medicare, you can still be
covered 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
and this Plan cover you, we pay first. See your TRICARE or CHAMPVA
Health Benefits Advisor if you have questions about these programs.

**Suspended FEHB coverage to enroll in TRICARE or CHAMPVA:** If you are
an annuitant or former spouse, you can suspend your FEHB coverage to
enroll in a 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 a 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 care

**for injuries** 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.

> We will provide health care services to you for the illness or injury,
> just as we would in any other case. However, if you accept the
> services from us, this acceptance constitutes your consent to the
> subrogation provisions discussed above.

**Member's Responsibilities** You must take such action, furnish such
information and assistance, and execute such instruments as we may
require to facilitate enforcement of our rights under this provision.
You shall take no action prejudicing the rights and interests of the
Plan under this provision. If you fail to cooperate in our
administration of this subrogation provision, you be responsible for the
Usual and Reasonable Charges for services subject to this Part and any
legal costs incurred by the Plan to enforce our rights under this Part.

  -----------------------------------------------------------------------
  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 *Section 4*.

**Copayment** A copayment is a fixed amount of money you pay when you
receive covered services. See *Section 4.*

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

**Custodial care** Care in which room, board, and other personal
assistance services are provided, generally on a long-term basis and
which does not include a medical component.

**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 *Section 4*.

Any healthcare services where the Healthcare service in question is
either: 1) not recognized in accordance with generally accepted medical
standards as being safe and effective for treatment of the condition in
question, regardless of whether the service is authorized by law or used
in testing or other studies; or 2) requires approval by any governmental
authority and such approval has not been granted prior to the service
being rendered.

**Medical necessity** Health care services that are appropriate, in
terms or type, frequency, level, setting, and duration, to your
diagnosis or condition, and diagnostic testing and preventative
services. Medically necessary care must:

-   Be consistent with generally accepted standards of medical practice
    as recognized by the plan, as determined by health care providers in
    the same or similar general specialty as typically manages the
    condition, procedure, or treatment at issue; and

-   Help restore or maintain your health; or

-   Prevent deterioration of your condition; or

-   Prevent the reasonably likely onset of a health problem or detect an
    incipient problem; or

-   Not considered experimental or investigative.

    **Plan allowance** Plan allowance is the amount we use to determine
    our payment and your coinsurance for covered services. Plans
    determine their allowances in different ways. We determine our
    allowance as follows: For in-network coverage the allowance is based
    on a percent of discounted charges that the Plan has negotiated with
    Participating Providers; in-network providers accept the plan
    allowance as payment in full. For out-of-network providers the
    allowance is based on a percent of eligible reasonable and customary
    charges.

    **Us/We** Us and we refer to *Sioux Valley Health Plan*

    **Utilization Management** A set of formal techniques designed to
    monitor the use of, or evaluate the clinical necessity,
    appropriateness, efficacy, or efficiency of, health care services,
    procedures, or facilities.

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

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

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

**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

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

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

• When you may change your enrollment;

• How you can cover your family members;

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

• When your enrollment ends; and

• When the next open season for enrollment begins.

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

**Types of 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,

-   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 make any changes
    after retirement. Contact you 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 first pay period that starts on or after
    January 1. Annuitants' coverage and premiums begin on January 1. If
    you joined at any other time during the year, your employing office
    will tell you the effective date of coverage.

    **Your medical and claims**

    **records are confidential** We will keep your medical and claims
    information confidential. Only the following will have access to it:

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-   OPM, this Plan, and subcontractors when they administer this
    contract;

-   This Plan and appropriate third parties, such as other insurance
    plans and the Office of Workers\' Compensation Programs (OWCP), when
    coordinating benefit payments and subrogating claims;

-   Law enforcement officials when investigating and/or prosecuting
    alleged civil or criminal actions;

-   OPM and the General Accounting Office when conducting audits;

-   Individuals involved in bona fide medical research or education that
    does not disclose your identity; or

-   OPM, when reviewing a disputed claim or defending litigation about a
    claim.

-   **records are confidential**

    **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:

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```
-   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-FEHBP
    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 coverage (TCC)** If you leave Federal service, or if you lose
    coverage because you no 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)

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

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

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

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

**•Getting a Certificate of**

**Group Health Plan Coverage** 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); refer to the \"TCC and HIPAA\" frequently
asked question. 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 it
has 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***

1.  **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 us, or any
    other medical, dental, or vision care plan you or your dependents
    may have

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

-   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

2.  **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!

3.  Enroll online anytime during Open Season (November 10 through
    December 8, 2003) at **www.fsafeds.com**.

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

    **What is SHPS?** SHPS is a third-party administrator hired by OPM
    to manage the FSAFEDS Program. SHPS is the largest FSA administrator
    in the nation and will be responsible for enrollment, claims
    processing, customer service, and day-to-day operations of FSAFEDS.

    **Who is eligible to enroll?** If you are a Federal employee
    eligible for FEHB -- even if you're not enrolled in FEHB-- you can
    choose to participate in either, or both, of the flexible spending
    accounts. If you are not eligible for FEHB, you are not eligible to
    enroll for a Health Care FSA. However, almost all Federal employees
    are eligible to enroll for the Dependent Care FSA. The only
    exception is intermittent (also called when actually employed
    \[WAE\]) employees expected to work less than 180 days during the
    year.

    *Note:* FSAFEDS is the FSA Program established for all Executive
    Branch employees and Legislative Branch employees whose employers
    signed on. Under IRS law, FSAs are not available to annuitants. In
    addition, the U.S. Postal Service and the Judicial Branch, among
    others, are Federal agencies that have their own plans with slightly
    different rules, but the advantages of having an FSA are the same no
    matter what agency you work for.

5.  **How much should I** Plan carefully when deciding how much to
    contribute to an FSA. Because of

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

    The **FSAFEDS Calculator** at www.fsafeds.com will help you plan
    your FSA allocations and provide an estimate of your tax savings
    based on your individual situation.

6.  **What can my HCFSA** Every FEHB health plan includes cost sharing
    features, such as deductibles you **pay for?** must meet before the
    Plan provides benefits, coinsurance or copayments that

    you pay when you and the Plan share costs, and medical services and
    supplies that are not covered by the Plan and for which you must
    pay. These out-of-pocket costs are summarized on page 10 and
    detailed throughout this brochure. Your HCFSA will reimburse you for
    such costs when they are for tax deductible medical care for you and
    your dependents that is NOT covered by this FEHB Plan or any other
    coverage that you have.

    Under both the High and Standard Options of this Plan, typical
    out-of-pocket expenses include: coinsurance for inpatient admissions
    related to family planning, diagnosis and treatment of infertility,
    and vision services. However, three common but significant expenses
    not covered by the Plan also includes reversal of voluntary
    sterilization, in-vitro fertilization, and laser surgery to correct
    myopia, hyperopia or stigmatic error.

    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.

7.  **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.

1.  **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
    exception is not available on your Federal income tax return.

    **Dependent care expenses** The DCFSA generally allows many families
    to save more than they would with the Federal tax credit for
    dependent care expenses. Note that you may only be reimbursed from
    the DCFSA up to your current account balance. If you file a claim
    for more than your current balance, it will be held until additional
    payroll allotments have been added to your account.

    Visit www.fsafeds.com 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

    **to participate in FSAFEDS?** HCFSA and 1.5% of the annual election
    for a DCFSA, most agencies have elected to pay these fees out of
    their share of employment tax savings. To be sure, check the
    FSAFEDS.com 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.

2.  **Contact us** To find out more or to enroll, please visit the
    **FSAFEDS Web site** at

    **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.

    1.  E-mail: fsafeds@shps.net

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

    3.  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:

1.  **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.

2.  **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.

3.  **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.

4.  **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.

  -----------------------------------------------------------------------
  **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 25

Allergy tests 15

Alternative treatment 19

Allogenetic (donor) bone marrow transplant 22

Ambulance 23, 24

Anesthesia 22

Autologous bone marrow transplant 22

**B**iopsies 20

Birthing centers 14

Blood and blood plasma 23,24

Breast cancer screening 13

Casts 18

Catastrophic protection 10

Chemotherapy 15

Childbirth 14

Chiropractic 19

Cholesterol tests 13

Claims 36

Coinsurance 10

Colorectal cancer screening 13

Congenital anomalies 20

Contraceptive devices and drugs 28

Coordination of benefits 39

Covered charges 7

Covered providers 7

Crutches 18

**D**eductible 10

Definitions 44

Dental care 31

Diagnostic services 12

Disputed claims review 37

Donor expenses (transplants) 22

Dressings 23

Durable medical equipment (DME) 18

**E**ducational classes and programs 19

Effective date of enrollment 47

Emergency 25

Experimental or investigational 35

Eyeglasses 16

**F**amily planning 14

Fecal occult blood test 13

Fraud 1

**G**eneral Exclusions 35

**H**earing services 16

Home health services 18

Hospice care 24

Home nursing care 18

Hospital 23

**I**mmunizations 13

Infant Circumcision 14

Infertility 15

Inhospital physician care 23

Inpatient Hospital Benefits 23

Insulin 29

**L**aboratory and pathological services 23

**M**agnetic Resonance Imagings (MRIs) 12

Mail Order Prescription Drugs 28

Mammograms 13

Maternity Benefits 14

Medicaid 43

Medically necessary 16, 24, 26, 35, 44

Medicare 39-42

Mental Conditions/Substance Abuse Benefits 27

**N**ewborn care 14

Nursing Care 23-24

Nurse Anesthetist 23-24

Nurse Practitioner 12

**O**bstetrical care 14

Occupational therapy 16

Ocular injury 16

Office visits 12

Oral and maxillofacial surgery 21

Orthopedic devices 17

Out-of-pocket expenses 10

Outpatient facility care 24

**P**ap test 13

Physical examination 13

Physical therapy 16

Physician 12

Physician's Assistant 12

Point of service (POS) 32

Prior approval 9

Preventive care, adult 13

Preventive care, children 13

Prescription drugs 28

Preventive services 13

Prostate cancer screening 13

Prosthetic devices 17

Psychologist 27

**R**adiation therapy 15

Renal dialysis 15

Room and board 23

**S**econd surgical opinion 12

Skilled nursing facility care 24

Smoking cessation 19

Speech therapy 16

Sterilization procedures 14

Subrogation 43

Substance abuse 27

Surgery 20

-   Anesthesia 22

-   Oral 21

-   Outpatient 24

-   Reconstructive 21

    **T**emporary continuation of coverage 48

    Transplants 22

    Treatment Therapies 15

    **V**ision services 16

    **W**ell child care 13

    Wheelchairs 18

    Workers' compensation 42

    **X**-rays 12

  -----------------------------------------------------------------------
  **Summary of benefits for the *Sioux Valley Health Plan* 2004 High
  Option**

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

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

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

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

+-------------------------------------+--------------------------+----+
| **Benefits**                        | **You Pay**              | ** |
|                                     |                          | Pa |
|                                     |                          | ge |
|                                     |                          | ** |
+-------------------------------------+--------------------------+----+
| Medical services provided by        | Office visit copay: \$20 | 12 |
| physicians:                         | primary care; \$30       |    |
|                                     | specialist visit         |    |
| -   Diagnostic and treatment        |                          |    |
|     services provided in the office |                          |    |
+-------------------------------------+--------------------------+----+
| Services provided by a hospital:    | \$100 per day copay up   | 23 |
|                                     | to \$500 per admission   |    |
| -   Inpatient                       |                          | 24 |
|                                     | \$50 per visit           |    |
| -   Outpatient Surgery              |                          | 24 |
|                                     | Nothing                  |    |
| -   Outpatient Hospital             |                          | 16 |
|     Services.......                 | \$30 per outpatient      |    |
| ................................... | visit                    |    |
|                                     |                          |    |
| -   Outpatient Rehabilitative       |                          |    |
|     Services (cardiac rehab,        |                          |    |
|     physical, occupational, and     |                          |    |
|     speech                          |                          |    |
|     therapies).                     |                          |    |
| ................................... |                          |    |
+-------------------------------------+--------------------------+----+
| Emergency benefits:                 | \$100 per visit; waived  | 25 |
|                                     | if admitted              |    |
| -   In-area                         |                          | 25 |
|                                     | \$100 per visit; waived  |    |
| -   Out-of-area                     | if admitted              |    |
+-------------------------------------+--------------------------+----+
| Mental health and substance abuse   | Regular cost sharing.    | 27 |
| treatment                           |                          |    |
+-------------------------------------+--------------------------+----+
| Prescription drugs (30 day supply): | \$ 15 copay              | 29 |
|                                     |                          |    |
| Generic drugs                       | \$ 30 copay              |    |
|                                     |                          |    |
| Formulary brand name drugs          | \$ 50 copay              |    |
|                                     |                          |    |
| Non-formulary brand name drugs      | NOTE: If there is no     |    |
|                                     | generic equivalent       |    |
|                                     | available, you will      |    |
|                                     | still have to pay the    |    |
|                                     | brand name copay.        |    |
+-------------------------------------+--------------------------+----+
| Dental Care                         | No benefit.              | 31 |
+-------------------------------------+--------------------------+----+
| Vision Care                         | \$30 copay               | 13 |
|                                     |                          |    |
| (Eye exams for children through age |                          |    |
| 17.)                                |                          |    |
+-------------------------------------+--------------------------+----+
| Special features: 24 hour nurse     |                          | 30 |
| line, Services for deaf and hearing |                          |    |
| impaired, Healthy Pregnancy         |                          |    |
| Program, Centers of Excellence for  |                          |    |
| transplants                         |                          |    |
+-------------------------------------+--------------------------+----+
| Point of Service benefits \-- Yes   |                          | 32 |
+-------------------------------------+--------------------------+----+
| Protection against catastrophic     | Nothing after            | 10 |
| costs                               | \$4,000/Self Only or     |    |
|                                     | \$4,000/Family           |    |
| (your catastrophic protection       | enrollment per year      |    |
| out-of-pocket maximum)              |                          |    |
|                                     | Any costs above          |    |
|                                     | reasonable and customary |    |
|                                     | charges do not count     |    |
|                                     | toward this protection.  |    |
+-------------------------------------+--------------------------+----+

  -----------------------------------------------------------------------
  **Summary of benefits for the *Sioux Valley Health Plan* 2004 Standard
  Option**

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

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

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

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

+-------------------------------------+--------------------------+----+
| **Benefits**                        | **You Pay**              | ** |
|                                     |                          | Pa |
|                                     |                          | ge |
|                                     |                          | ** |
+-------------------------------------+--------------------------+----+
| Medical services provided by        | Office visit copay: \$25 | 12 |
| physicians:                         | primary care; \$25       |    |
|                                     | specialist               |    |
| -   Diagnostic and treatment        |                          |    |
|     services provided in the office |                          |    |
+-------------------------------------+--------------------------+----+
| Services provided by a hospital:    | \$100 per day copay up   | 23 |
|                                     | to \$500 per admission   |    |
| -   Inpatient                       |                          | 24 |
|                                     | 20% coinsurance          |    |
| -   Outpatient Surgery              |                          | 24 |
|                                     | Nothing                  |    |
| -   Outpatient Hospital             |                          | 16 |
|     Services...........             | 20% coinsurance          |    |
| ................................... |                          |    |
|                                     |                          |    |
| -   Outpatient Rehabilitative       |                          |    |
|     Services (cardiac rehab,        |                          |    |
|     physical, occupational, and     |                          |    |
|     speech                          |                          |    |
|     therapies).                     |                          |    |
| ................................... |                          |    |
+-------------------------------------+--------------------------+----+
| Emergency benefits:                 | > \$100 per visit;       | >  |
|                                     | > waived if admitted     | 25 |
| -   In-area                         | >                        | >  |
|                                     | > \$100 per visit;       | >  |
| -   Out-of-area                     | > waived if admitted     | 25 |
+-------------------------------------+--------------------------+----+
| > Mental health and substance abuse | > Regular cost sharing.  | >  |
| > treatment                         |                          | 27 |
+-------------------------------------+--------------------------+----+
| Prescription drugs (30 day supply): | \$ 15 copay              | >  |
|                                     |                          | 29 |
| Generic drugs                       | \$ 30 copay              |    |
|                                     |                          |    |
| Formulary brand name drugs          | \$ 50 copay              |    |
|                                     |                          |    |
| Non-formulary brand name drugs      | > NOTE: If there is no   |    |
|                                     | > generic equivalent     |    |
|                                     | > available, you will    |    |
|                                     | > still have to pay the  |    |
|                                     | > brand name copay.      |    |
+-------------------------------------+--------------------------+----+
| Dental Care                         | > No benefit.            | >  |
|                                     |                          | 31 |
+-------------------------------------+--------------------------+----+
| Vision Care                         | > \$25 per visit         | >  |
|                                     |                          | 13 |
| (Eye exams for children through age |                          |    |
| 17.)                                |                          |    |
+-------------------------------------+--------------------------+----+
| > Special features: 24 hour nurse   |                          | >  |
| > line, Services for deaf and       |                          | 30 |
| > hearing impaired, Healthy         |                          |    |
| > Pregnancy Program, Centers of     |                          |    |
| > Excellence for transplants        |                          |    |
+-------------------------------------+--------------------------+----+
| > Point of Service benefits \-- Yes |                          | >  |
|                                     |                          | 32 |
+-------------------------------------+--------------------------+----+
| Protection against catastrophic     | Nothing after            | >  |
| costs                               | \$3,000/Self Only or     | 10 |
|                                     | \$5,000/Family           |    |
| (your catastrophic protection       | enrollment per year      |    |
| out-of-pocket maximum)              |                          |    |
|                                     | Any costs above          |    |
|                                     | reasonable and customary |    |
|                                     | charges do not count     |    |
|                                     | toward this protection.  |    |
+-------------------------------------+--------------------------+----+

**2004 Rate Information for Sioux Valley Health Plan**

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

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

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

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

**Central, Eastern South Dakota and counties surrounding the Rapid City
area**

and Northwestern Iowa

+--------------+-----+-------+-------+-------+-------+-------+-------+
| **High       | *   | **    | *     | **    | **    | **    | *     |
| Option**     | *AU | \$121 | *\$92 | \$263 | \$199 | \$143 | *\$70 |
|              | 1** | .40** | .26** | .03** | .90** | .23** | .34** |
| **Self       |     |       |       |       |       |       |       |
| Only**       |     |       |       |       |       |       |       |
+--------------+-----+-------+-------+-------+-------+-------+-------+
| **High       | *   | **    | **    | **    | **    | **    | **    |
| Option**     | *AU | \$277 | \$214 | \$600 | \$494 | \$327 | \$164 |
|              | 2** | .09** | .16** | .36** | .02** | .12** | .13** |
| **Self and   |     |       |       |       |       |       |       |
| Family**     |     |       |       |       |       |       |       |
+--------------+-----+-------+-------+-------+-------+-------+-------+
| **Standard   | *   | **    | *     | **    | **    | **    | *     |
| Option**     | *AU | \$121 | *\$59 | \$263 | \$129 | \$143 | *\$38 |
|              | 4** | .40** | .92** | .03** | .83** | .23** | .00** |
| **Self       |     |       |       |       |       |       |       |
| Only**       |     |       |       |       |       |       |       |
+--------------+-----+-------+-------+-------+-------+-------+-------+
| **Standard   | *   | **    | **    | **    | **    | **    | *     |
| Option**     | *AU | \$277 | \$139 | \$600 | \$302 | \$327 | *\$89 |
|              | 5** | .09** | .74** | .36** | .77** | .12** | .71** |
| **Self and   |     |       |       |       |       |       |       |
| Family**     |     |       |       |       |       |       |       |
+--------------+-----+-------+-------+-------+-------+-------+-------+

#