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Dear Federal Employees Health Benefits Program Participant:

Welcome to the 2005 Open Season! By continuing to introduce pro-consumer
health care ideas, the Office of Personnel Management (OPM) team has
given you greater, cost effective choices. This year several national
and local health plans are offering new options, strengthening the
Federal Employees Health Benefits (FEHB) Program and highlighting once
again its unique and distinctive market-oriented features. I remain firm
in my belief that you, when fully informed as a Federal subscriber, are
in the best position to make the decisions that meet your needs and
those of your family. Plan brochures provide information to help
subscribers make these fully informed decisions. Please take the time to
review the plan's benefits, particularly Section 2, which explains plan
changes.

Exciting new features this year give you additional opportunities to
save and better manage your hard-earned dollars. For 2005, I am very
pleased and enthusiastic about the new High Deductible Health Plans
(HDHP) with a Health Savings Account (HSA) or Health Reimbursement
Arrangement (HRA) component. This combination of health plan and savings
vehicle provides a new opportunity to save and better manage your money.
If an HDHP/HSA is not for you and you are not retired, I encourage you
to consider a Flexible Spending Account (FSA) for health care. FSAs
allow you to reduce your out-of-pocket health care costs by 20 to more
than 40 percent by paying for certain health care expenses with tax-free
dollars, instead of after-tax dollars.

Since prevention remains a major factor in the cost of health care, last
year OPM launched the *HealthierFeds* campaign. Through this effort we
are encouraging Federal team members to take greater responsibility for
living a healthier lifestyle. The positive effect of a healthier life
style brings dividends for you and reduces the demands and costs within
the health care system. This campaign embraces four key "actions" that
can lead to a healthy America: be physically active every day, eat a
nutritious diet, seek out preventative screenings, and make healthy
lifestyle choices. Be sure to visit *HealthierFeds* at
[www.healthierfeds.opm.gov](http://www.healthierfeds.opm.gov/) for more
details on this important initiative. I also encourage you to visit the
Department of Health and Human Services website on Wellness and Safety,
[www.hhs.gov/safety/index.shtml](http://www.hhs.gov/safety/index.shtml),
which complements and broadens healthier lifestyle resources. The site
provides extensive information from health care experts and
organizations to support your personal interest is staying healthy.

The FEHB Program offers the Federal team the widest array of
cost-effective health care options and the information needed to make
the best choice for you and your family. You will find comprehensive
health plan information in this brochure, in the 2005 Guide to FEHB
Plans, and on the OPM Website at
[www.opm.gov/insure](http://www.opm.gov/insure). I hope you find these
resources useful, and thank you once again for your service to the
nation.

> Sincerely,
>
> Kay Coles James
>
> Director

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**Notice of the United States Office of Personnel Management's**

**Privacy Practices**

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW
IT CAREFULLY.

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

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

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

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

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

-   Where required by law.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

-   Get a separate paper copy of this notice.

For more information on exercising your rights set out in this notice,
look at [www.opm.gov/insure](http://www.opm.gov/insure) on the Web. You
may also call 202-606-0745 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

Unites States Office of Personnel Management

P.O. Box 707

Washington, DC 20004-0707

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

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

Table of Contents

[Introduction 3](#introduction)

[Plain Language 3](#plain-language)

[Stop Health Care Fraud! 3](#stop-health-care-fraud)

[Preventing medical mistakes 4](#preventing-medical-mistakes)

[Section 1. Facts about this HMO plan
6](#section-1.-facts-about-this-hmo-plan)

[We also have Point of Service (POS) benefits
6](#we-also-have-point-of-service-pos-benefits)

[How we pay providers 6](#how-we-pay-providers)

[Your Rights 6](#your-rights)

[Service Area 6](#service-area)

[Section 2. How we changed for 2005
8](#section-2.-how-we-changed-for-2005)

[Program-wide changes 8](#program-wide-changes)

[Changes to this Plan 8](#changes-to-this-plan)

[Section 3. How you get care 9](#section-3.-how-you-get-care)

[Identification cards 9](#identification-cards)

[Where you get covered care 9](#where-you-get-covered-care)

[• Plan providers 9](#plan-providers)

[• Plan facilities 9](#plan-facilities)

[What you must do to get covered care
9](#what-you-must-do-to-get-covered-care)

[• Primary care 9](#primary-care)

[• Specialty care 10](#specialty-care)

[• Hospital care 10](#hospital-care)

[Circumstances beyond our control 11](#circumstances-beyond-our-control)

[Services requiring our prior approval
11](#services-requiring-our-prior-approval)

[Prior Approval Process 11](#prior-approval-process)

[Section 4. Your costs for covered services
12](#section-4.-your-costs-for-covered-services)

[Copayments 12](#copayments)

[Deductible 12](#deductible)

[Coinsurance 12](#coinsurance)

[Your catastrophic protection out-of-pocket maximum
12](#your-catastrophic-protection-out-of-pocket-maximum)

[Section 5. Benefits -- OVERVIEW *(See page 8 for how our benefits
changed this year and page 68-69 for a benefits summary.)*
13](#section-5.-benefits-overview-see-page-8-for-how-our-benefits-changed-this-year-and-page-68-69-for-a-benefits-summary.)

[Section 5(a) Medical services and supplies provided by physicians and
other health care professionals
15](#section-5a-medical-services-and-supplies-provided-by-physicians-and-other-health-care-professionals)

[Section 5(b) Surgical and anesthesia services provided by physicians
and other health care professionals
27](#section-5b-surgical-and-anesthesia-services-provided-by-physicians-and-other-health-care-professionals)

[Section 5(c) Services provided by a hospital or other facility, and
ambulance services
32](#section-5c-services-provided-by-a-hospital-or-other-facility-and-ambulance-services)

[Section 5(d) Emergency services/accidents
36](#section-5d-emergency-servicesaccidents)

[Section 5(e) Mental health and substance abuse benefits
39](#section-5e-mental-health-and-substance-abuse-benefits)

[Section 5(f) Prescription drug benefits
41](#section-5f-prescription-drug-benefits)

[Section 5(g) Special features 44](#section-5g-special-features)

-   
-   
-   
-   

[24 hour nurse line 44](#hour-nurse-line)[Services for deaf and hearing
impaired 44](#services-for-deaf-and-hearing-impaired)[Pregnancy Programs
44](#pregnancy-programs)[Centers of excellence
44](#centers-of-excellence)[Section 5(h) Dental benefits
45](#section-5h-dental-benefits)

[Section 5(i) Point of Service benefits
46](#section-5i-point-of-service-benefits)

[Section 6. General exclusions -- things we don't cover
49](#section-6.-general-exclusions-things-we-dont-cover)

[Section 7. Filing a claim for covered services
50](#section-7.-filing-a-claim-for-covered-services)

[Section 8. The disputed claims process
51](#section-8.-the-disputed-claims-process)

[Section 9. Coordinating benefits with other coverage
53](#section-9.-coordinating-benefits-with-other-coverage)

[When you have other health coverage
53](#when-you-have-other-health-coverage)

[What is Medicare? 53](#what-is-medicare)

[• Should I enroll in Medicare? 53](#should-i-enroll-in-medicare)

[• The Original Medicare Plan (Part A or Part B)
53](#the-original-medicare-plan-part-a-or-part-b)

[• Medicare Advantage 56](#medicare-advantage)

[TRICARE and CHAMPVA 56](#tricare-and-champva)

[Workers' Compensation 56](#workers-compensation)

[Medicaid 56](#medicaid)

[When other Government agencies are responsible for your care
57](#when-other-government-agencies-are-responsible-for-your-care)

[When others are responsible for injuries
57](#when-others-are-responsible-for-injuries)

[Section 10. Definitions of terms we use in this brochure
58](#section-10.-definitions-of-terms-we-use-in-this-brochure)

[Section 11. FEHB Facts 59](#section-11.-fehb-facts)

[Coverage information 59](#coverage-information)

[• No pre-existing condition limitation
59](#no-pre-existing-condition-limitation)

[• Where you can get information about enrolling in the FEHB Program
59](#where-you-can-get-information-about-enrolling-in-the-fehb-program)

[• Types of coverage available for you and your family
59](#types-of-coverage-available-for-you-and-your-family)

[• Children's Equity Act 60](#childrens-equity-act)

[• When benefits and premiums start
60](#when-benefits-and-premiums-start)

[• Your medical claims records are confidential
60](#your-medical-claims-records-are-confidential)

[• When you retire 60](#when-you-retire)

[When you lose benefits 61](#when-you-lose-benefits)

[• When FEHB coverage ends 61](#when-fehb-coverage-ends)

[• Spouse equity coverage 61](#spouse-equity-coverage)

[• Temporary Continuation of Coverage (TCC)
61](#temporary-continuation-of-coverage-tcc)

[• Converting to individual coverage
61](#converting-to-individual-coverage)

[• Getting a Certificate of Group Health Plan Coverage
61](#getting-a-certificate-of-group-health-plan-coverage)

[• Getting a Certificate of Group Health Plan Coverage *(continued)*
62](#getting-a-certificate-of-group-health-plan-coverage-continued)

[Section 12.Two Federal Programs complement FEHB benefits
63](#section-12.two-federal-programs-complement-fehb-benefits)

[The Federal Flexible Spending Account Program -- *FSAFEDS*
63](#the-federal-flexible-spending-account-program-fsafeds)

[The Federal Long Term Care Insurance Program
66](#the-federal-long-term-care-insurance-program)

[Index 67](#index)

[Summary of benefits for the *Sioux Valley Health Plan -* 2005 Standard
Option
68](#summary-of-benefits-for-the-sioux-valley-health-plan---2005-standard-option)

[Summary of benefits for the *Sioux Valley Health Plan -* 2005 High
Option
69](#summary-of-benefits-for-the-sioux-valley-health-plan---2005-high-option)

[2005 Rate Information for Sioux Valley Health Plan
70](#rate-information-for-sioux-valley-health-plan)

# Introduction

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

Sioux Valley Health Plan

5300 Broadband Lane, Suite 300

Sioux Falls, SD 57108

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, 2005, unless those benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefit
changes are effective January 1, 2005, and changes are summarized on
page 8. Rates are shown at the end of this brochure.

# Plain Language

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

-   Except for necessary technical terms, we use common words. For
    instance, "you" means the enrollee or family member, "we" means
    Sioux Valley Health Plan*.*

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

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

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

# Stop Health Care Fraud!

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

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

**[Protect Yourself From Fraud]{.underline}** -- Here are some things
that 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 605/328-6868
    and explain the situation.

    If we do not resolve the issue:

-   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, with your
    retirement office (such as OPM) if you are retired, or with the
    National Finance Center if you are enrolled under Temporary
    Continuation of Coverage.

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

# Preventing medical mistakes

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

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

-   Ask questions and make sure you understand the answers.

-   Choose a doctor with whom you feel comfortable talking.

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

2.  **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.

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

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

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

-   Call your doctor and ask for your results.

-   Ask what the results mean for your care.

4.  **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.

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

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

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

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

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

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

# Section 1. Facts about this HMO plan

This Plan is a health maintenance organization (HMO). We require you to
see specific physicians, hospitals, and other providers that contract
with us. These Plan providers coordinate your health care services. You
are encouraged to select a Sioux Valley Health Plan participating
Primary Care Provider (PCP) to provide and coordinate your health
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 pay only 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 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 Web site
([www.opm.gov/insure](http://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.svhp.com](../www.siouxvalley.org).

### Service Area

To enroll in this Plan, you must live in or work 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 moves 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
moves, you do not have to wait until Open Season to change plans.
Contact your employing or retirement office.

# Section 2. How we changed for 2005

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

-   In Section 9, we revised the **Medicare Primary Payer Chart** and
    updated the language regarding Medicare Advantage plans (formerly
    called Medicare + Choice plans).

-   In Section 12, we revised the language regarding the Flexible
    Spending Account Program - *FSAFEDS* and the Federal Long Term Care
    Insurance Program.

### Changes to this Plan

-   Your share of the non-Postal premium for High Option will decrease
    by 1 % for Self Only and will not change for Self and Family.

-   Your share of the non-Postal premium for Standard Option will
    increase by 14.1 % for Self Only and 14.7 % for Self and Family.

# Section 3. How you get care

+--------------------+-------------------------------------------------+
| ### Id             | We will send you an identification (ID) card    |
| entification cards | 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.svhp.com](../www.siouxvalley.org)          |
+--------------------+-------------------------------------------------+
| ### Where yo       | You get care from "Plan providers" and "Plan    |
| u get covered care | 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 are physicians and other health  |
| ### Plan providers | care professionals in our service area that we  |
|                    | contract with to provide covered services to    |
|                    | our members. We credential Plan providers       |
|                    | according to NCQA national standards            |
|                    |                                                 |
|                    | We list Plan providers in the provider          |
|                    | directory, which we update periodically. The    |
|                    | list is also on our Web site.                   |
+--------------------+-------------------------------------------------+
| ##                 | Plan facilities are hospitals and other         |
| ## Plan facilities | facilities in our service area that we contract |
|                    | with to provide covered services to our         |
|                    | members. We list these in the provider          |
|                    | directory, which we update periodically. The    |
|                    | list is also on our Web site.                   |
+--------------------+-------------------------------------------------+
| ###                | It depends on the type of care you need. First, |
| What you must do t | you and each family member must choose a        |
| o get covered care | 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.                                            |
+--------------------+-------------------------------------------------+
| #                  | Your primary care physician may refer you to a  |
| ### Specialty care | 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 some 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 and disabling         |
|                    |     condition and lose access to your           |
|                    |     specialist because we:                      |
|                    |                                                 |
|                    | ```{=html}                                      |
|                    | <!-- -->                                        |
|                    | ```                                             |
|                    | -   Terminate our contract with your specialist |
|                    |     for other than cause; or                    |
|                    |                                                 |
|                    | -   Drop out of the Federal Employees Health    |
|                    |     Benefits (FEHB) Program and you enroll in   |
|                    |     another FEHB program 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:                                          |
|                    |                                                 |
|                    | -   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  | Under certain extraordinary circumstances, such |
| beyond our control | 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. |
+--------------------+-------------------------------------------------+
| ### S              | You are ultimately responsible for obtaining    |
| ervices requiring  | Prior Approval from the Health Services         |
| our prior approval | 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 Approval based  |
|                    | on appropriateness of care and service and      |
|                    | existence of coverage.                          |
|                    |                                                 |
|                    | **Services that Require Prior Approval          |
|                    | 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;                                       |
|                    |                                                 |
|                    | • Outpatient Surgeries;                         |
|                    |                                                 |
|                    | • Covered dental procedures;                    |
|                    |                                                 |
|                    | • 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 Approval is required for the   |
|                    | purposes of receiving In-Network coverage only. |
|                    | If Prior Approval is not obtained for referrals |
|                    | to Non-Participating Providers, the services    |
|                    | will be covered at the Out of Network coverage  |
|                    | level. Prior Approval 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.                         |
+--------------------+-------------------------------------------------+
| ### Prio           | To receive detailed instructions on the Prior   |
| r Approval Process | Approval process for elective inpatient         |
|                    | hospitalizations, non urgent care,              |
|                    | pharmaceutical decisions, behavioral health,    |
|                    | 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 Approval from the Health Services         |
|                    | Department. Failure to obtain Prior Approval    |
|                    | 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 costs of some services. You are responsible for:

+------------------+---------------------------------------------------+
| ### Copayments   | A copayment is a fixed amount of money you pay to |
|                  | the provider, facility, pharmacy, etc., when you  |
|                  | receive services.                                 |
|                  |                                                   |
|                  | Example: 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 outpatient surgery 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.                      |
+------------------+---------------------------------------------------+
| ### You          | Under the **High Option,** after your in-network  |
| r catastrophic p | copayments total \$4,000 Self enrollment or       |
| rotection out-of | \$4,000 Self and Family enrollment in any         |
| -pocket maximum  | 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 8 for how our benefits changed this year and page 68-69 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 605/328-6869or at our Web site at
[www.svhp.com](http://www.xxx.xxx/).*

[Section 5(a) Medical services and supplies provided by physicians and
other health care professionals
15](#section-5a-medical-services-and-supplies-provided-by-physicians-and-other-health-care-professionals)

[Diagnostic and treatment services
15](#diagnostic-and-treatment-services)

[Lab, X-ray and other diagnostic tests
16](#lab-x-ray-and-other-diagnostic-tests)

[Preventive care, adult 16](#preventive-care-adult)

[Preventive care, adult 17](#preventive-care-adult-continued)

[Preventive care, children 17](#preventive-care-children)

[Maternity care 18](#maternity-care)

[Family planning 18](#family-planning)

[Infertility services 19](#infertility-services)

[Allergy care 19](#allergy-care)

[Treatment therapies 20](#treatment-therapies)

[Physical, Cariac and occupational therapies
20](#physical-cardiac-and-occupational-therapies)

[Speech therapy 21](#speech-therapy)

[Hearing services (testing, treatment, and supplies)
21](#hearing-services-testing-treatment-and-supplies)

[Vision services (testing, treatment, and supplies)
21](#vision-services-testing-treatment-and-supplies)

[Foot care 22](#foot-care)

[Orthopedic and prosthetic devices
22](#orthopedic-and-prosthetic-devices)

[Durable medical equipment (DME) 24](#durable-medical-equipment-dme)

[Durable medical equipment (DME)
25](#durable-medical-equipment-dme-continued)

[Home health services 25](#home-health-services)

[Chiropractic 26](#chiropractic)

[Alternative treatments 26](#alternative-treatments)

[Educational classes and programs 26](#educational-classes-and-programs)

[Section 5(b) Surgical and anesthesia services provided by physicians
and other health care professionals
27](#section-5b-surgical-and-anesthesia-services-provided-by-physicians-and-other-health-care-professionals)

[Surgical procedures 27](#surgical-procedures)

[Reconstructive surgery 29](#reconstructive-surgery)

[Oral and maxillofacial surgery 30](#oral-and-maxillofacial-surgery)

[Organ/tissue transplants 30](#organtissue-transplants)

[Anesthesia 31](#anesthesia)

[Section 5(c) Services provided by a hospital or other facility, and
ambulance services
32](#section-5c-services-provided-by-a-hospital-or-other-facility-and-ambulance-services)

[Inpatient hospital 32](#inpatient-hospital)

[Outpatient hospital or ambulatory surgical center
34](#outpatient-hospital-or-ambulatory-surgical-center)

[Extended care benefits/Skilled nursing care facility benefits
34](#extended-care-benefitsskilled-nursing-care-facility-benefits)

[Hospice care 35](#hospice-care)

[Ambulance 35](#ambulance)

[Section 5(d) Emergency services/accidents
36](#section-5d-emergency-servicesaccidents)

[Emergency within our service area 37](#__RefHeading___Toc84127799)

[Emergency outside our service area 38](#__RefHeading___Toc84127800)

[Ambulance 38](#__RefHeading___Toc84127801)

[Section 5(e) Mental health and substance abuse benefits
39](#section-5e-mental-health-and-substance-abuse-benefits)

[Mental health and substance abuse benefits
39](#mental-health-and-substance-abuse-benefits)

[Section 5(f) Prescription drug benefits
41](#section-5f-prescription-drug-benefits)

[Covered medications and supplies 42](#covered-medications-and-supplies)

[Covered medications and supplies
43](#covered-medications-and-supplies-continued)

[Section 5(g) Special features 44](#section-5g-special-features)

[24 hour nurse line 44](#hour-nurse-line)

[Services for deaf and hearing impaired
44](#services-for-deaf-and-hearing-impaired)

[Pregnancy Programs 44](#pregnancy-programs)

[Centers of excellence 44](#centers-of-excellence)

[Section 5(h) Dental benefits 45](#section-5h-dental-benefits)

[Accidental injury benefit 45](#accidental-injury-benefit)

[Dental benefits 45](#dental-benefits)

[Section 5(i) Point of Service benefits
46](#section-5i-point-of-service-benefits)

[Summary of benefits for the *Sioux Valley Health Plan --* 2005 Standard
Option
67](#summary-of-benefits-for-the-sioux-valley-health-plan---2005-standard-option)

[Summary of benefits for the *Sioux Valley Health Plan --* 2005 High
Option
67](#summary-of-benefits-for-the-sioux-valley-health-plan---2005-high-option)

[2005 Rate Information for Sioux Valley Health Plan
67](#rate-information-for-sioux-valley-health-plan)

## Section 5(a) Medical services and supplies provided by physicians and other health care professionals

+---+---+---------------------------+-----------------+--------+---+------+
|   | * | **Here are some important |                 |        | * |      |
|   | * | things you should keep in |                 |        | * |      |
|   | I | mind about these          |                 |        | I |      |
|   | * | benefits:**               |                 |        | * |      |
|   | * |                           |                 |        | * |      |
|   |   | -   Please remember that  |                 |        |   |      |
|   | * |     all benefits are      |                 |        | * |      |
|   | * |     subject to the        |                 |        | * |      |
|   | M |     definitions,          |                 |        | M |      |
|   | * |     limitations, and      |                 |        | * |      |
|   | * |     exclusions in this    |                 |        | * |      |
|   |   |     brochure and are      |                 |        |   |      |
|   | * |     payable only when we  |                 |        | * |      |
|   | * |     determine they are    |                 |        | * |      |
|   | P |     medically necessary.  |                 |        | P |      |
|   | * |                           |                 |        | * |      |
|   | * | -   **Under High          |                 |        | * |      |
|   |   |     Option,** we have no  |                 |        |   |      |
|   | * |     calendar year         |                 |        | * |      |
|   | * |     deductible for In     |                 |        | * |      |
|   | O |     Network services.     |                 |        | O |      |
|   | * |                           |                 |        | * |      |
|   | * | -   **Under Standard      |                 |        | * |      |
|   |   |     Option,** the         |                 |        |   |      |
|   | * |     calendar year         |                 |        | * |      |
|   | * |     deductible for In     |                 |        | * |      |
|   | R |     Network services is   |                 |        | R |      |
|   | * |     \$500 per person      |                 |        | * |      |
|   | * |     (\$1,000 per family). |                 |        | * |      |
|   |   |     The calendar year     |                 |        |   |      |
|   | * |     deductible applies to |                 |        | * |      |
|   | * |     almost all benefits   |                 |        | * |      |
|   | T |     in this section. We   |                 |        | T |      |
|   | * |     added "(No            |                 |        | * |      |
|   | * |     deductible)" to show  |                 |        | * |      |
|   |   |     when the calendar     |                 |        |   |      |
|   | * |     year deductible does  |                 |        | * |      |
|   | * |     not apply.            |                 |        | * |      |
|   | A |                           |                 |        | A |      |
|   | * | -   **Under both High and |                 |        | * |      |
|   | * |     Standard Options,**   |                 |        | * |      |
|   |   |     you must use Plan     |                 |        |   |      |
|   | * |     Providers in order to |                 |        | * |      |
|   | * |     receive In Network    |                 |        | * |      |
|   | N |     benefit coverage.     |                 |        | N |      |
|   | * |                           |                 |        | * |      |
|   | * | -   Be sure to read       |                 |        | * |      |
|   |   |     Section 4, *Your      |                 |        |   |      |
|   | * |     costs for covered     |                 |        | * |      |
|   | * |     services*, for        |                 |        | * |      |
|   | T |     valuable information  |                 |        | T |      |
|   | * |     about how cost        |                 |        | * |      |
|   | * |     sharing works. Also   |                 |        | * |      |
|   |   |     read Section 9 about  |                 |        |   |      |
|   |   |     coordinating benefits |                 |        |   |      |
|   |   |     with other coverage,  |                 |        |   |      |
|   |   |     including with        |                 |        |   |      |
|   |   |     Medicare.             |                 |        |   |      |
+---+---+---------------------------+-----------------+--------+---+------+
| B |   |                           | You pay -       | **You  |   |      |
| e |   |                           |                 | pay    |   |      |
| n |   |                           | High Option     | -**    |   |      |
| e |   |                           |                 |        |   |      |
| f |   |                           |                 | **St   |   |      |
| i |   |                           |                 | andard |   |      |
| t |   |                           |                 | Op     |   |      |
| D |   |                           |                 | tion** |   |      |
| e |   |                           |                 |        |   |      |
| s |   |                           |                 | After  |   |      |
| c |   |                           |                 | the    |   |      |
| r |   |                           |                 | ca     |   |      |
| i |   |                           |                 | lendar |   |      |
| p |   |                           |                 | year   |   |      |
| t |   |                           |                 | deduc  |   |      |
| i |   |                           |                 | tible\ |   |      |
| o |   |                           |                 | ...... |   |      |
| n |   |                           |                 |        |   |      |
+---+---+---------------------------+-----------------+--------+---+------+
| * |   |                           |                 |        |   |      |
| * |   |                           |                 |        |   |      |
| N |   |                           |                 |        |   |      |
| o |   |                           |                 |        |   |      |
| t |   |                           |                 |        |   |      |
| e |   |                           |                 |        |   |      |
| : |   |                           |                 |        |   |      |
| T |   |                           |                 |        |   |      |
| h |   |                           |                 |        |   |      |
| e |   |                           |                 |        |   |      |
| c |   |                           |                 |        |   |      |
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| * |   |                           |                 |        |   |      |
+---+---+---------------------------+-----------------+--------+---+------+
| # |   |                           |                 |        |   |      |
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+---+---+---------------------------+-----------------+--------+---+------+
| P |   |                           | \$20 copay per  | \$25   |   |      |
| r |   |                           | primary care    | copay  |   |      |
| o |   |                           | visit           | p      |   |      |
| f |   |                           |                 | rimary |   |      |
| e |   |                           | \$30 copay per  | or     |   |      |
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+---+---+---------------------------+-----------------+--------+---+------+
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| # |   |                           |                 | pay**  |   |      |
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| # |   |                           |                 | **St   |   |      |
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+---+---+---------------------------+-----------------+--------+---+------+
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+---+---+---------------------------+-----------------+--------+---+------+
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+---+---+---------------------------+-----------------+--------+---+------+
| # |   |                           | You pay -       | **You  |   |      |
| # |   |                           |                 | pay    |   |      |
| # |   |                           | High Option     | -**    |   |      |
| # |   |                           |                 |        |   |      |
| # |   |                           |                 | **St   |   |      |
| # |   |                           |                 | andard |   |      |
|   |   |                           |                 | Op     |   |      |
| P |   |                           |                 | tion** |   |      |
| r |   |                           |                 |        |   |      |
| e |   |                           |                 | After  |   |      |
| v |   |                           |                 | the    |   |      |
| e |   |                           |                 | ca     |   |      |
| n |   |                           |                 | lendar |   |      |
| t |   |                           |                 | year   |   |      |
| i |   |                           |                 | de     |   |      |
| v |   |                           |                 | ductib |   |      |
| e |   |                           |                 | le\... |   |      |
|   |   |                           |                 |        |   |      |
| c |   |                           |                 |        |   |      |
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+---+---+---------------------------+-----------------+--------+---+------+
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+---+---+---------------------------+-----------------+--------+---+------+
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| - |   |                           | Nothing         | N      |   |      |
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+---+---+---------------------------+-----------------+--------+---+------+
| - |   |                           | Nothing         | N      |   |      |
|   |   |                           |                 | othing |   |      |
|   |   |                           | \$20 copay per  |        |   |      |
|   |   |                           | primary care    | \$25   |   |      |
| W |   |                           | visit           | copay  |   |      |
| e |   |                           |                 | per    |   |      |
| l |   |                           | \$30 copay per  | visit\ |   |      |
| l |   |                           | specialist      | (No    |   |      |
| - |   |                           | visit           | deduc  |   |      |
| c |   |                           |                 | tible) |   |      |
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| # |   |                           | **You pay -**   | **You  |   |      |
| # |   |                           |                 | pay    |   |      |
| # |   |                           | High Option     | -**    |   |      |
| # |   |                           |                 |        |   |      |
| # |   |                           |                 | **St   |   |      |
| # |   |                           |                 | andard |   |      |
|   |   |                           |                 | Op     |   |      |
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| i |   |                           |                 | year   |   |      |
| t |   |                           |                 | de     |   |      |
| y |   |                           |                 | ductib |   |      |
|   |   |                           |                 | le\... |   |      |
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+---+---+---------------------------+-----------------+--------+---+------+
| # |   |                           |                 |        |   |      |
| # |   |                           |                 |        |   |      |
| # |   |                           |                 |        |   |      |
| # |   |                           |                 |        |   |      |
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| l |   |                           |                 |        |   |      |
| y |   |                           |                 |        |   |      |
|   |   |                           |                 |        |   |      |
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+---+---+---------------------------+-----------------+--------+---+------+
| A |   |                           | \$20 copay per  | 20% of |   |      |
| r |   |                           | primary care    | all    |   |      |
| a |   |                           | visit           | c      |   |      |
| n |   |                           |                 | harges |   |      |
| g |   |                           | \$30 copay per  |        |   |      |
| e |   |                           | specialist      |        |   |      |
| o |   |                           | visit           |        |   |      |
| f |   |                           |                 |        |   |      |
| v |   |                           | 20% of charges  |        |   |      |
| o |   |                           | per inpatient   |        |   |      |
| l |   |                           | admission       |        |   |      |
| u |   |                           |                 |        |   |      |
| n |   |                           | \$50 per        |        |   |      |
| t |   |                           | outpatient      |        |   |      |
| a |   |                           | surgery         |        |   |      |
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+---+---+---------------------------+-----------------+--------+---+------+
| V |   |                           | 20% of charges  | 20% of |   |      |
| o |   |                           | per inpatient   | c      |   |      |
| l |   |                           | admission,      | harges |   |      |
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| . |   |                           |                 |        |   |      |
+---+---+---------------------------+-----------------+--------+---+------+
| * |   |                           | *All charges.*  | *All   |   |      |
| N |   |                           |                 | cha    |   |      |
| o |   |                           |                 | rges.* |   |      |
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| r |   |                           |                 |        |   |      |
| t |   |                           |                 |        |   |      |
| e |   |                           |                 |        |   |      |
| s |   |                           |                 |        |   |      |
| t |   |                           |                 |        |   |      |
| i |   |                           |                 |        |   |      |
| n |   |                           |                 |        |   |      |
| g |   |                           |                 |        |   |      |
| . |   |                           |                 |        |   |      |
| * |   |                           |                 |        |   |      |
+---+---+---------------------------+-----------------+--------+---+------+
| # |   |                           | **You pay -**   | **You  |   |      |
| # |   |                           |                 | pay    |   |      |
| # |   |                           | High Option     | -**    |   |      |
| # |   |                           |                 |        |   |      |
| # |   |                           |                 | **St   |   |      |
| # |   |                           |                 | andard |   |      |
|   |   |                           |                 | Op     |   |      |
| I |   |                           |                 | tion** |   |      |
| n |   |                           |                 |        |   |      |
| f |   |                           |                 | After  |   |      |
| e |   |                           |                 | the    |   |      |
| r |   |                           |                 | ca     |   |      |
| t |   |                           |                 | lendar |   |      |
| i |   |                           |                 | year   |   |      |
| l |   |                           |                 | de     |   |      |
| i |   |                           |                 | ductib |   |      |
| t |   |                           |                 | le\... |   |      |
| y |   |                           |                 |        |   |      |
|   |   |                           |                 |        |   |      |
| s |   |                           |                 |        |   |      |
| e |   |                           |                 |        |   |      |
| r |   |                           |                 |        |   |      |
| v |   |                           |                 |        |   |      |
| i |   |                           |                 |        |   |      |
| c |   |                           |                 |        |   |      |
| e |   |                           |                 |        |   |      |
| s |   |                           |                 |        |   |      |
+---+---+---------------------------+-----------------+--------+---+------+
| D |   |                           | \$30 per        | 20% of |   |      |
| i |   |                           | specialist      | all    |   |      |
| a |   |                           | visit           | c      |   |      |
| g |   |                           |                 | harges |   |      |
| n |   |                           | 20% of charges  |        |   |      |
| o |   |                           | per inpatient   |        |   |      |
| s |   |                           | admission       |        |   |      |
| i |   |                           |                 |        |   |      |
| s |   |                           | \$50 per        |        |   |      |
| a |   |                           | outpatient      |        |   |      |
| n |   |                           | surgery         |        |   |      |
| d |   |                           |                 |        |   |      |
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| a |   |                           |                 |        |   |      |
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|   |   |                           |                 |        |   |      |
|   |   |                           |                 |        |   |      |
|   |   |                           |                 |        |   |      |
|   |   |                           |                 |        |   |      |
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| n |   |                           |                 |        |   |      |
| s |   |                           |                 |        |   |      |
| e |   |                           |                 |        |   |      |
| m |   |                           |                 |        |   |      |
| i |   |                           |                 |        |   |      |
| n |   |                           |                 |        |   |      |
| a |   |                           |                 |        |   |      |
| t |   |                           |                 |        |   |      |
| i |   |                           |                 |        |   |      |
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+---+---+---------------------------+-----------------+--------+---+------+
| * |   |                           | *All charges.*  | *All   |   |      |
| N |   |                           |                 | cha    |   |      |
| o |   |                           |                 | rges.* |   |      |
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| # |   |                           |                 |        |   |      |
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| - |   |                           | \$30 per        | \$25   |   |      |
|   |   |                           | specialist      | copay  |   |      |
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| A |   |                           | Nothing         | N      |   |      |
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+---+---+---------------------------+-----------------+--------+---+------+
| * |   |                           | *All charges.*  | *All   |   |      |
| N |   |                           |                 | cha    |   |      |
| o |   |                           |                 | rges.* |   |      |
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| # |   |                           | You pay -       | **You  |   |      |
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| # |   |                           | High Option     | -**    |   |      |
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| C |   |                           | \$30 per        | 20% of |   |      |
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| e |   |                           |                 |        |   |      |
|   |   |                           |                 |        |   |      |
|   |   |                           |                 |        |   |      |
|   |   |                           |                 |        |   |      |
|   |   |                           |                 |        |   |      |
| t |   |                           |                 |        |   |      |
| h |   |                           |                 |        |   |      |
| e |   |                           |                 |        |   |      |
| r |   |                           |                 |        |   |      |
| a |   |                           |                 |        |   |      |
| p |   |                           |                 |        |   |      |
| y |   |                           |                 |        |   |      |
| * |   |                           |                 |        |   |      |
|   |   |                           |                 |        |   |      |
| - |   |                           |                 |        |   |      |
|   |   |                           |                 |        |   |      |
|   |   |                           |                 |        |   |      |
|   |   |                           |                 |        |   |      |
| * |   |                           |                 |        |   |      |
| E |   |                           |                 |        |   |      |
| x |   |                           |                 |        |   |      |
| e |   |                           |                 |        |   |      |
| r |   |                           |                 |        |   |      |
| c |   |                           |                 |        |   |      |
| i |   |                           |                 |        |   |      |
| s |   |                           |                 |        |   |      |
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|   |   |                           |                 |        |   |      |
| p |   |                           |                 |        |   |      |
| r |   |                           |                 |        |   |      |
| o |   |                           |                 |        |   |      |
| g |   |                           |                 |        |   |      |
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| a |   |                           |                 |        |   |      |
| m |   |                           |                 |        |   |      |
| s |   |                           |                 |        |   |      |
| * |   |                           |                 |        |   |      |
+---+---+---------------------------+-----------------+--------+---+------+
| # |   |                           | **You pay -**   | **You  |   |      |
| # |   |                           |                 | pay    |   |      |
| # |   |                           | High Option     | -**    |   |      |
| # |   |                           |                 |        |   |      |
| # |   |                           |                 | **St   |   |      |
| # |   |                           |                 | andard |   |      |
|   |   |                           |                 | Op     |   |      |
| S |   |                           |                 | tion** |   |      |
| p |   |                           |                 |        |   |      |
| e |   |                           |                 | After  |   |      |
| e |   |                           |                 | the    |   |      |
| c |   |                           |                 | ca     |   |      |
| h |   |                           |                 | lendar |   |      |
|   |   |                           |                 | year   |   |      |
| t |   |                           |                 | de     |   |      |
| h |   |                           |                 | ductib |   |      |
| e |   |                           |                 | le\... |   |      |
| r |   |                           |                 |        |   |      |
| a |   |                           |                 |        |   |      |
| p |   |                           |                 |        |   |      |
| y |   |                           |                 |        |   |      |
|   |   |                           |                 |        |   |      |
+---+---+---------------------------+-----------------+--------+---+------+
| C |   |                           | \$30 per        | 20% of |   |      |
| o |   |                           | outpatient      | c      |   |      |
| v |   |                           | visit           | harges |   |      |
| e |   |                           |                 |        |   |      |
| r |   |                           | Nothing per     |        |   |      |
| a |   |                           | visit during    |        |   |      |
| g |   |                           | covered         |        |   |      |
| e |   |                           | inpatient       |        |   |      |
| u |   |                           | admission       |        |   |      |
| p |   |                           |                 |        |   |      |
| t |   |                           |                 |        |   |      |
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| 2 |   |                           |                 |        |   |      |
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| d |   |                           |                 |        |   |      |
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| a |   |                           |                 |        |   |      |
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| s |   |                           |                 |        |   |      |
| t |   |                           |                 |        |   |      |
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| q |   |                           |                 |        |   |      |
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| u |   |                           |                 |        |   |      |
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| P |   |                           |                 |        |   |      |
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| i |   |                           |                 |        |   |      |
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| A |   |                           |                 |        |   |      |
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| a |   |                           |                 |        |   |      |
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| n |   |                           |                 |        |   |      |
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| 3 |   |                           |                 |        |   |      |
| ) |   |                           |                 |        |   |      |
| . |   |                           |                 |        |   |      |
+---+---+---------------------------+-----------------+--------+---+------+
| * |   |                           | *All charges.*  | *All   |   |      |
| N |   |                           |                 | cha    |   |      |
| o |   |                           |                 | rges.* |   |      |
| t |   |                           |                 |        |   |      |
| c |   |                           |                 |        |   |      |
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+---+---+---------------------------+-----------------+--------+---+------+
| # |   |                           |                 |        |   |      |
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+---+---+---------------------------+-----------------+--------+---+------+
| - |   |                           | \$30 per        | \$25   |   |      |
|   |   |                           | specialist      | copay  |   |      |
|   |   |                           | visit           | per    |   |      |
|   |   |                           |                 | visit  |   |      |
| F |   |                           |                 | (No    |   |      |
| i |   |                           |                 | deduc  |   |      |
| r |   |                           |                 | tible) |   |      |
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| d |   |                           |                 |        |   |      |
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+---+---+---------------------------+-----------------+--------+---+------+
| - |   |                           | \$20 per        | \$25   |   |      |
|   |   |                           | primary care    | copay  |   |      |
|   |   |                           | visit           | per    |   |      |
|   |   |                           |                 | visit  |   |      |
| E |   |                           | \$30 per        | (No    |   |      |
| y |   |                           | specialist      | deduc  |   |      |
| e |   |                           | visit           | tible) |   |      |
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| ) |   |                           |                 |        |   |      |
| * |   |                           |                 |        |   |      |
+---+---+---------------------------+-----------------+--------+---+------+
| - |   |                           | \$20 per        | \$25   |   |      |
|   |   |                           | primary care    | copay  |   |      |
|   |   |                           | visit           | per    |   |      |
|   |   |                           |                 | visit  |   |      |
| E |   |                           | \$30 per        | (No    |   |      |
| y |   |                           | specialist      | deduc  |   |      |
| e |   |                           | visit           | tible) |   |      |
|   |   |                           |                 |        |   |      |
|   |   |                           |                 |        |   |      |
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+---+---+---------------------------+-----------------+--------+---+------+
| * |   |                           | *All charges.*  | *All   |   |      |
| N |   |                           |                 | cha    |   |      |
| o |   |                           |                 | rges.* |   |      |
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+---+---+---------------------------+-----------------+--------+---+------+
| # |   |                           | **You pay -**   | **You  |   |      |
| # |   |                           |                 | pay    |   |      |
| # |   |                           | High Option     | -**    |   |      |
| # |   |                           |                 |        |   |      |
| # |   |                           |                 | **St   |   |      |
| # |   |                           |                 | andard |   |      |
|   |   |                           |                 | Op     |   |      |
| F |   |                           |                 | tion** |   |      |
| o |   |                           |                 |        |   |      |
| o |   |                           |                 | After  |   |      |
| t |   |                           |                 | the    |   |      |
|   |   |                           |                 | ca     |   |      |
| c |   |                           |                 | lendar |   |      |
| a |   |                           |                 | year   |   |      |
| r |   |                           |                 | de     |   |      |
| e |   |                           |                 | ductib |   |      |
|   |   |                           |                 | le\... |   |      |
+---+---+---------------------------+-----------------+--------+---+------+
| R |   |                           | \$20 per        | \$25   |   |      |
| o |   |                           | primary care    | copay  |   |      |
| u |   |                           | visit           | per    |   |      |
| t |   |                           |                 | visit  |   |      |
| i |   |                           | \$30 per        | (No    |   |      |
| n |   |                           | specialist      | deduc  |   |      |
| e |   |                           |                 | tible) |   |      |
| f |   |                           |                 |        |   |      |
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| i |   |                           |                 |        |   |      |
| c |   |                           |                 |        |   |      |
| s |   |                           |                 |        |   |      |
| h |   |                           |                 |        |   |      |
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| . |   |                           |                 |        |   |      |
+---+---+---------------------------+-----------------+--------+---+------+
| * |   |                           | *All charges.*  | *All   |   |      |
| N |   |                           |                 | cha    |   |      |
| o |   |                           |                 | rges.* |   |      |
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+---+---+---------------------------+-----------------+--------+---+------+
| * |   |                           |                 |        |   |      |
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| t |   |                           |                 |        |   |      |
| h |   |                           |                 |        |   |      |
| o |   |                           |                 |        |   |      |
| p |   |                           |                 |        |   |      |
| e |   |                           |                 |        |   |      |
| d |   |                           |                 |        |   |      |
| i |   |                           |                 |        |   |      |
| c |   |                           |                 |        |   |      |
| a |   |                           |                 |        |   |      |
| n |   |                           |                 |        |   |      |
| d |   |                           |                 |        |   |      |
| p |   |                           |                 |        |   |      |
| r |   |                           |                 |        |   |      |
| o |   |                           |                 |        |   |      |
| s |   |                           |                 |        |   |      |
| t |   |                           |                 |        |   |      |
| h |   |                           |                 |        |   |      |
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| d |   |                           |                 |        |   |      |
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| v |   |                           |                 |        |   |      |
| i |   |                           |                 |        |   |      |
| c |   |                           |                 |        |   |      |
| e |   |                           |                 |        |   |      |
| s |   |                           |                 |        |   |      |
|   |   |                           |                 |        |   |      |
| - |   |                           |                 |        |   |      |
| c |   |                           |                 |        |   |      |
| o |   |                           |                 |        |   |      |
| n |   |                           |                 |        |   |      |
| t |   |                           |                 |        |   |      |
| i |   |                           |                 |        |   |      |
| n |   |                           |                 |        |   |      |
| u |   |                           |                 |        |   |      |
| e |   |                           |                 |        |   |      |
| d |   |                           |                 |        |   |      |
| o |   |                           |                 |        |   |      |
| n |   |                           |                 |        |   |      |
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| x |   |                           |                 |        |   |      |
| t |   |                           |                 |        |   |      |
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| g |   |                           |                 |        |   |      |
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| * |   |                           |                 |        |   |      |
+---+---+---------------------------+-----------------+--------+---+------+
| # |   |                           | You pay -       | **You  |   |      |
| # |   |                           |                 | pay    |   |      |
| # |   |                           | High Option     | -**    |   |      |
| # |   |                           |                 |        |   |      |
| # |   |                           |                 | **St   |   |      |
| # |   |                           |                 | andard |   |      |
|   |   |                           |                 | Op     |   |      |
| O |   |                           |                 | tion** |   |      |
| r |   |                           |                 |        |   |      |
| t |   |                           |                 | After  |   |      |
| h |   |                           |                 | the    |   |      |
| o |   |                           |                 | ca     |   |      |
| p |   |                           |                 | lendar |   |      |
| e |   |                           |                 | year   |   |      |
| d |   |                           |                 | de     |   |      |
| i |   |                           |                 | ductib |   |      |
| c |   |                           |                 | le\... |   |      |
|   |   |                           |                 |        |   |      |
| a |   |                           |                 |        |   |      |
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| d |   |                           |                 |        |   |      |
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| * |   |                           |                 |        |   |      |
|   |   |                           |                 |        |   |      |
+---+---+---------------------------+-----------------+--------+---+------+
| * |   |                           | *All charges.*  | *All   |   |      |
| N |   |                           |                 | cha    |   |      |
| o |   |                           |                 | rges.* |   |      |
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+---+---+---------------------------+-----------------+--------+---+------+
| # |   |                           | You pay -       | **You  |   |      |
| # |   |                           |                 | pay    |   |      |
| # |   |                           | High Option     | -**    |   |      |
| # |   |                           |                 |        |   |      |
| # |   |                           |                 | **St   |   |      |
| # |   |                           |                 | andard |   |      |
|   |   |                           |                 | Op     |   |      |
| D |   |                           |                 | tion** |   |      |
| u |   |                           |                 |        |   |      |
| r |   |                           |                 | After  |   |      |
| a |   |                           |                 | the    |   |      |
| b |   |                           |                 | ca     |   |      |
| l |   |                           |                 | lendar |   |      |
| e |   |                           |                 | year   |   |      |
|   |   |                           |                 | de     |   |      |
| m |   |                           |                 | ductib |   |      |
| e |   |                           |                 | le\... |   |      |
| d |   |                           |                 |        |   |      |
| i |   |                           |                 |        |   |      |
| c |   |                           |                 |        |   |      |
| a |   |                           |                 |        |   |      |
| l |   |                           |                 |        |   |      |
|   |   |                           |                 |        |   |      |
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| p |   |                           |                 |        |   |      |
| m |   |                           |                 |        |   |      |
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|   |   |                           |                 |        |   |      |
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| ) |   |                           |                 |        |   |      |
+---+---+---------------------------+-----------------+--------+---+------+
| R |   |                           | 20% of charges  | 20% of |   |      |
| e |   |                           |                 | c      |   |      |
| n |   |                           | Note: You must  | harges |   |      |
| t |   |                           | obtain          |        |   |      |
| a |   |                           | prio            | Note:  |   |      |
| l |   |                           | r-authorization | You    |   |      |
| o |   |                           | for             | must   |   |      |
| r |   |                           | sup             | obtain |   |      |
| p |   |                           | plies/equipment | p      |   |      |
| u |   |                           | with a retail   | rior-a |   |      |
| r |   |                           | value of \$200  | uthori |   |      |
| c |   |                           | or more.        | zation |   |      |
| h |   |                           | Failure to      | for    |   |      |
| a |   |                           | obtain Prior    | suppli |   |      |
| s |   |                           | Approval will   | es/equ |   |      |
| e |   |                           | result in       | ipment |   |      |
| , |   |                           | benefits being  | with a |   |      |
| a |   |                           | pad at the      | retail |   |      |
| t |   |                           | Point of        | value  |   |      |
| o |   |                           | Service benefit | of     |   |      |
| u |   |                           | level.          | \$200  |   |      |
| r |   |                           |                 | or     |   |      |
| o |   |                           |                 | more.  |   |      |
| p |   |                           |                 | F      |   |      |
| t |   |                           |                 | ailure |   |      |
| i |   |                           |                 | to     |   |      |
| o |   |                           |                 | obtain |   |      |
| n |   |                           |                 | prior  |   |      |
| , |   |                           |                 | ap     |   |      |
| i |   |                           |                 | proval |   |      |
| n |   |                           |                 | will   |   |      |
| c |   |                           |                 | result |   |      |
| l |   |                           |                 | in     |   |      |
| u |   |                           |                 | be     |   |      |
| d |   |                           |                 | nefits |   |      |
| i |   |                           |                 | being  |   |      |
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+---+---+---------------------------+-----------------+--------+---+------+
| * |   |                           |                 |        |   |      |
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+---+---+---------------------------+-----------------+--------+---+------+
| # |   |                           | You pay -       | **You  |   |      |
| # |   |                           |                 | pay    |   |      |
| # |   |                           | High Option     | -**    |   |      |
| # |   |                           |                 |        |   |      |
| # |   |                           |                 | **St   |   |      |
| # |   |                           |                 | andard |   |      |
|   |   |                           |                 | Op     |   |      |
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| a |   |                           |                 | the    |   |      |
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| e |   |                           |                 | year   |   |      |
|   |   |                           |                 | de     |   |      |
| m |   |                           |                 | ductib |   |      |
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+---+---+---------------------------+-----------------+--------+---+------+
| * |   |                           | *All charges.*  | *All   |   |      |
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| * |   |                           | *All charges.*  | *All   |   |      |
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| o |   |                           |                 | rges.* |   |      |
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| b |   |                           |                 |        |   |      |
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| l |   |                           |                 |        |   |      |
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+---+---+---------------------------+-----------------+--------+---+------+
| # |   |                           | You pay -       | **You  |   |      |
| # |   |                           |                 | pay    |   |      |
| # |   |                           | High Option     | -**    |   |      |
| # |   |                           |                 |        |   |      |
| # |   |                           |                 | **St   |   |      |
| # |   |                           |                 | andard |   |      |
|   |   |                           |                 | Op     |   |      |
| C |   |                           |                 | tion** |   |      |
| h |   |                           |                 |        |   |      |
| i |   |                           |                 | After  |   |      |
| r |   |                           |                 | the    |   |      |
| o |   |                           |                 | ca     |   |      |
| p |   |                           |                 | lendar |   |      |
| r |   |                           |                 | year   |   |      |
| a |   |                           |                 | de     |   |      |
| c |   |                           |                 | ductib |   |      |
| t |   |                           |                 | le\... |   |      |
| i |   |                           |                 |        |   |      |
| c |   |                           |                 |        |   |      |
|   |   |                           |                 |        |   |      |
+---+---+---------------------------+-----------------+--------+---+------+
| - |   |                           | \$20 per visit  | \$25   |   |      |
|   |   |                           |                 | copay  |   |      |
|   |   |                           |                 | per    |   |      |
|   |   |                           |                 | visit  |   |      |
| M |   |                           |                 | (No    |   |      |
| a |   |                           |                 | deduc  |   |      |
| n |   |                           |                 | tible) |   |      |
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|   |   |                           |                 |        |   |      |
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|   |   |                           |                 |        |   |      |
|   |   |                           |                 |        |   |      |
| b |   |                           |                 |        |   |      |
| e |   |                           |                 |        |   |      |
|   |   |                           |                 |        |   |      |
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|   |   |                           |                 |        |   |      |
|   |   |                           |                 |        |   |      |
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| d |   |                           |                 |        |   |      |
| . |   |                           |                 |        |   |      |
+---+---+---------------------------+-----------------+--------+---+------+

## **Section** 5(b) Surgical and anesthesia services provided by physicians and other health care professionals

+---+---+--------------------------+------------------+------------+---+---+
|   | * | **Here are some          |                  |            | * |   |
|   | * | important things you     |                  |            | * |   |
|   | I | should keep in mind      |                  |            | I |   |
|   | * | about these benefits:**  |                  |            | * |   |
|   | * |                          |                  |            | * |   |
|   |   | -   Please remember that |                  |            |   |   |
|   | * |     all benefits are     |                  |            | * |   |
|   | * |     subject to the       |                  |            | * |   |
|   | M |     definitions,         |                  |            | M |   |
|   | * |     limitations, and     |                  |            | * |   |
|   | * |     exclusions in this   |                  |            | * |   |
|   |   |     brochure and are     |                  |            |   |   |
|   | * |     payable only when we |                  |            | * |   |
|   | * |     determine they are   |                  |            | * |   |
|   | P |     medically necessary. |                  |            | P |   |
|   | * |                          |                  |            | * |   |
|   | * | -   **Under High         |                  |            | * |   |
|   |   |     Option**, we have no |                  |            |   |   |
|   | * |     calendar year        |                  |            | * |   |
|   | * |     deductible for In    |                  |            | * |   |
|   | O |     Network services     |                  |            | O |   |
|   | * |                          |                  |            | * |   |
|   | * | -   **Under Standard     |                  |            | * |   |
|   |   |     Option** The         |                  |            |   |   |
|   | * |     calendar year        |                  |            | * |   |
|   | * |     deductible is: \$500 |                  |            | * |   |
|   | R |     per person (\$1000   |                  |            | R |   |
|   | * |     per family). The     |                  |            | * |   |
|   | * |     calendar year        |                  |            | * |   |
|   |   |     deductible applies   |                  |            |   |   |
|   | * |     to almost all        |                  |            | * |   |
|   | * |     benefits in this     |                  |            | * |   |
|   | T |     Section. We added    |                  |            | T |   |
|   | * |     \"(No deductible)\"  |                  |            | * |   |
|   | * |     to show when the     |                  |            | * |   |
|   |   |     calendar year        |                  |            |   |   |
|   | * |     deductible does not  |                  |            | * |   |
|   | * |     apply.               |                  |            | * |   |
|   | A |                          |                  |            | A |   |
|   | * | -   Under both **High**  |                  |            | * |   |
|   | * |     and **Standard       |                  |            | * |   |
|   |   |     Options**, you must  |                  |            |   |   |
|   | * |     use Plan Providers   |                  |            | * |   |
|   | * |     in order to receive  |                  |            | * |   |
|   | N |     in-network benefit   |                  |            | N |   |
|   | * |     coverage.            |                  |            | * |   |
|   | * |                          |                  |            | * |   |
|   |   | -   Be sure to read      |                  |            |   |   |
|   | * |     Section 4, *Your     |                  |            | * |   |
|   | * |     costs for covered    |                  |            | * |   |
|   | T |     services*, for       |                  |            | T |   |
|   | * |     valuable information |                  |            | * |   |
|   | * |     about how cost       |                  |            | * |   |
|   |   |     sharing works. Also  |                  |            |   |   |
|   |   |     read Section 9 about |                  |            |   |   |
|   |   |     coordinating         |                  |            |   |   |
|   |   |     benefits with other  |                  |            |   |   |
|   |   |     coverage, including  |                  |            |   |   |
|   |   |     with Medicare.       |                  |            |   |   |
|   |   |                          |                  |            |   |   |
|   |   | -   The amounts listed   |                  |            |   |   |
|   |   |     below are for the    |                  |            |   |   |
|   |   |     charges billed by a  |                  |            |   |   |
|   |   |     physician or other   |                  |            |   |   |
|   |   |     health care          |                  |            |   |   |
|   |   |     professional for     |                  |            |   |   |
|   |   |     your surgical care.  |                  |            |   |   |
|   |   |     Look in Section 5(c) |                  |            |   |   |
|   |   |     for charges          |                  |            |   |   |
|   |   |     associated with the  |                  |            |   |   |
|   |   |     facility (i.e.       |                  |            |   |   |
|   |   |     hospital, surgical   |                  |            |   |   |
|   |   |     center, etc.).       |                  |            |   |   |
|   |   |                          |                  |            |   |   |
|   |   | -   **YOU OR YOUR        |                  |            |   |   |
|   |   |     PHYSICIAN MUST GET   |                  |            |   |   |
|   |   |     PRIOR APPROVAL OF    |                  |            |   |   |
|   |   |     SOME SURGICAL        |                  |            |   |   |
|   |   |     PROCEDURES**. Please |                  |            |   |   |
|   |   |     refer to the prior   |                  |            |   |   |
|   |   |     approval information |                  |            |   |   |
|   |   |     shown in Section 3   |                  |            |   |   |
|   |   |     to be sure which     |                  |            |   |   |
|   |   |     services require     |                  |            |   |   |
|   |   |     prior approval and   |                  |            |   |   |
|   |   |     identify which       |                  |            |   |   |
|   |   |     surgeries require    |                  |            |   |   |
|   |   |     prior approval**.**  |                  |            |   |   |
+---+---+--------------------------+------------------+------------+---+---+
| B |   |                          | You pay -        | You pay -  |   |   |
| e |   |                          |                  |            |   |   |
| n |   |                          | High Option      | Standard   |   |   |
| e |   |                          |                  | Option     |   |   |
| f |   |                          |                  |            |   |   |
| i |   |                          |                  | After the  |   |   |
| t |   |                          |                  | calendar   |   |   |
| D |   |                          |                  | year       |   |   |
| e |   |                          |                  | dedu       |   |   |
| s |   |                          |                  | ctible\... |   |   |
| c |   |                          |                  |            |   |   |
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| i |   |                          |                  |            |   |   |
| o |   |                          |                  |            |   |   |
| n |   |                          |                  |            |   |   |
+---+---+--------------------------+------------------+------------+---+---+
| * |   |                          |                  |            |   |   |
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+---+---+--------------------------+------------------+------------+---+---+
| # |   |                          |                  |            |   |   |
| # |   |                          |                  |            |   |   |
| # |   |                          |                  |            |   |   |
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+---+---+--------------------------+------------------+------------+---+---+
| A |   |                          | \$30 per         | \$25 copay |   |   |
| c |   |                          | specialist visit | per office |   |   |
| o |   |                          |                  | visit (No  |   |   |
| m |   |                          | \$100 per day    | d          |   |   |
| p |   |                          | copay up to      | eductible) |   |   |
| r |   |                          | \$500 per        |            |   |   |
| e |   |                          | inpatient        | \$100 per  |   |   |
| h |   |                          | surgery or       | day copay  |   |   |
| e |   |                          | service          | up to      |   |   |
| n |   |                          |                  | \$500 per  |   |   |
| s |   |                          | \$50 per         | inpatient  |   |   |
| i |   |                          | outpatient       | surgery or |   |   |
| v |   |                          | surgery or       | service    |   |   |
| e |   |                          | service          |            |   |   |
| r |   |                          |                  | 20% of     |   |   |
| a |   |                          |                  | outpatient |   |   |
| n |   |                          |                  | charges    |   |   |
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| i |   |                          |                  |            |   |   |
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|   |   |                          |                  |            |   |   |
|   |   |                          |                  |            |   |   |
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|   |   |                          |                  |            |   |   |
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| ) |   |                          |                  |            |   |   |
+---+---+--------------------------+------------------+------------+---+---+

*Surgical procedures - continued on next page*

+--------------------------------+------------------+------------------+
| Surgical procedures            | You pay -        | **You pay -**    |
| *(continued)*                  |                  |                  |
|                                | High Option      | **Standard       |
|                                |                  | Option**         |
|                                |                  |                  |
|                                |                  | After the        |
|                                |                  | calendar year    |
|                                |                  | deductible\...   |
+--------------------------------+------------------+------------------+
| -   Surgical treatment of      | \$30 per         | \$25 copay per   |
|     morbid obesity \-- a       | specialist visit | office visit (No |
|     condition in which an      |                  | deductible)      |
|     individual weighs 100      | \$100 per day    |                  |
|     pounds or 100% over his or | copay up to      | \$100 per day    |
|     her normal weight          | \$500 per        | copay up to      |
|     according to current       | inpatient        | \$500 per        |
|     underwriting standards;    | surgery or       | inpatient        |
|     eligible members must be   | service          | surgery or       |
|     age 18 or over             |                  | service          |
|                                | \$50 per         |                  |
| -   Insertion of internal      | outpatient       | 20% of           |
|     prosthetic devices. See    | surgery or       | outpatient       |
|     5(a) -- Orthopedic and     | service          | charges          |
|     prosthetic devices for     |                  |                  |
|     device coverage            |                  |                  |
|     information                |                  |                  |
|                                |                  |                  |
| -   Voluntary sterilization    |                  |                  |
|     (e.g., Tubal ligation,     |                  |                  |
|     Vasectomy)                 |                  |                  |
|                                |                  |                  |
| -   Treatment of burns         |                  |                  |
|                                |                  |                  |
| Note: Generally, we pay for    |                  |                  |
| internal prostheses (devices)  |                  |                  |
| according to where the         |                  |                  |
| procedure is done. For         |                  |                  |
| example, we pay Hospital       |                  |                  |
| benefits for a pacemaker and   |                  |                  |
| Surgery benefits for insertion |                  |                  |
| of the pacemaker.              |                  |                  |
+--------------------------------+------------------+------------------+
| *Not covered:*                 | *All charges.*   | *All charges.*   |
|                                |                  |                  |
| -   *Reversal of voluntary     |                  |                  |
|     sterilization*             |                  |                  |
+--------------------------------+------------------+------------------+
| ###### Reconstructive surgery  | **You pay -**    | **You pay -**    |
|                                |                  |                  |
|                                | **High Option**  | **Standard       |
|                                |                  | Option**         |
|                                |                  |                  |
|                                |                  | **After the      |
|                                |                  | calendar year    |
|                                |                  | dedu             |
|                                |                  | ctible\...\...** |
+--------------------------------+------------------+------------------+
| -   Surgery to correct a       | \$30 per         | \$25 copay per   |
|     functional defect          | specialist visit | office visit (No |
|                                |                  | deductible)      |
| -   Surgery to correct a       | \$100 day copay  |                  |
|     condition caused by injury | up to \$500 per  | \$100 per day    |
|     or illness if:             | inpatient        | copay up to      |
|                                | surgery or       | \$500 per        |
| ```{=html}                     | service          | inpatient        |
| <!-- -->                       |                  | surgery or       |
| ```                            | \$50 per         | service          |
| -   the condition produced a   | outpatient       |                  |
|     major effect on the        | surgery or       | 20% of           |
|     member's appearance and    | service          | outpatient       |
|                                |                  | charges          |
| -   the condition can          |                  |                  |
|     reasonably be expected to  |                  |                  |
|     be corrected by such       |                  |                  |
|     surgery                    |                  |                  |
|                                |                  |                  |
| ```{=html}                     |                  |                  |
| <!-- -->                       |                  |                  |
| ```                            |                  |                  |
| -   Surgery to correct a       |                  |                  |
|     condition that existed at  |                  |                  |
|     or from birth and is a     |                  |                  |
|     significant deviation from |                  |                  |
|     the common form or norm.   |                  |                  |
|     Examples of congenital     |                  |                  |
|     anomalies are: protruding  |                  |                  |
|     ear deformities; cleft     |                  |                  |
|     lip; cleft palate; birth   |                  |                  |
|     marks; webbed fingers; and |                  |                  |
|     webbed toes.               |                  |                  |
|                                |                  |                  |
| -   All stages of breast       |                  |                  |
|     reconstruction surgery     |                  |                  |
|     following a mastectomy,    |                  |                  |
|     such as:                   |                  |                  |
|                                |                  |                  |
| ```{=html}                     |                  |                  |
| <!-- -->                       |                  |                  |
| ```                            |                  |                  |
| -   surgery to produce a       |                  |                  |
|     symmetrical appearance of  |                  |                  |
|     breasts;                   |                  |                  |
|                                |                  |                  |
| -   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 charges.*   | *All 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*            |                  |                  |
+--------------------------------+------------------+------------------+
| ###### O                       | You pay -        | **You pay -**    |
| ral and maxillofacial surgery  |                  |                  |
|                                | High Option      | **Standard       |
|                                |                  | Option**         |
|                                |                  |                  |
|                                |                  | After the        |
|                                |                  | calendar year    |
|                                |                  | deductible\...   |
+--------------------------------+------------------+------------------+
| Oral surgical procedures,      | \$30 per         | \$25 copay per   |
| limited to:                    | specialist visit | visit (No        |
|                                |                  | deductible)      |
| -   Reduction of fractures of  | \$100 per day    |                  |
|     the jaws or facial bones;  | copay up to      | \$100 per day    |
|                                | \$500 per        | copay up to      |
| -   Surgical correction of     | inpatient        | \$500 per        |
|     cleft lip, cleft palate or | surgery or       | inpatient        |
|     severe functional          | service          | surgery or       |
|     malocclusion;              |                  | service          |
|                                | \$50 per         |                  |
| -   Removal of stones from     | outpatient       | 20% of           |
|     salivary ducts;            | surgery or       | outpatient       |
|                                | service          | charges          |
| -   Excision of leukoplakia or |                  |                  |
|     malignancies;              |                  |                  |
|                                |                  |                  |
| -   Excision of cysts and      |                  |                  |
|     incision of abscesses when |                  |                  |
|     done as independent        |                  |                  |
|     procedures; and            |                  |                  |
|                                |                  |                  |
| -   Other surgical procedures  |                  |                  |
|     that do not involve the    |                  |                  |
|     teeth or their supporting  |                  |                  |
|     structures.                |                  |                  |
|                                |                  |                  |
| -   Surgery to correct TMJ is  |                  |                  |
|     covered upon radiological  |                  |                  |
|     determination of pathology |                  |                  |
|     (See Services requiring    |                  |                  |
|     our prior approval in      |                  |                  |
|     Section 3*)*               |                  |                  |
+--------------------------------+------------------+------------------+
| *Not covered:*                 | *All charges.*   | *All charges.*   |
|                                |                  |                  |
| -   *Oral implants and         |                  |                  |
|     transplants*               |                  |                  |
|                                |                  |                  |
| -   *Procedures that involve   |                  |                  |
|     the teeth or their         |                  |                  |
|     supporting structures      |                  |                  |
|     (such as the periodontal   |                  |                  |
|     membrane, gingiva, and     |                  |                  |
|     alveolar bone)*            |                  |                  |
+--------------------------------+------------------+------------------+
| #                              |                  |                  |
| ##### Organ/tissue transplants |                  |                  |
+--------------------------------+------------------+------------------+
| Limited to:                    | 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                   |                  |                  |
+--------------------------------+------------------+------------------+
| *Organ/tissue transplants --   |                  |                  |
| continued on next page*        |                  |                  |
+--------------------------------+------------------+------------------+
| Organ/tissue transplants       | You pay -        | **You pay -**    |
| *(continued)*                  |                  |                  |
|                                | High Option      | **Standard       |
|                                |                  | Option**         |
|                                |                  |                  |
|                                |                  | After the        |
|                                |                  | calendar year    |
|                                |                  | deductible\...   |
+--------------------------------+------------------+------------------+
| -   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 a National Cancer Institute |                  |                  |
| -- or National Institutes of   |                  |                  |
| Health-approved clinical trial |                  |                  |
| at a Plan-designated center of |                  |                  |
| excellence and if approved by  |                  |                  |
| the Plan's medical director in |                  |                  |
| accordance with the Plan's     |                  |                  |
| protocols.                     |                  |                  |
|                                |                  |                  |
| Note: We cover related medical |                  |                  |
| and hospital expenses of the   |                  |                  |
| donor when we cover the        |                  |                  |
| recipient. All transplants     |                  |                  |
| must be provided at Plan       |                  |                  |
| participating Center of        |                  |                  |
| Excellence facilities.         |                  |                  |
+--------------------------------+------------------+------------------+
| *Not covered:*                 | *All charges.*   | *All charges.*   |
|                                |                  |                  |
| -   *Donor screening tests and |                  |                  |
|     donor search expenses,     |                  |                  |
|     except those performed for |                  |                  |
|     the actual donor*          |                  |                  |
|                                |                  |                  |
| -   *Autologous tandem         |                  |                  |
|     transplants*               |                  |                  |
|                                |                  |                  |
| -   *Harvesting and storage of |                  |                  |
|     stem cells*                |                  |                  |
|                                |                  |                  |
| -   *Transplants not listed as |                  |                  |
|     covered*                   |                  |                  |
+--------------------------------+------------------+------------------+
| ###### Anesthesia              |                  |                  |
+--------------------------------+------------------+------------------+
| Professional services provided | Nothing          | 20% of charges   |
| in --                          |                  |                  |
|                                |                  |                  |
| -   Hospital (inpatient)       |                  |                  |
+--------------------------------+------------------+------------------+
| -   Hospital outpatient        | Nothing          | 20% of charges   |
|     department                 |                  |                  |
|                                |                  |                  |
| -   Skilled nursing facility   |                  |                  |
|                                |                  |                  |
| -   Ambulatory surgical center |                  |                  |
|                                |                  |                  |
| -   Office                     |                  |                  |
+--------------------------------+------------------+------------------+
| *Not Covered: Hypnotic         | *All charges.*   | *All charges.*   |
| Anesthesia*                    |                  |                  |
+--------------------------------+------------------+------------------+

## **Section** 5(c) Services provided by a hospital or other facility, and ambulance services 

+---+---+---------------------------+------------------+------------+---+---+
|   | * | **Here are some important |                  |            | * |   |
|   | * | things you should keep in |                  |            | * |   |
|   | I | mind about these          |                  |            | I |   |
|   | * | benefits:**               |                  |            | * |   |
|   | * |                           |                  |            | * |   |
|   |   | -   Please remember that  |                  |            |   |   |
|   | * |     all benefits are      |                  |            | * |   |
|   | * |     subject to the        |                  |            | * |   |
|   | M |     definitions,          |                  |            | M |   |
|   | * |     limitations, and      |                  |            | * |   |
|   | * |     exclusions in this    |                  |            | * |   |
|   |   |     brochure and are      |                  |            |   |   |
|   | * |     payable only when we  |                  |            | * |   |
|   | * |     determine they are    |                  |            | * |   |
|   | P |     medically necessary.  |                  |            | P |   |
|   | * |                           |                  |            | * |   |
|   | * | -   Plan physicians must  |                  |            | * |   |
|   |   |     provide or arrange    |                  |            |   |   |
|   | * |     your care and you     |                  |            | * |   |
|   | * |     must be hospitalized  |                  |            | * |   |
|   | O |     in a Plan facility.   |                  |            | O |   |
|   | * |                           |                  |            | * |   |
|   | * | -   Under **High          |                  |            | * |   |
|   |   |     Option**, we have no  |                  |            |   |   |
|   | * |     calendar year         |                  |            | * |   |
|   | * |     deductible for In     |                  |            | * |   |
|   | R |     Network services.     |                  |            | R |   |
|   | * |                           |                  |            | * |   |
|   | * | -   Under **Standard      |                  |            | * |   |
|   |   |     Option**, the         |                  |            |   |   |
|   | * |     calendar year         |                  |            | * |   |
|   | * |     deductible for        |                  |            | * |   |
|   | T |     Participating         |                  |            | T |   |
|   | * |     Providers is \$500    |                  |            | * |   |
|   | * |     per person (\$1,000   |                  |            | * |   |
|   |   |     per family). The      |                  |            |   |   |
|   | * |     calendar year         |                  |            | * |   |
|   | * |     deductible applies to |                  |            | * |   |
|   | A |     almost all benefits   |                  |            | A |   |
|   | * |     in this section. We   |                  |            | * |   |
|   | * |     added "(No            |                  |            | * |   |
|   |   |     deductible)" to show  |                  |            |   |   |
|   | * |     when the calendar     |                  |            | * |   |
|   | * |     year deductible does  |                  |            | * |   |
|   | N |     not apply.            |                  |            | N |   |
|   | * |                           |                  |            | * |   |
|   | * | -   Under both **High and |                  |            | * |   |
|   |   |     Standard Options**,   |                  |            |   |   |
|   | * |     you must use Plan     |                  |            | * |   |
|   | * |     Providers in order to |                  |            | * |   |
|   | T |     receive in-network    |                  |            | T |   |
|   | * |     benefit coverage.     |                  |            | * |   |
|   | * |                           |                  |            | * |   |
|   |   | -   Be sure to read       |                  |            |   |   |
|   |   |     Section 4, *Your      |                  |            |   |   |
|   |   |     costs for covered     |                  |            |   |   |
|   |   |     services* for         |                  |            |   |   |
|   |   |     valuable information  |                  |            |   |   |
|   |   |     about how cost        |                  |            |   |   |
|   |   |     sharing works. Also   |                  |            |   |   |
|   |   |     read Section 9 about  |                  |            |   |   |
|   |   |     coordinating benefits |                  |            |   |   |
|   |   |     with other coverage,  |                  |            |   |   |
|   |   |     including with        |                  |            |   |   |
|   |   |     Medicare.             |                  |            |   |   |
|   |   |                           |                  |            |   |   |
|   |   | -   The amounts listed    |                  |            |   |   |
|   |   |     below are for the     |                  |            |   |   |
|   |   |     charges billed by the |                  |            |   |   |
|   |   |     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 |                  |            |   |   |
|   |   |     in Sections 5(a) or   |                  |            |   |   |
|   |   |     (b).                  |                  |            |   |   |
|   |   |                           |                  |            |   |   |
|   |   | -   **YOUR PHYSICIAN MUST |                  |            |   |   |
|   |   |     GET PRIOR APPROVAL OF |                  |            |   |   |
|   |   |     HOSPITAL STAYS**.     |                  |            |   |   |
|   |   |     Please refer to       |                  |            |   |   |
|   |   |     Section 3 to be sure  |                  |            |   |   |
|   |   |     which services        |                  |            |   |   |
|   |   |     require Prior         |                  |            |   |   |
|   |   |     approval.             |                  |            |   |   |
+---+---+---------------------------+------------------+------------+---+---+
| B |   |                           | You pay -        | You pay -  |   |   |
| e |   |                           |                  |            |   |   |
| n |   |                           | High Option      | Standard   |   |   |
| e |   |                           |                  | Option     |   |   |
| f |   |                           |                  |            |   |   |
| i |   |                           |                  | After the  |   |   |
| t |   |                           |                  | calendar   |   |   |
| D |   |                           |                  | year       |   |   |
| e |   |                           |                  | dedu       |   |   |
| s |   |                           |                  | ctible\... |   |   |
| c |   |                           |                  |            |   |   |
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| i |   |                           |                  |            |   |   |
| o |   |                           |                  |            |   |   |
| n |   |                           |                  |            |   |   |
+---+---+---------------------------+------------------+------------+---+---+
| * |   |                           |                  |            |   |   |
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+---+---+---------------------------+------------------+------------+---+---+
| # |   |                           |                  |            |   |   |
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+---+---+---------------------------+------------------+------------+---+---+
| R |   |                           | \$100 per day    | \$100 per  |   |   |
| o |   |                           | copay up to      | day copay  |   |   |
| o |   |                           | \$500 per        | up to      |   |   |
| m |   |                           | admission        | \$500 per  |   |   |
| a |   |                           |                  | admission  |   |   |
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| t |   |                           |                  |            |   |   |
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| s |   |                           |                  |            |   |   |
| n |   |                           |                  |            |   |   |
| o |   |                           |                  |            |   |   |
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| o |   |                           |                  |            |   |   |
| u |   |                           |                  |            |   |   |
| p |   |                           |                  |            |   |   |
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| t |   |                           |                  |            |   |   |
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| d |   |                           |                  |            |   |   |
| d |   |                           |                  |            |   |   |
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| t |   |                           |                  |            |   |   |
| i |   |                           |                  |            |   |   |
| o |   |                           |                  |            |   |   |
| n |   |                           |                  |            |   |   |
| a |   |                           |                  |            |   |   |
| l |   |                           |                  |            |   |   |
| c |   |                           |                  |            |   |   |
| h |   |                           |                  |            |   |   |
| a |   |                           |                  |            |   |   |
| r |   |                           |                  |            |   |   |
| g |   |                           |                  |            |   |   |
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| a |   |                           |                  |            |   |   |
| b |   |                           |                  |            |   |   |
| o |   |                           |                  |            |   |   |
| v |   |                           |                  |            |   |   |
| e |   |                           |                  |            |   |   |
| t |   |                           |                  |            |   |   |
| h |   |                           |                  |            |   |   |
| e |   |                           |                  |            |   |   |
| s |   |                           |                  |            |   |   |
| e |   |                           |                  |            |   |   |
| m |   |                           |                  |            |   |   |
| i |   |                           |                  |            |   |   |
| p |   |                           |                  |            |   |   |
| r |   |                           |                  |            |   |   |
| i |   |                           |                  |            |   |   |
| v |   |                           |                  |            |   |   |
| a |   |                           |                  |            |   |   |
| t |   |                           |                  |            |   |   |
| e |   |                           |                  |            |   |   |
| r |   |                           |                  |            |   |   |
| o |   |                           |                  |            |   |   |
| o |   |                           |                  |            |   |   |
| m |   |                           |                  |            |   |   |
| r |   |                           |                  |            |   |   |
| a |   |                           |                  |            |   |   |
| t |   |                           |                  |            |   |   |
| e |   |                           |                  |            |   |   |
| . |   |                           |                  |            |   |   |
+---+---+---------------------------+------------------+------------+---+---+

*Inpatient hospital - continued on next page.*

+--------------------------------+------------------+------------------+
| **Inpatient hospital**         | **You pay -**    | **You pay -**    |
| *(continued)*                  |                  |                  |
|                                | **High Option**  | **Standard       |
|                                |                  | Option**         |
|                                |                  |                  |
|                                |                  | **After the      |
|                                |                  | calendar year    |
|                                |                  | deductible\...** |
+--------------------------------+------------------+------------------+
| Other hospital services and    | Nothing          | Nothing          |
| supplies, such as:             |                  |                  |
|                                |                  |                  |
| -   Operating, recovery,       |                  |                  |
|     maternity, and other       |                  |                  |
|     treatment rooms            |                  |                  |
|                                |                  |                  |
| -   Prescribed drugs and       |                  |                  |
|     medicines                  |                  |                  |
|                                |                  |                  |
| -   Diagnostic laboratory      |                  |                  |
|     tests and X-rays           |                  |                  |
|                                |                  |                  |
| -   Administration of blood or |                  |                  |
|     blood products.            |                  |                  |
|                                |                  |                  |
| -   Dressings, splints, casts, |                  |                  |
|     and sterile tray services  |                  |                  |
|                                |                  |                  |
| -   Medical supplies and       |                  |                  |
|     equipment, including       |                  |                  |
|     oxygen                     |                  |                  |
|                                |                  |                  |
| -   Anesthetics, including     |                  |                  |
|     nurse anesthetist services |                  |                  |
|                                |                  |                  |
| -   Medical supplies,          |                  |                  |
|     appliances, medical        |                  |                  |
|     equipment, and any covered |                  |                  |
|     items billed by a hospital |                  |                  |
|     for use at home or take    |                  |                  |
|     home items                 |                  |                  |
+--------------------------------+------------------+------------------+
| *Not covered:*                 | *All charges.*   | *All charges.*   |
|                                |                  |                  |
| -   *Custodial care*           |                  |                  |
|                                |                  |                  |
| -   *Non-covered facilities,   |                  |                  |
|     such as nursing homes,     |                  |                  |
|     schools*                   |                  |                  |
|                                |                  |                  |
| -   *Personal comfort items    |                  |                  |
|     (telephone, television,    |                  |                  |
|     guest meals and beds*      |                  |                  |
|                                |                  |                  |
| -   *Private nursing care or   |                  |                  |
|     costs associated with      |                  |                  |
|     private rooms*             |                  |                  |
|                                |                  |                  |
| -   *Admissions to hospitals   |                  |                  |
|     performed only for the     |                  |                  |
|     convenience of the member, |                  |                  |
|     the member's family or the |                  |                  |
|     member's physician or      |                  |                  |
|     other provider*            |                  |                  |
+--------------------------------+------------------+------------------+
| ###### Outpatient hospital     | **You pay -**    | **You pay -**    |
|  or ambulatory surgical center |                  |                  |
|                                | **High Option**  | **Standard       |
|                                |                  | Option**         |
|                                |                  |                  |
|                                |                  | **After the      |
|                                |                  | calendar year    |
|                                |                  | deductible\...** |
+--------------------------------+------------------+------------------+
| -   Operating, recovery, and   | \$50 per visit   | 20% of charges   |
|     other treatment rooms      |                  |                  |
|                                |                  |                  |
| -   Prescribed drugs and       |                  |                  |
|     medicines                  |                  |                  |
|                                |                  |                  |
| -   Diagnostic laboratory      |                  |                  |
|     tests, X-rays, and         |                  |                  |
|     pathology services         |                  |                  |
|                                |                  |                  |
| -   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 charges.*   | *All charges.*   |
| derivatives not replaced by    |                  |                  |
| the member*                    |                  |                  |
+--------------------------------+------------------+------------------+
| ###### E                       |                  |                  |
| xtended care benefits/Skilled  |                  |                  |
| nursing care facility benefits |                  |                  |
+--------------------------------+------------------+------------------+
| All necessary services ordered | \$100 per day    | \$100 per day    |
| by a Plan doctor are covered,  | copay up to      | copay up to      |
| including:                     | \$500 per        | \$500 per        |
|                                | admission        | admission        |
| -   Unlimited days             |                  |                  |
|                                |                  |                  |
| -   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:*                 | *All charges.*   | *All charges.*   |
|                                |                  |                  |
| -   *Custodial care*           |                  |                  |
|                                |                  |                  |
| -   *Convalescent care*        |                  |                  |
|                                |                  |                  |
| -   *Intermediate level or     |                  |                  |
|     domiciliary care*          |                  |                  |
|                                |                  |                  |
| -   *Residential care*         |                  |                  |
|                                |                  |                  |
| -   Rest cures or services to  |                  |                  |
|     assist in activities of    |                  |                  |
|     daily living               |                  |                  |
+--------------------------------+------------------+------------------+
| ###### Hospice care            | **You pay -**    | **You pay -**    |
|                                |                  |                  |
|                                | **High Option**  | **Standard       |
|                                |                  | Option**         |
|                                |                  |                  |
|                                |                  | **After the      |
|                                |                  | calendar year    |
|                                |                  | deductible\...** |
+--------------------------------+------------------+------------------+
| -   Admission to a hospice     | Nothing          | 20% of charges   |
|     facility, hospital, or     |                  |                  |
|     skilled nursing 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      | *All charges.*   | *All charges.*   |
| nursing, homemaker services*   |                  |                  |
+--------------------------------+------------------+------------------+
| ###### Ambulance               |                  |                  |
+--------------------------------+------------------+------------------+
| -   Local professional ground  | \$50 copay       | 20% of charges   |
|     and/or air ambulance       |                  |                  |
|     service when medically     |                  |                  |
|     necessary and plan         |                  |                  |
|     approved hospital          |                  |                  |
|     transfers.                 |                  |                  |
+--------------------------------+------------------+------------------+
| *Not covered:*                 | *All charges.*   | *All 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.*                    |                  |                  |
+--------------------------------+------------------+------------------+

## Section 5(d) Emergency services/accidents

+---+---+---------------------------+-----------------+---------+---+-----+
| # | * | **Here are some important |                 |         | * |     |
| # | * | things to keep in mind    |                 |         | * |     |
| # | I | about these benefits:**   |                 |         | I |     |
| # | * |                           |                 |         | * |     |
| # | * | -   Please remember that  |                 |         | * |     |
|   |   |     all benefits are      |                 |         |   |     |
|   | * |     subject to the        |                 |         | * |     |
|   | * |     definitions,          |                 |         | * |     |
|   | M |     limitations, and      |                 |         | M |     |
|   | * |     exclusions in this    |                 |         | * |     |
|   | * |     brochure and are      |                 |         | * |     |
|   |   |     payable only when we  |                 |         |   |     |
|   | * |     determine they are    |                 |         | * |     |
|   | * |     medically necessary.  |                 |         | * |     |
|   | P |                           |                 |         | P |     |
|   | * | -   Under **High          |                 |         | * |     |
|   | * |     Option**, we have no  |                 |         | * |     |
|   |   |     calendar year         |                 |         |   |     |
|   | * |     deductible for In     |                 |         | * |     |
|   | * |     Network services.     |                 |         | * |     |
|   | O |                           |                 |         | O |     |
|   | * | -   Under **Standard      |                 |         | * |     |
|   | * |     Option**, the         |                 |         | * |     |
|   |   |     calendar year         |                 |         |   |     |
|   | * |     deductible for        |                 |         | * |     |
|   | * |     Participating         |                 |         | * |     |
|   | R |     Providers is \$500    |                 |         | R |     |
|   | * |     per person (\$1,000   |                 |         | * |     |
|   | * |     per family). The      |                 |         | * |     |
|   |   |     calendar year         |                 |         |   |     |
|   | * |     deductible applies to |                 |         | * |     |
|   | * |     almost all benefits   |                 |         | * |     |
|   | T |     in this section. We   |                 |         | T |     |
|   | * |     added "(No            |                 |         | * |     |
|   | * |     deductible)" to show  |                 |         | * |     |
|   |   |     when the calendar     |                 |         |   |     |
|   | * |     year deductible does  |                 |         | * |     |
|   | * |     not apply.            |                 |         | * |     |
|   | A |                           |                 |         | A |     |
|   | * | -   Under both **High and |                 |         | * |     |
|   | * |     Standard Options**,   |                 |         | * |     |
|   |   |     you must use Plan     |                 |         |   |     |
|   | * |     Providers in order to |                 |         | * |     |
|   | * |     receive in-network    |                 |         | * |     |
|   | N |     benefit coverage.     |                 |         | N |     |
|   | * |                           |                 |         | * |     |
|   | * | -   Be sure to read       |                 |         | * |     |
|   |   |     Section 4, *Your      |                 |         |   |     |
|   | * |     costs for covered     |                 |         | * |     |
|   | * |     services,* for        |                 |         | * |     |
|   | T |     valuable information  |                 |         | T |     |
|   | * |     about how cost        |                 |         | * |     |
|   | * |     sharing works. Also   |                 |         | * |     |
|   |   |     read Section 9 about  |                 |         |   |     |
|   |   |     coordinating benefits |                 |         |   |     |
|   |   |     with other coverage,  |                 |         |   |     |
|   |   |     including with        |                 |         |   |     |
|   |   |     Medicare.             |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   | #####                     |                 |         |   |     |
+---+---+---------------------------+-----------------+---------+---+-----+
| * |   |                           |                 |         |   |     |
| * |   |                           |                 |         |   |     |
| W |   |                           |                 |         |   |     |
| h |   |                           |                 |         |   |     |
| a |   |                           |                 |         |   |     |
| t |   |                           |                 |         |   |     |
| i |   |                           |                 |         |   |     |
| s |   |                           |                 |         |   |     |
| a |   |                           |                 |         |   |     |
| m |   |                           |                 |         |   |     |
| e |   |                           |                 |         |   |     |
| d |   |                           |                 |         |   |     |
| i |   |                           |                 |         |   |     |
| c |   |                           |                 |         |   |     |
| a |   |                           |                 |         |   |     |
| l |   |                           |                 |         |   |     |
| e |   |                           |                 |         |   |     |
| m |   |                           |                 |         |   |     |
| e |   |                           |                 |         |   |     |
| r |   |                           |                 |         |   |     |
| g |   |                           |                 |         |   |     |
| e |   |                           |                 |         |   |     |
| n |   |                           |                 |         |   |     |
| c |   |                           |                 |         |   |     |
| y |   |                           |                 |         |   |     |
| ? |   |                           |                 |         |   |     |
| * |   |                           |                 |         |   |     |
| * |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
| A |   |                           |                 |         |   |     |
| m |   |                           |                 |         |   |     |
| e |   |                           |                 |         |   |     |
| d |   |                           |                 |         |   |     |
| i |   |                           |                 |         |   |     |
| c |   |                           |                 |         |   |     |
| a |   |                           |                 |         |   |     |
| l |   |                           |                 |         |   |     |
| e |   |                           |                 |         |   |     |
| m |   |                           |                 |         |   |     |
| e |   |                           |                 |         |   |     |
| r |   |                           |                 |         |   |     |
| g |   |                           |                 |         |   |     |
| e |   |                           |                 |         |   |     |
| n |   |                           |                 |         |   |     |
| c |   |                           |                 |         |   |     |
| y |   |                           |                 |         |   |     |
| i |   |                           |                 |         |   |     |
| s |   |                           |                 |         |   |     |
| t |   |                           |                 |         |   |     |
| h |   |                           |                 |         |   |     |
| e |   |                           |                 |         |   |     |
| s |   |                           |                 |         |   |     |
| u |   |                           |                 |         |   |     |
| d |   |                           |                 |         |   |     |
| d |   |                           |                 |         |   |     |
| e |   |                           |                 |         |   |     |
| n |   |                           |                 |         |   |     |
| a |   |                           |                 |         |   |     |
| n |   |                           |                 |         |   |     |
| d |   |                           |                 |         |   |     |
| u |   |                           |                 |         |   |     |
| n |   |                           |                 |         |   |     |
| e |   |                           |                 |         |   |     |
| x |   |                           |                 |         |   |     |
| p |   |                           |                 |         |   |     |
| e |   |                           |                 |         |   |     |
| c |   |                           |                 |         |   |     |
| t |   |                           |                 |         |   |     |
| e |   |                           |                 |         |   |     |
| d |   |                           |                 |         |   |     |
| o |   |                           |                 |         |   |     |
| n |   |                           |                 |         |   |     |
| s |   |                           |                 |         |   |     |
| e |   |                           |                 |         |   |     |
| t |   |                           |                 |         |   |     |
| o |   |                           |                 |         |   |     |
| f |   |                           |                 |         |   |     |
| a |   |                           |                 |         |   |     |
| c |   |                           |                 |         |   |     |
| o |   |                           |                 |         |   |     |
| n |   |                           |                 |         |   |     |
| d |   |                           |                 |         |   |     |
| i |   |                           |                 |         |   |     |
| t |   |                           |                 |         |   |     |
| i |   |                           |                 |         |   |     |
| o |   |                           |                 |         |   |     |
| n |   |                           |                 |         |   |     |
| o |   |                           |                 |         |   |     |
| r |   |                           |                 |         |   |     |
| a |   |                           |                 |         |   |     |
| n |   |                           |                 |         |   |     |
| i |   |                           |                 |         |   |     |
| n |   |                           |                 |         |   |     |
| j |   |                           |                 |         |   |     |
| u |   |                           |                 |         |   |     |
| r |   |                           |                 |         |   |     |
| y |   |                           |                 |         |   |     |
| t |   |                           |                 |         |   |     |
| h |   |                           |                 |         |   |     |
| a |   |                           |                 |         |   |     |
| t |   |                           |                 |         |   |     |
| y |   |                           |                 |         |   |     |
| o |   |                           |                 |         |   |     |
| u |   |                           |                 |         |   |     |
| b |   |                           |                 |         |   |     |
| e |   |                           |                 |         |   |     |
| l |   |                           |                 |         |   |     |
| i |   |                           |                 |         |   |     |
| e |   |                           |                 |         |   |     |
| v |   |                           |                 |         |   |     |
| e |   |                           |                 |         |   |     |
| e |   |                           |                 |         |   |     |
| n |   |                           |                 |         |   |     |
| d |   |                           |                 |         |   |     |
| a |   |                           |                 |         |   |     |
| n |   |                           |                 |         |   |     |
| g |   |                           |                 |         |   |     |
| e |   |                           |                 |         |   |     |
| r |   |                           |                 |         |   |     |
| s |   |                           |                 |         |   |     |
| y |   |                           |                 |         |   |     |
| o |   |                           |                 |         |   |     |
| u |   |                           |                 |         |   |     |
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+---+---+---------------------------+-----------------+---------+---+-----+
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| a |   |                           |                 |         |   |     |
| y |   |                           |                 |         |   |     |
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| ( |   |                           |                 |         |   |     |
| N |   |                           |                 |         |   |     |
| o |   |                           |                 |         |   |     |
| d |   |                           |                 |         |   |     |
| e |   |                           |                 |         |   |     |
| d |   |                           |                 |         |   |     |
| u |   |                           |                 |         |   |     |
| c |   |                           |                 |         |   |     |
| t |   |                           |                 |         |   |     |
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| w |   |                           |                 |         |   |     |
| h |   |                           |                 |         |   |     |
| e |   |                           |                 |         |   |     |
| n |   |                           |                 |         |   |     |
| i |   |                           |                 |         |   |     |
| t |   |                           |                 |         |   |     |
| d |   |                           |                 |         |   |     |
| o |   |                           |                 |         |   |     |
| e |   |                           |                 |         |   |     |
| s |   |                           |                 |         |   |     |
| n |   |                           |                 |         |   |     |
| o |   |                           |                 |         |   |     |
| t |   |                           |                 |         |   |     |
| a |   |                           |                 |         |   |     |
| p |   |                           |                 |         |   |     |
| p |   |                           |                 |         |   |     |
| l |   |                           |                 |         |   |     |
| y |   |                           |                 |         |   |     |
| . |   |                           |                 |         |   |     |
| * |   |                           |                 |         |   |     |
| * |   |                           |                 |         |   |     |
+---+---+---------------------------+-----------------+---------+---+-----+
| E |   |                           |                 |         |   |     |
| m |   |                           |                 |         |   |     |
| e |   |                           |                 |         |   |     |
| r |   |                           |                 |         |   |     |
| g |   |                           |                 |         |   |     |
| e |   |                           |                 |         |   |     |
| n |   |                           |                 |         |   |     |
| c |   |                           |                 |         |   |     |
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| n |   |                           |                 |         |   |     |
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| u |   |                           |                 |         |   |     |
| r |   |                           |                 |         |   |     |
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| e |   |                           |                 |         |   |     |
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| v |   |                           |                 |         |   |     |
| i |   |                           |                 |         |   |     |
| c |   |                           |                 |         |   |     |
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| a |   |                           |                 |         |   |     |
| r |   |                           |                 |         |   |     |
| e |   |                           |                 |         |   |     |
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| ] |   |                           |                 |         |   |     |
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| _ |   |                           |                 |         |   |     |
| _ |   |                           |                 |         |   |     |
| R |   |                           |                 |         |   |     |
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| d |   |                           |                 |         |   |     |
| i |   |                           |                 |         |   |     |
| n |   |                           |                 |         |   |     |
| g |   |                           |                 |         |   |     |
| _ |   |                           |                 |         |   |     |
| _ |   |                           |                 |         |   |     |
| _ |   |                           |                 |         |   |     |
| T |   |                           |                 |         |   |     |
| o |   |                           |                 |         |   |     |
| c |   |                           |                 |         |   |     |
| 8 |   |                           |                 |         |   |     |
| 4 |   |                           |                 |         |   |     |
| 1 |   |                           |                 |         |   |     |
| 2 |   |                           |                 |         |   |     |
| 7 |   |                           |                 |         |   |     |
| 7 |   |                           |                 |         |   |     |
| 9 |   |                           |                 |         |   |     |
| 9 |   |                           |                 |         |   |     |
| . |   |                           |                 |         |   |     |
| a |   |                           |                 |         |   |     |
| n |   |                           |                 |         |   |     |
| c |   |                           |                 |         |   |     |
| h |   |                           |                 |         |   |     |
| o |   |                           |                 |         |   |     |
| r |   |                           |                 |         |   |     |
| } |   |                           |                 |         |   |     |
+---+---+---------------------------+-----------------+---------+---+-----+
| - |   |                           | \$20 per        | \$25    |   |     |
|   |   |                           | primary care    | copay   |   |     |
|   |   |                           | visit           | per     |   |     |
|   |   |                           |                 | primary |   |     |
| E |   |                           | \$30 per        | care or |   |     |
| m |   |                           | specialist      | spe     |   |     |
| e |   |                           | visit           | cialist |   |     |
| r |   |                           |                 | visit   |   |     |
| g |   |                           |                 | (No     |   |     |
| e |   |                           |                 | dedu    |   |     |
| n |   |                           |                 | ctible) |   |     |
| c |   |                           |                 |         |   |     |
| y |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
| c |   |                           |                 |         |   |     |
| a |   |                           |                 |         |   |     |
| r |   |                           |                 |         |   |     |
| e |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
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| t |   |                           |                 |         |   |     |
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|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
| d |   |                           |                 |         |   |     |
| o |   |                           |                 |         |   |     |
| c |   |                           |                 |         |   |     |
| t |   |                           |                 |         |   |     |
| o |   |                           |                 |         |   |     |
| r |   |                           |                 |         |   |     |
| ' |   |                           |                 |         |   |     |
| s |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
| o |   |                           |                 |         |   |     |
| f |   |                           |                 |         |   |     |
| f |   |                           |                 |         |   |     |
| i |   |                           |                 |         |   |     |
| c |   |                           |                 |         |   |     |
| e |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
| - |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
| E |   |                           |                 |         |   |     |
| m |   |                           |                 |         |   |     |
| e |   |                           |                 |         |   |     |
| r |   |                           |                 |         |   |     |
| g |   |                           |                 |         |   |     |
| e |   |                           |                 |         |   |     |
| n |   |                           |                 |         |   |     |
| c |   |                           |                 |         |   |     |
| y |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
| c |   |                           |                 |         |   |     |
| a |   |                           |                 |         |   |     |
| r |   |                           |                 |         |   |     |
| e |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
| a |   |                           |                 |         |   |     |
| t |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
| a |   |                           |                 |         |   |     |
| n |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
| u |   |                           |                 |         |   |     |
| r |   |                           |                 |         |   |     |
| g |   |                           |                 |         |   |     |
| e |   |                           |                 |         |   |     |
| n |   |                           |                 |         |   |     |
| t |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
| c |   |                           |                 |         |   |     |
| a |   |                           |                 |         |   |     |
| r |   |                           |                 |         |   |     |
| e |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
| c |   |                           |                 |         |   |     |
| e |   |                           |                 |         |   |     |
| n |   |                           |                 |         |   |     |
| t |   |                           |                 |         |   |     |
| e |   |                           |                 |         |   |     |
| r |   |                           |                 |         |   |     |
+---+---+---------------------------+-----------------+---------+---+-----+
| - |   |                           | \$100 per       | \$100   |   |     |
|   |   |                           | visit, waived   | per     |   |     |
|   |   |                           | if admitted     | visit,  |   |     |
|   |   |                           |                 | waived  |   |     |
| E |   |                           |                 | if      |   |     |
| m |   |                           |                 | a       |   |     |
| e |   |                           |                 | dmitted |   |     |
| r |   |                           |                 | (No     |   |     |
| g |   |                           |                 | deduc   |   |     |
| e |   |                           |                 | tible). |   |     |
| n |   |                           |                 |         |   |     |
| c |   |                           |                 |         |   |     |
| y |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
| c |   |                           |                 |         |   |     |
| a |   |                           |                 |         |   |     |
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| e |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
| a |   |                           |                 |         |   |     |
| s |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
| a |   |                           |                 |         |   |     |
| n |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
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|   |   |                           |                 |         |   |     |
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|   |   |                           |                 |         |   |     |
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|   |   |                           |                 |         |   |     |
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| n |   |                           |                 |         |   |     |
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|   |   |                           |                 |         |   |     |
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|   |   |                           |                 |         |   |     |
| d |   |                           |                 |         |   |     |
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| c |   |                           |                 |         |   |     |
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| r |   |                           |                 |         |   |     |
| s |   |                           |                 |         |   |     |
| ' |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
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|   |   |                           |                 |         |   |     |
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+---+---+---------------------------+-----------------+---------+---+-----+
| * |   |                           | *All charges.*  | *All    |   |     |
| N |   |                           |                 | ch      |   |     |
| o |   |                           |                 | arges.* |   |     |
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| c |   |                           |                 |         |   |     |
| a |   |                           |                 |         |   |     |
| r |   |                           |                 |         |   |     |
| e |   |                           |                 |         |   |     |
| * |   |                           |                 |         |   |     |
+---+---+---------------------------+-----------------+---------+---+-----+
| E |   |                           | You pay -       | **You   |   |     |
| m |   |                           |                 | pay -** |   |     |
| e |   |                           | High Option     |         |   |     |
| r |   |                           |                 | **S     |   |     |
| g |   |                           |                 | tandard |   |     |
| e |   |                           |                 | O       |   |     |
| n |   |                           |                 | ption** |   |     |
| c |   |                           |                 |         |   |     |
| y |   |                           |                 | After   |   |     |
| o |   |                           |                 | the     |   |     |
| u |   |                           |                 | c       |   |     |
| t |   |                           |                 | alendar |   |     |
| s |   |                           |                 | year    |   |     |
| i |   |                           |                 | deducti |   |     |
| d |   |                           |                 | ble\... |   |     |
| e |   |                           |                 |         |   |     |
| o |   |                           |                 |         |   |     |
| u |   |                           |                 |         |   |     |
| r |   |                           |                 |         |   |     |
| s |   |                           |                 |         |   |     |
| e |   |                           |                 |         |   |     |
| r |   |                           |                 |         |   |     |
| v |   |                           |                 |         |   |     |
| i |   |                           |                 |         |   |     |
| c |   |                           |                 |         |   |     |
| e |   |                           |                 |         |   |     |
| a |   |                           |                 |         |   |     |
| r |   |                           |                 |         |   |     |
| e |   |                           |                 |         |   |     |
| a |   |                           |                 |         |   |     |
| [ |   |                           |                 |         |   |     |
| ] |   |                           |                 |         |   |     |
| { |   |                           |                 |         |   |     |
| # |   |                           |                 |         |   |     |
| _ |   |                           |                 |         |   |     |
| _ |   |                           |                 |         |   |     |
| R |   |                           |                 |         |   |     |
| e |   |                           |                 |         |   |     |
| f |   |                           |                 |         |   |     |
| H |   |                           |                 |         |   |     |
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| a |   |                           |                 |         |   |     |
| d |   |                           |                 |         |   |     |
| i |   |                           |                 |         |   |     |
| n |   |                           |                 |         |   |     |
| g |   |                           |                 |         |   |     |
| _ |   |                           |                 |         |   |     |
| _ |   |                           |                 |         |   |     |
| _ |   |                           |                 |         |   |     |
| T |   |                           |                 |         |   |     |
| o |   |                           |                 |         |   |     |
| c |   |                           |                 |         |   |     |
| 8 |   |                           |                 |         |   |     |
| 4 |   |                           |                 |         |   |     |
| 1 |   |                           |                 |         |   |     |
| 2 |   |                           |                 |         |   |     |
| 7 |   |                           |                 |         |   |     |
| 8 |   |                           |                 |         |   |     |
| 0 |   |                           |                 |         |   |     |
| 0 |   |                           |                 |         |   |     |
| . |   |                           |                 |         |   |     |
| a |   |                           |                 |         |   |     |
| n |   |                           |                 |         |   |     |
| c |   |                           |                 |         |   |     |
| h |   |                           |                 |         |   |     |
| o |   |                           |                 |         |   |     |
| r |   |                           |                 |         |   |     |
| } |   |                           |                 |         |   |     |
+---+---+---------------------------+-----------------+---------+---+-----+
| - |   |                           | \$20 per        | \$25    |   |     |
|   |   |                           | primary care    | copay   |   |     |
|   |   |                           | visit           | per     |   |     |
|   |   |                           |                 | primary |   |     |
| E |   |                           | \$30 per        | care or |   |     |
| m |   |                           | specialist      | spe     |   |     |
| e |   |                           | visit           | cialist |   |     |
| r |   |                           |                 | visit   |   |     |
| g |   |                           |                 | (No     |   |     |
| e |   |                           |                 | dedu    |   |     |
| n |   |                           |                 | ctible) |   |     |
| c |   |                           |                 |         |   |     |
| y |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
| c |   |                           |                 |         |   |     |
| a |   |                           |                 |         |   |     |
| r |   |                           |                 |         |   |     |
| e |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
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|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
| d |   |                           |                 |         |   |     |
| o |   |                           |                 |         |   |     |
| c |   |                           |                 |         |   |     |
| t |   |                           |                 |         |   |     |
| o |   |                           |                 |         |   |     |
| r |   |                           |                 |         |   |     |
| ' |   |                           |                 |         |   |     |
| s |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
| o |   |                           |                 |         |   |     |
| f |   |                           |                 |         |   |     |
| f |   |                           |                 |         |   |     |
| i |   |                           |                 |         |   |     |
| c |   |                           |                 |         |   |     |
| e |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
| - |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
| E |   |                           |                 |         |   |     |
| m |   |                           |                 |         |   |     |
| e |   |                           |                 |         |   |     |
| r |   |                           |                 |         |   |     |
| g |   |                           |                 |         |   |     |
| e |   |                           |                 |         |   |     |
| n |   |                           |                 |         |   |     |
| c |   |                           |                 |         |   |     |
| y |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
| c |   |                           |                 |         |   |     |
| a |   |                           |                 |         |   |     |
| r |   |                           |                 |         |   |     |
| e |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
| a |   |                           |                 |         |   |     |
| t |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
| a |   |                           |                 |         |   |     |
| n |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
| u |   |                           |                 |         |   |     |
| r |   |                           |                 |         |   |     |
| g |   |                           |                 |         |   |     |
| e |   |                           |                 |         |   |     |
| n |   |                           |                 |         |   |     |
| t |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
| c |   |                           |                 |         |   |     |
| a |   |                           |                 |         |   |     |
| r |   |                           |                 |         |   |     |
| e |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
| c |   |                           |                 |         |   |     |
| e |   |                           |                 |         |   |     |
| n |   |                           |                 |         |   |     |
| t |   |                           |                 |         |   |     |
| e |   |                           |                 |         |   |     |
| r |   |                           |                 |         |   |     |
+---+---+---------------------------+-----------------+---------+---+-----+
| - |   |                           | \$100 per       | \$100   |   |     |
|   |   |                           | visit, waived   | per     |   |     |
|   |   |                           | if admitted     | visit,  |   |     |
|   |   |                           |                 | waived  |   |     |
| E |   |                           |                 | if      |   |     |
| m |   |                           |                 | a       |   |     |
| e |   |                           |                 | dmitted |   |     |
| r |   |                           |                 | (No     |   |     |
| g |   |                           |                 | deduc   |   |     |
| e |   |                           |                 | tible). |   |     |
| n |   |                           |                 |         |   |     |
| c |   |                           |                 |         |   |     |
| y |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
| c |   |                           |                 |         |   |     |
| a |   |                           |                 |         |   |     |
| r |   |                           |                 |         |   |     |
| e |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
| a |   |                           |                 |         |   |     |
| s |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
| a |   |                           |                 |         |   |     |
| n |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
|   |   |                           |                 |         |   |     |
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|   |   |                           |                 |         |   |     |
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+---+---+---------------------------+-----------------+---------+---+-----+
| * |   |                           | *All charges.*  | *All    |   |     |
| N |   |                           |                 | ch      |   |     |
| o |   |                           |                 | arges.* |   |     |
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| . |   |                           |                 |         |   |     |
+---+---+---------------------------+-----------------+---------+---+-----+
| * |   |                           | *All charges.*  | *All    |   |     |
| N |   |                           |                 | ch      |   |     |
| o |   |                           |                 | arges.* |   |     |
| t |   |                           |                 |         |   |     |
| c |   |                           |                 |         |   |     |
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| * |   |                           |                 |         |   |     |
+---+---+---------------------------+-----------------+---------+---+-----+

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

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

*Mental health and substance abuse benefits − continued on next page.*

+--------------------------------+------------------+------------------+
| Mental health and substance    | **You pay -**    | **You pay -**    |
| abuse benefits *(continued)*   |                  |                  |
|                                | **High Option**  | **Standard       |
|                                |                  | Option**         |
|                                |                  |                  |
|                                |                  | **After the      |
|                                |                  | calendar year    |
|                                |                  | deductible\...** |
+--------------------------------+------------------+------------------+
| -   Services provided by a     | \$100 per day    | \$100 per day    |
|     hospital or other facility | copay up to      | copay up to      |
|                                | \$500 per        | \$500 per        |
| -   Services in approved       | inpatient        | inpatient        |
|     alternative care settings  | admission        | admission        |
|     such as partial            |                  |                  |
|     hospitalization, half-way  |                  |                  |
|     house, residential         |                  |                  |
|     treatment, full-day        |                  |                  |
|     hospitalization, facility  |                  |                  |
|     based intensive outpatient |                  |                  |
|     treatment                  |                  |                  |
+--------------------------------+------------------+------------------+
| *Not covered:*                 | *All charges.*   | *All charges.*   |
|                                |                  |                  |
| -   *Services we have not      |                  |                  |
|     approved.*                 |                  |                  |
|                                |                  |                  |
| -   *Marriage, family, or      |                  |                  |
|     bereavement counseling*    |                  |                  |
|                                |                  |                  |
| -   *Pastoral counseling*      |                  |                  |
|                                |                  |                  |
| -   *Financial or legal        |                  |                  |
|     counseling*                |                  |                  |
|                                |                  |                  |
| -   *Custodial care            |                  |                  |
|     counseling*                |                  |                  |
|                                |                  |                  |
| -   *Services we have not      |                  |                  |
|     approved.*                 |                  |                  |
|                                |                  |                  |
| -   *Long term custodial       |                  |                  |
|     care.*                     |                  |                  |
+--------------------------------+------------------+------------------+
| **Preauthorization** To be     |                  |                  |
| eligible to receive these      |                  |                  |
| benefits you must obtain a     |                  |                  |
| treatment plan and follow the  |                  |                  |
| authorization processes:       |                  |                  |
|                                |                  |                  |
| Contact our Health Services    |                  |                  |
| Department for the prior       |                  |                  |
| approval 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  |                  |                  |
| 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 approval   |                  |                  |
| from the Health Services       |                  |                  |
| Department. Failure to obtain  |                  |                  |
| prior approval will result in  |                  |                  |
| a reduction to the Out of      |                  |                  |
| Network benefits level.        |                  |                  |
| However, information provided  |                  |                  |
| by the physician's office also |                  |                  |
| satisfies this requirement     |                  |                  |
+--------------------------------+------------------+------------------+
| **Limitation** We may limit    |                  |                  |
| your benefits if you do not    |                  |                  |
| obtain a treatment plan.       |                  |                  |
+--------------------------------+------------------+------------------+

## **Section** 5(f) Prescription drug benefits

+---+---+---+-------------------------+------------------+----------+---+---+
|   |   | * | **Here are some         |                  |          | * |   |
|   |   | * | important things to     |                  |          | * |   |
|   |   | I | keep in mind about      |                  |          | I |   |
|   |   | * | these benefits:**       |                  |          | * |   |
|   |   | * |                         |                  |          | * |   |
|   |   |   | -   We cover prescribed |                  |          |   |   |
|   |   | * |     drugs and           |                  |          | * |   |
|   |   | * |     medications, as     |                  |          | * |   |
|   |   | M |     described in the    |                  |          | M |   |
|   |   | * |     chart beginning on  |                  |          | * |   |
|   |   | * |     the next page.      |                  |          | * |   |
|   |   |   |                         |                  |          |   |   |
|   |   | * | -   All benefits are    |                  |          | * |   |
|   |   | * |     subject to the      |                  |          | * |   |
|   |   | P |     definitions,        |                  |          | P |   |
|   |   | * |     limitations and     |                  |          | * |   |
|   |   | * |     exclusions in this  |                  |          | * |   |
|   |   |   |     brochure and are    |                  |          |   |   |
|   |   | * |     payable only when   |                  |          | * |   |
|   |   | * |     we determine they   |                  |          | * |   |
|   |   | O |     are medically       |                  |          | O |   |
|   |   | * |     necessary.          |                  |          | * |   |
|   |   | * |                         |                  |          | * |   |
|   |   |   | -   Under **High        |                  |          |   |   |
|   |   | * |     Option**, we have   |                  |          | * |   |
|   |   | * |     no calendar year    |                  |          | * |   |
|   |   | R |     deductible for In   |                  |          | R |   |
|   |   | * |     Network services.   |                  |          | * |   |
|   |   | * |                         |                  |          | * |   |
|   |   |   | -   Under **Standard    |                  |          |   |   |
|   |   | * |     Option**, the       |                  |          | * |   |
|   |   | * |     calendar year       |                  |          | * |   |
|   |   | T |     deductible for      |                  |          | T |   |
|   |   | * |     Participating       |                  |          | * |   |
|   |   | * |     Providers is \$500  |                  |          | * |   |
|   |   |   |     per person (\$1,000 |                  |          |   |   |
|   |   | * |     per family). The    |                  |          | * |   |
|   |   | * |     calendar year       |                  |          | * |   |
|   |   | A |     deductible applies  |                  |          | A |   |
|   |   | * |     to almost all       |                  |          | * |   |
|   |   | * |     benefits in this    |                  |          | * |   |
|   |   |   |     section. We added   |                  |          |   |   |
|   |   | * |     "(No deductible)"   |                  |          | * |   |
|   |   | * |     to show when the    |                  |          | * |   |
|   |   | N |     calendar year       |                  |          | N |   |
|   |   | * |     deductible does not |                  |          | * |   |
|   |   | * |     apply.              |                  |          | * |   |
|   |   |   |                         |                  |          |   |   |
|   |   | * | -   Under both **High   |                  |          | * |   |
|   |   | * |     and Standard        |                  |          | * |   |
|   |   | T |     Options**, you must |                  |          | T |   |
|   |   | * |     use Plan Providers; |                  |          | * |   |
|   |   | * |     there are no Point  |                  |          | * |   |
|   |   |   |     of Service          |                  |          |   |   |
|   |   |   |     (out-of-network)    |                  |          |   |   |
|   |   |   |     benefits.           |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
|   |   |   | -   •Be sure to read    |                  |          |   |   |
|   |   |   |     Section 4, Your     |                  |          |   |   |
|   |   |   |     costs for covered   |                  |          |   |   |
|   |   |   |     services, for       |                  |          |   |   |
|   |   |   |     valuable            |                  |          |   |   |
|   |   |   |     information about   |                  |          |   |   |
|   |   |   |     how cost sharing    |                  |          |   |   |
|   |   |   |     works. Also read    |                  |          |   |   |
|   |   |   |     Section 9 about     |                  |          |   |   |
|   |   |   |     coordinating        |                  |          |   |   |
|   |   |   |     benefits with other |                  |          |   |   |
|   |   |   |     coverage, including |                  |          |   |   |
|   |   |   |     with Medicare.      |                  |          |   |   |
+---+---+---+-------------------------+------------------+----------+---+---+
|   | * |   |                         |                  |          |   |   |
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|   | a |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
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|   | c |   |                         |                  |          |   |   |
|   | l |   |                         |                  |          |   |   |
|   | a |   |                         |                  |          |   |   |
|   | i |   |                         |                  |          |   |   |
|   | m |   |                         |                  |          |   |   |
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|   | f |   |                         |                  |          |   |   |
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|   | r |   |                         |                  |          |   |   |
|   | m |   |                         |                  |          |   |   |
|   | . |   |                         |                  |          |   |   |
+---+---+---+-------------------------+------------------+----------+---+---+
| B |   |   |                         | You pay -        | You pay  |   |   |
| e |   |   |                         |                  | -        |   |   |
| n |   |   |                         | High Option      |          |   |   |
| e |   |   |                         |                  | Standard |   |   |
| f |   |   |                         |                  | Option   |   |   |
| i |   |   |                         |                  |          |   |   |
| t |   |   |                         |                  | After    |   |   |
| D |   |   |                         |                  | the      |   |   |
| e |   |   |                         |                  | calendar |   |   |
| s |   |   |                         |                  | year     |   |   |
| c |   |   |                         |                  | deduct   |   |   |
| r |   |   |                         |                  | ible\... |   |   |
| i |   |   |                         |                  |          |   |   |
| p |   |   |                         |                  |          |   |   |
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| n |   |   |                         |                  |          |   |   |
+---+---+---+-------------------------+------------------+----------+---+---+
| * |   |   |                         |                  |          |   |   |
| * |   |   |                         |                  |          |   |   |
| N |   |   |                         |                  |          |   |   |
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| . |   |   |                         |                  |          |   |   |
| * |   |   |                         |                  |          |   |   |
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|   |   |   |                         |                  |          |   |   |
| * |   |   |                         |                  |          |   |   |
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| a |   |   |                         |                  |          |   |   |
| y |   |   |                         |                  |          |   |   |
| \ |   |   |                         |                  |          |   |   |
| " |   |   |                         |                  |          |   |   |
| ( |   |   |                         |                  |          |   |   |
| N |   |   |                         |                  |          |   |   |
| o |   |   |                         |                  |          |   |   |
| d |   |   |                         |                  |          |   |   |
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| u |   |   |                         |                  |          |   |   |
| c |   |   |                         |                  |          |   |   |
| t |   |   |                         |                  |          |   |   |
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| b |   |   |                         |                  |          |   |   |
| l |   |   |                         |                  |          |   |   |
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| ) |   |   |                         |                  |          |   |   |
| \ |   |   |                         |                  |          |   |   |
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| w |   |   |                         |                  |          |   |   |
| h |   |   |                         |                  |          |   |   |
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| o |   |   |                         |                  |          |   |   |
| t |   |   |                         |                  |          |   |   |
| a |   |   |                         |                  |          |   |   |
| p |   |   |                         |                  |          |   |   |
| p |   |   |                         |                  |          |   |   |
| l |   |   |                         |                  |          |   |   |
| y |   |   |                         |                  |          |   |   |
| . |   |   |                         |                  |          |   |   |
| * |   |   |                         |                  |          |   |   |
| * |   |   |                         |                  |          |   |   |
+---+---+---+-------------------------+------------------+----------+---+---+
| # |   |   |                         |                  |          |   |   |
| # |   |   |                         |                  |          |   |   |
| # |   |   |                         |                  |          |   |   |
| # |   |   |                         |                  |          |   |   |
| # |   |   |                         |                  |          |   |   |
| # |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
| C |   |   |                         |                  |          |   |   |
| o |   |   |                         |                  |          |   |   |
| v |   |   |                         |                  |          |   |   |
| e |   |   |                         |                  |          |   |   |
| r |   |   |                         |                  |          |   |   |
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| d |   |   |                         |                  |          |   |   |
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| m |   |   |                         |                  |          |   |   |
| e |   |   |                         |                  |          |   |   |
| d |   |   |                         |                  |          |   |   |
| i |   |   |                         |                  |          |   |   |
| c |   |   |                         |                  |          |   |   |
| a |   |   |                         |                  |          |   |   |
| t |   |   |                         |                  |          |   |   |
| i |   |   |                         |                  |          |   |   |
| o |   |   |                         |                  |          |   |   |
| n |   |   |                         |                  |          |   |   |
| s |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
| a |   |   |                         |                  |          |   |   |
| n |   |   |                         |                  |          |   |   |
| d |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
| s |   |   |                         |                  |          |   |   |
| u |   |   |                         |                  |          |   |   |
| p |   |   |                         |                  |          |   |   |
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| l |   |   |                         |                  |          |   |   |
| i |   |   |                         |                  |          |   |   |
| e |   |   |                         |                  |          |   |   |
| s |   |   |                         |                  |          |   |   |
+---+---+---+-------------------------+------------------+----------+---+---+
| W |   |   |                         | \$15 per         | \$15 per |   |   |
| e |   |   |                         | formulary        | f        |   |   |
| c |   |   |                         | generic drug     | ormulary |   |   |
| o |   |   |                         | \$30 per         | generic  |   |   |
| v |   |   |                         | formulary brand  | drug     |   |   |
| e |   |   |                         | name drug        | \$30 per |   |   |
| r |   |   |                         |                  | f        |   |   |
| t |   |   |                         | \$50 per         | ormulary |   |   |
| h |   |   |                         | non-formulary    | brand    |   |   |
| e |   |   |                         | brand name drug. | name     |   |   |
| f |   |   |                         |                  | drug     |   |   |
| o |   |   |                         | NOTE: If you     |          |   |   |
| l |   |   |                         | request that you | \$50 per |   |   |
| l |   |   |                         | receive the      | non-f    |   |   |
| o |   |   |                         | brand name drug  | ormulary |   |   |
| w |   |   |                         | when there is an | brand    |   |   |
| i |   |   |                         | equivalent       | name     |   |   |
| n |   |   |                         | generic          | drug.    |   |   |
| g |   |   |                         | alternative      | (No      |   |   |
| m |   |   |                         | available, you   | ded      |   |   |
| e |   |   |                         | will be required | uctible) |   |   |
| d |   |   |                         | to pay the price |          |   |   |
| i |   |   |                         | difference       | NOTE: If |   |   |
| c |   |   |                         | between the      | you      |   |   |
| a |   |   |                         | brand and the    | request  |   |   |
| t |   |   |                         | generic in       | that you |   |   |
| i |   |   |                         | addition to your | receive  |   |   |
| o |   |   |                         | copay.           | the      |   |   |
| n |   |   |                         |                  | brand    |   |   |
| s |   |   |                         |                  | name     |   |   |
| a |   |   |                         |                  | drug     |   |   |
| n |   |   |                         |                  | when     |   |   |
| d |   |   |                         |                  | there is |   |   |
| s |   |   |                         |                  | an       |   |   |
| u |   |   |                         |                  | eq       |   |   |
| p |   |   |                         |                  | uivalent |   |   |
| p |   |   |                         |                  | generic  |   |   |
| l |   |   |                         |                  | alt      |   |   |
| i |   |   |                         |                  | ernative |   |   |
| e |   |   |                         |                  | av       |   |   |
| s |   |   |                         |                  | ailable, |   |   |
| p |   |   |                         |                  | you will |   |   |
| r |   |   |                         |                  | be       |   |   |
| e |   |   |                         |                  | required |   |   |
| s |   |   |                         |                  | to pay   |   |   |
| c |   |   |                         |                  | the      |   |   |
| r |   |   |                         |                  | price    |   |   |
| i |   |   |                         |                  | di       |   |   |
| b |   |   |                         |                  | fference |   |   |
| e |   |   |                         |                  | between  |   |   |
| d |   |   |                         |                  | the      |   |   |
| b |   |   |                         |                  | brand    |   |   |
| y |   |   |                         |                  | and the  |   |   |
| a |   |   |                         |                  | generic  |   |   |
| P |   |   |                         |                  | in       |   |   |
| l |   |   |                         |                  | addition |   |   |
| a |   |   |                         |                  | to your  |   |   |
| n |   |   |                         |                  | copay.   |   |   |
| p |   |   |                         |                  |          |   |   |
| h |   |   |                         |                  |          |   |   |
| y |   |   |                         |                  |          |   |   |
| s |   |   |                         |                  |          |   |   |
| i |   |   |                         |                  |          |   |   |
| c |   |   |                         |                  |          |   |   |
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| a |   |   |                         |                  |          |   |   |
| n |   |   |                         |                  |          |   |   |
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|   |   |   |                         |                  |          |   |   |
| - |   |   |                         |                  |          |   |   |
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| D |   |   |                         |                  |          |   |   |
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| F |   |   |                         |                  |          |   |   |
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| w |   |   |                         |                  |          |   |   |
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| d |   |   |                         |                  |          |   |   |
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| r |   |   |                         |                  |          |   |   |
+---+---+---+-------------------------+------------------+----------+---+---+
| D |   |   |                         | \$15 copay per   | \$15     |   |   |
| i |   |   |                         | 30 day supply    | copay    |   |   |
| a |   |   |                         | for each         | per 30   |   |   |
| b |   |   |                         | individual item  | day      |   |   |
| e |   |   |                         |                  | supply   |   |   |
| t |   |   |                         |                  | for each |   |   |
| i |   |   |                         |                  | in       |   |   |
| c |   |   |                         |                  | dividual |   |   |
| D |   |   |                         |                  | item (No |   |   |
| r |   |   |                         |                  | ded      |   |   |
| u |   |   |                         |                  | uctible) |   |   |
| g |   |   |                         |                  |          |   |   |
| s |   |   |                         |                  |          |   |   |
| / |   |   |                         |                  |          |   |   |
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|   |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
| a |   |   |                         |                  |          |   |   |
| n |   |   |                         |                  |          |   |   |
| d |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
| a |   |   |                         |                  |          |   |   |
| l |   |   |                         |                  |          |   |   |
| l |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
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| s |   |   |                         |                  |          |   |   |
| u |   |   |                         |                  |          |   |   |
| p |   |   |                         |                  |          |   |   |
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| s |   |   |                         |                  |          |   |   |
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| u |   |   |                         |                  |          |   |   |
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| n |   |   |                         |                  |          |   |   |
| s |   |   |                         |                  |          |   |   |
| u |   |   |                         |                  |          |   |   |
| l |   |   |                         |                  |          |   |   |
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| n |   |   |                         |                  |          |   |   |
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| d |   |   |                         |                  |          |   |   |
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| v |   |   |                         |                  |          |   |   |
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| c |   |   |                         |                  |          |   |   |
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| s |   |   |                         |                  |          |   |   |
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|   |   |   |                         |                  |          |   |   |
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| r |   |   |                         |                  |          |   |   |
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| s |   |   |                         |                  |          |   |   |
| c |   |   |                         |                  |          |   |   |
| r |   |   |                         |                  |          |   |   |
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| b |   |   |                         |                  |          |   |   |
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| d |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
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| r |   |   |                         |                  |          |   |   |
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| l |   |   |                         |                  |          |   |   |
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| a |   |   |                         |                  |          |   |   |
| g |   |   |                         |                  |          |   |   |
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| t |   |   |                         |                  |          |   |   |
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| c |   |   |                         |                  |          |   |   |
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| n |   |   |                         |                  |          |   |   |
| t |   |   |                         |                  |          |   |   |
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| i |   |   |                         |                  |          |   |   |
| n |   |   |                         |                  |          |   |   |
| g |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
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| b |   |   |                         |                  |          |   |   |
| l |   |   |                         |                  |          |   |   |
| o |   |   |                         |                  |          |   |   |
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| d |   |   |                         |                  |          |   |   |
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| a |   |   |                         |                  |          |   |   |
| n |   |   |                         |                  |          |   |   |
| c |   |   |                         |                  |          |   |   |
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| n |   |   |                         |                  |          |   |   |
| d |   |   |                         |                  |          |   |   |
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| l |   |   |                         |                  |          |   |   |
| a |   |   |                         |                  |          |   |   |
| n |   |   |                         |                  |          |   |   |
| c |   |   |                         |                  |          |   |   |
| e |   |   |                         |                  |          |   |   |
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|   |   |   |                         |                  |          |   |   |
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| d |   |   |                         |                  |          |   |   |
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| v |   |   |                         |                  |          |   |   |
| i |   |   |                         |                  |          |   |   |
| c |   |   |                         |                  |          |   |   |
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| s |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
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|   |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
| B |   |   |                         |                  |          |   |   |
| l |   |   |                         |                  |          |   |   |
| o |   |   |                         |                  |          |   |   |
| o |   |   |                         |                  |          |   |   |
| d |   |   |                         |                  |          |   |   |
| / |   |   |                         |                  |          |   |   |
| u |   |   |                         |                  |          |   |   |
| r |   |   |                         |                  |          |   |   |
| i |   |   |                         |                  |          |   |   |
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| i |   |   |                         |                  |          |   |   |
| n |   |   |                         |                  |          |   |   |
| g |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
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| t |   |   |                         |                  |          |   |   |
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| ( |   |   |                         |                  |          |   |   |
| m |   |   |                         |                  |          |   |   |
| a |   |   |                         |                  |          |   |   |
| x |   |   |                         |                  |          |   |   |
| i |   |   |                         |                  |          |   |   |
| m |   |   |                         |                  |          |   |   |
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| f |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
| 2 |   |   |                         |                  |          |   |   |
| 0 |   |   |                         |                  |          |   |   |
| 0 |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
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| s |   |   |                         |                  |          |   |   |
| t |   |   |                         |                  |          |   |   |
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| n |   |   |                         |                  |          |   |   |
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|   |   |   |                         |                  |          |   |   |
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| s |   |   |                         |                  |          |   |   |
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| p |   |   |                         |                  |          |   |   |
| p |   |   |                         |                  |          |   |   |
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| ) |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
| - |   |   |                         |                  |          |   |   |
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| G |   |   |                         |                  |          |   |   |
| l |   |   |                         |                  |          |   |   |
| u |   |   |                         |                  |          |   |   |
| c |   |   |                         |                  |          |   |   |
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| s |   |   |                         |                  |          |   |   |
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|   |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
| a |   |   |                         |                  |          |   |   |
| g |   |   |                         |                  |          |   |   |
| e |   |   |                         |                  |          |   |   |
| n |   |   |                         |                  |          |   |   |
| t |   |   |                         |                  |          |   |   |
| s |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
| - |   |   |                         |                  |          |   |   |
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|   |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
| G |   |   |                         |                  |          |   |   |
| l |   |   |                         |                  |          |   |   |
| u |   |   |                         |                  |          |   |   |
| c |   |   |                         |                  |          |   |   |
| a |   |   |                         |                  |          |   |   |
| g |   |   |                         |                  |          |   |   |
| o |   |   |                         |                  |          |   |   |
| n |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
| k |   |   |                         |                  |          |   |   |
| i |   |   |                         |                  |          |   |   |
| t |   |   |                         |                  |          |   |   |
| s |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
| - |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
| S |   |   |                         |                  |          |   |   |
| y |   |   |                         |                  |          |   |   |
| r |   |   |                         |                  |          |   |   |
| i |   |   |                         |                  |          |   |   |
| n |   |   |                         |                  |          |   |   |
| g |   |   |                         |                  |          |   |   |
| e |   |   |                         |                  |          |   |   |
| s |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
| f |   |   |                         |                  |          |   |   |
| o |   |   |                         |                  |          |   |   |
| r |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
| t |   |   |                         |                  |          |   |   |
| h |   |   |                         |                  |          |   |   |
| e |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
| a |   |   |                         |                  |          |   |   |
| d |   |   |                         |                  |          |   |   |
| m |   |   |                         |                  |          |   |   |
| i |   |   |                         |                  |          |   |   |
| n |   |   |                         |                  |          |   |   |
| i |   |   |                         |                  |          |   |   |
| s |   |   |                         |                  |          |   |   |
| t |   |   |                         |                  |          |   |   |
| r |   |   |                         |                  |          |   |   |
| a |   |   |                         |                  |          |   |   |
| t |   |   |                         |                  |          |   |   |
| i |   |   |                         |                  |          |   |   |
| o |   |   |                         |                  |          |   |   |
| n |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
| o |   |   |                         |                  |          |   |   |
| f |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
| c |   |   |                         |                  |          |   |   |
| o |   |   |                         |                  |          |   |   |
| v |   |   |                         |                  |          |   |   |
| e |   |   |                         |                  |          |   |   |
| r |   |   |                         |                  |          |   |   |
| e |   |   |                         |                  |          |   |   |
| d |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
| m |   |   |                         |                  |          |   |   |
| e |   |   |                         |                  |          |   |   |
| d |   |   |                         |                  |          |   |   |
| i |   |   |                         |                  |          |   |   |
| c |   |   |                         |                  |          |   |   |
| a |   |   |                         |                  |          |   |   |
| t |   |   |                         |                  |          |   |   |
| i |   |   |                         |                  |          |   |   |
| o |   |   |                         |                  |          |   |   |
| n |   |   |                         |                  |          |   |   |
| s |   |   |                         |                  |          |   |   |
+---+---+---+-------------------------+------------------+----------+---+---+
| * |   |   |                         |                  |          |   |   |
| C |   |   |                         |                  |          |   |   |
| o |   |   |                         |                  |          |   |   |
| v |   |   |                         |                  |          |   |   |
| e |   |   |                         |                  |          |   |   |
| r |   |   |                         |                  |          |   |   |
| e |   |   |                         |                  |          |   |   |
| d |   |   |                         |                  |          |   |   |
| m |   |   |                         |                  |          |   |   |
| e |   |   |                         |                  |          |   |   |
| d |   |   |                         |                  |          |   |   |
| i |   |   |                         |                  |          |   |   |
| c |   |   |                         |                  |          |   |   |
| a |   |   |                         |                  |          |   |   |
| t |   |   |                         |                  |          |   |   |
| i |   |   |                         |                  |          |   |   |
| o |   |   |                         |                  |          |   |   |
| n |   |   |                         |                  |          |   |   |
| s |   |   |                         |                  |          |   |   |
| a |   |   |                         |                  |          |   |   |
| n |   |   |                         |                  |          |   |   |
| d |   |   |                         |                  |          |   |   |
| s |   |   |                         |                  |          |   |   |
| u |   |   |                         |                  |          |   |   |
| p |   |   |                         |                  |          |   |   |
| p |   |   |                         |                  |          |   |   |
| l |   |   |                         |                  |          |   |   |
| i |   |   |                         |                  |          |   |   |
| e |   |   |                         |                  |          |   |   |
| s |   |   |                         |                  |          |   |   |
| - |   |   |                         |                  |          |   |   |
| - |   |   |                         |                  |          |   |   |
| c |   |   |                         |                  |          |   |   |
| o |   |   |                         |                  |          |   |   |
| n |   |   |                         |                  |          |   |   |
| t |   |   |                         |                  |          |   |   |
| i |   |   |                         |                  |          |   |   |
| n |   |   |                         |                  |          |   |   |
| u |   |   |                         |                  |          |   |   |
| e |   |   |                         |                  |          |   |   |
| d |   |   |                         |                  |          |   |   |
| o |   |   |                         |                  |          |   |   |
| n |   |   |                         |                  |          |   |   |
| n |   |   |                         |                  |          |   |   |
| e |   |   |                         |                  |          |   |   |
| x |   |   |                         |                  |          |   |   |
| t |   |   |                         |                  |          |   |   |
| p |   |   |                         |                  |          |   |   |
| a |   |   |                         |                  |          |   |   |
| g |   |   |                         |                  |          |   |   |
| e |   |   |                         |                  |          |   |   |
| * |   |   |                         |                  |          |   |   |
+---+---+---+-------------------------+------------------+----------+---+---+
| # |   |   |                         | **You pay -**    | **You    |   |   |
| # |   |   |                         |                  | pay -**  |   |   |
| # |   |   |                         | **High Option**  |          |   |   |
| # |   |   |                         |                  | **       |   |   |
| # |   |   |                         |                  | Standard |   |   |
| # |   |   |                         |                  | Option** |   |   |
|   |   |   |                         |                  |          |   |   |
| C |   |   |                         |                  | **After  |   |   |
| o |   |   |                         |                  | the      |   |   |
| v |   |   |                         |                  | calendar |   |   |
| e |   |   |                         |                  | year     |   |   |
| r |   |   |                         |                  | deductib |   |   |
| e |   |   |                         |                  | le\...** |   |   |
| d |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
| m |   |   |                         |                  |          |   |   |
| e |   |   |                         |                  |          |   |   |
| d |   |   |                         |                  |          |   |   |
| i |   |   |                         |                  |          |   |   |
| c |   |   |                         |                  |          |   |   |
| a |   |   |                         |                  |          |   |   |
| t |   |   |                         |                  |          |   |   |
| i |   |   |                         |                  |          |   |   |
| o |   |   |                         |                  |          |   |   |
| n |   |   |                         |                  |          |   |   |
| s |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
| a |   |   |                         |                  |          |   |   |
| n |   |   |                         |                  |          |   |   |
| d |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
| s |   |   |                         |                  |          |   |   |
| u |   |   |                         |                  |          |   |   |
| p |   |   |                         |                  |          |   |   |
| p |   |   |                         |                  |          |   |   |
| l |   |   |                         |                  |          |   |   |
| i |   |   |                         |                  |          |   |   |
| e |   |   |                         |                  |          |   |   |
| s |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
| * |   |   |                         |                  |          |   |   |
| ( |   |   |                         |                  |          |   |   |
| c |   |   |                         |                  |          |   |   |
| o |   |   |                         |                  |          |   |   |
| n |   |   |                         |                  |          |   |   |
| t |   |   |                         |                  |          |   |   |
| i |   |   |                         |                  |          |   |   |
| n |   |   |                         |                  |          |   |   |
| u |   |   |                         |                  |          |   |   |
| e |   |   |                         |                  |          |   |   |
| d |   |   |                         |                  |          |   |   |
| ) |   |   |                         |                  |          |   |   |
| * |   |   |                         |                  |          |   |   |
+---+---+---+-------------------------+------------------+----------+---+---+
| * |   |   |                         | *All charges.*   | *All     |   |   |
| N |   |   |                         |                  | c        |   |   |
| o |   |   |                         |                  | harges.* |   |   |
| t |   |   |                         |                  |          |   |   |
| C |   |   |                         |                  |          |   |   |
| o |   |   |                         |                  |          |   |   |
| v |   |   |                         |                  |          |   |   |
| e |   |   |                         |                  |          |   |   |
| r |   |   |                         |                  |          |   |   |
| e |   |   |                         |                  |          |   |   |
| d |   |   |                         |                  |          |   |   |
| * |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
| * |   |   |                         |                  |          |   |   |
| • |   |   |                         |                  |          |   |   |
| D |   |   |                         |                  |          |   |   |
| r |   |   |                         |                  |          |   |   |
| u |   |   |                         |                  |          |   |   |
| g |   |   |                         |                  |          |   |   |
| s |   |   |                         |                  |          |   |   |
| a |   |   |                         |                  |          |   |   |
| n |   |   |                         |                  |          |   |   |
| d |   |   |                         |                  |          |   |   |
| s |   |   |                         |                  |          |   |   |
| u |   |   |                         |                  |          |   |   |
| p |   |   |                         |                  |          |   |   |
| p |   |   |                         |                  |          |   |   |
| l |   |   |                         |                  |          |   |   |
| i |   |   |                         |                  |          |   |   |
| e |   |   |                         |                  |          |   |   |
| s |   |   |                         |                  |          |   |   |
| f |   |   |                         |                  |          |   |   |
| o |   |   |                         |                  |          |   |   |
| r |   |   |                         |                  |          |   |   |
| c |   |   |                         |                  |          |   |   |
| o |   |   |                         |                  |          |   |   |
| s |   |   |                         |                  |          |   |   |
| m |   |   |                         |                  |          |   |   |
| e |   |   |                         |                  |          |   |   |
| t |   |   |                         |                  |          |   |   |
| i |   |   |                         |                  |          |   |   |
| c |   |   |                         |                  |          |   |   |
| p |   |   |                         |                  |          |   |   |
| u |   |   |                         |                  |          |   |   |
| r |   |   |                         |                  |          |   |   |
| p |   |   |                         |                  |          |   |   |
| o |   |   |                         |                  |          |   |   |
| s |   |   |                         |                  |          |   |   |
| e |   |   |                         |                  |          |   |   |
| s |   |   |                         |                  |          |   |   |
| i |   |   |                         |                  |          |   |   |
| n |   |   |                         |                  |          |   |   |
| c |   |   |                         |                  |          |   |   |
| l |   |   |                         |                  |          |   |   |
| u |   |   |                         |                  |          |   |   |
| d |   |   |                         |                  |          |   |   |
| i |   |   |                         |                  |          |   |   |
| n |   |   |                         |                  |          |   |   |
| g |   |   |                         |                  |          |   |   |
| b |   |   |                         |                  |          |   |   |
| a |   |   |                         |                  |          |   |   |
| l |   |   |                         |                  |          |   |   |
| d |   |   |                         |                  |          |   |   |
| n |   |   |                         |                  |          |   |   |
| e |   |   |                         |                  |          |   |   |
| s |   |   |                         |                  |          |   |   |
| s |   |   |                         |                  |          |   |   |
| a |   |   |                         |                  |          |   |   |
| n |   |   |                         |                  |          |   |   |
| d |   |   |                         |                  |          |   |   |
| a |   |   |                         |                  |          |   |   |
| p |   |   |                         |                  |          |   |   |
| p |   |   |                         |                  |          |   |   |
| e |   |   |                         |                  |          |   |   |
| t |   |   |                         |                  |          |   |   |
| i |   |   |                         |                  |          |   |   |
| t |   |   |                         |                  |          |   |   |
| e |   |   |                         |                  |          |   |   |
| s |   |   |                         |                  |          |   |   |
| u |   |   |                         |                  |          |   |   |
| p |   |   |                         |                  |          |   |   |
| p |   |   |                         |                  |          |   |   |
| r |   |   |                         |                  |          |   |   |
| e |   |   |                         |                  |          |   |   |
| s |   |   |                         |                  |          |   |   |
| s |   |   |                         |                  |          |   |   |
| a |   |   |                         |                  |          |   |   |
| n |   |   |                         |                  |          |   |   |
| t |   |   |                         |                  |          |   |   |
| s |   |   |                         |                  |          |   |   |
| * |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
| * |   |   |                         |                  |          |   |   |
| • |   |   |                         |                  |          |   |   |
| D |   |   |                         |                  |          |   |   |
| r |   |   |                         |                  |          |   |   |
| u |   |   |                         |                  |          |   |   |
| g |   |   |                         |                  |          |   |   |
| s |   |   |                         |                  |          |   |   |
| t |   |   |                         |                  |          |   |   |
| o |   |   |                         |                  |          |   |   |
| e |   |   |                         |                  |          |   |   |
| n |   |   |                         |                  |          |   |   |
| h |   |   |                         |                  |          |   |   |
| a |   |   |                         |                  |          |   |   |
| n |   |   |                         |                  |          |   |   |
| c |   |   |                         |                  |          |   |   |
| e |   |   |                         |                  |          |   |   |
| a |   |   |                         |                  |          |   |   |
| t |   |   |                         |                  |          |   |   |
| h |   |   |                         |                  |          |   |   |
| l |   |   |                         |                  |          |   |   |
| e |   |   |                         |                  |          |   |   |
| t |   |   |                         |                  |          |   |   |
| i |   |   |                         |                  |          |   |   |
| c |   |   |                         |                  |          |   |   |
| p |   |   |                         |                  |          |   |   |
| e |   |   |                         |                  |          |   |   |
| r |   |   |                         |                  |          |   |   |
| f |   |   |                         |                  |          |   |   |
| o |   |   |                         |                  |          |   |   |
| r |   |   |                         |                  |          |   |   |
| m |   |   |                         |                  |          |   |   |
| a |   |   |                         |                  |          |   |   |
| n |   |   |                         |                  |          |   |   |
| c |   |   |                         |                  |          |   |   |
| e |   |   |                         |                  |          |   |   |
| * |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
| * |   |   |                         |                  |          |   |   |
| • |   |   |                         |                  |          |   |   |
| F |   |   |                         |                  |          |   |   |
| e |   |   |                         |                  |          |   |   |
| r |   |   |                         |                  |          |   |   |
| t |   |   |                         |                  |          |   |   |
| i |   |   |                         |                  |          |   |   |
| l |   |   |                         |                  |          |   |   |
| i |   |   |                         |                  |          |   |   |
| t |   |   |                         |                  |          |   |   |
| y |   |   |                         |                  |          |   |   |
| d |   |   |                         |                  |          |   |   |
| r |   |   |                         |                  |          |   |   |
| u |   |   |                         |                  |          |   |   |
| g |   |   |                         |                  |          |   |   |
| s |   |   |                         |                  |          |   |   |
| * |   |   |                         |                  |          |   |   |
|   |   |   |                         |                  |          |   |   |
| * |   |   |                         |                  |          |   |   |
| • |   |   |                         |                  |          |   |   |
| D |   |   |                         |                  |          |   |   |
| r |   |   |                         |                  |          |   |   |
| u |   |   |                         |                  |          |   |   |
| g |   |   |                         |                  |          |   |   |
| s |   |   |                         |                  |          |   |   |
| o |   |   |                         |                  |          |   |   |
| b |   |   |                         |                  |          |   |   |
| t |   |   |                         |                  |          |   |   |
| a |   |   |                         |                  |          |   |   |
| i |   |   |                         |                  |          |   |   |
| n |   |   |                         |                  |          |   |   |
| e |   |   |                         |                  |          |   |   |
| d |   |   |                         |                  |          |   |   |
| a |   |   |                         |                  |          |   |   |
| t |   |   |                         |                  |          |   |   |
| a |   |   |                         |                  |          |   |   |
| n |   |   |                         |                  |          |   |   |
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| n |   |   |                         |                  |          |   |   |
| - |   |   |                         |                  |          |   |   |
| P |   |   |                         |                  |          |   |   |
| l |   |   |                         |                  |          |   |   |
| a |   |   |                         |                  |          |   |   |
| n |   |   |                         |                  |          |   |   |
| p |   |   |                         |                  |          |   |   |
| h |   |   |                         |                  |          |   |   |
| a |   |   |                         |                  |          |   |   |
| r |   |   |                         |                  |          |   |   |
| m |   |   |                         |                  |          |   |   |
| a |   |   |                         |                  |          |   |   |
| c |   |   |                         |                  |          |   |   |
| y |   |   |                         |                  |          |   |   |
| ; |   |   |                         |                  |          |   |   |
| e |   |   |                         |                  |          |   |   |
| x |   |   |                         |                  |          |   |   |
| c |   |   |                         |                  |          |   |   |
| e |   |   |                         |                  |          |   |   |
| p |   |   |                         |                  |          |   |   |
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| f |   |   |                         |                  |          |   |   |
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| , |   |   |                         |                  |          |   |   |
| n |   |   |                         |                  |          |   |   |
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| a |   |   |                         |                  |          |   |   |
| g |   |   |                         |                  |          |   |   |
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| t |   |   |                         |                  |          |   |   |
| h |   |   |                         |                  |          |   |   |
| i |   |   |                         |                  |          |   |   |
| r |   |   |                         |                  |          |   |   |
| t |   |   |                         |                  |          |   |   |
| y |   |   |                         |                  |          |   |   |
| - |   |   |                         |                  |          |   |   |
| f |   |   |                         |                  |          |   |   |
| i |   |   |                         |                  |          |   |   |
| v |   |   |                         |                  |          |   |   |
| e |   |   |                         |                  |          |   |   |
| * |   |   |                         |                  |          |   |   |
+---+---+---+-------------------------+------------------+----------+---+---+

## **Section** 5(g) Special features

+----------------------+-----------------------------------------------+
| Feature              | Description                                   |
+----------------------+-----------------------------------------------+
| ####                 | For any of your health concerns, 24 hours a   |
| # 24 hour nurse line | day, 7 days a week, you may call Health       |
|                      | Information at 605/333-4444 and talk with a   |
|                      | registered nurse who will discuss treatment   |
|                      | options and answer your health questions.     |
+----------------------+-----------------------------------------------+
| ####                 | For individuals needing assistance, please    |
| # Services for deaf  | contact our TTY line at 605/328-6869.         |
| and hearing impaired |                                               |
+----------------------+-----------------------------------------------+
| ####                 | Individuals may contact the Healthy Pregnancy |
| # Pregnancy Programs | Program at 1-800/752-5863 to enroll           |
+----------------------+-----------------------------------------------+
| ##### Ce             | We utilize the contracted Centers of          |
| nters of excellence  | Excellence Network for transplant services.   |
|                      | Please contact us at 605/328-6807 for any     |
|                      | information needed                            |
+----------------------+-----------------------------------------------+

## **Section** 5(h) Dental benefits 

+---+---+----------------------------+-----------------+----------+---+---+
|   | * | **Here are some important  |                 |          | * |   |
|   | * | things to keep in mind     |                 |          | * |   |
|   | I | about these benefits:**    |                 |          | I |   |
|   | * |                            |                 |          | * |   |
|   | * | -   Please remember that   |                 |          | * |   |
|   |   |     all benefits are       |                 |          |   |   |
|   | * |     subject to the         |                 |          | * |   |
|   | * |     definitions,           |                 |          | * |   |
|   | M |     limitations, and       |                 |          | M |   |
|   | * |     exclusions in this     |                 |          | * |   |
|   | * |     brochure and are       |                 |          | * |   |
|   |   |     payable only when we   |                 |          |   |   |
|   | * |     determine they are     |                 |          | * |   |
|   | * |     medically necessary.   |                 |          | * |   |
|   | P |                            |                 |          | P |   |
|   | * | -   Plan dentists must     |                 |          | * |   |
|   | * |     provide or arrange     |                 |          | * |   |
|   |   |     your care.             |                 |          |   |   |
|   | * |                            |                 |          | * |   |
|   | * | -   Under **High Option**, |                 |          | * |   |
|   | O |     we have no calendar    |                 |          | O |   |
|   | * |     year deductible for In |                 |          | * |   |
|   | * |     Network services.      |                 |          | * |   |
|   |   |                            |                 |          |   |   |
|   | * | -   Under **Standard       |                 |          | * |   |
|   | * |     Option**, the calendar |                 |          | * |   |
|   | R |     year deductible for    |                 |          | R |   |
|   | * |     Participating          |                 |          | * |   |
|   | * |     Providers is \$500 per |                 |          | * |   |
|   |   |     person (\$1,000 per    |                 |          |   |   |
|   | * |     family). The calendar  |                 |          | * |   |
|   | * |     year deductible        |                 |          | * |   |
|   | T |     applies to almost all  |                 |          | T |   |
|   | * |     benefits in this       |                 |          | * |   |
|   | * |     section. We added "(No |                 |          | * |   |
|   |   |     deductible)" to show   |                 |          |   |   |
|   | * |     when the calendar year |                 |          | * |   |
|   | * |     deductible does not    |                 |          | * |   |
|   | A |     apply.                 |                 |          | A |   |
|   | * |                            |                 |          | * |   |
|   | * | -   Under both **High and  |                 |          | * |   |
|   |   |     Standard Options**,    |                 |          |   |   |
|   | * |     you must use Plan      |                 |          | * |   |
|   | * |     Providers in order to  |                 |          | * |   |
|   | N |     receive in-network     |                 |          | N |   |
|   | * |     benefit coverage.      |                 |          | * |   |
|   | * |                            |                 |          | * |   |
|   |   | -   We cover               |                 |          |   |   |
|   | * |     hospitalization for    |                 |          | * |   |
|   | * |     dental procedures only |                 |          | * |   |
|   | T |     when a non-dental      |                 |          | T |   |
|   | * |     physical impairment    |                 |          | * |   |
|   | * |     exists which makes     |                 |          | * |   |
|   |   |     hospitalization        |                 |          |   |   |
|   |   |     necessary to safeguard |                 |          |   |   |
|   |   |     the health of the      |                 |          |   |   |
|   |   |     patient. See Section   |                 |          |   |   |
|   |   |     5 (c) for inpatient    |                 |          |   |   |
|   |   |     hospital benefits. We  |                 |          |   |   |
|   |   |     do not cover the       |                 |          |   |   |
|   |   |     dental procedure       |                 |          |   |   |
|   |   |     unless it is described |                 |          |   |   |
|   |   |     below.                 |                 |          |   |   |
|   |   |                            |                 |          |   |   |
|   |   | -   Be sure to read        |                 |          |   |   |
|   |   |     Section 4, Your costs  |                 |          |   |   |
|   |   |     for covered services,  |                 |          |   |   |
|   |   |     for valuable           |                 |          |   |   |
|   |   |     information about how  |                 |          |   |   |
|   |   |     cost sharing works.    |                 |          |   |   |
|   |   |     Also read Section 9    |                 |          |   |   |
|   |   |     about coordinating     |                 |          |   |   |
|   |   |     benefits with other    |                 |          |   |   |
|   |   |     coverage, including    |                 |          |   |   |
|   |   |     with Medicare.         |                 |          |   |   |
|   |   |                            |                 |          |   |   |
|   |   | -   **YOU OR YOUR          |                 |          |   |   |
|   |   |     PHYSICIAN MUST GET     |                 |          |   |   |
|   |   |     PRIOR APPROVAL OF SOME |                 |          |   |   |
|   |   |     DENTAL** PROCEDURES.   |                 |          |   |   |
|   |   |     Please refer to the    |                 |          |   |   |
|   |   |     prior approval         |                 |          |   |   |
|   |   |     information shown in   |                 |          |   |   |
|   |   |     Section 3 to be sure   |                 |          |   |   |
|   |   |     which services require |                 |          |   |   |
|   |   |     prior approval.        |                 |          |   |   |
+===+===+============================+=================+==========+===+===+
| # |   |                            | **You pay -**   | **You    |   |   |
| # |   |                            |                 | pay -**  |   |   |
| # |   |                            | High Option     |          |   |   |
| # |   |                            |                 | **       |   |   |
| # |   |                            |                 | Standard |   |   |
| # |   |                            |                 | Option** |   |   |
|   |   |                            |                 |          |   |   |
| A |   |                            |                 | After    |   |   |
| c |   |                            |                 | the      |   |   |
| c |   |                            |                 | calendar |   |   |
| i |   |                            |                 | year     |   |   |
| d |   |                            |                 | deduct   |   |   |
| e |   |                            |                 | ible\... |   |   |
| n |   |                            |                 |          |   |   |
| t |   |                            |                 |          |   |   |
| a |   |                            |                 |          |   |   |
| l |   |                            |                 |          |   |   |
|   |   |                            |                 |          |   |   |
| i |   |                            |                 |          |   |   |
| n |   |                            |                 |          |   |   |
| j |   |                            |                 |          |   |   |
| u |   |                            |                 |          |   |   |
| r |   |                            |                 |          |   |   |
| y |   |                            |                 |          |   |   |
|   |   |                            |                 |          |   |   |
| b |   |                            |                 |          |   |   |
| e |   |                            |                 |          |   |   |
| n |   |                            |                 |          |   |   |
| e |   |                            |                 |          |   |   |
| f |   |                            |                 |          |   |   |
| i |   |                            |                 |          |   |   |
| t |   |                            |                 |          |   |   |
+---+---+----------------------------+-----------------+----------+---+---+
| W |   |                            | \$30 per        | 20% of   |   |   |
| e |   |                            | specialist      | charges  |   |   |
| c |   |                            | visit           | for      |   |   |
| o |   |                            |                 | sp       |   |   |
| v |   |                            | \$50 per        | ecialist |   |   |
| e |   |                            | outpatient      | visit or |   |   |
| r |   |                            | surgery         | ou       |   |   |
| r |   |                            |                 | tpatient |   |   |
| e |   |                            | \$100 per day   | surgery  |   |   |
| s |   |                            | copay up to     |          |   |   |
| t |   |                            | \$500 per       | \$100    |   |   |
| o |   |                            | inpatient       | per day  |   |   |
| r |   |                            | admission       | copay up |   |   |
| a |   |                            |                 | to \$500 |   |   |
| t |   |                            |                 | per      |   |   |
| i |   |                            |                 | i        |   |   |
| v |   |                            |                 | npatient |   |   |
| e |   |                            |                 | a        |   |   |
| s |   |                            |                 | dmission |   |   |
| e |   |                            |                 |          |   |   |
| r |   |                            |                 |          |   |   |
| v |   |                            |                 |          |   |   |
| i |   |                            |                 |          |   |   |
| c |   |                            |                 |          |   |   |
| e |   |                            |                 |          |   |   |
| s |   |                            |                 |          |   |   |
| a |   |                            |                 |          |   |   |
| n |   |                            |                 |          |   |   |
| d |   |                            |                 |          |   |   |
| s |   |                            |                 |          |   |   |
| u |   |                            |                 |          |   |   |
| p |   |                            |                 |          |   |   |
| p |   |                            |                 |          |   |   |
| l |   |                            |                 |          |   |   |
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| s |   |                            |                 |          |   |   |
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+---+---+----------------------------+-----------------+----------+---+---+
| • |   |                            | \$30 per        | 20% of   |   |   |
| D |   |                            | specialist      | charges  |   |   |
| e |   |                            | visit           | for      |   |   |
| n |   |                            |                 | sp       |   |   |
| t |   |                            | \$50 per        | ecialist |   |   |
| a |   |                            | outpatient      | visit or |   |   |
| l |   |                            | surgery         | ou       |   |   |
| s |   |                            |                 | tpatient |   |   |
| e |   |                            | \$100 per day   | surgery  |   |   |
| r |   |                            | copay up to     |          |   |   |
| v |   |                            | \$500 per       | \$100    |   |   |
| i |   |                            | inpatient       | per day  |   |   |
| c |   |                            | admission       | copay up |   |   |
| e |   |                            |                 | to \$500 |   |   |
| r |   |                            |                 | per      |   |   |
| e |   |                            |                 | i        |   |   |
| q |   |                            |                 | npatient |   |   |
| u |   |                            |                 | a        |   |   |
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| s |   |                            |                 |          |   |   |
+---+---+----------------------------+-----------------+----------+---+---+
| * |   |                            | *All charges.*  | *All     |   |   |
| W |   |                            |                 | c        |   |   |
| e |   |                            |                 | harges.* |   |   |
| h |   |                            |                 |          |   |   |
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| f |   |                            |                 |          |   |   |
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| s |   |                            |                 |          |   |   |
| . |   |                            |                 |          |   |   |
| * |   |                            |                 |          |   |   |
+---+---+----------------------------+-----------------+----------+---+---+

## **Section** 5(i) Point of Service benefits

+---+---+--------------------------------------------------------+---+---+
|   | * | **Here are some important things to keep in mind about | * |   |
|   | * | these benefits:**                                      | * |   |
|   | I |                                                        | I |   |
|   | * | -   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           | M |   |
|   | * |     deductible is \$500 per person and \$1,000 per     | * |   |
|   | * |     family.                                            | * |   |
|   |   |                                                        |   |   |
|   | * | -   Under **Standard Option**, the calendar year       | * |   |
|   | * |     deductible for non-Participating Providers is      | * |   |
|   | P |     \$1,000 per person and \$3,000 per family. The     | P |   |
|   | * |     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.                         | * |   |
|   | * |                                                        | * |   |
|   | O | -   Under both **High and Standard Options**, you must | O |   |
|   | * |     use Plan Providers; there are no Point of Service  | * |   |
|   | * |     (out-of-network) benefits.                         | * |   |
|   |   |                                                        |   |   |
|   | * | -   •Be sure to read Section 4, Your costs for covered | * |   |
|   | * |     services, for valuable information about how cost  | * |   |
|   | R |     sharing works. Also read Section 9 about           | R |   |
|   | * |     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 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

[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.

[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.

[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.

[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

# 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 and      | In most cases, providers and facilities file      |
| hospital         | claims for you. Physicians must file on the form  |
| benefits         | HCFA-1500, Health Insurance Claim Form. Your      |
|                  | facility 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 the Plan's service   |
|                  | area -- submit it on the HCFA-1500 or a claim     |
|                  | form that includes the information shown below.   |
|                  | Bills and receipts should be itemized and show:   |
|                  |                                                   |
|                  | -   Covered member's name and ID number;          |
|                  |                                                   |
|                  | -   Name and address of the physician or facility |
|                  |     that provided the service or supply;          |
|                  |                                                   |
|                  | -   Dates you received the services or supplies;  |
|                  |                                                   |
|                  | -   Diagnosis;                                    |
|                  |                                                   |
|                  | -   Type of each service or supply;               |
|                  |                                                   |
|                  | -   The charge for each service or supply;        |
|                  |                                                   |
|                  | -   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     | Send us all of the documents for your claim as    |
| filing your      | soon as possible. You must submit the claim by    |
| claim            | 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     | Please reply promptly when we ask for additional  |
| more information | information. We may delay processing or deny your |
|                  | claim if you do not respond.                      |
+------------------+---------------------------------------------------+

# Section 8. The disputed claims process

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

+----+-----------------------------------------------------------------+
| St | Description                                                     |
| ep |                                                                 |
+----+-----------------------------------------------------------------+
| 1  | Ask us in writing to reconsider our initial decision. You must: |
|    |                                                                 |
|    | a)  Write to us within 6 months from the date of our decision;  |
|    |     and                                                         |
|    |                                                                 |
|    | b)  Send your request to us at Valley Health Plan, PO Box       |
|    |     91110, Sioux Falls, SD 57109-1110, and                      |
|    |                                                                 |
|    | c)  Include a statement about why you believe our initial       |
|    |     decision was wrong, based on specific benefit provisions in |
|    |     this brochure; and                                          |
|    |                                                                 |
|    | d)  Include copies of documents that support your claim, such   |
|    |     as physicians\' letters, operative reports, bills, medical  |
|    |     records, and explanation of benefits (EOB) forms.           |
+----+-----------------------------------------------------------------+
| 2  | We have 30 days from the date we receive your request to:       |
|    |                                                                 |
|    | 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.                                                  |
+----+-----------------------------------------------------------------+
| 3  | You or your provider must send the information so that we       |
|    | receive it within 60 days of our request. We will then decide   |
|    | 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.                         |
+----+-----------------------------------------------------------------+
| 4  | If you do not agree with our decision, you may ask OPM to       |
|    | review it.                                                      |
+----+-----------------------------------------------------------------+
|    | 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.                                      |
+----+-----------------------------------------------------------------+
|    |                                                                 |
+----+-----------------------------------------------------------------+
|    |                                                                 |
+----+-----------------------------------------------------------------+
| T  |                                                                 |
| he |                                                                 |
| di |                                                                 |
| sp |                                                                 |
| ut |                                                                 |
| ed |                                                                 |
| cl |                                                                 |
| ai |                                                                 |
| ms |                                                                 |
| p  |                                                                 |
| ro |                                                                 |
| ce |                                                                 |
| ss |                                                                 |
| *  |                                                                 |
| (c |                                                                 |
| on |                                                                 |
| ti |                                                                 |
| nu |                                                                 |
| ed |                                                                 |
| )* |                                                                 |
+----+-----------------------------------------------------------------+
|    | 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    |
| *5 | information it collects from you and us to decide whether our   |
| ** | 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        |
|    | approval/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
    preauthorization/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 preauthorization/prior
    approval, then:

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

-   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

+------------------+---------------------------------------------------+
| ### Whe          | You must tell us if you or a covered family       |
| n you have other | member have coverage under another group health   |
|  health coverage | 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.                       |
+------------------+---------------------------------------------------+
| ### W            | Medicare is a Health Insurance Program for:       |
| hat is Medicare? |                                                   |
|                  | -   People 65 years of age or older.              |
|                  |                                                   |
|                  | -   Some people with disabilities under 65 years  |
|                  |     of age.                                       |
|                  |                                                   |
|                  | -   People with End-Stage Renal Disease           |
|                  |     (permanent kidney failure requiring dialysis  |
|                  |     or a transplant).                             |
|                  |                                                   |
|                  | Medicare has two parts:                           |
|                  |                                                   |
|                  | -   Part A (Hospital Insurance). Most people do   |
|                  |     not have to pay for Part A. If you or your    |
|                  |     spouse worked for at least 10 years in        |
|                  |     Medicare-covered employment, you should be    |
|                  |     able to qualify for premium-free Part A       |
|                  |     insurance. (Someone who was a Federal         |
|                  |     employee on January 1, 1983 or since          |
|                  |     automatically qualifies.) Otherwise, if you   |
|                  |     are age 65 or older, you may be able to buy   |
|                  |     it. Contact 1-800-MEDICARE for more           |
|                  |     information.                                  |
|                  |                                                   |
|                  | -   Part B (Medical Insurance). Most people pay   |
|                  |     monthly for Part B. Generally, Part B         |
|                  |     premiums are withheld from your monthly       |
|                  |     Social Security check or your retirement      |
|                  |     check.                                        |
+------------------+---------------------------------------------------+
| #                | The decision to enroll in Medicare is yours. We   |
| ### Should I enr | encourage you to apply for Medicare benefits 3    |
| oll in Medicare? | 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 |
|                  | Advantage is the term used to describe the        |
|                  | various private health plan choices available to  |
|                  | Medicare beneficiaries. The information in the    |
|                  | next few pages shows how we coordinate benefits   |
|                  | with Medicare, depending on whether you are in    |
|                  | the Original Medicare Plan or a private Medicare  |
|                  | Advantage plan.                                   |
+------------------+---------------------------------------------------+
| ##               | The Original Medicare Plan (Original Medicare) is |
| ## The Original  | available everywhere in the United States. It is  |
| Medicare Plan (P | the way everyone used to get Medicare benefits    |
| art A or Part B) | 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, such as most     |
|                  | prescription drugs (but coverage through private  |
|                  | prescription drug plans will be available         |
|                  | starting in 2006).                                |
|                  |                                                   |
|                  | 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.                                  |
|                  |                                                   |
|                  | -   When Original Medicare is the primary payer,  |
|                  |     Medicare processes your claim first. In most  |
|                  |     cases, your claim will be coordinated         |
|                  |     automatically and we will then provide        |
|                  |     secondary benefits for covered charges. You   |
|                  |     will not need to do anything. To find out if  |
|                  |     you need to do something to file your claim,  |
|                  |     call us at 605/328-6800 or 1-800/752-5863 .   |
|                  |                                                   |
|                  | **We do not waive any costs if the Original       |
|                  | Medicare Plan is your primary payer.**            |
+------------------+---------------------------------------------------+

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   | **The |        |
| 65 or over and have Medicare and you...**          | pr    |        |
|                                                    | imary |        |
|                                                    | payer |        |
|                                                    | for   |        |
|                                                    | the   |        |
|                                                    | indiv |        |
|                                                    | idual |        |
|                                                    | with  |        |
|                                                    | Med   |        |
|                                                    | icare |        |
|                                                    | is    |        |
|                                                    | ...** |        |
+----------------------------------------------------+-------+--------+
|                                                    | **    | **This |
|                                                    | Medic | Plan** |
|                                                    | are** |        |
+----------------------------------------------------+-------+--------+
| 1)  Have FEHB coverage on your own as an active    |       | ****  |
|     employee or through your spouse who is an      |       |        |
|     active employee                                |       |        |
+----------------------------------------------------+-------+--------+
| 2)  Have FEHB coverage on your own as an annuitant | **** |        |
|     or through your spouse who is an annuitant     |       |        |
+----------------------------------------------------+-------+--------+
| 3)  Are a reemployed annuitant with the Federal    | **** |        |
|     government and your position is excluded from  |       |        |
|     the FEHB (your employing office will know if   |       |        |
|     this is the case) and you are not covered      |       |        |
|     under FEHB through your spouse under #1 above  |       |        |
+----------------------------------------------------+-------+--------+
| 4)  Are a reemployed annuitant with the Federal    |       | ****  |
|     government and your position is not excluded   |       |        |
|     from the FEHB (your employing office will know |       |        |
|     if this is the case) and ...                   |       |        |
|                                                    |       |        |
|     You have FEHB coverage on your own or through  |       |        |
|     your spouse who is also an active employee     |       |        |
+----------------------------------------------------+-------+--------+
| You have FEHB coverage through your spouse who is  | **** |        |
| an annuitant                                       |       |        |
+----------------------------------------------------+-------+--------+
| 5)  Are a Federal judge who retired under title    | ###   |        |
|     28, U.S.C., or a Tax Court judge who retired   | ###  |        |
|     under Section 7447 of title 26, U.S.C. (or if  |       |        |
|     your covered spouse is this type of judge) and |       |        |
|     you are not covered under FEHB through your    |       |        |
|     spouse under #1 above                          |       |        |
+----------------------------------------------------+-------+--------+
| 6)  Are enrolled in Part B only, regardless of     | **** | ****  |
|     your employment status                         | for   | for    |
|                                                    | Part  | other  |
|                                                    | B     | se     |
|                                                    | ser   | rvices |
|                                                    | vices |        |
+----------------------------------------------------+-------+--------+
| 7)  Are a former Federal employee receiving        | **    |        |
|     Workers' Compensation and the Office of        | \*** |        |
|     Workers' Compensation Programs has determined  |       |        |
|     that you are unable to return to duty          |       |        |
+----------------------------------------------------+-------+--------+
| **B. When you or a covered family member...**      |       |        |
+----------------------------------------------------+-------+--------+
| 1)  Have Medicare solely based on end stage renal  |       | ****  |
|     disease (ESRD) and...                          |       |        |
|                                                    |       |        |
| -   It is within the first 30 months of            |       |        |
|     eligibility for or entitlement to Medicare due |       |        |
|     to ESRD (30-month coordination period)         |       |        |
+----------------------------------------------------+-------+--------+
| -   It is beyond the 30-month coordination period  | **** |        |
|     and you or a family member are still entitled  |       |        |
|     to Medicare due to ESRD                        |       |        |
+----------------------------------------------------+-------+--------+
| 2)  Become eligible for Medicare due to ESRD while |       | **     |
|     already a Medicare beneficiary and**...**      |       | **for |
|                                                    |       | 30     |
| -   This Plan was the primary payer before         |       | -month |
|     eligibility due to ESRD                        |       | coordi |
|                                                    |       | nation |
|                                                    |       | period |
+----------------------------------------------------+-------+--------+
| -   Medicare was the primary payer before          | **** |        |
|     eligibility due to ESRD                        |       |        |
+----------------------------------------------------+-------+--------+
| **C. When either you or a covered family member    |       |        |
| are eligible for Medicare solely due to disability |       |        |
| and you...**                                       |       |        |
+----------------------------------------------------+-------+--------+
| 1)  Have FEHB coverage on your own as an active    |       | ****  |
|     employee or through a family member who is an  |       |        |
|     active employee                                |       |        |
+----------------------------------------------------+-------+--------+
| 2)  Have FEHB coverage on your own as an annuitant | **** | []{    |
|     or through a family member who is an annuitant |       | .mark} |
+----------------------------------------------------+-------+--------+
| **D. When you are covered under the FEHB Spouse    | **** |        |
| Equity provision as a former spouse**              |       |        |
+----------------------------------------------------+-------+--------+

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

+--------------------+-------------------------------------------------+
| ####               | If you are eligible for Medicare, you may       |
| Medicare Advantage | choose to enroll in and get your Medicare       |
|                    | benefits from a Medicare Advantage plan. These  |
|                    | are private health care choices (like HMOs) in  |
|                    | some areas of the country. In most Medicare     |
|                    | Advantage plans, you can only go to doctors,    |
|                    | specialists, or hospitals that are part of the  |
|                    | plan. Medicare Advantage plans provide all the  |
|                    | benefits that Original Medicare covers. Some    |
|                    | cover extras, like prescription drugs. To learn |
|                    | more about enrolling in a Medicare Advantage    |
|                    | plan, contact Medicare at 1-800/MEDICARE        |
|                    | (1-800/633-4227) or at                          |
|                    | [www.medicare.gov](http://www.medicare.gov/).   |
|                    |                                                 |
|                    | If you enroll in a Medicare Advantage plan, the |
|                    | following options are available to you:         |
|                    |                                                 |
|                    | **This Plan and another plan\'s Medicare        |
|                    | Advantage plan:** You may enroll in another     |
|                    | plan's Medicare Advantage plan and also remain  |
|                    | enrolled in our FEHB plan. We will still        |
|                    | provide benefits when your Medicare Advantage   |
|                    | plan is primary, even out of the Medicare       |
|                    | Advantage 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     |
|                    | Advantage plan, tell us. We will need to know   |
|                    | whether you are in the Original Medicare Plan   |
|                    | or in a Medicare Advantage plan so we can       |
|                    | correctly coordinate benefits with Medicare.    |
|                    |                                                 |
|                    | **Suspended FEHB coverage to enroll in a        |
|                    | Medicare** Advantage **plan:** If you are an    |
|                    | annuitant or former spouse, you can suspend     |
|                    | your FEHB coverage to enroll in a Medicare      |
|                    | Advantage plan, eliminating your FEHB premium.  |
|                    | (OPM does not contribute to your Medicare       |
|                    | Advantage 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 Advantage plan\'s service area.    |
+--------------------+-------------------------------------------------+
| ### T              | TRICARE is the health care program for eligible |
| RICARE and CHAMPVA | dependents of military persons, and retirees of |
|                    | the military. TRICARE includes the CHAMPUS      |
|                    | program. CHAMPVA provides health coverage to    |
|                    | disabled Veterans and their eligible            |
|                    | dependents. IF TRICARE or CHAMPVA and this Plan |
|                    | cover you, we pay first. See your TRICARE or    |
|                    | CHAMPVA Health Benefits Advisor if you have     |
|                    | questions about these programs.                 |
|                    |                                                 |
|                    | **Suspended FEHB coverage to enroll in TRICARE  |
|                    | or CHAMPVA:** If you are an annuitant or former |
|                    | spouse, you can suspend your FEHB coverage to   |
|                    | enroll in one of these programs, eliminating    |
|                    | your FEHB premium. (OPM does not contribute to  |
|                    | any applicable plan premiums.) For information  |
|                    | on suspending your FEHB enrollment, contact     |
|                    | your retirement office. If you later want to    |
|                    | re-enroll in the FEHB Program, generally you    |
|                    | may do so only at the next Open Season unless   |
|                    | you involuntarily lose coverage under the       |
|                    | program.                                        |
+--------------------+-------------------------------------------------+
| ### Wor            | We do not cover services that:                  |
| kers' Compensation |                                                 |
|                    | -   You need because of a workplace-related     |
|                    |     illness or injury that the Office of        |
|                    |     Workers' Compensation Programs (OWCP) or a  |
|                    |     similar Federal or State agency determines  |
|                    |     they must provide; or                       |
|                    |                                                 |
|                    | -   OWCP or a similar agency pays for through a |
|                    |     third-party injury settlement or other      |
|                    |     similar proceeding that is based on a claim |
|                    |     you filed under OWCP or similar laws.       |
|                    |                                                 |
|                    | Once OWCP or similar agency pays its maximum    |
|                    | benefits for your treatment, we will cover your |
|                    | care.                                           |
+--------------------+-------------------------------------------------+
| ### Medicaid       | When you have this Plan and Medicaid, we pay    |
|                    | first.                                          |
|                    |                                                 |
|                    | **Suspended FEHB coverage to enroll in Medicaid |
|                    | or a similar State-sponsored program of medical |
|                    | assistance:** If you are an annuitant or former |
|                    | spouse, you can suspend your FEHB coverage to   |
|                    | enroll in one of these State programs,          |
|                    | eliminating your FEHB premium. For information  |
|                    | on suspending your FEHB enrollment, contact     |
|                    | your retirement office. If you later want to    |
|                    | re-enroll in the FEHB Program, generally you    |
|                    | may do so only at the next Open Season unless   |
|                    | you involuntarily lose coverage under the State |
|                    | program.                                        |
+--------------------+-------------------------------------------------+
| ### When o         | We do not cover services and supplies when a    |
| ther Government ag | local, State, or Federal government agency      |
| encies are respons | directly or indirectly pays for them.           |
| ible for your care |                                                 |
+--------------------+-------------------------------------------------+
| ### When           | When you receive money to compensate you for    |
|  others are respon | medical or hospital care for injuries or        |
| sible for injuries | 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                                           |
+--------------------+-------------------------------------------------+
| ###                |                                                 |
+--------------------+-------------------------------------------------+

# 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.*     |
+------------------+---------------------------------------------------+
| Experimental or  | Any healthcare services where the Healthcare      |
| investigational  | service in question is either: 1) not recognized  |
| services         | 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          | Health care services that are appropriate, in     |
| necessity        | 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.                 |
+------------------+---------------------------------------------------+
| Utilization      | A set of formal techniques designed to monitor    |
| Management       | the use of, or evaluate the clinical necessity,   |
|                  | appropriateness, efficacy, or efficiency of,      |
|                  | health care services, procedures, or facilities.  |
+------------------+---------------------------------------------------+
| Us/We            | Us and We refer to *Sioux Valley Health Plan.*    |
+------------------+---------------------------------------------------+
| You              | You refers to the enrollee and each covered       |
|                  | family member.                                    |
+------------------+---------------------------------------------------+

# Section 11. FEHB Facts

### Coverage information

+------------------+---------------------------------------------------+
| #### No p        | We will not refuse to cover the treatment of a    |
| re-existing cond | condition you had before you enrolled in this     |
| ition limitation | Plan solely because you had the condition before  |
|                  | you enrolled.                                     |
+------------------+---------------------------------------------------+
| #### W           | See                                               |
| here you can get | [www.opm.gov/insure](http://www.opm.gov/insure).  |
|  information abo | Also, your employing or retirement office can     |
| ut enrolling in  | answer your questions, and give you a *Guide to   |
| the FEHB Program | Federal Employees Health Benefits Plans,*         |
|                  | brochures for other plans, and other materials    |
|                  | you need to make an informed decision about your  |
|                  | FEHB coverage. These materials tell you:          |
|                  |                                                   |
|                  | -   When you may change your enrollment;          |
|                  |                                                   |
|                  | -   How you can cover your family members;        |
|                  |                                                   |
|                  | -   What happens when you transfer to another     |
|                  |     Federal agency, go on leave without pay,      |
|                  |     enter military service, or retire;            |
|                  |                                                   |
|                  | -   When your enrollment ends; and                |
|                  |                                                   |
|                  | -   When the next open season for enrollment      |
|                  |     begins.                                       |
|                  |                                                   |
|                  | We don't determine who is eligible for coverage   |
|                  | and, in most cases, cannot change your enrollment |
|                  | status without information from your employing or |
|                  | retirement office.                                |
+------------------+---------------------------------------------------+
| #### Typ         | Self Only coverage is for you alone. Self and     |
| es of coverage a | Family coverage is for you, your spouse, and your |
| vailable for you | unmarried dependent children under age 22,        |
|  and your family | 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 enrollments 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 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.                                             |
+------------------+---------------------------------------------------+
| #### Child       | OPM has implemented the Federal Employees Health  |
| ren's Equity Act | Benefits Children's Equity Act of 2000. This law  |
|                  | mandates that you be enrolled for Self and Family |
|                  | coverage in the FEHB Program, if you are an       |
|                  | employee subject to a court or administrative     |
|                  | order requiring you to provide health benefits    |
|                  | for your child(ren).                              |
|                  |                                                   |
|                  | If this law applies to you, you must enroll for   |
|                  | Self and Family coverage in a health plan that    |
|                  | provides full benefits in the area where your     |
|                  | children live or provide documentation to your    |
|                  | employing office that you have obtained other     |
|                  | health benefits coverage for your children. If    |
|                  | you do not do so, your employing office will      |
|                  | enroll you involuntarily as follows:              |
|                  |                                                   |
|                  | -   If you have no FEHB coverage, your employing  |
|                  |     office will enroll you for Self and Family    |
|                  |     coverage in the Blue Cross and Blue Shield    |
|                  |     Service Benefit Plan's Basic Option;          |
|                  |                                                   |
|                  | -   If you have a Self Only enrollment in a       |
|                  |     fee-for-service plan or in an HMO that serves |
|                  |     the area where your children live, your       |
|                  |     employing office will change your enrollment  |
|                  |     to Self and Family in the same option of the  |
|                  |     same plan; or                                 |
|                  |                                                   |
|                  | -   If you are enrolled in an HMO that does not   |
|                  |     serve the area where the children live, your  |
|                  |     employing office will change your enrollment  |
|                  |     to Self and Family in the Blue Cross and Blue |
|                  |     Shield Service Benefit Plan's Basic Option.   |
|                  |                                                   |
|                  | As long as the court/administrative order is in   |
|                  | effect, and you have at least one child           |
|                  | identified in the order who is still eligible     |
|                  | under the FEHB Program, you cannot cancel your    |
|                  | enrollment, change to Self Only, or change to a   |
|                  | plan that doesn\'t serve the area in which your   |
|                  | children live, unless you provide documentation   |
|                  | that you have other coverage for the children. If |
|                  | the court/administrative order is still in effect |
|                  | when you retire, and you have at least one child  |
|                  | still eligible for FEHB coverage, you must        |
|                  | continue your FEHB coverage into retirement (if   |
|                  | eligible) and cannot make any changes after       |
|                  | retirement. Contact you employing office for      |
|                  | further information.                              |
+------------------+---------------------------------------------------+
| ####             | The benefits in this brochure are effective       |
| When benefits an | January 1. If you joined this Plan during Open    |
| d premiums start | 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.          |
+------------------+---------------------------------------------------+
| #                | We will keep your medical and claims information  |
| ### Your medical | confidential. Only the following will have access |
|  claims records  | to it:                                            |
| are confidential |                                                   |
|                  | • 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, you can usually stay in the FEHB |
|  When you retire | 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 FE     | You will receive an additional 31 days of         |
| HB coverage ends | coverage, for no additional premium, when:        |
|                  |                                                   |
|                  | -   Your enrollment ends, unless you cancel your  |
|                  |     enrollment, or                                |
|                  |                                                   |
|                  | -   You are a family member no longer eligible    |
|                  |     for coverage.                                 |
|                  |                                                   |
|                  | You may be eligible for spouse equity coverage or |
|                  | Temporary Continuation of Coverage (TCC), or a    |
|                  | conversion policy (a non-FEHB individual policy.) |
+------------------+---------------------------------------------------+
| #### Spouse      | If you are divorced from a Federal employee or    |
|  equity coverage | annuitant, you may not continue to get benefits   |
|                  | under your former spouse's enrollment. This is    |
|                  | the case even when the court has ordered your     |
|                  | former spouse to provide health coverage to you.  |
|                  | But, you may be eligible for your own FEHB        |
|                  | coverage under the spouse equity law or Temporary |
|                  | Continuation of Coverage (TCC). If you are        |
|                  | recently divorced or are anticipating a divorce,  |
|                  | contact your ex-spouse's employing or retirement  |
|                  | office to get RI 70-5, the *Guide To Federal      |
|                  | Employees Health Benefits Plans for Temporary     |
|                  | Continuation of Coverage and Former Spouse        |
|                  | Enrollees,* or other information about your       |
|                  | coverage choices. You can also download the guide |
|                  | from OPM's Web site,                              |
|                  | [www.opm.gov/insure](http://www.opm.gov/insure).  |
+------------------+---------------------------------------------------+
| #### Temporar    | If you leave Federal service, or if you lose      |
| y Continuation o | coverage because you no longer qualify as a       |
| f Coverage (TCC) | family member, you may be eligible for Temporary  |
|                  | Continuation of Coverage (TCC). For example, you  |
|                  | can receive TCC if you are not able to continue   |
|                  | your FEHB enrollment after you retire, if you     |
|                  | lose your Federal job, if you are a covered       |
|                  | dependent child and you turn 22 or marry, etc.    |
|                  |                                                   |
|                  | You may not elect TCC if you are fired from your  |
|                  | Federal job due to gross misconduct.              |
|                  |                                                   |
|                  | **Enrolling in TCC.** Get the RI 79-27, which     |
|                  | describes TCC, and the RI 70-5, the *Guide to     |
|                  | Federal Employees Health Benefits Plans for       |
|                  | Temporary Continuation of Coverage and Former     |
|                  | Spouse Enrollees,* from your employing or         |
|                  | retirement office or from                         |
|                  | [www.opm.gov/insure](http://www.opm/gov/insure).  |
|                  | It explains what you have to do to enroll.        |
+------------------+---------------------------------------------------+
| #### C           | You may convert to a non-FEHB individual policy   |
| onverting to ind | if:                                               |
| ividual 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.          |
+------------------+---------------------------------------------------+
| #### Get         | The Health Insurance Portability and              |
| ting a Certifica | Accountability Act of 1996 (HIPAA) is a Federal   |
| te of Group Heal | law that offers limited Federal protections for   |
| th Plan Coverage | 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.                                 |
+------------------+---------------------------------------------------+
| #### G           | For more information, get OPM pamphlet RI 79-27,  |
| etting a Certifi | *Temporary Continuation of Coverage* *(TCC) under |
| cate of Group He | the FEHB Program*. See also the FEHB Web site at  |
| alth Plan Covera | [www.opm.gov/                                     |
| ge *(continued)* | insure/health](http://www.opm.gov/insure/health); |
|                  | refer to the "TCC and HIPAA" frequently asked     |
|                  | questions. These highlight HIPAA rules, such as   |
|                  | the requirement that Federal employees must       |
|                  | exhaust any TCC eligibility as one condition for  |
|                  | guaranteed access to individual health coverage   |
|                  | under HIPAA, and information about Federal and    |
|                  | State agencies you can contact for more           |
|                  | information.                                      |
+------------------+---------------------------------------------------+

# Section 12.Two Federal Programs complement FEHB benefits

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

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

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

+------------------+--------------------------------+--------+--------+
| -   What is an   | It is a tax-favored benefit    |        |        |
|     FSA?         | 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 FSAFEDS             |        |        |
+------------------+--------------------------------+--------+--------+
| Health Care      | -   Covers eligible health     |        |        |
| Flexible         |     care expenses not          |        |        |
| Spending Account |     reimbursed by this Plan,   |        |        |
| (HCFSA)          |     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 of a    |        |        |
|                  |     "family member" than is    |        |        |
|                  |     used under the FEHB        |        |        |
|                  |     Program to provide         |        |        |
|                  |     benefits by your FEHB      |        |        |
|                  |     Plan.                      |        |        |
|                  |                                |        |        |
|                  | -   The maximum annual amount  |        |        |
|                  |     that can be allotted for   |        |        |
|                  |     the HCFSA is \$4,000.      |        |        |
|                  |     *Note:* The Federal        |        |        |
|                  |     workforce includes a       |        |        |
|                  |     number of employees        |        |        |
|                  |     married to each other. If  |        |        |
|                  |     each spouse/employee is    |        |        |
|                  |     eligible for FEHB          |        |        |
|                  |     coverage, both may enroll  |        |        |
|                  |     for a HCFSA up to the      |        |        |
|                  |     maximum of \$4,000 each    |        |        |
|                  |     (\$8,000 total). Both are  |        |        |
|                  |     covered under each other's |        |        |
|                  |     HCFSA. The minimum annual  |        |        |
|                  |     amount is \$250.           |        |        |
+------------------+--------------------------------+--------+--------+
| Dependent Care   | -   Covers eligible dependent  |        |        |
| Flexible         |     care expenses incurred so  |        |        |
| Spending Account |     you, and your spouse, if   |        |        |
| (DCFSA)          |     married, can work, look    |        |        |
|                  |     for work, or attend school |        |        |
|                  |     full-time.                 |        |        |
|                  |                                |        |        |
|                  | -   Qualifying dependents for  |        |        |
|                  |     this account include your  |        |        |
|                  |     dependent children under   |        |        |
|                  |     age 13, or any person of   |        |        |
|                  |     any age whom you claim as  |        |        |
|                  |     a dependent on your        |        |        |
|                  |     Federal Income Tax return  |        |        |
|                  |     (and who is mentally or    |        |        |
|                  |     physically incapable of    |        |        |
|                  |     self care).                |        |        |
|                  |                                |        |        |
|                  | -   The maximum annual amount  |        |        |
|                  |     that can be allotted for   |        |        |
|                  |     the DCFSA is \$5,000. The  |        |        |
|                  |     minimum annual amount is   |        |        |
|                  |     \$250. *Note:* The IRS     |        |        |
|                  |     limits contributions to a  |        |        |
|                  |     DCFSA. 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.               |        |        |
+------------------+--------------------------------+--------+--------+
| -   Enroll       | You **must make an election**  |        |        |
|     during Open  | to enroll in an FSA during the |        |        |
|     Season       | 2005 FEHB Open Season. Even if |        |        |
|                  | you enrolled during 2004, you  |        |        |
|                  | must make a new election to    |        |        |
|                  | continue participating in      |        |        |
|                  | 2005. Enrollment is easy!      |        |        |
|                  |                                |        |        |
|                  | -   **Online: visit            |        |        |
|                  |     [www.FSAFEDS               |        |        |
|                  | .com](http://www.FSAFEDS.com/) |        |        |
|                  |     and click on               |        |        |
|                  |     [Enroll]{.underline}.**    |        |        |
|                  |                                |        |        |
|                  | -   Telephone: call an FSAFEDS |        |        |
|                  |     Benefits Counselor         |        |        |
|                  |     toll-free at 1-877-FSAFEDS |        |        |
|                  |     (372-3337), Monday through |        |        |
|                  |     Friday, from 9 a.m. until  |        |        |
|                  |     9 p.m., Eastern Time. TTY: |        |        |
|                  |     1-800-952-0450.            |        |        |
+------------------+--------------------------------+--------+--------+
| 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 is responsible for         |        |        |
|                  | enrollment, claims processing, |        |        |
|                  | customer service, and          |        |        |
|                  | day-to-day operations of       |        |        |
|                  | FSAFEDS.                       |        |        |
+------------------+--------------------------------+--------+--------+
| Who is eligible  | If you are a Federal employee  |        |        |
| to enroll?       | eligible for FEHB -- even if   |        |        |
|                  | you're not enrolled in FEHB -- |        |        |
|                  | you can choose to participate  |        |        |
|                  | in either, or both, of the     |        |        |
|                  | FSAs. *However, if you enroll  |        |        |
|                  | in a High Deductible Health    |        |        |
|                  | Plan (HDHP) with a Health      |        |        |
|                  | Savings Account (HSA), you are |        |        |
|                  | not eligible to participate in |        |        |
|                  | an HCFSA*.                     |        |        |
|                  |                                |        |        |
|                  | Almost all Federal employees   |        |        |
|                  | are eligible to enroll for a   |        |        |
|                  | DCFSA. The only exception is   |        |        |
|                  | intermittent (also called      |        |        |
|                  | "when actually employed"       |        |        |
|                  | \[WAE\]) employees expected to |        |        |
|                  | work fewer than 180 days       |        |        |
|                  | during the year.               |        |        |
|                  |                                |        |        |
|                  | ***Note**:* FSAFEDS is the FSA |        |        |
|                  | Program established for all    |        |        |
|                  | Executive Branch employees and |        |        |
|                  | Legislative Branch employees   |        |        |
|                  | whose employers have signed on |        |        |
|                  | to participate. Under IRS law, |        |        |
|                  | FSAs are not available to      |        |        |
|                  | annuitants. Also, the U.S.     |        |        |
|                  | Postal Service and the         |        |        |
|                  | Judicial Branch, among others, |        |        |
|                  | have their own plans with      |        |        |
|                  | slightly different rules.      |        |        |
|                  | However, the advantages of     |        |        |
|                  | having an FSA are the same     |        |        |
|                  | regardless of the agency for   |        |        |
|                  | which you work.                |        |        |
+------------------+--------------------------------+--------+--------+
| -   How much     | Plan carefully when deciding   |        |        |
|     should I     | how much to contribute to an   |        |        |
|     contribute   | FSA. Because of the tax        |        |        |
|     to my FSA?   | benefits an FSA provides, the  |        |        |
|                  | IRS places strict guidelines   |        |        |
|                  | on how the money can be used.  |        |        |
|                  | Under current IRS tax rules,   |        |        |
|                  | you are required to forfeit    |        |        |
|                  | any money for which you did    |        |        |
|                  | not incur an eligible expense  |        |        |
|                  | under your FSA account(s)      |        |        |
|                  | during the Plan Year. This is  |        |        |
|                  | known as the                   |        |        |
|                  | "use-it-or-lose-it" rule. You  |        |        |
|                  | will have until April 30,      |        |        |
|                  | following the end of the Plan  |        |        |
|                  | Year to submit claims for your |        |        |
|                  | eligible expenses incurred     |        |        |
|                  | from January 1through December |        |        |
|                  | 31. For example if you enroll  |        |        |
|                  | in FSAFEDS for the 2005 Plan   |        |        |
|                  | Year, you will have until      |        |        |
|                  | April 30, 2006 to submit       |        |        |
|                  | claims for eligible expenses.  |        |        |
|                  |                                |        |        |
|                  | The [FSAFEDS                   |        |        |
|                  | Calculator]{.underline} at     |        |        |
|                  | [www.FSAFEDS                   |        |        |
|                  | .com](http://www.fsafeds.com/) |        |        |
|                  | will help you plan your FSA    |        |        |
|                  | allocations and provide an     |        |        |
|                  | estimate of your tax savings   |        |        |
|                  | based on your individual       |        |        |
|                  | situation.                     |        |        |
+------------------+--------------------------------+--------+--------+
| -   What can my  | Every FEHB plan includes cost  |        |        |
|     HCFSA pay    | sharing features, such as      |        |        |
|     for?         | deductibles you must meet      |        |        |
|                  | before the Plan provides       |        |        |
|                  | benefits, coinsurance or       |        |        |
|                  | copayments that you pay when   |        |        |
|                  | you and the Plan share costs,  |        |        |
|                  | and medical services and       |        |        |
|                  | supplies that are not covered  |        |        |
|                  | by the Plan and for which you  |        |        |
|                  | must pay. These out-of-pocket  |        |        |
|                  | costs are summarized on page   |        |        |
|                  | 12 and detailed throughout     |        |        |
|                  | this brochure. Your HCFSA will |        |        |
|                  | reimburse you when those costs |        |        |
|                  | are for qualified medical care |        |        |
|                  | that you, your spouse and/or   |        |        |
|                  | your dependents receive that   |        |        |
|                  | is NOT covered or reimbursed   |        |        |
|                  | 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 include 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>. |        |        |
|                  | The FSAFEDS Web site also has  |        |        |
|                  | a comprehensive list of        |        |        |
|                  | eligible expenses at           |        |        |
|                  | [www.FSAFEDS.com/fsafeds/eli   |        |        |
|                  | gibleexpenses.asp](http://www. |        |        |
|                  | irs.gov/pub/irs-pdf/p502.pdf). |        |        |
|                  | If you do not see your service |        |        |
|                  | or expense listed please call  |        |        |
|                  | an FSAFEDS Benefits Counselor  |        |        |
|                  | at 1-877-FSAFEDS (372-3337),   |        |        |
|                  | who will be able to answer     |        |        |
|                  | your specific questions.       |        |        |
+------------------+--------------------------------+--------+--------+
| -   Tax savings  | An FSA lets you allot money    |        |        |
|     with an FSA  | 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 be less. 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 | **Wi   |
|                  |                                | FSA**  | thout\ |
|                  |                                |        | FSA**  |
+------------------+--------------------------------+--------+--------+
|                  | If your taxable income is:     | \$     | \$     |
|                  |                                | 50,000 | 50,000 |
+------------------+--------------------------------+--------+--------+
|                  | And you deposit this amount    | \      | -\$0-  |
|                  | into an FSA:                   | $2,000 |        |
+------------------+--------------------------------+--------+--------+
|                  | Your taxable income is now:    | \$     | \$     |
|                  |                                | 48,000 | 50,000 |
+------------------+--------------------------------+--------+--------+
|                  | Subtract Federal & Social      | \$     | \$     |
|                  | Security taxes:                | 13,807 | 14,383 |
+------------------+--------------------------------+--------+--------+
|                  | If you spend after-tax dollars | -\$0-  | \      |
|                  | for expenses:                  |        | $2,000 |
+------------------+--------------------------------+--------+--------+
|                  | 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 the retirement |        |        |
|                  | system in which you are        |        |        |
|                  | enrolled (CSRS or FERS), your  |        |        |
|                  | state of residence, and your   |        |        |
|                  | individual tax situation. In   |        |        |
|                  | this example, the individual   |        |        |
|                  | received \$2,000 in services   |        |        |
|                  | for \$1,424 - a discount of    |        |        |
|                  | almost 36%! You may also wish  |        |        |
|                  | to consult a tax professional  |        |        |
|                  | for more information on the    |        |        |
|                  | tax implications of an FSA.    |        |        |
+------------------+--------------------------------+--------+--------+
| -   Tax credits  | You *cannot* claim expenses on |        |        |
|     and          | your Federal Income Tax return |        |        |
|     deductions   | if you receive reimbursement   |        |        |
|                  | for them from your HCFSA or    |        |        |
|                  | DCFSA. Below are some          |        |        |
|                  | guidelines that may help you   |        |        |
|                  | decide whether to participate  |        |        |
|                  | in FSAFEDS.                    |        |        |
+------------------+--------------------------------+--------+--------+
| Health care      | The HCFSA is Federal Income    |        |        |
| expenses         | Tax-free from the first        |        |        |
|                  | dollar. In addition, you may   |        |        |
|                  | be reimbursed from your 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      |        |        |
|                  | shown above, 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 an HCFSA is also |        |        |
|                  | exempt from FICA taxes. This   |        |        |
|                  | exemption is not available on  |        |        |
|                  | your Federal Income Tax        |        |        |
|                  | return.                        |        |        |
+------------------+--------------------------------+--------+--------+
| Dependent care   | The DCFSA generally allows     |        |        |
| expenses         | many families to save more     |        |        |
|                  | than they would with the       |        |        |
|                  | Federal tax credit for         |        |        |
|                  | dependent care expenses. Note  |        |        |
|                  | that you may only be           |        |        |
|                  | reimbursed from the DCFSA up   |        |        |
|                  | to your current account        |        |        |
|                  | balance. If you file a claim   |        |        |
|                  | for more than your current     |        |        |
|                  | balance, it will be held until |        |        |
|                  | additional payroll allotments  |        |        |
|                  | have been added to your        |        |        |
|                  | account.                       |        |        |
|                  |                                |        |        |
|                  | Visit                          |        |        |
|                  | [www.FSAFEDS                   |        |        |
|                  | .com](http://www.FSAFEDS.com/) |        |        |
|                  | and download the [Dependent    |        |        |
|                  | Care Tax Credit                |        |        |
|                  | Worksheet]{.underline} from    |        |        |
|                  | the Forms and Literature page  |        |        |
|                  | 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 | No. Section 1127 of the        |        |        |
|     me anything  | National Defense Authorization |        |        |
|     to           | Act (Public Law 108-136)       |        |        |
|     participate  | requires agencies that offer   |        |        |
|     in FSAFEDS?  | FSAFEDS to employees to cover  |        |        |
|                  | the administrative fee(s) on   |        |        |
|                  | behalf of their employees.     |        |        |
|                  | However, 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, resulting in the         |        |        |
|                  | forfeiture of funds remaining  |        |        |
|                  | in your account (the IRS       |        |        |
|                  | "use-it-or-lose-it" rule).     |        |        |
+------------------+--------------------------------+--------+--------+
| -   Contact us   | To learn more or to enroll,    |        |        |
|                  | please visit the **FSAFEDS Web |        |        |
|                  | site** at                      |        |        |
|                  | [www.FSAFEDS.                  |        |        |
|                  | com](http://www.fsafeds.com/), |        |        |
|                  | or contact SHPS directly via   |        |        |
|                  | email or by phone. FSAFEDS     |        |        |
|                  | Benefits Counselors are        |        |        |
|                  | available Monday through       |        |        |
|                  | Friday, from 9:00 a.m. until   |        |        |
|                  | 9:00 p.m. Eastern Time.        |        |        |
|                  |                                |        |        |
|                  | -   E-mail: <FSAFEDS@shps.net> |        |        |
|                  |                                |        |        |
|                  | -   Telephone: 1-877-FSAFEDS   |        |        |
|                  |     (1-877-372-3337)           |        |        |
|                  |                                |        |        |
|                  | -   TTY: 1-800-952-0450        |        |        |
+------------------+--------------------------------+--------+--------+

### The Federal Long Term Care Insurance Program

+------------------+---------------------------------------------------+
| -   It's         | Why should you consider applying for coverage     |
|     important    | under the Federal Long Term Care Insurance        |
|     protection   | Program (FLTCIP)?                                 |
|                  |                                                   |
|                  | -   **FEHB plans do not cover the cost of long    |
|                  |     term care.** Also called "custodial care,"    |
|                  |     long term care is help you receive to perform |
|                  |     activities of daily living -- such as bathing |
|                  |     or dressing yourself - or supervision you     |
|                  |     receive because of a severe cognitive         |
|                  |     impairment. The need for long term care can   |
|                  |     strike anyone at any age and the cost of care |
|                  |     can be substantial.                           |
|                  |                                                   |
|                  | -   **The Federal Long Term Care Insurance        |
|                  |     Program can help protect you from the         |
|                  |     potentially high cost of long term care.**    |
|                  |     This coverage gives you options regarding the |
|                  |     type of care you receive and where you        |
|                  |     receive it. With FLTCIP coverage, you won't   |
|                  |     have to worry about relying on your loved     |
|                  |     ones to provide or pay for your care.         |
|                  |                                                   |
|                  | -   **It's to your advantage to apply sooner      |
|                  |     rather than later.** In order to qualify for  |
|                  |     coverage under the FLTCIP, you must apply and |
|                  |     pass a medical screening (called              |
|                  |     underwriting). Certain medical conditions, or |
|                  |     combinations of 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 future       |
|                  |     change in your health disqualify you from     |
|                  |     obtaining coverage. Also, the younger you are |
|                  |     when you apply, the lower your premiums.      |
|                  |                                                   |
|                  | -   **You don't have to wait for an open season   |
|                  |     to apply.** The Federal Long Term Care        |
|                  |     Insurance Program accepts applications from   |
|                  |     eligible persons at any time. You will have   |
|                  |     to complete a full underwriting application,  |
|                  |     which asks a number of questions about your   |
|                  |     health. However, if you are a new or newly    |
|                  |     eligible employee, you (and your spouse, if   |
|                  |     applicable) have a limited opportunity to     |
|                  |     apply using the abbreviated underwriting      |
|                  |     application, which asks fewer questions.      |
|                  |     Newly married spouses of employees also have  |
|                  |     a limited opportunity to apply using          |
|                  |     abbreviated underwriting.                     |
|                  |                                                   |
|                  | -   **Qualified relatives are also eligible to    |
|                  |     apply.** Qualified relatives include spouses  |
|                  |     and adult children of employees and           |
|                  |     annuitants, and parents, parents-in-law, and  |
|                  |     stepparents of employees.                     |
+------------------+---------------------------------------------------+
| -   To find out  | Call 1-800-LTC-FEDS (1-800-582-3337) (TTY         |
|     more and to  | 1-800-843-3557) or visit                          |
|     request an   | [www.ltcfeds.com](http://www.ltcfeds.com/).       |
|     application  |                                                   |
+------------------+---------------------------------------------------+

# Index

Accidental injury 21, 29, 45

Allergy tests 19

Allogeneic (donor) bone marrow transplant 31

Alternative treatments 26

Ambulance 32, 35, 38

Anesthesia 5, 26, 27

Autologous bone marrow transplant 20, 31

Biopsy 27

Blood and blood plasma 34

Casts 33, 34

Catastrophic protection out-of-pocket maximum 12, 47, 68, 69

Changes for 2005 8

Chemotherapy 20

Chiropractic 26

Cholesterol tests 16

Circumcision 18

Claims 9, 13, 50, 51, 55, 60, 63

Coinsurance 6, 9, 12, 46, 47, 56, 58, 64

Colorectal cancer screening 16

Congenital anomalies 27, 29

Contraceptive drugs and devices 18, 42

Copayment 50

Covered charges 54

Crutches 24

Deductible 6, 9, 12, 15, 27, 32, 39, 41, 45, 46, 47, 48, 56, 58, 64

Definitions 15, 27, 32, 36, 39, 41, 45, 46, 58, 68, 69

Dental care 45, 68, 69

Diagnostic services 15, 33, 39, 68, 69

Donor expenses 31

Dressings 33

Durable medical equipment 24

Durable Medical Equipment 12

Educational classes and programs 26

Emergency 6, 36, 37, 38, 46, 47, 50, 68, 69

Experimental or investigational 49

Eyeglasses 21

Family planning 18

Fecal occult blood test 16

Formulary 41

Fraud 3, 4

General exclusions 49

General Exclusions 13

Hearing services 21

Home health services 25

Hospice care 35

Hospital 4, 5, 6, 9, 10, 22, 27, 28, 29, 31, 32, 33, 34, 37, 40, 45, 46,
50, 53, 56, 57, 68, 69

Immunizations 6, 17

Infertility 19

Inpatient hospital benefits 50

Insulin 42

Magnetic Resonance Imagings (MRIs) 16

Mammograms 16

Maternity benefits 18

Medicaid 56

Medically necessary 15, 18, 20, 27, 32, 36, 39, 41, 45, 46, 49

Medicare 39, 53, 55

Original 53

Members

Associate 70

Family 59

Plan 9, 28

Mental Health/Substance Abuse Benefits 39

myopia, hyperopia or stigmatic error 21

Newborn care 18

Nurse

Licensed Practical Nurse (LPN) 25

Nurse Anesthetist (NA) 33

Registered Nurse 44

Occupational therapy 20

Ocular injury 21

Office visits 6, 12

Oral and maxillofacial surgical 30

Orthopedic Applicances 12

Out-of-pocket expenses 47, 53, 64

Outpatient Surgery 12

Oxygen 24, 25, 33, 34

Pap test 16

Physician 24, 27

Point of Service (POS) 46, 48, 68, 69

Prescription drugs 20, 50, 56, 68, 69

Preventive care, adult 16

Preventive care, children 17

Preventive services 6

Prior approval 51, 52

Prosthetic devices 22, 28

Psychologist 39

Radiation therapy 20

Room and board 32

Sexual dysfunction 42

Skilled nursing facility care 10, 15, 31

Smoking cessation 26

Social worker 39

Speech therapy 21

Splints 33

Subrogation 57

Substance abuse 68, 69

Surgery 5, 18, 20, 21, 22, 28

Anesthesia 34

Oral 30

Reconstructive 27, 29

Syringes 42

Temporary Continuation of Coverage (TCC) 61

Transplants 20, 30

Treatment therapies 20

Vision care 68, 69

Vision services 21

Workers Compensation 56

X-rays 16, 33, 34

# Summary of benefits for the *Sioux Valley Health Plan -* 2005 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 or arranged by Plan physicians,
    except in emergencies.

+----------------------------------------+-----------------------+----+
| **Benefits**                           | **You pay**           | ** |
|                                        |                       | Pa |
|                                        |                       | ge |
|                                        |                       | ** |
+----------------------------------------+-----------------------+----+
| Medical services provided by           | Office visit copay:   | 15 |
| physicians:                            | \$25 primary care;    |    |
|                                        | \$25 specialist       |    |
| -   Diagnostic and treatment services  |                       |    |
|     provided in the office             |                       |    |
+----------------------------------------+-----------------------+----+
| Services provided by a hospital:       | \$100 per day copay   | 32 |
|                                        | up to \$500 per       |    |
| -   Inpatient                          | admission             | 34 |
|                                        |                       |    |
| -   Outpatient                         | 20% coinsurance       | 34 |
|                                        |                       |    |
| -   Outpatient Hospital Services       | 20% coinsurance       | 20 |
|                                        |                       |    |
| -   Outpatient Rehabilitative Services | 20% coinsurance       |    |
|     (cardiac rehab, physical,          |                       |    |
|     occupational, and speech           |                       |    |
|     therapies)                         |                       |    |
+----------------------------------------+-----------------------+----+
| Emergency benefits                     | \$100 per visit,      | 37 |
|                                        | waive if admitted     |    |
| -   In-area                            |                       | 38 |
|                                        | \$100 per visit,      |    |
| -   Out-of-area                        | waive if admitted     |    |
+----------------------------------------+-----------------------+----+
| Mental health and substance abuse      | Regular cost sharing  | 39 |
| treatment                              |                       |    |
+----------------------------------------+-----------------------+----+
| Prescription drugs 30-day supply:      | \$ 15 copay           | 41 |
|                                        |                       |    |
| 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.           | 45 |
+----------------------------------------+-----------------------+----+
| Vision care                            | \$25 Copay            | 21 |
|                                        |                       |    |
| (Eye exams for children through age    |                       |    |
| 17.)                                   |                       |    |
+----------------------------------------+-----------------------+----+
| Special features: 24 hour nurse line,  |                       | 44 |
| Services for deaf and hearing          |                       |    |
| impaired, Healthy Pregnancy Program,   |                       |    |
| Centers of Excellence for transplants  |                       |    |
+----------------------------------------+-----------------------+----+
| Point of Service benefits -- Yes       |                       | 46 |
+----------------------------------------+-----------------------+----+
| Protection against catastrophic costs  | Nothing after         | 12 |
|                                        | \$3,000/Self Only or  |    |
| (your catastrophic protection          | \$4,000/Family        |    |
| out-of-pocket maximum)                 | enrollment per year   |    |
|                                        |                       |    |
|                                        | Any costs above       |    |
|                                        | reasonable and        |    |
|                                        | customary charges do  |    |
|                                        | not count toward this |    |
|                                        | protection.           |    |
+----------------------------------------+-----------------------+----+

# Summary of benefits for the *Sioux Valley Health Plan -* 2005 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 or arranged by Plan physicians,
    except in emergencies.

+----------------------------------------+-----------------------+----+
| **Benefits**                           | **You pay**           | ** |
|                                        |                       | Pa |
|                                        |                       | ge |
|                                        |                       | ** |
+----------------------------------------+-----------------------+----+
| Medical services provided by           | Office visit copay:   | 15 |
| physicians:                            | \$20 primary care;    |    |
|                                        | \$30 specialist       |    |
| -   Diagnostic and treatment services  |                       |    |
|     provided in the office             |                       |    |
+----------------------------------------+-----------------------+----+
| Services provided by a hospital:       | \$100 per day copay   | 32 |
|                                        | up to \$500 per       |    |
| -   Inpatient                          | admission             | 34 |
|                                        |                       |    |
| -   Outpatient                         | \$50 per visit        | 34 |
|                                        |                       |    |
| -   Outpatient Hospital Services       | Nothing               | 20 |
|                                        |                       |    |
| -   Outpatient Rehabilitative Services | \$30 per outpatient   |    |
|     (cardiac rehab, physical,          | visit                 |    |
|     occupational, and speech           |                       |    |
|     therapies)                         |                       |    |
+----------------------------------------+-----------------------+----+
| Emergency benefits                     | \$100 per visit,      | 37 |
|                                        | waive if admitted     |    |
| -   In-area                            |                       | 38 |
|                                        | \$100 per visit,      |    |
| -   Out-of-area                        | waive if admitted     |    |
+----------------------------------------+-----------------------+----+
| Mental health and substance abuse      | Regular cost sharing  | 39 |
| treatment                              |                       |    |
+----------------------------------------+-----------------------+----+
| Prescription drugs 30-day supply:      | \$ 15 copay           | 41 |
|                                        |                       |    |
| 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.           | 45 |
+----------------------------------------+-----------------------+----+
| Vision care                            | \$30 copay            | 21 |
|                                        |                       |    |
| (Eye exams for children through age    |                       |    |
| 17.)                                   |                       |    |
+----------------------------------------+-----------------------+----+
| Special features: 24 hour nurse line,  |                       | 44 |
| Services for deaf and hearing          |                       |    |
| impaired, Healthy Pregnancy Program,   |                       |    |
| Centers of Excellence for transplants  |                       |    |
+----------------------------------------+-----------------------+----+
| Point of Service benefits -- Yes       |                       | 46 |
+----------------------------------------+-----------------------+----+
| Protection against catastrophic costs  | Nothing after         | 12 |
|                                        | \$4,000/Self Only or  |    |
| (your catastrophic protection          | \$4,000/Family        |    |
| out-of-pocket maximum)                 | enrollment per year   |    |
|                                        |                       |    |
|                                        | Any costs above       |    |
|                                        | reasonable and        |    |
|                                        | customary charges do  |    |
|                                        | not count toward this |    |
|                                        | protection.           |    |
+----------------------------------------+-----------------------+----+

# 2005 Rate Information for Sioux Valley Health Plan

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

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

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

+-------------+----------+--------------------------+-----------------+
| **Type**    | **Code** | ***Non-Postal Premium*** | ***Postal       |
|             |          |                          | Premium***      |
| **of**      |          | **                       |                 |
|             |          | [Biweekly]{.underline}** | **[Biweekly     |
| **E         |          | *                        | ]{.underline}** |
| nrollment** |          | *[Monthly]{.underline}** |                 |
|             |          |                          | **USPS Your**   |
|             |          | **Gov't Your Gov't       |                 |
|             |          | Your**                   | **Share Share** |
|             |          |                          |                 |
|             |          | **Share Share Share      |                 |
|             |          | Share**                  |                 |
+-------------+----------+--------------------------+-----------------+

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

+-------------+----------+--------------------------+-----------------+
| **High      | **AU1**  | **\$131.08 \$91.13       | **\$154.74      |
| Option**    |          | \$284.01 \$197.45**      | \$67.47**       |
|             | **AU2**  |                          |                 |
| **Self      |          | **\$298.23 \$213.10      | **\$352.08      |
| Only**      |          | \$646.17 \$461.71**      | \$159.25**      |
|             |          |                          |                 |
| **High      |          |                          |                 |
| Options**   |          |                          |                 |
|             |          |                          |                 |
| **Self &    |          |                          |                 |
| Family**    |          |                          |                 |
+-------------+----------+--------------------------+-----------------+

+-------------+----------+--------------------------+-----------------+
| **Standard  | **AU4**  | **\$131.08 \$68.38       | **\$154.74      |
| Option**    |          | \$284.01 \$148.15**      | \$44.72**       |
|             | **AU5**  |                          |                 |
| **Self      |          | **\$298.23 \$160.29      | **\$352.08      |
| Only**      |          | \$646.17 \$347.29**      | \$106.44**      |
|             |          |                          |                 |
| **Standard  |          |                          |                 |
| Option**    |          |                          |                 |
|             |          |                          |                 |
| **Self &    |          |                          |                 |
| Family**    |          |                          |                 |
+-------------+----------+--------------------------+-----------------+