![](media/image1.png){width="1.4597222222222221in"
height="0.30625in"}**GHI HMO**

[http://www.ghi.com](http://www.ghi.com/)

**2005**

#  

**A Health Maintenance Organization**

![](media/image2.wmf)

**Serving:** Albany -- Capital District Area, New York's Hudson Valley,

New York City Area

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

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

> ![](media/image3.png)

**Enrollment codes for this Plan:** *GHI HMO has Excellent
accreditation*

**Albany -- Capital District, Hudson Valley Area** *for commercial
products from the*

**X41 High Self Only** *National Committee for Quality Assurance (NCQA)*

**X42 High Self and Family** *See the 2005 Guide for more information on
accreditation*

**X44 Standard Self Only**

**X45 Standard Self and Family**

**New York City Area**

**6V1 High Self Only**

**6V2 High Self and Family**

**6V4 Standard Self**

**6V5 Standard Self and Family**

![](media/image4.png)

![](media/image6.png){width="4.84375in" height="1.1354166666666667in"}

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

![](media/image9.png){width="1.195138888888889in"
height="1.0354166666666667in"}
![](media/image10.png){width="1.1715277777777777in"
height="0.9208333333333333in"}

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

**Privacy Practices**

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

By law, the 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 healthcare 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

Office of Personnel Management

P.O. Box 707

Washington, DC 20004-0707

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

By law, OPM is required to follow the terms in this privacy notice. OPM
has the right to change the way your personal medical information is
used and given out. If OPM makes any changes, you will get a new notice
by mail within 60 days of the change. 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
7](#section-1.-facts-about-this-hmo-plan)

[How we pay providers 7](#how-we-pay-providers)

[Who provides my health care? 7](#who-provides-my-health-care)

[Your Rights 7](#your-rights)

[Service Area 8](#service-area)

[Section 2. How we change for 2005
9](#section-2.-how-we-change-for-2005)

[Program-wide changes 9](#program-wide-changes)

[Changes to this Plan 9](#changes-to-this-plan)

[Section 3. How you get care 10](#section-3.-how-you-get-care)

[Identification cards 10](#identification-cards)

[Where you get covered care 10](#where-you-get-covered-care)

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

[Circumstances beyond our control 12](#circumstances-beyond-our-control)

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

[Section 4. Your cost for covered services
13](#section-4.-your-cost-for-covered-services)

[Copayments 13](#copayments)

[Deductible 13](#deductible)

[Coinsurance 13](#coinsurance)

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

[Section 5. Benefits
14](#section-5.-benefits-overview-see-page-9-for-how-our-benefits-changed-this-year-and-page-72-for-a-benefits-summary.)

[Section 5(a) Medical services and supplies provided by physicians and
other health care professionals
16](#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
28](#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
34](#section-5c-services-provided-by-a-hospital-or-other-facility-and-ambulance-services)

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

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

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

[Section 5(g) Special features 48](#section-5g-special-features)

[Section 5(h) Dental benefits 49](#section-5h-dental-benefits)

[Section 5 (j) Non-FEHB benefits available to Plan members
50](#section-5-i-non-fehb-benefits-available-to-plan-members)

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

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

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

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

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

[What is Medicare? 55](#what-is-medicare)

[TRICARE and CHAMPVA 58](#tricare-and-champva)

[Workers' Compensation 58](#workers-compensation)

[Medicaid 59](#medicaid)

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

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

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

[Section 11. FEHB Facts 62](#section-11.-fehb-facts)

[Coverage Information 62](#coverage-information)

[When you lose benefits 64](#when-you-lose-benefits)

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

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

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

[Index 71](#index)

[Summary of benefits for the GHI HMO - 2005
72](#summary-of-benefits-for-ghi-hmo---2005)

[2005 Rate Information for GHI HMO 74](#rate-information-for-ghi-hmo)

# Introduction

This brochure describes the benefits of GHI HMO under our contract
(CS2655) with the United States Office of Personnel Management (OPM), as
authorized by the Federal Employees Health Benefits law. The address for
GHI HMO administrative offices is:

GHI HMO

789 Grant Avenue

Lake Katrine, NY 12449

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
9. 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 GHI
    HMO.

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

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

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

# Stop Health Care Fraud!

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

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

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

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

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

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

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

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

-   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 877-244-4466
    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 test or procedures.

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

-   Call your doctor and ask for your results.

-   Ask what the results mean for your care.

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?

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

```{=html}
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-   [www.npsf.org](http://www.npsf.org/). The National Patient Safety
    Foundation has information on how to ensure safer healthcare for you
    and your family.

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<!-- -->
```
-   [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.

```{=html}
<!-- -->
```
-   [www.leapfroggroup.org](http://www.leapfroggroup.org/). The Leapfrog
    Group is active in promoting safe practices in hospital care.

```{=html}
<!-- -->
```
-   [www.ahqa.org](http://www.ahqa.org/). The American Health Quality
    Association represents organizations and healthcare professionals
    working to improve patient safety.

```{=html}
<!-- -->
```
-   [www.quic.gov/report](http://www.quic.gov/report). Find out what
    federal agencies are doing to identify threats to patient safety and
    help prevent mistakes in the nation's healthcare delivery system.

#  {#section-1 .unnumbered}

# Section 1. Facts about this HMO plan

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

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

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

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

### How we pay providers

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

### Who provides my health care?

GHI HMO, an individual practice prepayment plan, is a New York State
certified, for-profit community-sponsored, primary care network model
Health Maintenance Organization (HMO).

GHI HMO organizes preventative and routine health care as well as needed
services for serious illness or injury. Care and coverage is provided by
approximately four thousand three hundred and forty three (4,343)
individually affiliated primary care doctors, one hundred fourteen (114)
area hospitals, twenty six thousand five hundred and sixty six (26,566)
local specialists.

GHI HMO administrative offices are located at 789 Grant Avenue, Lake
Katrine, NY 12449; and at 80 Wolf Road, Albany, NY 12205. Affiliated
primary care doctors, specialists and other health care providers are
conveniently located throughout the service area.

### Your Rights

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

-   Years in existence - GHI HMO is a subsidiary of GHI, the largest,
    not-for-profit health services corporation operating state-wide in
    New York, and has been operating in 26 counties of NYS since July
    1999.

-   Company profit status - GHI HMO is a for-profit HMO.

-   Drug Formulary - GHI HMO offers an open drug formulary.

-   Percentage of Board Certified Physicians - 86% of GHI HMO physicians
    are Board Certified*.*

If you want more information about us, call 1-877-244-4466, or write to
GHI HMO, Customer Service, PO Box 4332, Kingston, NY 12402. You may also
contact us by fax at (845) 334-8823 or visit our website at
[http://www.ghi.com](http://www.ghi.com/).

### Service Area

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

Albany -- Capital District Area: Albany, Broome, Columbia, Delaware,
Fulton, Greene, Montgomery, Otsego, Rensselaer, Saratoga, Schenectady,
Schoharie, Warren and Washington Counties.

Hudson Valley Area: Dutchess, Orange, Putnam, Rockland, Sullivan, and
Ulster Counties.

New York City Area: Bronx, Brooklyn, Manhattan, Nassau, Queens,
Richmond, Suffolk and Westchester.

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

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

#  {#section-2 .unnumbered}

# Section 2. How we change 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 will decrease by -4.1% for Self
    Only and increase by 5.4% for Self and Family for Code 6V.

-   Your share of the non-Postal premium will decrease by -2.5% for Self
    Only and decrease by -4.9% for Self and Family for Code X4.

-   We offer a High Option and a Standard Option for 2005. Enrollees who
    had GHI HMO coverage during 2004 will remain in the High Option
    coverage, unless they elect the Standard Option coverage or another
    health plan during Open Season.

-   We will cover infertility services for (inpatient and outpatient) in
    accordance with the New York State mandate which limits services to
    females 21-44 years of age. You pay a \$10 copay under High Option
    and a \$20 copay under Standard Option per office visit.

-   Fertility drugs are now covered under the Prescription Drug benefit.

# 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 1-877-244-4466 or write to us at GHI |
|                    | HMO, Customer Service, PO Box 4332, Kingston,   |
|                    | NY 12402.                                       |
+--------------------+-------------------------------------------------+
| ### Where yo       | You get care from " Participating Plan          |
| u get covered care | providers" and "Participating Plan facilities." |
|                    | You will only pay copayments, or coinsurance,   |
|                    | and you will not have to file claims.           |
+--------------------+-------------------------------------------------+
| #                  | Plan providers are physicians, including        |
| ### Plan providers | primary care physicians and specialists and     |
|                    | other health care professionals in our service  |
|                    | area that we contract with to provide covered   |
|                    | services to our members. We credential Plan     |
|                    | providers according to national standards.      |
|                    |                                                 |
|                    | We list Plan providers in the provider          |
|                    | directory, which we update periodically. The    |
|                    | directory is divided alphabetically by county.  |
|                    | Primary Care Physicians are listed first,       |
|                    | Specialty Care Physicians are listed second and |
|                    | all other providers (ancillary) are listed      |
|                    | third under each county. The list is also on    |
|                    | our website                                     |
|                    | [www.ghi.com](http://www.ghihmo.com/).          |
+--------------------+-------------------------------------------------+
| ##                 | 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 website.                    |
+--------------------+-------------------------------------------------+
| ###                | 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 listed in our |
|                    | provider directory and also on our web site.    |
|                    | You may also call our Customer Service          |
|                    | Department (1-877-244-4466) and they may assist |
|                    | you in selecting a provider near your home or   |
|                    | office.                                         |
+--------------------+-------------------------------------------------+
| #### Primary care  | Your primary care physician can be a family     |
|                    | practitioner, internist or pediatrician. Your   |
|                    | primary care physician will provide most of     |
|                    | your health care, or give you a referral to see |
|                    | a specialist.                                   |
|                    |                                                 |
|                    | If you want to change primary care physicians   |
|                    | or if your primary care physician leaves the    |
|                    | Plan, call us. We will help you select a new    |
|                    | one.                                            |
+--------------------+-------------------------------------------------+
| #                  | Your primary care physician will refer you to a |
| ### Specialty care | specialist for needed care. When you receive a  |
|                    | referral from your primary care physician, you  |
|                    | must return to the primary care physician after |
|                    | the consultation, unless your primary care      |
|                    | physician authorized a certain number of visits |
|                    | without additional referrals. The primary care  |
|                    | physician must provide or authorize all         |
|                    | follow-up care. Do not go to the specialist for |
|                    | return visits unless your primary care          |
|                    | physician gives you a referral. However, you    |
|                    | may see your OB/GYN twice a year without a      |
|                    | referral and a participating optometrist for a  |
|                    | routine vision exam annually without a          |
|                    | referral.                                       |
|                    |                                                 |
|                    | Here are other things you should know about     |
|                    | specialty care:                                 |
|                    |                                                 |
|                    | -   If you need to see a specialist frequently  |
|                    |     because of a chronic, complex, or serious   |
|                    |     medical condition, your primary care        |
|                    |     physician will work with specialists to     |
|                    |     develop a treatment plan that allows you to |
|                    |     see your specialist for a certain number of |
|                    |     visits without additional referrals. Your   |
|                    |     primary care physician will use our         |
|                    |     criteria when creating your treatment plan  |
|                    |     (the physician may have to get an           |
|                    |     authorization or approval beforehand).      |
|                    |                                                 |
|                    | -   If you are seeing a specialist when you     |
|                    |     enroll in our Plan, talk to your primary    |
|                    |     care physician. Your primary care physician |
|                    |     will decide what treatment you need. If he  |
|                    |     or she decides to refer you to a            |
|                    |     specialist, ask if you can see your current |
|                    |     specialist. If your current specialist does |
|                    |     not participate with us, you must receive   |
|                    |     treatment from a specialist who does.       |
|                    |     Generally, we will not pay for you to see a |
|                    |     specialist who does not participate with    |
|                    |     our Plan.                                   |
|                    |                                                 |
|                    | -   If you are seeing a specialist and your     |
|                    |     specialist leaves the Plan, call your       |
|                    |     primary care physician, who will arrange    |
|                    |     for you to see another specialist. You may  |
|                    |     receive services from your current          |
|                    |     specialist until we can make arrangements   |
|                    |     for you to see someone else.                |
|                    |                                                 |
|                    | -   If you have a chronic or disabling          |
|                    |     condition and lose access to your           |
|                    |     specialist because we:                      |
|                    |                                                 |
|                    | ```{=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 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 customer service   |
|                    | department immediately at 1-877-244-4466. 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 hospital     |
|                    | benefits of the hospitalized person. If your    |
|                    | plan terminates participation in the FEHB       |
|                    | Program in whole or in part, or if OPM orders   |
|                    | and enrollment change, this continuation of     |
|                    | coverage provision does not apply. In such      |
|                    | case, the hospitalized family member's benefits |
|                    | under the new plan begin on the effective date  |
|                    | of enrollment.                                  |
+--------------------+-------------------------------------------------+
| ### Circumstances  | 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              | Your primary care physician has authority to    |
| ervices requiring  | refer you for most services. For certain        |
| our prior approval | services, however, your physician must obtain   |
|                    | approval from us. Before giving approval, we    |
|                    | consider if the service is covered, medically   |
|                    | necessary, and follows generally accepted       |
|                    | medical practice.                               |
|                    |                                                 |
|                    | We call this review and approval process        |
|                    | precertification. Your physician must obtain    |
|                    | prior authorization from the GHI HMO Medical    |
|                    | Director. These services may include but are    |
|                    | not limited to:                                 |
|                    |                                                 |
|                    | a.  Specialist Referrals                        |
|                    |                                                 |
|                    | b.  Ambulatory Surgery                          |
|                    |                                                 |
|                    | c.  Hospital/Nursing Home admissions and any    |
|                    |     care rendered during stay                   |
|                    |                                                 |
|                    | d.  Physical Therapy and Cardiac Rehabilitation |
|                    |                                                 |
|                    | e.  Home Care and Hospice                       |
|                    |                                                 |
|                    | f.  Durable Medical Equipment over \$250 and    |
|                    |     all Orthotics                               |
|                    |                                                 |
|                    | g.  Non-Participating Providers                 |
|                    |                                                 |
|                    | h.  Member requests for experimental or         |
|                    |     investigative health care services.         |
|                    |                                                 |
|                    | i.  Mental Health and Substance Abuse (MH/SA)   |
|                    |                                                 |
|                    | GHI HMO may request supporting documentation    |
|                    | from your provider to substantiate Medical      |
|                    | Necessity of the requested service. All         |
|                    | inpatient admissions are reviewed to evaluate   |
|                    | that the services are covered services,         |
|                    | Medically Necessary and being rendered at the   |
|                    | appropriate level of care.                      |
|                    |                                                 |
|                    | You have the right to designate a               |
|                    | representative for utilization review. GHI HMO  |
|                    | will notify you and your provider, by phone and |
|                    | in writing for prospective, concurrent and      |
|                    | retrospective utilization review decisions. If  |
|                    | we deny services or won\'t pay your claim, you  |
|                    | may ask us to reconsider our decision. Your     |
|                    | request must:                                   |
|                    |                                                 |
|                    | 1.  Be in writing                               |
|                    |                                                 |
|                    | 2.  Refer to specific brochure wording in       |
|                    |     explaining why you believe our decision is  |
|                    |     wrong; and                                  |
|                    |                                                 |
|                    | 3.  Be made within six months from the date of  |
|                    |     our initial denial or refusal. We may       |
|                    |     extend this time limit if you show that you |
|                    |     were unable to make a timely request due to |
|                    |     reasons beyond your control.                |
|                    |                                                 |
|                    | We have 30 days from the date we receive your   |
|                    | reconsideration request to:                     |
|                    |                                                 |
|                    | 1.  Maintain our denial in writing;             |
|                    |                                                 |
|                    | 2.  Pay the claim;                              |
|                    |                                                 |
|                    | 3.  Arrange for a health care provider to give  |
|                    |     you the service; or                         |
|                    |                                                 |
|                    | 4.  Ask for more information                    |
|                    |                                                 |
|                    | If we ask your medical provider for more        |
|                    | information, we will send you a copy of our     |
|                    | request. We must make a decision within 30 days |
|                    | after we receive the additional information. If |
|                    | we do not receive the requested information     |
|                    | within 60 days, we will make our decision based |
|                    | on the information we already have.             |
+--------------------+-------------------------------------------------+

# Section 4. Your cost for covered services

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

+-----------------------------------+-----------------------------------+
| ### Copayments                    | A copayment is a fixed amount of  |
|                                   | money you pay to the provider,    |
|                                   | facility, pharmacy, etc., when    |
|                                   | you receive services.             |
|                                   |                                   |
|                                   | Example: When you see your        |
|                                   | primary care physician you pay a  |
|                                   | copayment of \$10 per office      |
|                                   | visit under the High Option and   |
|                                   | \$20 per office visit under the   |
|                                   | Standard Option and when you go   |
|                                   | in the hospital, you pay nothing. |
+-----------------------------------+-----------------------------------+
| ### Deductible                    | We do not have a deductible.      |
+-----------------------------------+-----------------------------------+
| ### Coinsurance                   | Coinsurance is the percentage of  |
|                                   | our negotiated that you must pay  |
|                                   | for your care.                    |
|                                   |                                   |
|                                   | Example: In our plan you pay 20%  |
|                                   | for durable medical equipment up  |
|                                   | to a maximum of \$1500 per        |
|                                   | person, per year under the High   |
|                                   | Option and up to a maximum of     |
|                                   | \$10,000 per person, per year     |
|                                   | under the Standard Option.        |
+-----------------------------------+-----------------------------------+
| ### Your catastrophic             | We do not have a catastrophic     |
|  protection out-of-pocket maximum | protection out-of-pocket maximum. |
+-----------------------------------+-----------------------------------+

# Section 5. Benefits -- OVERVIEW *(See page 9 for how our benefits changed this year and page 72 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 following subsections. To obtain claims forms, claims
filing advice, or more information about our benefits, contact us at
*1-877-2GH-IHMO or 1-877-244-4466* or at our website at
[www.ghi.com](http://www.ghi.com/)*.*

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

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

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

[Preventive care, adult 18](#preventive-care-adult)

[Preventive care, children 19](#preventive-care-children)

[Maternity care 19](#maternity-care)

[Family planning 23](#family-planning)

[Infertility services 20](#infertility-services)

[Allergy care 21](#allergy-care)

[Diabetic supplies and equipment 21](#diabetic-supplies-and-equipment)

[Treatment therapies 22](#treatment-therapies)

[Physical and occupational therapies
23](#physical-and-occupational-therapies)

[Speech therapy 23](#speech-therapy)

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

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

[Foot care 24](#foot-care)

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

[Durable medical equipment (DME) 26](#durable-medical-equipment-dme)

[Home health services 26](#home-health-services)

[Chiropractic 27](#chiropractic)

[Alternative treatments 27](#alternative-treatments)

[Educational classes and programs 27](#educational-classes-and-programs)

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

[Surgical procedures 28](#surgical-procedures)

[Reconstructive surgery 30](#reconstructive-surgery)

[Oral and maxillofacial surgery 31](#oral-and-maxillofacial-surgery)

[Organ/tissue transplants 32](#organtissue-transplants)

[Anesthesia 33](#anesthesia)

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

[Inpatient hospital 34](#inpatient-hospital)

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

[Extended care benefits/skilled nursing care facility benefits
36](#extended-care-benefitsskilled-nursing-care-facility-benefits)

[Hospice care 39](#hospice-care)

[Ambulance 37](#ambulance)

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

[Emergency within our service area
39](#emergency-within-our-service-area)

[Emergency outside our service area
39](#emergency-outside-our-service-area)

[Ambulance 40](#ambulance-1)

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

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

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

[Covered medications and supplies 46](#covered-medications-and-supplies)

[Section 5(g) Special features 48](#section-5g-special-features)

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

[Centers of excellence for transplants/heart surgery/etc
48](#centers-of-excellence-for-transplantsheart-surgeryetc.)

[PHIP - Personal Health Improvement Program
48](#phip---personal-health-improvement-program)

[Section 5(h) Dental benefits 49](#section-5h-dental-benefits)

[Accidental injury benefit 49](#accidental-injury-benefit)

[Dental benefits 49](#dental-benefits)

[Section 5 (j) Non-FEHB benefits available to Plan members
50](#section-5-i-non-fehb-benefits-available-to-plan-members)

[Summary of benefits for the GHI HMO *-*
2005](#__RefHeading___Toc78332776) 75

[2005 Rate Information for GHI HMO](#__RefHeading___Toc78332777) 77

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

+---+---+----------------------------------+-------------+---+---+----+
|   | * | **Here are some important things |             |   | * |    |
|   | * | to keep in mind about these      |             |   | * |    |
|   | I | benefits:**                      |             |   | I |    |
|   | * |                                  |             |   | * |    |
|   | * | -   Please remember that all     |             |   | * |    |
|   |   |     benefits are subject to the  |             |   |   |    |
|   | * |     definitions, limitations,    |             |   | * |    |
|   | * |     and exclusions in this       |             |   | * |    |
|   | M |     brochure and are payable     |             |   | M |    |
|   | * |     only when we determine they  |             |   | * |    |
|   | * |     are medically necessary.     |             |   | * |    |
|   |   |                                  |             |   |   |    |
|   | * | -   Plan physicians must provide |             |   | * |    |
|   | * |     or arrange your care.        |             |   | * |    |
|   | P |                                  |             |   | P |    |
|   | * | -   We have no calendar year     |             |   | * |    |
|   | * |     deductible*.*                |             |   | * |    |
|   |   |                                  |             |   |   |    |
|   | * | -   Be sure to read Section 4,   |             |   | * |    |
|   | * |     *Your costs for covered      |             |   | * |    |
|   | O |     services,* for valuable      |             |   | O |    |
|   | * |     information about how cost   |             |   | * |    |
|   | * |     sharing works. Also read     |             |   | * |    |
|   |   |     Section 9 about coordinating |             |   |   |    |
|   | * |     benefits with other          |             |   | * |    |
|   | * |     coverage, including with     |             |   | * |    |
|   | R |     Medicare.                    |             |   | R |    |
|   | * |                                  |             |   | * |    |
|   | * |                                  |             |   | * |    |
|   |   |                                  |             |   |   |    |
|   | * |                                  |             |   | * |    |
|   | * |                                  |             |   | * |    |
|   | T |                                  |             |   | T |    |
|   | * |                                  |             |   | * |    |
|   | * |                                  |             |   | * |    |
|   |   |                                  |             |   |   |    |
|   | * |                                  |             |   | * |    |
|   | * |                                  |             |   | * |    |
|   | A |                                  |             |   | A |    |
|   | * |                                  |             |   | * |    |
|   | * |                                  |             |   | * |    |
|   |   |                                  |             |   |   |    |
|   | * |                                  |             |   | * |    |
|   | * |                                  |             |   | * |    |
|   | N |                                  |             |   | N |    |
|   | * |                                  |             |   | * |    |
|   | * |                                  |             |   | * |    |
|   |   |                                  |             |   |   |    |
|   | * |                                  |             |   | * |    |
|   | * |                                  |             |   | * |    |
|   | T |                                  |             |   | T |    |
|   | * |                                  |             |   | * |    |
|   | * |                                  |             |   | * |    |
+---+---+----------------------------------+-------------+---+---+----+
| B |   |                                  | High Option | S |   |    |
| e |   |                                  |             | t |   |    |
| n |   |                                  |             | a |   |    |
| e |   |                                  |             | n |   |    |
| f |   |                                  |             | d |   |    |
| i |   |                                  |             | a |   |    |
| t |   |                                  |             | r |   |    |
| D |   |                                  |             | d |   |    |
| e |   |                                  |             | O |   |    |
| s |   |                                  |             | p |   |    |
| c |   |                                  |             | t |   |    |
| r |   |                                  |             | i |   |    |
| i |   |                                  |             | o |   |    |
| p |   |                                  |             | n |   |    |
| t |   |                                  |             |   |   |    |
| i |   |                                  |             |   |   |    |
| o |   |                                  |             |   |   |    |
| n |   |                                  |             |   |   |    |
+---+---+----------------------------------+-------------+---+---+----+
| # |   |                                  | You pay     | Y |   |    |
| # |   |                                  |             | o |   |    |
| # |   |                                  |             | u |   |    |
| # |   |                                  |             | p |   |    |
| # |   |                                  |             | a |   |    |
| # |   |                                  |             | y |   |    |
|   |   |                                  |             |   |   |    |
| D |   |                                  |             |   |   |    |
| i |   |                                  |             |   |   |    |
| a |   |                                  |             |   |   |    |
| g |   |                                  |             |   |   |    |
| n |   |                                  |             |   |   |    |
| o |   |                                  |             |   |   |    |
| s |   |                                  |             |   |   |    |
| t |   |                                  |             |   |   |    |
| i |   |                                  |             |   |   |    |
| c |   |                                  |             |   |   |    |
|   |   |                                  |             |   |   |    |
| a |   |                                  |             |   |   |    |
| n |   |                                  |             |   |   |    |
| d |   |                                  |             |   |   |    |
|   |   |                                  |             |   |   |    |
| t |   |                                  |             |   |   |    |
| r |   |                                  |             |   |   |    |
| e |   |                                  |             |   |   |    |
| a |   |                                  |             |   |   |    |
| t |   |                                  |             |   |   |    |
| m |   |                                  |             |   |   |    |
| e |   |                                  |             |   |   |    |
| n |   |                                  |             |   |   |    |
| t |   |                                  |             |   |   |    |
|   |   |                                  |             |   |   |    |
| s |   |                                  |             |   |   |    |
| e |   |                                  |             |   |   |    |
| r |   |                                  |             |   |   |    |
| v |   |                                  |             |   |   |    |
| i |   |                                  |             |   |   |    |
| c |   |                                  |             |   |   |    |
| e |   |                                  |             |   |   |    |
| s |   |                                  |             |   |   |    |
+---+---+----------------------------------+-------------+---+---+----+
| P |   |                                  | \$10 per    | \ |   |    |
| r |   |                                  | office      | $ |   |    |
| o |   |                                  | visit       | 2 |   |    |
| f |   |                                  |             | 0 |   |    |
| e |   |                                  |             | p |   |    |
| s |   |                                  |             | e |   |    |
| s |   |                                  |             | r |   |    |
| i |   |                                  |             | o |   |    |
| o |   |                                  |             | f |   |    |
| n |   |                                  |             | f |   |    |
| a |   |                                  |             | i |   |    |
| l |   |                                  |             | c |   |    |
| s |   |                                  |             | e |   |    |
| e |   |                                  |             | v |   |    |
| r |   |                                  |             | i |   |    |
| v |   |                                  |             | s |   |    |
| i |   |                                  |             | i |   |    |
| c |   |                                  |             | t |   |    |
| e |   |                                  |             |   |   |    |
| s |   |                                  |             | N |   |    |
| o |   |                                  |             | o |   |    |
| f |   |                                  |             | t |   |    |
| p |   |                                  |             | h |   |    |
| h |   |                                  |             | i |   |    |
| y |   |                                  |             | n |   |    |
| s |   |                                  |             | g |   |    |
| i |   |                                  |             | f |   |    |
| c |   |                                  |             | o |   |    |
| i |   |                                  |             | r |   |    |
| a |   |                                  |             | c |   |    |
| n |   |                                  |             | h |   |    |
| s |   |                                  |             | i |   |    |
|   |   |                                  |             | l |   |    |
| - |   |                                  |             | d |   |    |
|   |   |                                  |             | r |   |    |
|   |   |                                  |             | e |   |    |
|   |   |                                  |             | n |   |    |
| I |   |                                  |             | ( |   |    |
| n |   |                                  |             | t |   |    |
|   |   |                                  |             | h |   |    |
|   |   |                                  |             | r |   |    |
|   |   |                                  |             | o |   |    |
|   |   |                                  |             | u |   |    |
| p |   |                                  |             | g |   |    |
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+---+---+----------------------------------+-------------+---+---+----+

+------------------------------------------+------------+-------------+
| ###### Preventive care, adult            | High       | Standard    |
|                                          | Option     | Option      |
|                                          |            |             |
|                                          | You pay    | You pay     |
+------------------------------------------+------------+-------------+
| Routine screenings, such as:             | \$10 per   | \$20 per    |
|                                          | office     | office      |
| -   Total Blood Cholesterol -- once      | visit      | visit       |
|     every three years                    |            |             |
|                                          |            |             |
| -   Colorectal Cancer Screening          |            |             |
|     including                            |            |             |
|                                          |            |             |
| ```{=html}                               |            |             |
| <!-- -->                                 |            |             |
| ```                                      |            |             |
| -   Fecal occult blood test              |            |             |
|                                          |            |             |
| -   Sigmoidoscopy, screening - every     |            |             |
|     five years starting at age 50        |            |             |
|                                          |            |             |
| ```{=html}                               |            |             |
| <!-- -->                                 |            |             |
| ```                                      |            |             |
| -   Routine Prostate Specific Antigen    |            |             |
|     (PSA) - one annually for men age 40  |            |             |
|     and older                            |            |             |
|                                          |            |             |
| -   Routine pap test                     |            |             |
|                                          |            |             |
| Note: The pap test is covered if the     |            |             |
| office visit is on the same day the      |            |             |
| office copay still applies; see          |            |             |
| *Diagnostic and Treatment* on page 16.   |            |             |
+------------------------------------------+------------+-------------+
| Routine mammogram --covered for women    | Nothing    | Nothing     |
| age 35 and older, as follows:            |            |             |
|                                          |            |             |
| -   From age 35 through 39, one during   |            |             |
|     this five year period                |            |             |
|                                          |            |             |
| -   From age 40 through 64, one every    |            |             |
|     calendar year                        |            |             |
|                                          |            |             |
| -   At age 65 and older, one every two   |            |             |
|     consecutive calendar years           |            |             |
+------------------------------------------+------------+-------------+
| Routine immunizations, limited to:       | \$10 per   | \$20 per    |
|                                          | office     | office      |
| -   Tetanus-diphtheria (Td) booster --   | visit      | visit       |
|     once every 10 years, ages19 and over |            |             |
|     (except as provided for under        |            |             |
|     Childhood immunizations)             |            |             |
|                                          |            |             |
| -   Influenza vaccines, annually         |            |             |
|                                          |            |             |
| -   Pneumococcal vaccine, age 65 and     |            |             |
|     over                                 |            |             |
+------------------------------------------+------------+-------------+
| *Not covered: Physical exams required    | *All       | *All        |
| for obtaining or continuing employment   | charges*   | charges*    |
| or insurance, attending schools or camp, |            |             |
| or travel**.***                          |            |             |
+------------------------------------------+------------+-------------+
|                                          |            |             |
+------------------------------------------+------------+-------------+
| ###### Preventive care, children         | High       | Standard    |
|                                          | Option     | Option      |
|                                          |            |             |
|                                          | You pay    | You pay     |
+------------------------------------------+------------+-------------+
| -   Childhood immunizations recommended  | Nothing    | Nothing     |
|     by the American Academy of           |            |             |
|     Pediatrics                           |            |             |
+------------------------------------------+------------+-------------+
| -   Examinations, such as:               | \$10 per   | Nothing     |
|                                          | office     | (through    |
| ```{=html}                               | visit      | age 18)     |
| <!-- -->                                 |            |             |
| ```                                      |            |             |
| -   Ear exams through age 19 to          |            |             |
|     determine the need for hearing       |            |             |
|     correction by a primary care         |            |             |
|     physician                            |            |             |
+------------------------------------------+------------+-------------+
| -   Eye exams through age 19 to          | \$10 per   | \$20 per    |
|     determine the need for vision        | office     | office      |
|     correction.                          | visit      | visit       |
+------------------------------------------+------------+-------------+
| -   Examinations done on the day of      | Nothing    | Nothing     |
|     immunizations (under age 22)         |            |             |
|                                          |            |             |
| -   Well-child care charges for routine  |            |             |
|     examinations, immunizations and care |            |             |
|     (under age 22)                       |            |             |
+------------------------------------------+------------+-------------+
| ###### Maternity care                    |            |             |
+------------------------------------------+------------+-------------+
| Complete maternity (obstetrical) care,   | \$10       | Nothing     |
| such as:                                 | initial    |             |
|                                          | visit      |             |
| -   Prenatal care                        | only,      |             |
|                                          | nothing    |             |
| -   Delivery                             | for other  |             |
|                                          | pre and    |             |
| -   Postnatal care                       | postnatal  |             |
|                                          | visits.    |             |
| Note: Here are some things to keep in    |            |             |
| mind:                                    | Nothing    |             |
|                                          | for        |             |
| -   You do not need to precertify your   | Delivery   |             |
|     normal delivery; see page 12 for     |            |             |
|     other circumstances, such as         |            |             |
|     extended stays for you or your baby. |            |             |
|                                          |            |             |
| -   You may remain in the hospital up to |            |             |
|     48 hours after a regular delivery    |            |             |
|     and 96 hours after a cesarean        |            |             |
|     delivery. We will extend your        |            |             |
|     inpatient stay if medically          |            |             |
|     necessary.                           |            |             |
|                                          |            |             |
| -   We cover routine nursery care of the |            |             |
|     newborn child during the covered     |            |             |
|     portion of the mother's maternity    |            |             |
|     stay. We will cover other care of an |            |             |
|     infant who requires non-routine      |            |             |
|     treatment only if we cover the       |            |             |
|     infant under a Self and Family       |            |             |
|     enrollment. Circumcision is a        |            |             |
|     surgical benefit.                    |            |             |
|                                          |            |             |
| -   We pay hospitalization and surgeon   |            |             |
|     services (delivery) the same as for  |            |             |
|     illness and injury. See Hospital     |            |             |
|     benefits (Section 5c) and Surgery    |            |             |
|     benefits (Section 5b)*.*             |            |             |
+------------------------------------------+------------+-------------+
| *Not covered: Routine sonograms to       | *All       | *All        |
| determine fetal age, size or sex.*       | charges*   | charges*    |
+------------------------------------------+------------+-------------+
| ######  Family planning                  | High       | Standard    |
|                                          | Option     | Option      |
|                                          |            |             |
|                                          | You pay    | You pay     |
+------------------------------------------+------------+-------------+
| A range of voluntary family planning     | \$10 per   | \$20 per    |
| services, limited to:                    | office     | office      |
|                                          | visit      | visit       |
| -   Voluntary sterilization (See         |            |             |
|     Surgical procedures Section 5 (b))   |            |             |
|                                          |            |             |
| -   Surgically implanted contraceptives  |            |             |
|     (such as Norplant)                   |            |             |
|                                          |            |             |
| -   Injectable contraceptive drugs (such |            |             |
|     as Depo provera)                     |            |             |
|                                          |            |             |
| -   Intrauterine devices (IUDs)          |            |             |
|                                          |            |             |
| -   Diaphragms                           |            |             |
|                                          |            |             |
| Note: We cover oral contraceptives under |            |             |
| the prescription drug benefit.           |            |             |
+------------------------------------------+------------+-------------+
| *Not Covered:*                           | *All       | *All        |
|                                          | charges*   | charges*    |
| -   *Reversal of voluntary surgical      |            |             |
|     sterilization, genetic counseling*   |            |             |
+------------------------------------------+------------+-------------+
| ###### Infertility services              |            |             |
+------------------------------------------+------------+-------------+
| Diagnosis of infertility                 | \$10 per   | \$20 per    |
|                                          | office     | office      |
|                                          | visit      | visit       |
+------------------------------------------+------------+-------------+
| Treatment of Infertility, such as:       | \$10 per   | \$20 per    |
|                                          | office     | office      |
| -   Artificial insemination              | visit      | visit       |
|                                          |            |             |
| ```{=html}                               |            |             |
| <!-- -->                                 |            |             |
| ```                                      |            |             |
| -   *intravaginal insemination (IVI)*    |            |             |
|                                          |            |             |
| -   *intracervical insemination (ICI)*   |            |             |
|                                          |            |             |
| -   *intrauterine insemination (IUI)*    |            |             |
|                                          |            |             |
| ```{=html}                               |            |             |
| <!-- -->                                 |            |             |
| ```                                      |            |             |
| -   Fertility Drugs                      |            |             |
|                                          |            |             |
|     Note: Members must be at least 21    |            |             |
|     years of age but no more than 44     |            |             |
|     years of age to be covered for       |            |             |
|     infertility services. Services are   |            |             |
|     limited to three (3) cycles to       |            |             |
|     achieve pregnancy.                   |            |             |
|                                          |            |             |
| Note: Fertility drugs are covered under  |            |             |
| the prescription drug benefit. See page  |            |             |
| 46.                                      |            |             |
+------------------------------------------+------------+-------------+
|                                          |            |             |
+------------------------------------------+------------+-------------+
| Infertility services *(continued)*       | High       | Standard    |
|                                          | Option     | Option      |
|                                          |            |             |
|                                          | You pay    | You pay     |
+------------------------------------------+------------+-------------+
| *Not covered:*                           | *All       | *All        |
|                                          | charges*   | charges*    |
| -   *Assisted reproductive technology    |            |             |
|     (ART) procedures, such as:*          |            |             |
|                                          |            |             |
| ```{=html}                               |            |             |
| <!-- -->                                 |            |             |
| ```                                      |            |             |
| -   *in vitro fertilization*             |            |             |
|                                          |            |             |
| -   *embryo transfer, gamete             |            |             |
|     intra-fallopian (GIFT) and           |            |             |
|     zygoteintra-fallopian transfer       |            |             |
|     (ZIFT)*                              |            |             |
|                                          |            |             |
| ```{=html}                               |            |             |
| <!-- -->                                 |            |             |
| ```                                      |            |             |
| -   Services and supplies related to     |            |             |
|     excluded ART procedures              |            |             |
|                                          |            |             |
| -   Cost of donor sperm                  |            |             |
|                                          |            |             |
| -   Cost of donor egg                    |            |             |
+------------------------------------------+------------+-------------+
| ###### Allergy care                      |            |             |
+------------------------------------------+------------+-------------+
| -   Testing and treatment                | \$10 per   | \$20 per    |
|                                          | office     | office      |
| -   Allergy injection                    | visit      | visit       |
|                                          |            |             |
|                                          |            | Nothing for |
|                                          |            | children    |
|                                          |            | (through    |
|                                          |            | age 18) per |
|                                          |            | office      |
|                                          |            | visit       |
+------------------------------------------+------------+-------------+
| Allergy serum                            | Nothing    | Nothing     |
+------------------------------------------+------------+-------------+
| *Not covered: Provocative food testing   | *All       | *All        |
| and sublingual allergy desensitization*  | charges*   | charges*    |
+------------------------------------------+------------+-------------+
| ###### Diabetic supplies and equipment   |            |             |
+------------------------------------------+------------+-------------+
| Blood glucose monitors, data management  | \$10 copay | \$20 copay  |
| systems, test strips for glucose         | for        | for         |
| monitoring, insulin, injection aids,     | supplies   | supplies    |
| cartridges for legally blind, syringes,  |            |             |
| insulin pumps, insulin infusion devices, |            |             |
| oral agents for controlling blood sugar. |            |             |
+------------------------------------------+------------+-------------+
| ###### Treatment therapies               | High       | Standard    |
|                                          | Option     | Option      |
|                                          |            |             |
|                                          | You pay    | You pay     |
+------------------------------------------+------------+-------------+
| -   Chemotherapy and radiation therapy   | Nothing    | Nothing     |
|                                          |            |             |
| Note: High dose chemotherapy in          |            |             |
| association with autologous bone marrow  |            |             |
| transplants are limited to those         |            |             |
| transplants listed under Organ/Tissue    |            |             |
| Transplants on page 32.                  |            |             |
|                                          |            |             |
| -   Respiratory and inhalation therapy   |            |             |
|                                          |            |             |
| -   Dialysis - hemodialysis and          |            |             |
|     peritoneal dialysis                  |            |             |
|                                          |            |             |
| -   Intravenous (IV)/Infusion Therapy -- |            |             |
|     Home IV and antibiotic therapy       |            |             |
+------------------------------------------+------------+-------------+
| -   Growth hormone therapy (GHT)         | \$10       | \$1         |
|                                          | /\$20/\$30 | 0/\$20/\$30 |
| Note: Growth hormone is covered under    | copay for  | copay for   |
| the prescription drug benefit. See page  | pre        | pr          |
| 46.                                      | scriptions | escriptions |
|                                          |            |             |
| Note: -- We will only cover GHT when we  |            |             |
| preauthorize the treatment. Call or have |            |             |
| your physician call 1-877-2GH-IHMO or 1- |            |             |
| 877-244-4466 for preauthorization. We    |            |             |
| will ask you to submit information that  |            |             |
| establishes that the GHT is medically    |            |             |
| necessary. Ask us to authorize GHT       |            |             |
| before you begin treatment; otherwise,   |            |             |
| we will only cover GHT services from the |            |             |
| date you submit the information. If you  |            |             |
| do not ask or if we determine GHT is not |            |             |
| medically necessary, we will not cover   |            |             |
| the GHT or related services and          |            |             |
| supplies. This benefit is provided under |            |             |
| our Prescription Drug Benefits. See      |            |             |
| *Services requiring our prior approval*  |            |             |
| in Section 3.                            |            |             |
+------------------------------------------+------------+-------------+
| *Not covered:*                           | *All       | *All        |
|                                          | charges*   | charges*    |
| -   *Treatment for experimental or       |            |             |
|     investigational procedures*          |            |             |
|                                          |            |             |
| -   *Therapy necessary for transsexual   |            |             |
|     surgery*                             |            |             |
+------------------------------------------+------------+-------------+

+-------------------------------------------+------------+------------+
| #                                         | High       | Standard   |
| ##### Physical and occupational therapies | Option     | Option     |
|                                           |            |            |
|                                           | You pay    | You pay    |
+-------------------------------------------+------------+------------+
| Up to two consecutive months per          | \$10 per   | \$20 per   |
| condition if significant improvement can  | visit      | office     |
| be expected within two months for the     |            | visit      |
| following services:                       | Nothing    |            |
|                                           | per visit  | Nothing    |
| -   Qualified physical therapists and     | during     | per visit  |
|                                           | covered    | during     |
| -   occupational therapists.              | inpatient  | covered    |
|                                           | admission  | inpatient  |
| Note: We only cover therapy to restore    |            | admission  |
| bodily function when there has been a     |            |            |
| total or partial loss of bodily function  |            |            |
| due to illness or injury. Physical and    |            |            |
| occupational therapy is provided on an    |            |            |
| inpatient or outpatient basis for up to   |            |            |
| two consecutive months per condition if   |            |            |
| significant improvement can be expected   |            |            |
| within two months; you pay \$10 copay per |            |            |
| outpatient visit. Speech therapy is       |            |            |
| limited to treatment if certain speech    |            |            |
| impairments of organic origin.            |            |            |
| Occupational therapy is limited to        |            |            |
| services that assist the member to        |            |            |
| achieve and maintain self-care and        |            |            |
| improved functioning in other activities  |            |            |
| of daily living.                          |            |            |
|                                           |            |            |
| -   Cardiac rehabilitation following a    |            |            |
|     heart transplant, bypass surgery or a |            |            |
|     myocardial infarction, is provided    |            |            |
|     for up to 30 visits within 60 days    |            |            |
+-------------------------------------------+------------+------------+
| *Not covered:*                            | *All       | *All       |
|                                           | charges*   | charges*   |
| -   *Long term rehabilitative therapy*    |            |            |
|                                           |            |            |
| -   *Exercise programs*                   |            |            |
+-------------------------------------------+------------+------------+
| ###### Speech therapy                     |            |            |
+-------------------------------------------+------------+------------+
| Up to two consecutive months per          | \$10 per   | \$20 per   |
| condition when medically necessary.       | office     | office     |
|                                           | visit      | visit      |
+-------------------------------------------+------------+------------+
| ###### Hearing se                         |            |            |
| rvices (testing, treatment, and supplies) |            |            |
+-------------------------------------------+------------+------------+
| -   First hearing aid and testing only    | \$10 per   | \$20 per   |
|     when necessitated by accidental       | office     | office     |
|     injury                                | visit      | visit      |
|                                           |            |            |
| -   Hearing testing for children through  |            | Nothing    |
|     age 18 (see *Preventive care,         |            | for        |
|     children*)                            |            | children   |
|                                           |            | (through   |
|                                           |            | age 18)    |
|                                           |            | per office |
|                                           |            | visit      |
+-------------------------------------------+------------+------------+
| *Not covered:*                            | *All       | *All       |
|                                           | charges*   | charges*   |
| -   All other hearing testing             |            |            |
|                                           |            |            |
| -   Hearing aids, testing and             |            |            |
|     examinations for them                 |            |            |
+-------------------------------------------+------------+------------+

+-------------------------------------------+------------+---+---+-----------+
| ######  Vision se                         | High       | S |   |           |
| rvices (testing, treatment, and supplies) | Option     | t |   |           |
|                                           |            | a |   |           |
|                                           | You pay    | n |   |           |
|                                           |            | d |   |           |
|                                           |            | a |   |           |
|                                           |            | r |   |           |
|                                           |            | d |   |           |
|                                           |            | O |   |           |
|                                           |            | p |   |           |
|                                           |            | t |   |           |
|                                           |            | i |   |           |
|                                           |            | o |   |           |
|                                           |            | n |   |           |
|                                           |            |   |   |           |
|                                           |            | Y |   |           |
|                                           |            | o |   |           |
|                                           |            | u |   |           |
|                                           |            | p |   |           |
|                                           |            | a |   |           |
|                                           |            | y |   |           |
+-------------------------------------------+------------+---+---+-----------+
| -   Eye exam to determine the need for    | \$10 per   | \ |   |           |
|     vision correction (see preventive     | office     | $ |   |           |
|     care)                                 | visit      | 2 |   |           |
|                                           |            | 0 |   |           |
| -   Annual eye refractions                |            | p |   |           |
|                                           |            | e |   |           |
| Note: See preventive care, children for   |            | r |   |           |
| eye exam                                  |            | o |   |           |
|                                           |            | f |   |           |
|                                           |            | f |   |           |
|                                           |            | i |   |           |
|                                           |            | c |   |           |
|                                           |            | e |   |           |
|                                           |            | v |   |           |
|                                           |            | i |   |           |
|                                           |            | s |   |           |
|                                           |            | i |   |           |
|                                           |            | t |   |           |
+-------------------------------------------+------------+---+---+-----------+
| *Not covered:*                            | *All       | * |   |           |
|                                           | charges*   | A |   |           |
| -   *Eyeglasses or contact lenses*        |            | l |   |           |
|                                           |            | l |   |           |
| -   *Eye exercises and orthoptics*        |            | c |   |           |
|                                           |            | h |   |           |
| -   *Radial keratotomy and other          |            | a |   |           |
|     refractive surgery*                   |            | r |   |           |
|                                           |            | g |   |           |
|                                           |            | e |   |           |
|                                           |            | s |   |           |
|                                           |            | * |   |           |
+-------------------------------------------+------------+---+---+-----------+
| ###### Foot care                          |            |   |   |           |
+-------------------------------------------+------------+---+---+-----------+
| Routine foot care when you are under      | \$10 per   | \ |   |           |
| active treatment for a metabolic or       | office     | $ |   |           |
| peripheral vascular disease, such as      | visit      | 2 |   |           |
| diabetes.                                 |            | 0 |   |           |
|                                           |            | p |   |           |
| Note: See orthopedic and prosthetic       |            | e |   |           |
| devices for information on podiatric shoe |            | r |   |           |
| inserts.                                  |            | o |   |           |
|                                           |            | f |   |           |
|                                           |            | f |   |           |
|                                           |            | i |   |           |
|                                           |            | c |   |           |
|                                           |            | e |   |           |
|                                           |            | v |   |           |
|                                           |            | i |   |           |
|                                           |            | s |   |           |
|                                           |            | i |   |           |
|                                           |            | t |   |           |
|                                           |            |   |   |           |
|                                           |            | N |   |           |
|                                           |            | o |   |           |
|                                           |            | t |   |           |
|                                           |            | h |   |           |
|                                           |            | i |   |           |
|                                           |            | n |   |           |
|                                           |            | g |   |           |
|                                           |            | f |   |           |
|                                           |            | o |   |           |
|                                           |            | r |   |           |
|                                           |            | c |   |           |
|                                           |            | h |   |           |
|                                           |            | i |   |           |
|                                           |            | l |   |           |
|                                           |            | d |   |           |
|                                           |            | r |   |           |
|                                           |            | e |   |           |
|                                           |            | n |   |           |
|                                           |            | ( |   |           |
|                                           |            | t |   |           |
|                                           |            | h |   |           |
|                                           |            | r |   |           |
|                                           |            | o |   |           |
|                                           |            | u |   |           |
|                                           |            | g |   |           |
|                                           |            | h |   |           |
|                                           |            | a |   |           |
|                                           |            | g |   |           |
|                                           |            | e |   |           |
|                                           |            | 1 |   |           |
|                                           |            | 8 |   |           |
|                                           |            | ) |   |           |
|                                           |            | p |   |           |
|                                           |            | e |   |           |
|                                           |            | r |   |           |
|                                           |            | o |   |           |
|                                           |            | f |   |           |
|                                           |            | f |   |           |
|                                           |            | i |   |           |
|                                           |            | c |   |           |
|                                           |            | e |   |           |
|                                           |            | v |   |           |
|                                           |            | i |   |           |
|                                           |            | s |   |           |
|                                           |            | i |   |           |
|                                           |            | t |   |           |
+-------------------------------------------+------------+---+---+-----------+
| *Not covered:*                            | *All       | * |   |           |
|                                           | charges*   | A |   |           |
| -   *Cutting, trimming or removal of      |            | l |   |           |
|     corns, calluses, or the free edge of  |            | l |   |           |
|     toenails, and similar routine         |            | c |   |           |
|     treatment of conditions of the foot,  |            | h |   |           |
|     except as stated above*               |            | a |   |           |
|                                           |            | r |   |           |
| -   *Treatment of weak, strained or flat  |            | g |   |           |
|     feet or bunions or spurs; and of any  |            | e |   |           |
|     instability, imbalance or subluxation |            | s |   |           |
|     of the foot (unless the treatment is  |            | * |   |           |
|     by open cutting surgery)*             |            |   |   |           |
+-------------------------------------------+------------+---+---+-----------+
| ###### Orthopedic and prosthetic devices  | High       |   | S |           |
|                                           | Option     |   | t |           |
|                                           |            |   | a |           |
|                                           | You pay    |   | n |           |
|                                           |            |   | d |           |
|                                           |            |   | a |           |
|                                           |            |   | r |           |
|                                           |            |   | d |           |
|                                           |            |   | O |           |
|                                           |            |   | p |           |
|                                           |            |   | t |           |
|                                           |            |   | i |           |
|                                           |            |   | o |           |
|                                           |            |   | n |           |
|                                           |            |   |   |           |
|                                           |            |   | Y |           |
|                                           |            |   | o |           |
|                                           |            |   | u |           |
|                                           |            |   | p |           |
|                                           |            |   | a |           |
|                                           |            |   | y |           |
+-------------------------------------------+------------+---+---+-----------+
| -   Artificial limbs and eyes; stump hose | 20%        |   | 2 |           |
|                                           | c          |   | 0 |           |
| -   Externally worn breast prostheses and | oinsurance |   | % |           |
|     surgical bras, including necessary    | up to the  |   | c |           |
|     replacements, following a mastectomy  | Plan\'s    |   | o |           |
|                                           | maximum    |   | i |           |
| -   Internal prosthetic devices, such as  | benefit of |   | n |           |
|     artificial joints, pacemakers,        | \$1,500    |   | s |           |
|     cochlear implants, and surgically     | per        |   | u |           |
|     implanted breast implant following    | person,    |   | r |           |
|     mastectomy. Note: We pay internal     | per        |   | a |           |
|     prosthetic devices as hospital        | calendar   |   | n |           |
|     benefits; see Section 5 (c) for       | year       |   | c |           |
|     payment information. See 5(b) for     |            |   | e |           |
|     coverage of the surgery to insert the |            |   | u |           |
|     device.                               |            |   | p |           |
|                                           |            |   | t |           |
| -   Corrective orthopedic appliances for  |            |   | o |           |
|     non-dental treatment of               |            |   | t |           |
|     temporomandibular joint (TMJ) paid    |            |   | h |           |
|     dysfunction syndrome.                 |            |   | e |           |
|                                           |            |   | P |           |
|                                           |            |   | l |           |
|                                           |            |   | a |           |
|                                           |            |   | n |           |
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|                                           |            |   | t |           |
|                                           |            |   | o |           |
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|                                           |            |   | 0 |           |
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|                                           |            |   | p |           |
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|                                           |            |   | p |           |
|                                           |            |   | e |           |
|                                           |            |   | r |           |
|                                           |            |   | s |           |
|                                           |            |   | o |           |
|                                           |            |   | n |           |
|                                           |            |   | , |           |
|                                           |            |   | p |           |
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|                                           |            |   | e |           |
|                                           |            |   | a |           |
|                                           |            |   | r |           |
+-------------------------------------------+------------+---+---+-----------+
| *Not covered:*                            | *All       |   | * |           |
|                                           | charges*   |   | A |           |
| -   *[O]{.smallcaps}rthopedic and         |            |   | l |           |
|     corrective shoes*                     |            |   | l |           |
|                                           |            |   | c |           |
| -   *Arch supports*                       |            |   | h |           |
|                                           |            |   | a |           |
| -   *Foot orthotics*                      |            |   | r |           |
|                                           |            |   | g |           |
| -   *Heel pads and heel cups*             |            |   | e |           |
|                                           |            |   | s |           |
| -   *Lumbosacral supports*                |            |   | * |           |
|                                           |            |   |   |           |
| -   *Corsets, trusses, elastic stockings, |            |   |   |           |
|     support hose, and other supportive    |            |   |   |           |
|     devices*                              |            |   |   |           |
|                                           |            |   |   |           |
| -   *Prosthetic replacements provided     |            |   |   |           |
|     less than 3 years after the last one  |            |   |   |           |
|     we covered*                           |            |   |   |           |
+-------------------------------------------+------------+---+---+-----------+
| ######                                    |            |   |   |           |
+-------------------------------------------+------------+---+---+-----------+

+------------------------------------------+-------------+---+------------+
| ###### Durable medical equipment (DME)   | High Option |   | Standard   |
|                                          |             |   | Option     |
|                                          | You pay     |   |            |
|                                          |             |   | You pay    |
+------------------------------------------+-------------+---+------------+
| Rental or purchase, as determined by GHI | 20%         |   | 20%        |
| HMO, including repair and adjustment, of | coinsurance |   | c          |
| durable medical equipment prescribed by  | up to the   |   | oinsurance |
| your Plan physician, such as oxygen and  | Plan\'s     |   | up to the  |
| dialysis equipment. Under this benefit,  | maximum     |   | Plan\'s    |
| we also cover:                           | benefit of  |   | maximum    |
|                                          | \$1,500 per |   | benefit of |
| -   Hospital beds;                       | person, per |   | \$10,000   |
|                                          | calendar    |   | per        |
| -   Standard wheelchairs;                | year        |   | person,    |
|                                          |             |   | per        |
| -   Apnea monitors;                      |             |   | calendar   |
|                                          |             |   | year       |
| -   Nebulizers;                          |             |   |            |
|                                          |             |   |            |
| -   Crutches and;                        |             |   |            |
|                                          |             |   |            |
| -   Walkers                              |             |   |            |
|                                          |             |   |            |
| Note: Call us at 1-877-244-4466 as soon  |             |   |            |
| as your Plan physician prescribes this   |             |   |            |
| equipment. We will arrange with a health |             |   |            |
| care provider to rent or sell you        |             |   |            |
| durable medical equipment and will tell  |             |   |            |
| you more about this service when you     |             |   |            |
| call.                                    |             |   |            |
+------------------------------------------+-------------+---+------------+
| *Not covered:*                           | *All        |   | *All       |
|                                          | charges*    |   | charges*   |
| -   *Motorized wheel chairs*             |             |   |            |
|                                          |             |   |            |
| -   *Hearing aids*                       |             |   |            |
+------------------------------------------+-------------+---+------------+
| ###### Home health services              |             |   |            |
+------------------------------------------+-------------+---+------------+
| -   Home health care ordered by a Plan   | Nothing     |   | Nothing    |
|     physician and provided by a          |             |   |            |
|     registered nurse (R.N.), licensed    |             |   |            |
|     practical nurse (L.P.N.), or other   |             |   |            |
|     Home Health Care Agency personnel    |             |   |            |
|     licensed vocational nurse (L.V.N.),  |             |   |            |
|     or home health aide.                 |             |   |            |
|                                          |             |   |            |
| -   Services include oxygen therapy,     |             |   |            |
|     intravenous therapy and medications. |             |   |            |
+------------------------------------------+-------------+---+------------+
| *Not covered:*                           | *All        |   | *All       |
|                                          | charges*    |   | charges*   |
| -   *Nursing care requested by, or for   |             |   |            |
|     the convenience of, the patient or   |             |   |            |
|     the patient's family;*               |             |   |            |
|                                          |             |   |            |
| -   *Home health care primarily for      |             |   |            |
|     personal assistance that does not    |             |   |            |
|     include a medical component and is   |             |   |            |
|     not diagnostic, therapeutic, or      |             |   |            |
|     rehabilitative.*                     |             |   |            |
+------------------------------------------+-------------+---+------------+
| ###### Chiropractic                      | High Option | S |            |
|                                          |             | t |            |
|                                          | You pay     | a |            |
|                                          |             | n |            |
|                                          |             | d |            |
|                                          |             | a |            |
|                                          |             | r |            |
|                                          |             | d |            |
|                                          |             | O |            |
|                                          |             | p |            |
|                                          |             | t |            |
|                                          |             | i |            |
|                                          |             | o |            |
|                                          |             | n |            |
|                                          |             |   |            |
|                                          |             | Y |            |
|                                          |             | o |            |
|                                          |             | u |            |
|                                          |             | p |            |
|                                          |             | a |            |
|                                          |             | y |            |
+------------------------------------------+-------------+---+------------+
| -   Manipulation of the spine and        | \$10 per    | \ |            |
|     extremities                          | office      | $ |            |
|                                          | visit       | 2 |            |
| -   Adjunctive procedures such as        |             | 0 |            |
|     ultrasound, electrical muscle        |             | p |            |
|     stimulation, vibratory therapy, and  |             | e |            |
|     cold pack application                |             | r |            |
|                                          |             | o |            |
| -   Chiropractic services when           |             | f |            |
|     authorized by PCP                    |             | f |            |
|                                          |             | i |            |
|                                          |             | c |            |
|                                          |             | e |            |
|                                          |             | v |            |
|                                          |             | i |            |
|                                          |             | s |            |
|                                          |             | i |            |
|                                          |             | t |            |
+------------------------------------------+-------------+---+------------+
| ###### Alternative treatments            |             |   |            |
+------------------------------------------+-------------+---+------------+
| No Benefit                               | All charges | A |            |
|                                          |             | l |            |
|                                          |             | l |            |
|                                          |             | c |            |
|                                          |             | h |            |
|                                          |             | a |            |
|                                          |             | r |            |
|                                          |             | g |            |
|                                          |             | e |            |
|                                          |             | s |            |
+------------------------------------------+-------------+---+------------+
| ###### Educational classes and programs  |             |   |            |
+------------------------------------------+-------------+---+------------+
| Disease Management Programs available to | Nothing     | N |            |
| GHI HMO members:                         |             | o |            |
|                                          |             | t |            |
| -   Smoking Cessation                    |             | h |            |
|                                          |             | i |            |
| -   Diabetes Management                  |             | n |            |
|                                          |             | g |            |
| -   Asthma Management                    |             |   |            |
|                                          |             |   |            |
| -   Post Partum Depression Management    |             |   |            |
|                                          |             |   |            |
| -   Post Cardiac Depression Management   |             |   |            |
|                                          |             |   |            |
| -   Cardiac Management                   |             |   |            |
|                                          |             |   |            |
| -   Prenatal Management                  |             |   |            |
|                                          |             |   |            |
|     To enroll in these Programs, please  |             |   |            |
|     contact a Care Manager at            |             |   |            |
|     1-877-244-4466.                      |             |   |            |
+------------------------------------------+-------------+---+------------+

##  {#section-4 .unnumbered}

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

+---+---+----------------------------------+-------------+---+---+-----+
|   | * | **Here are some important things |             |   | * |     |
|   | * | you should keep in mind about    |             |   | * |     |
|   | I | these benefits:**                |             |   | I |     |
|   | * |                                  |             |   | * |     |
|   | * | -   Please remember that all     |             |   | * |     |
|   |   |     benefits are subject to the  |             |   |   |     |
|   | * |     definitions, limitations,    |             |   | * |     |
|   | * |     and exclusions in this       |             |   | * |     |
|   | M |     brochure and are payable     |             |   | M |     |
|   | * |     only when we determine they  |             |   | * |     |
|   | * |     are medically necessary.     |             |   | * |     |
|   |   |                                  |             |   |   |     |
|   | * | -   Plan physicians must provide |             |   | * |     |
|   | * |     or arrange your care.        |             |   | * |     |
|   | P |                                  |             |   | P |     |
|   | * | -   *We have no calendar year    |             |   | * |     |
|   | * |     deductible.*                 |             |   | * |     |
|   |   |                                  |             |   |   |     |
|   | * | -   Be sure to read Section 4,   |             |   | * |     |
|   | * |     *Your costs for covered      |             |   | * |     |
|   | O |     services*, for valuable      |             |   | O |     |
|   | * |     information about how cost   |             |   | * |     |
|   | * |     sharing works. Also read     |             |   | * |     |
|   |   |     Section 9 about coordinating |             |   |   |     |
|   | * |     benefits with other          |             |   | * |     |
|   | * |     coverage, including with     |             |   | * |     |
|   | R |     Medicare.                    |             |   | R |     |
|   | * |                                  |             |   | * |     |
|   | * | -   The amounts listed below are |             |   | * |     |
|   |   |     for the charges billed by a  |             |   |   |     |
|   | * |     physician or other health    |             |   | * |     |
|   | * |     care professional for your   |             |   | * |     |
|   | T |     surgical care. Look in       |             |   | T |     |
|   | * |     Section 5(c) for charges     |             |   | * |     |
|   | * |     associated with the facility |             |   | * |     |
|   |   |     (i.e. hospital, surgical     |             |   |   |     |
|   | * |     center, etc.).               |             |   | * |     |
|   | * |                                  |             |   | * |     |
|   | A | -   **YOUR PHYSICIAN MUST GET    |             |   | A |     |
|   | * |     PRECERTIFICATION OF SOME     |             |   | * |     |
|   | * |     SURGICAL PROCEDURES**.       |             |   | * |     |
|   |   |     Please refer to the          |             |   |   |     |
|   | * |     precertification information |             |   | * |     |
|   | * |     shown in Section 3 to be     |             |   | * |     |
|   | N |     sure which services require  |             |   | N |     |
|   | * |     prior authorization and      |             |   | * |     |
|   | * |     identify which surgeries     |             |   | * |     |
|   |   |     require prior authorization. |             |   |   |     |
|   | * |                                  |             |   | * |     |
|   | * |                                  |             |   | * |     |
|   | T |                                  |             |   | T |     |
|   | * |                                  |             |   | * |     |
|   | * |                                  |             |   | * |     |
+---+---+----------------------------------+-------------+---+---+-----+
| B |   |                                  | High Option | S |   |     |
| e |   |                                  |             | t |   |     |
| n |   |                                  | You pay     | a |   |     |
| e |   |                                  |             | n |   |     |
| f |   |                                  |             | d |   |     |
| i |   |                                  |             | a |   |     |
| t |   |                                  |             | r |   |     |
| D |   |                                  |             | d |   |     |
| e |   |                                  |             | O |   |     |
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| o |   |                                  |             | o |   |     |
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|   |   |                                  |             | P |   |     |
|   |   |                                  |             | a |   |     |
|   |   |                                  |             | y |   |     |
+---+---+----------------------------------+-------------+---+---+-----+
| # |   |                                  |             |   |   |     |
| # |   |                                  |             |   |   |     |
| # |   |                                  |             |   |   |     |
| # |   |                                  |             |   |   |     |
| # |   |                                  |             |   |   |     |
| # |   |                                  |             |   |   |     |
|   |   |                                  |             |   |   |     |
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|   |   |                                  |             |   |   |     |
+---+---+----------------------------------+-------------+---+---+-----+
| A |   |                                  | \$10 per    | \ |   |     |
| c |   |                                  | office      | $ |   |     |
| o |   |                                  | visit;      | 2 |   |     |
| m |   |                                  | nothing for | 0 |   |     |
| p |   |                                  | hospital    | p |   |     |
| r |   |                                  | visits      | e |   |     |
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|   |   |                                  |             |   |   |     |
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| d |   |                                  |             |   |   |     |
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|   |   |                                  |             |   |   |     |
|   |   |                                  |             |   |   |     |
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| p |   |                                  |             |   |   |     |
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|   |   |                                  |             |   |   |     |
|   |   |                                  |             |   |   |     |
|   |   |                                  |             |   |   |     |
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| d |   |                                  |             |   |   |     |
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| r |   |                                  |             |   |   |     |
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| s |   |                                  |             |   |   |     |
|   |   |                                  |             |   |   |     |
| - |   |                                  |             |   |   |     |
|   |   |                                  |             |   |   |     |
|   |   |                                  |             |   |   |     |
|   |   |                                  |             |   |   |     |
| B |   |                                  |             |   |   |     |
| i |   |                                  |             |   |   |     |
| o |   |                                  |             |   |   |     |
| p |   |                                  |             |   |   |     |
| s |   |                                  |             |   |   |     |
| y |   |                                  |             |   |   |     |
|   |   |                                  |             |   |   |     |
|   |   |                                  |             |   |   |     |
|   |   |                                  |             |   |   |     |
|   |   |                                  |             |   |   |     |
| p |   |                                  |             |   |   |     |
| r |   |                                  |             |   |   |     |
| o |   |                                  |             |   |   |     |
| c |   |                                  |             |   |   |     |
| e |   |                                  |             |   |   |     |
| d |   |                                  |             |   |   |     |
| u |   |                                  |             |   |   |     |
| r |   |                                  |             |   |   |     |
| e |   |                                  |             |   |   |     |
| s |   |                                  |             |   |   |     |
|   |   |                                  |             |   |   |     |
| # |   |                                  |             |   |   |     |
| # |   |                                  |             |   |   |     |
| # |   |                                  |             |   |   |     |
| # |   |                                  |             |   |   |     |
| # |   |                                  |             |   |   |     |
| # |   |                                  |             |   |   |     |
|   |   |                                  |             |   |   |     |
+---+---+----------------------------------+-------------+---+---+-----+

+------------------------------------------+-------------+-------------+
| Surgical *(continued)*                   | High Option | Standard    |
|                                          |             | Option      |
|                                          | You pay     |             |
|                                          |             | You pay     |
+------------------------------------------+-------------+-------------+
| -   Removal of tumors and cysts          | \$10 per    | \$20 per    |
|                                          | office      | office      |
| -   Correction of congenital anomalies   | visit;      | visit;      |
|     (see reconstructive surgery)         | nothing for | nothing for |
|                                          | hospital    | hospital    |
| -   Surgical treatment of morbid obesity | visits      |             |
|     \-- a condition in which an          |             | Nothing for |
|     individual weighs 100 pounds or 100% | \$10 per    | children    |
|     over his or her normal weight        | outpatient  | (through    |
|     according to current underwriting    | visits      | age 18)     |
|     standards; eligible members must be  |             |             |
|     age 18 or over                       |             | \$20 per    |
|                                          |             | outpatient  |
| -   Insertion of internal prosthetic     |             | visits      |
|     devices. See 5(a) -- Orthopedic and  |             |             |
|     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        | *All        |
|                                          | charges*    | charges*    |
| -   *Reversal of voluntary               |             |             |
|     sterilization*                       |             |             |
|                                          |             |             |
| -   *Routine treatment of conditions of  |             |             |
|     the foot; see Foot care.*            |             |             |
+------------------------------------------+-------------+-------------+

+------------------------------------------+------------+---+-------------+
| ###### Reconstructive surgery            | High       | S |             |
|                                          | Option     | t |             |
|                                          |            | a |             |
|                                          | You pay    | n |             |
|                                          |            | d |             |
|                                          |            | a |             |
|                                          |            | r |             |
|                                          |            | d |             |
|                                          |            | O |             |
|                                          |            | p |             |
|                                          |            | t |             |
|                                          |            | i |             |
|                                          |            | o |             |
|                                          |            | n |             |
|                                          |            |   |             |
|                                          |            | Y |             |
|                                          |            | o |             |
|                                          |            | u |             |
|                                          |            | p |             |
|                                          |            | a |             |
|                                          |            | y |             |
+------------------------------------------+------------+---+-------------+
| -   Surgery to correct a functional      | \$10 per   | \ |             |
|     defect                               | office     | $ |             |
|                                          | visit;     | 2 |             |
| -   Surgery to correct a condition       | nothing    | 0 |             |
|     caused by injury or illness if:      | for        | p |             |
|                                          | hospital   | e |             |
| ```{=html}                               | visits     | r |             |
| <!-- -->                                 |            | o |             |
| ```                                      | \$10 per   | f |             |
| -   the condition produced a major       | outpatient | f |             |
|     effect on the member's appearance    | visit      | i |             |
|     and                                  |            | c |             |
|                                          |            | e |             |
| -   the condition can reasonably be      |            | v |             |
|     expected to be corrected by such     |            | i |             |
|     surgery                              |            | s |             |
|                                          |            | i |             |
| ```{=html}                               |            | t |             |
| <!-- -->                                 |            | ; |             |
| ```                                      |            | n |             |
| -   Surgery to correct a condition that  |            | o |             |
|     existed at or from birth and is a    |            | t |             |
|     significant deviation from the       |            | h |             |
|     common form or norm. Examples of     |            | i |             |
|     congenital anomalies are: protruding |            | n |             |
|     ear deformities; cleft lip; cleft    |            | g |             |
|     palate; birth marks; webbed fingers; |            | f |             |
|     and webbed toes.                     |            | o |             |
|                                          |            | r |             |
| -   All stages of breast reconstruction  |            | h |             |
|     surgery following a mastectomy, such |            | o |             |
|     as:                                  |            | s |             |
|                                          |            | p |             |
| ```{=html}                               |            | i |             |
| <!-- -->                                 |            | t |             |
| ```                                      |            | a |             |
| -   surgery to produce a symmetrical     |            | l |             |
|     appearance on the other breast;      |            | v |             |
|                                          |            | i |             |
| -   treatment of any physical            |            | s |             |
|     complications, such as lymphedemas;  |            | i |             |
|                                          |            | t |             |
| -   breast prostheses and surgical bras  |            | s |             |
|     and replacements (see Prosthetic     |            |   |             |
|     devices)                             |            | N |             |
|                                          |            | o |             |
| Note: If you need a mastectomy, you may  |            | t |             |
| choose to have the procedure performed   |            | h |             |
| on an inpatient basis and remain in the  |            | i |             |
| hospital up to 48 hours after the        |            | n |             |
| procedure                                |            | g |             |
|                                          |            | f |             |
|                                          |            | o |             |
|                                          |            | r |             |
|                                          |            | c |             |
|                                          |            | h |             |
|                                          |            | i |             |
|                                          |            | l |             |
|                                          |            | d |             |
|                                          |            | r |             |
|                                          |            | e |             |
|                                          |            | n |             |
|                                          |            | ( |             |
|                                          |            | t |             |
|                                          |            | h |             |
|                                          |            | r |             |
|                                          |            | o |             |
|                                          |            | u |             |
|                                          |            | g |             |
|                                          |            | h |             |
|                                          |            | a |             |
|                                          |            | g |             |
|                                          |            | e |             |
|                                          |            | 1 |             |
|                                          |            | 8 |             |
|                                          |            | ) |             |
|                                          |            |   |             |
|                                          |            | \ |             |
|                                          |            | $ |             |
|                                          |            | 2 |             |
|                                          |            | 0 |             |
|                                          |            | p |             |
|                                          |            | e |             |
|                                          |            | r |             |
|                                          |            | o |             |
|                                          |            | u |             |
|                                          |            | t |             |
|                                          |            | p |             |
|                                          |            | a |             |
|                                          |            | t |             |
|                                          |            | i |             |
|                                          |            | e |             |
|                                          |            | n |             |
|                                          |            | t |             |
|                                          |            | v |             |
|                                          |            | i |             |
|                                          |            | s |             |
|                                          |            | i |             |
|                                          |            | t |             |
+------------------------------------------+------------+---+-------------+
| *Not covered:*                           | *All       | * |             |
|                                          | charges*   | A |             |
| -   *Cosmetic surgery -- any surgical    |            | l |             |
|     procedure (or any portion of a       |            | l |             |
|     procedure) performed primarily to    |            | c |             |
|     improve physical appearance through  |            | h |             |
|     change in bodily form, except repair |            | a |             |
|     of accidental injury*                |            | r |             |
|                                          |            | g |             |
| -   *Surgeries related to sex            |            | e |             |
|     transformation*                      |            | s |             |
|                                          |            | * |             |
+------------------------------------------+------------+---+-------------+
| ###### Oral and maxillofacial surgery    | High       | S |             |
|                                          | Option     | t |             |
|                                          |            | a |             |
|                                          | You pay    | n |             |
|                                          |            | d |             |
|                                          |            | a |             |
|                                          |            | r |             |
|                                          |            | d |             |
|                                          |            | O |             |
|                                          |            | p |             |
|                                          |            | t |             |
|                                          |            | i |             |
|                                          |            | o |             |
|                                          |            | n |             |
|                                          |            |   |             |
|                                          |            | Y |             |
|                                          |            | o |             |
|                                          |            | u |             |
|                                          |            | p |             |
|                                          |            | a |             |
|                                          |            | y |             |
+------------------------------------------+------------+---+-------------+
| Oral surgical procedures, limited to:    | \$10 per   | \ |             |
|                                          | office     | $ |             |
| -   Reduction of fractures of the jaws   | visit;     | 2 |             |
|     or facial bones;                     | nothing    | 0 |             |
|                                          | for        | p |             |
| -   Surgical correction of cleft lip,    | hospital   | e |             |
|     cleft palate or severe functional    | visit      | r |             |
|     malocclusion;                        |            | o |             |
|                                          | \$10 per   | f |             |
| -   Removal of stones from salivary      | outpatient | f |             |
|     ducts;                               | visit      | i |             |
|                                          |            | c |             |
| -   Excision of leukoplakia or           |            | e |             |
|     malignancies;                        |            | v |             |
|                                          |            | i |             |
| -   Excision of cysts and incision of    |            | s |             |
|     abscesses when done as independent   |            | i |             |
|     procedures;                          |            | t |             |
|                                          |            | ; |             |
| -   Temporanmandibular Joint treatment   |            | n |             |
|     (TMJ); and                           |            | o |             |
|                                          |            | t |             |
| -   Other surgical procedures that do    |            | h |             |
|     not involve the teeth or their       |            | i |             |
|     supporting structures.               |            | n |             |
|                                          |            | g |             |
|                                          |            | f |             |
|                                          |            | o |             |
|                                          |            | r |             |
|                                          |            | h |             |
|                                          |            | o |             |
|                                          |            | s |             |
|                                          |            | p |             |
|                                          |            | i |             |
|                                          |            | t |             |
|                                          |            | a |             |
|                                          |            | l |             |
|                                          |            | v |             |
|                                          |            | i |             |
|                                          |            | s |             |
|                                          |            | i |             |
|                                          |            | t |             |
|                                          |            | s |             |
|                                          |            |   |             |
|                                          |            | N |             |
|                                          |            | o |             |
|                                          |            | t |             |
|                                          |            | h |             |
|                                          |            | i |             |
|                                          |            | n |             |
|                                          |            | g |             |
|                                          |            | f |             |
|                                          |            | o |             |
|                                          |            | r |             |
|                                          |            | c |             |
|                                          |            | h |             |
|                                          |            | i |             |
|                                          |            | l |             |
|                                          |            | d |             |
|                                          |            | r |             |
|                                          |            | e |             |
|                                          |            | n |             |
|                                          |            | ( |             |
|                                          |            | t |             |
|                                          |            | h |             |
|                                          |            | r |             |
|                                          |            | o |             |
|                                          |            | u |             |
|                                          |            | g |             |
|                                          |            | h |             |
|                                          |            | a |             |
|                                          |            | g |             |
|                                          |            | e |             |
|                                          |            | 1 |             |
|                                          |            | 8 |             |
|                                          |            | ) |             |
|                                          |            |   |             |
|                                          |            | \ |             |
|                                          |            | $ |             |
|                                          |            | 2 |             |
|                                          |            | 0 |             |
|                                          |            | p |             |
|                                          |            | e |             |
|                                          |            | r |             |
|                                          |            | o |             |
|                                          |            | u |             |
|                                          |            | t |             |
|                                          |            | p |             |
|                                          |            | a |             |
|                                          |            | t |             |
|                                          |            | i |             |
|                                          |            | e |             |
|                                          |            | n |             |
|                                          |            | t |             |
|                                          |            | v |             |
|                                          |            | i |             |
|                                          |            | s |             |
|                                          |            | i |             |
|                                          |            | t |             |
+------------------------------------------+------------+---+-------------+
| *Not covered:*                           | *All       | * |             |
|                                          | charges*   | A |             |
| -   *Oral implants and transplants*      |            | l |             |
|                                          |            | l |             |
| -   *Procedures that involve the teeth   |            | c |             |
|     or their supporting structures (such |            | h |             |
|     as the periodontal membrane,         |            | a |             |
|     gingiva, and alveolar bone)*         |            | r |             |
|                                          |            | g |             |
| -   *All other procedures involving the  |            | e |             |
|     teeth or intra-oral areas            |            | s |             |
|     surrounding the teeth are not        |            | * |             |
|     covered, including any dental care   |            |   |             |
|     involved in the treatment of         |            |   |             |
|     temporomandibular joint (TMJ) pain   |            |   |             |
|     dysfunction syndrome.*               |            |   |             |
+------------------------------------------+------------+---+-------------+
| ###### Organ/tissue transplants          | You pay    |   | You pay     |
+------------------------------------------+------------+---+-------------+
| Limited to:                              | Nothing    |   | Nothing     |
|                                          |            |   |             |
| -   Cornea                               |            |   |             |
|                                          |            |   |             |
| -   Heart                                |            |   |             |
|                                          |            |   |             |
| -   Heart/lung                           |            |   |             |
|                                          |            |   |             |
| -   Kidney                               |            |   |             |
|                                          |            |   |             |
| -   Kidney/Pancreas                      |            |   |             |
|                                          |            |   |             |
| -   Liver                                |            |   |             |
|                                          |            |   |             |
| -   Lung: Single --Double                |            |   |             |
|                                          |            |   |             |
| -   Pancreas                             |            |   |             |
|                                          |            |   |             |
| -   Allogenic (donor) bone marrow        |            |   |             |
|     transplants                          |            |   |             |
|                                          |            |   |             |
| -   Autologous bone marrow transplants   |            |   |             |
|     (autologous stem cell and peripheral |            |   |             |
|     stem cell support) for the following |            |   |             |
|     conditions: acute lymphocytic or     |            |   |             |
|     non-lymphocytic leukemia; advanced   |            |   |             |
|     Hodgkin\'s lymphoma; advanced        |            |   |             |
|     non-Hodgkin\'s lymphoma; advanced    |            |   |             |
|     neuroblastoma; breast cancer;        |            |   |             |
|     multiple myeloma; epithelial ovarian |            |   |             |
|     cancer; and testicular, mediastinal, |            |   |             |
|     retroperitoneal and ovarian germ     |            |   |             |
|     cell tumors                          |            |   |             |
|                                          |            |   |             |
| -   Intestinal transplants (small        |            |   |             |
|     intestine) and the small intestine   |            |   |             |
|     with the liver or small intestine    |            |   |             |
|     with multiple organs such as the     |            |   |             |
|     liver, stomach, and pancreas         |            |   |             |
|                                          |            |   |             |
| -   National Transplant Program (NTP) -- |            |   |             |
|     GHI HMO will cover transplants       |            |   |             |
|     approved as safe and effective for a |            |   |             |
|     specific disease by the Federal Drug |            |   |             |
|     Administration (FDA) or National     |            |   |             |
|     Institute of Health or which GHI     |            |   |             |
|     HMO's Medical Director determines is |            |   |             |
|     medically necessary, appropriate and |            |   |             |
|     advisable on a case-by-case basis.   |            |   |             |
|     GHI HMO will cover the medical and   |            |   |             |
|     hospital services, and related organ |            |   |             |
|     acquisition costs. Eligibility for   |            |   |             |
|     transplants shall be determined      |            |   |             |
|     solely by GHI HMO's Medical Director |            |   |             |
|     upon recommendation of an Enrollee's |            |   |             |
|     Primary Care Physician. Eligibility  |            |   |             |
|     for transplants must be approved in  |            |   |             |
|     advance of surgery by GHI HMO's      |            |   |             |
|     Medical Director. Additionally, all  |            |   |             |
|     transplants must be performed at     |            |   |             |
|     hospitals specifically approved and  |            |   |             |
|     designated by GHI HMO to perform     |            |   |             |
|     these procedures. Specialty          |            |   |             |
|     physician experts from our           |            |   |             |
|     designated centers of excellence     |            |   |             |
|     will provide clinical review and     |            |   |             |
|     support to the Medical Director's    |            |   |             |
|     decision.                            |            |   |             |
|                                          |            |   |             |
| Limited Benefits -- Treatment for breast |            |   |             |
| cancer, multiple myeloma, and epithelial |            |   |             |
| ovarian cancer may be provided in an     |            |   |             |
| NCI- or NIH-approved clinical trial at a |            |   |             |
| Plan-designated center of excellence and |            |   |             |
| if approved by the Plan's medical        |            |   |             |
| director in accordance with the Plan's   |            |   |             |
| protocols.                               |            |   |             |
|                                          |            |   |             |
| Note: We cover related medical and       |            |   |             |
| hospital expenses of the donor when we   |            |   |             |
| cover the recipient.                     |            |   |             |
+------------------------------------------+------------+---+-------------+
| Organ/tissue transplants *(continued)*   | High       |   | Standard    |
|                                          | Option     |   | Option      |
|                                          |            |   |             |
|                                          | You pay    |   | You pay     |
+------------------------------------------+------------+---+-------------+
| *Not covered:*                           | *All       |   | *All        |
|                                          | Charges*   |   | Charges*    |
| -   *Donor screening tests and donor     |            |   |             |
|     search expenses, except those*       |            |   |             |
|                                          |            |   |             |
| -   *Performed for the actual donor*     |            |   |             |
|                                          |            |   |             |
| -   *Implants of artificial organs*      |            |   |             |
|                                          |            |   |             |
| -   *Transplants not listed as covered*  |            |   |             |
+------------------------------------------+------------+---+-------------+
| ###### Anesthesia                        |            |   |             |
+------------------------------------------+------------+---+-------------+
| Professional services provided in --     | Nothing    |   | Nothing     |
|                                          |            |   |             |
| -   Hospital (inpatient)                 |            |   |             |
+------------------------------------------+------------+---+-------------+
| Professional services provided in --     | Nothing    |   | Nothing     |
|                                          |            |   |             |
| -   Hospital outpatient department       |            |   |             |
|                                          |            |   |             |
| -   Skilled nursing facility             |            |   |             |
|                                          |            |   |             |
| -   Ambulatory surgical center           |            |   |             |
|                                          |            |   |             |
| -   Office                               |            |   |             |
+------------------------------------------+------------+---+-------------+

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

+----+---+-----------------------------------+------------+---+---+-----+
|    | * | > **Here are some important       |            |   | * |     |
|    | * | > things to remember about these  |            |   | * |     |
|    | I | > benefits:**                     |            |   | I |     |
|    | * |                                   |            |   | * |     |
|    | * | -   Please remember that all      |            |   | * |     |
|    |   |     benefits are subject to the   |            |   |   |     |
|    | * |     definitions, limitations, and |            |   | * |     |
|    | * |     exclusions in this brochure   |            |   | * |     |
|    | M |     and are payable only when we  |            |   | M |     |
|    | * |     determine they are medically  |            |   | * |     |
|    | * |     necessary.                    |            |   | * |     |
|    |   |                                   |            |   |   |     |
|    | * | -   Plan physicians must provide  |            |   | * |     |
|    | * |     or arrange your care and you  |            |   | * |     |
|    | P |     must be hospitalized in a     |            |   | P |     |
|    | * |     Plan facility.                |            |   | * |     |
|    | * |                                   |            |   | * |     |
|    |   | -   *We have no calendar year     |            |   |   |     |
|    | * |     deductible.*                  |            |   | * |     |
|    | * |                                   |            |   | * |     |
|    | O | -   Be sure to read Section 4,    |            |   | O |     |
|    | * |     *Your costs for covered       |            |   | * |     |
|    | * |     services,* for valuable       |            |   | * |     |
|    |   |     information about how cost    |            |   |   |     |
|    | * |     sharing works. Also read      |            |   | * |     |
|    | * |     Section 9 about coordinating  |            |   | * |     |
|    | R |     benefits with other coverage, |            |   | R |     |
|    | * |     including with Medicare.      |            |   | * |     |
|    | * |                                   |            |   | * |     |
|    |   | -   The amounts listed below are  |            |   |   |     |
|    | * |     for the charges billed by the |            |   | * |     |
|    | * |     facility (i.e., hospital or   |            |   | * |     |
|    | T |     surgical center) or ambulance |            |   | T |     |
|    | * |     service for your surgery or   |            |   | * |     |
|    | * |     care. Any costs associated    |            |   | * |     |
|    |   |     with the professional charge  |            |   |   |     |
|    | * |     (i.e., physicians, etc.) are  |            |   | * |     |
|    | * |     covered in Sections 5(a) or   |            |   | * |     |
|    | A |     (b).                          |            |   | A |     |
|    | * |                                   |            |   | * |     |
|    | * | -   **YOUR PHYSICIAN MUST GET     |            |   | * |     |
|    |   |     PRIOR AUTHORIZATION OF        |            |   |   |     |
|    | * |     HOSPITAL STAYS.** Please      |            |   | * |     |
|    | * |     refer to Section 3 to be sure |            |   | * |     |
|    | N |     which services require prior  |            |   | N |     |
|    | * |     authorization                 |            |   | * |     |
|    | * |     precertification.             |            |   | * |     |
|    |   |                                   |            |   |   |     |
|    | * | -                                 |            |   | * |     |
|    | * |                                   |            |   | * |     |
|    | T |                                   |            |   | T |     |
|    | * |                                   |            |   | * |     |
|    | * |                                   |            |   | * |     |
+----+---+-----------------------------------+------------+---+---+-----+
| B  |   |                                   | High       | S |   |     |
| en |   |                                   | Option     | t |   |     |
| ef |   |                                   |            | a |   |     |
| it |   |                                   | You pay    | n |   |     |
| D  |   |                                   |            | d |   |     |
| es |   |                                   |            | a |   |     |
| cr |   |                                   |            | r |   |     |
| ip |   |                                   |            | d |   |     |
| ti |   |                                   |            | O |   |     |
| on |   |                                   |            | p |   |     |
|    |   |                                   |            | t |   |     |
|    |   |                                   |            | i |   |     |
|    |   |                                   |            | o |   |     |
|    |   |                                   |            | n |   |     |
|    |   |                                   |            |   |   |     |
|    |   |                                   |            | Y |   |     |
|    |   |                                   |            | o |   |     |
|    |   |                                   |            | u |   |     |
|    |   |                                   |            | P |   |     |
|    |   |                                   |            | a |   |     |
|    |   |                                   |            | y |   |     |
+----+---+-----------------------------------+------------+---+---+-----+
| #  |   |                                   |            |   |   |     |
| ## |   |                                   |            |   |   |     |
| ## |   |                                   |            |   |   |     |
| #  |   |                                   |            |   |   |     |
| In |   |                                   |            |   |   |     |
| pa |   |                                   |            |   |   |     |
| ti |   |                                   |            |   |   |     |
| en |   |                                   |            |   |   |     |
| t  |   |                                   |            |   |   |     |
| ho |   |                                   |            |   |   |     |
| sp |   |                                   |            |   |   |     |
| it |   |                                   |            |   |   |     |
| al |   |                                   |            |   |   |     |
+----+---+-----------------------------------+------------+---+---+-----+
| Ro |   |                                   | Nothing    | N |   |     |
| om |   |                                   |            | o |   |     |
| a  |   |                                   |            | t |   |     |
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|    |   |                                   |            |   |   |     |
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|    |   |                                   |            |   |   |     |
|  W |   |                                   |            |   |   |     |
| ar |   |                                   |            |   |   |     |
| d, |   |                                   |            |   |   |     |
|    |   |                                   |            |   |   |     |
|    |   |                                   |            |   |   |     |
| se |   |                                   |            |   |   |     |
| mi |   |                                   |            |   |   |     |
| pr |   |                                   |            |   |   |     |
| iv |   |                                   |            |   |   |     |
| at |   |                                   |            |   |   |     |
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|    |   |                                   |            |   |   |     |
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| or |   |                                   |            |   |   |     |
|    |   |                                   |            |   |   |     |
|    |   |                                   |            |   |   |     |
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| nt |   |                                   |            |   |   |     |
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|    |   |                                   |            |   |   |     |
|    |   |                                   |            |   |   |     |
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|    |   |                                   |            |   |   |     |
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|    |   |                                   |            |   |   |     |
|    |   |                                   |            |   |   |     |
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| ar |   |                                   |            |   |   |     |
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|    |   |                                   |            |   |   |     |
|    |   |                                   |            |   |   |     |
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| nd |   |                                   |            |   |   |     |
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|    |   |                                   |            |   |   |     |
|  M |   |                                   |            |   |   |     |
| ea |   |                                   |            |   |   |     |
| ls |   |                                   |            |   |   |     |
|    |   |                                   |            |   |   |     |
|    |   |                                   |            |   |   |     |
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| nd |   |                                   |            |   |   |     |
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| pe |   |                                   |            |   |   |     |
| ci |   |                                   |            |   |   |     |
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|    |   |                                   |            |   |   |     |
|    |   |                                   |            |   |   |     |
|  d |   |                                   |            |   |   |     |
| ie |   |                                   |            |   |   |     |
| ts |   |                                   |            |   |   |     |
|    |   |                                   |            |   |   |     |
| -  |   |                                   |            |   |   |     |
|    |   |                                   |            |   |   |     |
|  S |   |                                   |            |   |   |     |
| pe |   |                                   |            |   |   |     |
| ci |   |                                   |            |   |   |     |
| al |   |                                   |            |   |   |     |
|    |   |                                   |            |   |   |     |
|    |   |                                   |            |   |   |     |
| du |   |                                   |            |   |   |     |
| ty |   |                                   |            |   |   |     |
|    |   |                                   |            |   |   |     |
|    |   |                                   |            |   |   |     |
|  n |   |                                   |            |   |   |     |
| ur |   |                                   |            |   |   |     |
| si |   |                                   |            |   |   |     |
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|    |   |                                   |            |   |   |     |
|    |   |                                   |            |   |   |     |
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| nd |   |                                   |            |   |   |     |
|    |   |                                   |            |   |   |     |
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|  p |   |                                   |            |   |   |     |
| ri |   |                                   |            |   |   |     |
| va |   |                                   |            |   |   |     |
| te |   |                                   |            |   |   |     |
|    |   |                                   |            |   |   |     |
|    |   |                                   |            |   |   |     |
|  r |   |                                   |            |   |   |     |
| oo |   |                                   |            |   |   |     |
| ms |   |                                   |            |   |   |     |
|    |   |                                   |            |   |   |     |
|    |   |                                   |            |   |   |     |
| du |   |                                   |            |   |   |     |
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| ng |   |                                   |            |   |   |     |
|    |   |                                   |            |   |   |     |
|    |   |                                   |            |   |   |     |
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| np |   |                                   |            |   |   |     |
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| nt |   |                                   |            |   |   |     |
|    |   |                                   |            |   |   |     |
|    |   |                                   |            |   |   |     |
|  h |   |                                   |            |   |   |     |
| os |   |                                   |            |   |   |     |
| pi |   |                                   |            |   |   |     |
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|    |   |                                   |            |   |   |     |
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|    |   |                                   |            |   |   |     |
|    |   |                                   |            |   |   |     |
|  n |   |                                   |            |   |   |     |
| ec |   |                                   |            |   |   |     |
| es |   |                                   |            |   |   |     |
| sa |   |                                   |            |   |   |     |
| ry |   |                                   |            |   |   |     |
|    |   |                                   |            |   |   |     |
|    |   |                                   |            |   |   |     |
|  a |   |                                   |            |   |   |     |
| nd |   |                                   |            |   |   |     |
|    |   |                                   |            |   |   |     |
|    |   |                                   |            |   |   |     |
| ap |   |                                   |            |   |   |     |
| pr |   |                                   |            |   |   |     |
| ov |   |                                   |            |   |   |     |
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|    |   |                                   |            |   |   |     |
|    |   |                                   |            |   |   |     |
| by |   |                                   |            |   |   |     |
|    |   |                                   |            |   |   |     |
|    |   |                                   |            |   |   |     |
|  G |   |                                   |            |   |   |     |
| HI |   |                                   |            |   |   |     |
|    |   |                                   |            |   |   |     |
|    |   |                                   |            |   |   |     |
|  H |   |                                   |            |   |   |     |
| MO |   |                                   |            |   |   |     |
|    |   |                                   |            |   |   |     |
|    |   |                                   |            |   |   |     |
|  M |   |                                   |            |   |   |     |
| ed |   |                                   |            |   |   |     |
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|    |   |                                   |            |   |   |     |
|    |   |                                   |            |   |   |     |
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|    |   |                                   |            |   |   |     |
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| ss |   |                                   |            |   |   |     |
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| ge |   |                                   |            |   |   |     |
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| bo |   |                                   |            |   |   |     |
| ve |   |                                   |            |   |   |     |
| t  |   |                                   |            |   |   |     |
| he |   |                                   |            |   |   |     |
| s  |   |                                   |            |   |   |     |
| em |   |                                   |            |   |   |     |
| ip |   |                                   |            |   |   |     |
| ri |   |                                   |            |   |   |     |
| va |   |                                   |            |   |   |     |
| te |   |                                   |            |   |   |     |
| ro |   |                                   |            |   |   |     |
| om |   |                                   |            |   |   |     |
| r  |   |                                   |            |   |   |     |
| at |   |                                   |            |   |   |     |
| e. |   |                                   |            |   |   |     |
+----+---+-----------------------------------+------------+---+---+-----+

*.*

+--------------------------------------------+-----------+---+------------+
| Inpatient hospital *(continued)*           | High      | S |            |
|                                            | Option    | t |            |
|                                            |           | a |            |
|                                            | You pay   | n |            |
|                                            |           | d |            |
|                                            |           | a |            |
|                                            |           | r |            |
|                                            |           | d |            |
|                                            |           | O |            |
|                                            |           | p |            |
|                                            |           | t |            |
|                                            |           | i |            |
|                                            |           | o |            |
|                                            |           | n |            |
|                                            |           |   |            |
|                                            |           | Y |            |
|                                            |           | o |            |
|                                            |           | u |            |
|                                            |           | p |            |
|                                            |           | a |            |
|                                            |           | y |            |
+--------------------------------------------+-----------+---+------------+
| Other hospital services and supplies, such | Nothing   | N |            |
| as:                                        |           | o |            |
|                                            |           | t |            |
| -   Operating, recovery, maternity, and    |           | h |            |
|     other treatment rooms                  |           | i |            |
|                                            |           | n |            |
| -   Prescribed drugs and medicines         |           | g |            |
|                                            |           |   |            |
| -   Diagnostic laboratory tests and X-rays |           |   |            |
|                                            |           |   |            |
| -   Administration of blood and blood      |           |   |            |
|     products                               |           |   |            |
|                                            |           |   |            |
| -   Blood or blood plasma, if not donated  |           |   |            |
|     or replaced                            |           |   |            |
|                                            |           |   |            |
| -   Dressings, splints, casts, and sterile |           |   |            |
|     tray services                          |           |   |            |
|                                            |           |   |            |
| -   Medical supplies and equipment,        |           |   |            |
|     including oxygen                       |           |   |            |
|                                            |           |   |            |
| -   Anesthetics, including nurse           |           |   |            |
|     anesthetist services                   |           |   |            |
|                                            |           |   |            |
| -   Take-home items                        |           |   |            |
|                                            |           |   |            |
| -   Medical supplies, appliances, medical  |           |   |            |
|     equipment, and any covered items       |           |   |            |
|     billed by a hospital for use at home   |           |   |            |
+--------------------------------------------+-----------+---+------------+
| *Not covered:*                             | *All      | * |            |
|                                            | charges*  | A |            |
| -   *Custodial care*                       |           | l |            |
|                                            |           | l |            |
| -   *Non-covered facilities, such as       |           | c |            |
|     nursing homes, schools*                |           | h |            |
|                                            |           | a |            |
| -   *Personal comfort items, such as       |           | r |            |
|     telephone, television, barber          |           | g |            |
|     services, guest meals and beds*        |           | e |            |
|                                            |           | s |            |
| -   *Private nursing care*                 |           | * |            |
+--------------------------------------------+-----------+---+------------+
| ###### Outpati                             | High      |   | Standard   |
| ent hospital or ambulatory surgical center | Option    |   | Option     |
|                                            |           |   |            |
|                                            | You pay   |   | You pay    |
+--------------------------------------------+-----------+---+------------+
| -   Operating, recovery, and other         | Nothing   |   | \$75 copay |
|     treatment rooms                        |           |   | per visit  |
|                                            |           |   |            |
| -   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                            |           |   |            |
|                                            |           |   |            |
| -   Pre-surgical testing                   |           |   |            |
|                                            |           |   |            |
| -   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 if in connection with an        |           |   |            |
| accidental injury to sound natural teeth   |           |   |            |
| within twelve (12) months of the accident, |           |   |            |
| or in the judgement of GHI HMO's Medical   |           |   |            |
| Director, a hazardous concurrent medical   |           |   |            |
| condition requires hospitalization.        |           |   |            |
| Hospital care is only available when a     |           |   |            |
| medical condition necessitates such care.  |           |   |            |
| We do not cover the dental procedures.     |           |   |            |
|                                            |           |   |            |
| #######                                    |           |   |            |
+--------------------------------------------+-----------+---+------------+
| *Not covered: Blood and blood derivatives  | *Nothing* |   | *Nothing*  |
| not replaced by the member*                |           |   |            |
+--------------------------------------------+-----------+---+------------+
| ###### Extended care benef                 |           |   |            |
| its/skilled nursing care facility benefits |           |   |            |
+--------------------------------------------+-----------+---+------------+
| Skilled nursing facility (SNF):            | Nothing   |   | Nothing    |
|                                            |           |   |            |
| Limited to 120 days per person per         |           |   |            |
| calendar year :                            |           |   |            |
|                                            |           |   |            |
| -   Bed, board and general nursing care    |           |   |            |
|                                            |           |   |            |
| -   Drugs, biologicals, supplies and       |           |   |            |
|     equipment ordinarily provided or       |           |   |            |
|     arranged by the skilled nursing        |           |   |            |
|     facility when prescribed by your plan  |           |   |            |
|     doctor.                                |           |   |            |
+--------------------------------------------+-----------+---+------------+
| *Not covered: Custodial care*              | *All      |   | *All       |
|                                            | charges*  |   | charges*   |
+--------------------------------------------+-----------+---+------------+
| ###### Hospice care                        |           |   |            |
+--------------------------------------------+-----------+---+------------+
| Supportive and palliative care for the     | Nothing   |   | Nothing    |
| terminally ill member is covered in the    |           |   |            |
| home or hospice facility. Services include |           |   |            |
| inpatient and outpatient care and family   |           |   |            |
| counseling. Benefits are limited to 210    |           |   |            |
| days; bereavement counseling services are  |           |   |            |
| covered up to five (5) days.               |           |   |            |
+--------------------------------------------+-----------+---+------------+
| ###### Hospice care *(continued)*          | High      |   | Standard   |
|                                            | Option    |   | Option     |
|                                            |           |   |            |
|                                            | You pay   |   | You pay    |
+--------------------------------------------+-----------+---+------------+
| *Not covered: Independent nursing,         | *All      |   | *All       |
| homemaker services*                        | charges*  |   | charges*   |
+--------------------------------------------+-----------+---+------------+
| ###### Ambulance                           |           |   |            |
+--------------------------------------------+-----------+---+------------+
| -   Local professional ambulance service   | Nothing   |   | \$50 copay |
|     when medically appropriate             |           |   | per visit  |
+--------------------------------------------+-----------+---+------------+

## Section 5(d) Emergency services/accidents

+---+---+--------------------------------------+---------+----+---+----+
|   | * | > **Here are some important things   |         |    | * | ## |
|   | * | > to keep in mind about these        |         |    | * | ## |
|   | I | > benefits:**                        |         |    | I | #  |
|   | * |                                      |         |    | * |    |
|   | * | -   Please remember that all         |         |    | * |    |
|   |   |     benefits are subject to the      |         |    |   |    |
|   | * |     definitions, limitations, and    |         |    | * |    |
|   | * |     exclusions in this brochure and  |         |    | * |    |
|   | M |     are payable only when we         |         |    | M |    |
|   | * |     determine they are medically     |         |    | * |    |
|   | * |     necessary.                       |         |    | * |    |
|   |   |                                      |         |    |   |    |
|   | * | -   *We have no calendar year        |         |    | * |    |
|   | * |     deductible.*                     |         |    | * |    |
|   | P |                                      |         |    | P |    |
|   | * | -   Be sure to read Section 4, *Your |         |    | * |    |
|   | * |     costs for covered services,* for |         |    | * |    |
|   |   |     valuable information about how   |         |    |   |    |
|   | * |     cost sharing works. Also read    |         |    | * |    |
|   | * |     Section 9 about coordinating     |         |    | * |    |
|   | O |     benefits with other coverage,    |         |    | O |    |
|   | * |     including with Medicare.         |         |    | * |    |
|   | * |                                      |         |    | * |    |
|   |   | #####                                |         |    |   |    |
|   | * |                                      |         |    | * |    |
|   | * |                                      |         |    | * |    |
|   | R |                                      |         |    | R |    |
|   | * |                                      |         |    | * |    |
|   | * |                                      |         |    | * |    |
|   |   |                                      |         |    |   |    |
|   | * |                                      |         |    | * |    |
|   | * |                                      |         |    | * |    |
|   | T |                                      |         |    | T |    |
|   | * |                                      |         |    | * |    |
|   | * |                                      |         |    | * |    |
|   |   |                                      |         |    |   |    |
|   | * |                                      |         |    | * |    |
|   | * |                                      |         |    | * |    |
|   | A |                                      |         |    | A |    |
|   | * |                                      |         |    | * |    |
|   | * |                                      |         |    | * |    |
|   |   |                                      |         |    |   |    |
|   | * |                                      |         |    | * |    |
|   | * |                                      |         |    | * |    |
|   | N |                                      |         |    | N |    |
|   | * |                                      |         |    | * |    |
|   | * |                                      |         |    | * |    |
|   |   |                                      |         |    |   |    |
|   | * |                                      |         |    | * |    |
|   | * |                                      |         |    | * |    |
|   | T |                                      |         |    | T |    |
|   | * |                                      |         |    | * |    |
|   | * |                                      |         |    | * |    |
+---+---+--------------------------------------+---------+----+---+----+
| * |   |                                      |         |    |   |    |
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+---+---+--------------------------------------+---------+----+---+----+
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+---+---+--------------------------------------+---------+----+---+----+

##### 

##  {#section-10 .unnumbered}

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

+---+---+---------------------------------------+-----------+----+---+---+
|   | * | When you get our approval for         |           |    | * | # |
|   | * | services and follow a treatment plan  |           |    | * | # |
|   | I | we approve, cost-sharing and          |           |    | I | # |
|   | * | limitations for Plan mental health    |           |    | * | # |
|   | * | and substance abuse benefits will be  |           |    | * | # |
|   |   | no greater than for similar benefits  |           |    |   |   |
|   | * | for other illnesses and conditions.   |           |    | * |   |
|   | * |                                       |           |    | * |   |
|   | M | **Here are some important things to   |           |    | M |   |
|   | * | keep in mind about these benefits:**  |           |    | * |   |
|   | * |                                       |           |    | * |   |
|   |   | -   Please remember that all benefits |           |    |   |   |
|   | * |     are subject to the definitions,   |           |    | * |   |
|   | * |     limitations, and exclusions in    |           |    | * |   |
|   | P |     this brochure and are payable     |           |    | P |   |
|   | * |     only when we determine they are   |           |    | * |   |
|   | * |     medically necessary.              |           |    | * |   |
|   |   |                                       |           |    |   |   |
|   | * | -   *We have no calendar year         |           |    | * |   |
|   | * |     deductible*                       |           |    | * |   |
|   | O |                                       |           |    | O |   |
|   | * | -   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      |           |    | * |   |
|   | R |     benefits with other coverage,     |           |    | R |   |
|   | * |     including with Medicare.          |           |    | * |   |
|   | * |                                       |           |    | * |   |
|   |   | -   **YOU MUST GET PREAUTHORIZATION   |           |    |   |   |
|   | * |     OF THESE SERVICES**. See the      |           |    | * |   |
|   | * |     instructions after the benefits   |           |    | * |   |
|   | T |     description below.                |           |    | T |   |
|   | * |                                       |           |    | * |   |
|   | * |                                       |           |    | * |   |
|   |   |                                       |           |    |   |   |
|   | * |                                       |           |    | * |   |
|   | * |                                       |           |    | * |   |
|   | A |                                       |           |    | A |   |
|   | * |                                       |           |    | * |   |
|   | * |                                       |           |    | * |   |
|   |   |                                       |           |    |   |   |
|   | * |                                       |           |    | * |   |
|   | * |                                       |           |    | * |   |
|   | N |                                       |           |    | N |   |
|   | * |                                       |           |    | * |   |
|   | * |                                       |           |    | * |   |
|   |   |                                       |           |    |   |   |
|   | * |                                       |           |    | * |   |
|   | * |                                       |           |    | * |   |
|   | T |                                       |           |    | T |   |
|   | * |                                       |           |    | * |   |
|   | * |                                       |           |    | * |   |
+---+---+---------------------------------------+-----------+----+---+---+
| B |   |                                       | High      | St |   |   |
| e |   |                                       | Option    | an |   |   |
| n |   |                                       |           | da |   |   |
| e |   |                                       | You pay   | rd |   |   |
| f |   |                                       |           | Op |   |   |
| i |   |                                       |           | ti |   |   |
| t |   |                                       |           | on |   |   |
| D |   |                                       |           |    |   |   |
| e |   |                                       |           | Y  |   |   |
| s |   |                                       |           | ou |   |   |
| c |   |                                       |           | p  |   |   |
| r |   |                                       |           | ay |   |   |
| i |   |                                       |           |    |   |   |
| p |   |                                       |           |    |   |   |
| t |   |                                       |           |    |   |   |
| i |   |                                       |           |    |   |   |
| o |   |                                       |           |    |   |   |
| n |   |                                       |           |    |   |   |
+---+---+---------------------------------------+-----------+----+---+---+
| # |   |                                       | ###       |    |   |   |
| # |   |                                       |           |    |   |   |
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|   |   |                                       |           |    |   |   |
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+---+---+---------------------------------------+-----------+----+---+---+

+---------------------------------------------+----------+-------------+
| Mental health and substance abuse benefits  | High     | Standard    |
| *(continued)*                               | Option   | Option      |
|                                             |          |             |
|                                             | You pay  | You pay     |
+---------------------------------------------+----------+-------------+
| Lab work                                    | Nothing  | Nothing if  |
|                                             | if you   | you receive |
|                                             | receive  | these       |
|                                             | these    | services    |
|                                             | services | during your |
|                                             | during   | office      |
|                                             | your     | visit;      |
|                                             | office   | otherwise   |
|                                             | visit;   | \$20 per    |
|                                             | ot       | office      |
|                                             | herwise, | visit       |
|                                             | \$10 per |             |
|                                             | office   |             |
|                                             | visit    |             |
+---------------------------------------------+----------+-------------+
| X-Ray and other Diagnostic Tests, such as:  | \$10     | \$20 copay  |
|                                             | copay at | at an       |
| -   X-rays                                  | an       | outpatient  |
|                                             | ou       | facility    |
| -   Diagnostic test                         | tpatient |             |
|                                             | facility |             |
+---------------------------------------------+----------+-------------+
| -   Services provided by a hospital or      | Nothing  | Nothing     |
|     other facility                          |          |             |
|                                             |          |             |
| -   Services in approved alternative care   |          |             |
|     settings such as:                       |          |             |
|                                             |          |             |
| ```{=html}                                  |          |             |
| <!-- -->                                    |          |             |
| ```                                         |          |             |
| -   partial hospitalization                 |          |             |
|                                             |          |             |
| -   residential treatment                   |          |             |
|                                             |          |             |
| -   full-day hospitalization                |          |             |
|                                             |          |             |
| -   facility based intensive outpatient     |          |             |
|     treatment                               |          |             |
+---------------------------------------------+----------+-------------+
| *Not covered in the network: The same       | *All     | *All        |
| exclusions contained in this brochure that  | charges* | charges*    |
| apply to other benefits apply to these      |          |             |
| mental health and substance abuse benefits, |          |             |
| unless the services are included in a       |          |             |
| treatment plan that we approve.*            |          |             |
|                                             |          |             |
| *Note: OPM will base its review of disputes |          |             |
| about treatment plans on the treatment      |          |             |
| plan\'s clinical appropriateness. OPM will  |          |             |
| generally not order us to pay or provide    |          |             |
| one clinically appropriate treatment plan   |          |             |
| in favor of another.*                       |          |             |
+---------------------------------------------+----------+-------------+

+-----------------------------------------------------------------------+
| Preauthorization                                                      |
|                                                                       |
| > To be eligible to receive these benefits you must follow your       |
| > treatment plan and all of our network authorization processes.      |
| >                                                                     |
| > Merit Behavioral Health Care an affiliate of Magellan Behavioral    |
| > Health has been contracted to manage your behavioral health         |
| > benefits. In order to access your benefits; please call the Merit   |
| > Behavioral Health Care toll free number at 1-800-836-2256. You will |
| > be connected to a customer service representative who will be able  |
| > to assist you in identifying a behavioral health care provider in   |
| > your area or to verify if your current provider is a participating  |
| > provider in the Behavioral Health network.                          |
| >                                                                     |
| > If participating, the customer service representative will verify   |
| > benefits/eligibility and an authorization for treatment will be     |
| > sent out to your provider. They will continue to follow their       |
| > contractual obligations and submit treatment plan reports for       |
| > continued authorization. The treatment reports will be reviewed by  |
| > a New York State licensed clinician to determine if the treatment   |
| > you are receiving meets medical necessity criteria for the level of |
| > care and the intensity of treatment you are receiving.              |
| >                                                                     |
| > If non-participating, the customer service representative will      |
| > either offer you a provider participating in the network that       |
| > specializes in your area of need or will offer to forward a         |
| > treatment report to you. You will be responsible for your provider  |
| > completing the forms in their entirety and returning them to the    |
| > address provided. The treatment reports will be reviewed by a New   |
| > York State licensed clinician to determine if the treatment you are |
| > receiving meets medical necessity criteria for the level of care    |
| > and the intensity of treatment you are receiving.                   |
| >                                                                     |
| > Treatment will not be interrupted if the licensed clinician         |
| > reviewer finds your treatment to be needed and appropriately        |
| > provided. At that point, your non-participating provider will be    |
| > required to sign an ad hoc agreement, which will allow you to       |
| > continue in treatment. Your non-participating provider will be      |
| > required to accept contracted rates. They will be required to       |
| > follow all the same contract requirements as a participating        |
| > provider.                                                           |
| >                                                                     |
| > Inpatient and alternative levels of care, which are more intense,   |
| > than routine outpatient therapy must be called in by using the same |
| > toll free number. New York State licensed staff is available 24     |
| > hours a day, 7 days a week, 365 days a year.                        |
| >                                                                     |
| > Participating provider directories can be obtained by calling the   |
| > Customer Service department at GHI HMO at 1-877-244-4466 or view    |
| > the directory on our website at                                     |
| > [www.ghi.com](http://www.ghihmo.com/).                              |
+-----------------------------------------------------------------------+
| **How to submit claims**                                              |
|                                                                       |
| > There are no claim forms. You must work through participating       |
| > providers. In the event you are in the transitional period, you     |
| > must notify the Plan and have the provider contact the Plan. If you |
| > have mistakenly received a bill for covered services or your        |
| > provider needs to contact GHI HMO, please contact customer service  |
| > at 1-877-244-4466. Mail billing statements to GHI HMO, Attn:        |
| > Claims, PO BOX 4332, Kingston, NY 12402.                            |
+-----------------------------------------------------------------------+
| **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 keep in mind about     | * |   |
|   | * | your prescription drug benefits:**                         | * |   |
|   | I |                                                            | I |   |
|   | * | -   GHI HMO covers your prescription medications, as       | * |   |
|   | * |     described in the chart beginning on the next page.     | * |   |
|   |   |                                                            |   |   |
|   | * | -   All prescription drug benefits are subject to the      | * |   |
|   | * |     definitions, limitations and exclusions in this        | * |   |
|   | M |     brochure. In addition, these benefits are payable only | M |   |
|   | * |     when determined by GHI HMO that they are medically     | * |   |
|   | * |     necessary.                                             | * |   |
|   |   |                                                            |   |   |
|   | * | -   *We have no calendar year deductible*                  | * |   |
|   | * |                                                            | * |   |
|   | P | -   Please refer to Section 4, *Your costs for covered     | P |   |
|   | * |     services*, for valuable information about cost         | * |   |
|   | * |     sharing, as well as the special sections for members   | * |   |
|   |   |     who are 65 years of age or over. In addition, Section  |   |   |
|   | * |     9 details how you can coordinate your prescription     | * |   |
|   | * |     drug benefits with other coverage, including Medicare. | * |   |
|   | O |                                                            | O |   |
|   | * |                                                            | * |   |
|   | * |                                                            | * |   |
|   |   |                                                            |   |   |
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|   | * |                                                            | * |   |
+---+---+------------------------------------------------------------+---+---+
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+---+---+------------------------------------------------------------+---+---+

Prescription drug benefits begin on the next page

+--------------------------------------------+------------+-----------+
| > **Benefit Description**                  | High       | Standard  |
|                                            | Option     | Option    |
|                                            |            |           |
|                                            | You pay    | You pay   |
+--------------------------------------------+------------+-----------+
| ###### Covered medications and supplies    |            |           |
+--------------------------------------------+------------+-----------+
| We cover the following medications and     | Retail     | Retail    |
| supplies prescribed by a Plan physician    | Pharmacy:  | Pharmacy: |
| and obtained from a Plan pharmacy or       |            |           |
| through our mail order program:            | \$10 copay | \$10      |
|                                            | generic    | copay     |
| -   Prescription drugs prescribed by a     |            | generic   |
|     Plan or referral doctor and obtained   | \$20 copay |           |
|     at a Plan retail pharmacy will be      | preferred  | \$20      |
|     dispensed for up to a 30-day supply or |            | copay     |
|     100 unit supply, whichever is less,    | \$30 copay | preferred |
|     240 milligrams of liquid (8 oz.); 60   | non        |           |
|     grams of ointment, creams or topical   | -preferred | \$30      |
|     preparation; or one commercially       | brand      | copay     |
|     prepared unit (i.e. one inhaler, one   |            | non-      |
|     vial ophthalmic medication or          | (30-day    | preferred |
|     insulin).                              | supply)    | brand     |
|                                            |            |           |
| -   Contraceptive drugs                    | Mail       | (30-day   |
|                                            | Order:     | supply)   |
| -   Fertility Drugs                        |            |           |
|                                            | \$20 copay | Mail      |
| -   Insulin                                | generic    | Order:    |
|                                            |            |           |
| -   Disposable needles and syringes for    | \$40 copay | \$20      |
|     the administration of covered          | preferred  | copay     |
|     medications                            |            | generic   |
|                                            | \$50 copay |           |
|                                            | non        | \$40      |
|                                            | -preferred | copay     |
|                                            | brand      | preferred |
|                                            |            |           |
|                                            | (90-day    | \$50 co   |
|                                            | supply for | pay       |
|                                            | m          | non-      |
|                                            | aintenance | preferred |
|                                            | me         | brand     |
|                                            | dications) |           |
|                                            |            | (90-day   |
|                                            |            | supply    |
|                                            |            | for       |
|                                            |            | ma        |
|                                            |            | intenance |
|                                            |            | med       |
|                                            |            | ications) |
+--------------------------------------------+------------+-----------+
|                                            |            |           |
+--------------------------------------------+------------+-----------+

+---------------------------------------------+-----------+-----------+
| Covered medications and supplies            | > **High  | > *       |
| *(continued)*                               | >         | *Standard |
|                                             |  Option** | >         |
|                                             | >         |  Option** |
|                                             | > **You   | >         |
|                                             | > pay**   | > **You   |
|                                             |           | > pay**   |
+---------------------------------------------+-----------+-----------+
| *Not covered:*                              | *All      | *All      |
|                                             | Charges*  | Charges*  |
| -   *Drugs and supplies for cosmetic        |           |           |
|     purposes*                               |           |           |
|                                             |           |           |
| -   *Drugs to enhance athletic performance* |           |           |
|                                             |           |           |
| -   *Drugs obtained at a non-Plan pharmacy; |           |           |
|     except for out-of-area emergencies*     |           |           |
|                                             |           |           |
| -   *Vitamins, nutrients and food           |           |           |
|     supplements even if a physician         |           |           |
|     prescribes or administers them*         |           |           |
|                                             |           |           |
| -   *Nonprescription medicines:*            |           |           |
|                                             |           |           |
| ```{=html}                                  |           |           |
| <!-- -->                                    |           |           |
| ```                                         |           |           |
| -   *Drugs and medicines that by Federal    |           |           |
|     law of the United States require a      |           |           |
|     physician's prescription for their      |           |           |
|     purchase, except as excluded below:*    |           |           |
|                                             |           |           |
| ```{=html}                                  |           |           |
| <!-- -->                                    |           |           |
| ```                                         |           |           |
| -   *Prescription drugs for diet or weight  |           |           |
|     control including anorexic agent*       |           |           |
|                                             |           |           |
| -   *Drugs utilized for treatment of sexual |           |           |
|     dysfunction are limited to 6 doses per  |           |           |
|     month*                                  |           |           |
|                                             |           |           |
| -   *Prescription drugs not obtained at a   |           |           |
|     GHI HMO participating pharmacy or Mail  |           |           |
|     Order pharmacy*                         |           |           |
|                                             |           |           |
| -   *Initial prescriptions or refills in    |           |           |
|     excess of a 30 consecutive days supply  |           |           |
|     or one month\'s cycle of any oral       |           |           |
|     contraceptive drug (Mail Order          |           |           |
|     available for up to a 90 day supply)*   |           |           |
|                                             |           |           |
| -   *Drugs related to non-covered medical   |           |           |
|     services*                               |           |           |
|                                             |           |           |
| -   *OTC drugs*                             |           |           |
|                                             |           |           |
| -   *Contraceptive devices such as condoms  |           |           |
|     and spermacidal agents*                 |           |           |
|                                             |           |           |
| -   *Drugs not approved by the FDA*         |           |           |
|                                             |           |           |
| -   *Medications for cosmetic purposes      |           |           |
|     only*                                   |           |           |
+---------------------------------------------+-----------+-----------+

##  {#section-13 .unnumbered}

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

+-----------------------+----------------------------------------------+
| Feature               | Description                                  |
+-----------------------+----------------------------------------------+
| ##                    | We provide a TDD Line for the deaf and       |
| ### Services for deaf | hearing impaired, 1-877-208-7920             |
|  and hearing impaired |                                              |
+-----------------------+----------------------------------------------+
| ##### Centers of exc  | Life Trac -- National Ancillary providers    |
| ellence for transplan | for organ transplants utilizing 31 Centers   |
| ts/heart surgery/etc. | of Excellence throughout the United States.  |
+-----------------------+----------------------------------------------+
| #####                 | GHI HMO is now offering the Personal Health  |
| PHIP - Personal Healt | Improvement Program (PHIP) to our members.   |
| h Improvement Program | PHIP is a behavioral medicine intervention   |
|                       | for the following types of patients:         |
|                       |                                              |
|                       | \(1\) those with stress related illnesses    |
|                       | such as headaches, back pain, fatigue,       |
|                       | insomnia, and gastrointestinal discomfort.   |
|                       |                                              |
|                       | \(2\) those learning to deal with a chronic  |
|                       | disease such as multiple sclerosis,          |
|                       | fibromyalgia and diabetes.                   |
|                       |                                              |
|                       | \(3\) patients whose mood (anxiety,          |
|                       | depression, etc.) seems to influence their   |
|                       | physical health.                             |
|                       |                                              |
|                       | PHIP is based on the mind-body theory that   |
|                       | mood and physical health are closely         |
|                       | correlated. It helps patients reduce         |
|                       | suffering and the symptoms of chronic        |
|                       | illnesses by allowing participants to become |
|                       | aware of how their bodily reactions are      |
|                       | related to behavioral patterns, including    |
|                       | coping styles. By making such connections,   |
|                       | participants learn to adopt new behaviors    |
|                       | that will relieve their pain or discomfort.  |
|                       |                                              |
|                       | The program consists of six weekly two hour  |
|                       | classes led by a trained facilitator. The    |
|                       | classes consist of a combination of group    |
|                       | discussion and specific exercises designed   |
|                       | to help participants become aware of their   |
|                       | own reactions to daily life. Participants    |
|                       | are provided with a workbook and home-study  |
|                       | questions, as well as an audiotape to guide  |
|                       | them through an awareness exercise that they |
|                       | are asked to do daily.                       |
+-----------------------+----------------------------------------------+

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

+---+---+-------------------------------------+-----------+---+---+---------+
|   | * | **Here are some important things to |           |   | * |         |
|   | * | keep in mind about these            |           |   | * |         |
|   | I | benefits:**                         |           |   | I |         |
|   | * |                                     |           |   | * |         |
|   | * | -   Please remember that all        |           |   | * |         |
|   |   |     benefits are subject to the     |           |   |   |         |
|   | * |     definitions, limitations, and   |           |   | * |         |
|   | * |     exclusions in this brochure and |           |   | * |         |
|   | M |     are payable only when we        |           |   | M |         |
|   | * |     determine they are medically    |           |   | * |         |
|   | * |     necessary.                      |           |   | * |         |
|   |   |                                     |           |   |   |         |
|   | * | -   GHI HMO does not provide dental |           |   | * |         |
|   | * |     benefits.                       |           |   | * |         |
|   | P |                                     |           |   | P |         |
|   | * | -   We cover hospitalization for    |           |   | * |         |
|   | * |     dental procedures only when a   |           |   | * |         |
|   |   |     nondental physical impairment   |           |   |   |         |
|   | * |     exists which makes              |           |   | * |         |
|   | * |     hospitalization necessary to    |           |   | * |         |
|   | O |     safeguard the health of the     |           |   | O |         |
|   | * |     patient; we do not cover the    |           |   | * |         |
|   | * |     dental procedure unless it is   |           |   | * |         |
|   |   |     described below.                |           |   |   |         |
|   | * |                                     |           |   | * |         |
|   | * | -   Be sure to read Section 4,      |           |   | * |         |
|   | R |     *Your costs for covered         |           |   | R |         |
|   | * |     services,* for valuable         |           |   | * |         |
|   | * |     information about how cost      |           |   | * |         |
|   |   |     sharing works. Also read        |           |   |   |         |
|   | * |     Section 9 about coordinating    |           |   | * |         |
|   | * |     benefits with other coverage,   |           |   | * |         |
|   | T |     including with Medicare.        |           |   | T |         |
|   | * |                                     |           |   | * |         |
|   | * |                                     |           |   | * |         |
|   |   |                                     |           |   |   |         |
|   | * |                                     |           |   | * |         |
|   | * |                                     |           |   | * |         |
|   | A |                                     |           |   | A |         |
|   | * |                                     |           |   | * |         |
|   | * |                                     |           |   | * |         |
|   |   |                                     |           |   |   |         |
|   | * |                                     |           |   | * |         |
|   | * |                                     |           |   | * |         |
|   | N |                                     |           |   | N |         |
|   | * |                                     |           |   | * |         |
|   | * |                                     |           |   | * |         |
|   |   |                                     |           |   |   |         |
|   | * |                                     |           |   | * |         |
|   | * |                                     |           |   | * |         |
|   | T |                                     |           |   | T |         |
|   | * |                                     |           |   | * |         |
|   | * |                                     |           |   | * |         |
+===+===+=====================================+===========+===+===+=========+
| # |   |                                     | High      | S |   |         |
| # |   |                                     | Option    | t |   |         |
| # |   |                                     |           | a |   |         |
| # |   |                                     | You pay   | n |   |         |
| # |   |                                     |           | d |   |         |
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+---+---+-------------------------------------+-----------+---+---+---------+
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| . |   |                                     |           |   |   |         |
+---+---+-------------------------------------+-----------+---+---+---------+
| # |   |                                     |           |   |   |         |
| # |   |                                     |           |   |   |         |
| # |   |                                     |           |   |   |         |
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|   |   |                                     |           |   |   |         |
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|   |   |                                     |           |   |   |         |
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| i |   |                                     |           |   |   |         |
| t |   |                                     |           |   |   |         |
| s |   |                                     |           |   |   |         |
+---+---+-------------------------------------+-----------+---+---+---------+
| W |   |                                     |           |   |   |         |
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| h |   |                                     |           |   |   |         |
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| o |   |                                     |           |   |   |         |
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| h |   |                                     |           |   |   |         |
| e |   |                                     |           |   |   |         |
| r |   |                                     |           |   |   |         |
| d |   |                                     |           |   |   |         |
| e |   |                                     |           |   |   |         |
| n |   |                                     |           |   |   |         |
| t |   |                                     |           |   |   |         |
| a |   |                                     |           |   |   |         |
| l |   |                                     |           |   |   |         |
| b |   |                                     |           |   |   |         |
| e |   |                                     |           |   |   |         |
| n |   |                                     |           |   |   |         |
| e |   |                                     |           |   |   |         |
| f |   |                                     |           |   |   |         |
| i |   |                                     |           |   |   |         |
| t |   |                                     |           |   |   |         |
| s |   |                                     |           |   |   |         |
| . |   |                                     |           |   |   |         |
+---+---+-------------------------------------+-----------+---+---+---------+

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

+-----------------------------------------------------------------------+
| The benefits on this page are not part of the FEHB contract or        |
| premium, **and you cannot file an FEHB disputed claim about them.**   |
| Fees you pay for these services do not count toward FEHB deductibles  |
| or catastrophic protection out-of-pocket maximum                      |
+-----------------------------------------------------------------------+
| GHI HMO Good Health Incentives Program. At GHI HMO we have your best  |
| health in mind. That's why we are making available to you the Good    |
| Health Incentives Program, which offers special discounts on a wide   |
| variety of health-related products and services.                      |
|                                                                       |
| **General Nutrition Centers (GNC) --** Offering a wide variety of     |
| discounts on vitamins and health products (participating GNC stores   |
| only). For a 15% discount coupon -- web site:                         |
| [www.gnc.com](http://www.gnc.com/).                                   |
|                                                                       |
| **Wellquest Fitness Network -- Discount Health Club Membership** --   |
| No long-term contracts, lower enrollment fees and monthly dues,       |
| opportunity to switch primary clubs at any time. Telephone            |
| 1-800-595-8448. Web site:                                             |
| [www.wellquestonline.com](http://www.wellquestonline.com/).           |
|                                                                       |
| **Weight Watchers Online** **-- Internet Weight Loss Program          |
| Discount** -- Offering the best weight-loss tools on the Internet,    |
| accessible from your home or office. To receive \$10 off a 3-month    |
| subscription -- web site:                                             |
| [ww                                                                   |
| w.weightwatchers.com/cs/ghi/](http://www.weightwatchers.com/cs/ghi/). |
|                                                                       |
| **Weight Watchers Weight Loss Program Discount** -- Free registration |
| anytime. Telephone: 1-800-651-6000. Web site:                         |
| [www.weightwatchers.com](http://www.weightwatchers.com/cs/ghi/).      |
|                                                                       |
| **My Medical CD^TM^** -- 33% savings on personal medical data credit  |
| card size disc, reimbursable for participants in a Flexible Spending  |
| Account Program, instant access to your medical information.          |
| Telephone: 1-866-MY MED CD (1-866-696-3323). Web site:                |
| [www.mymedicalcd.com](http://www.mymedicalcd.com/).                   |
|                                                                       |
| **Davis Vision -- Laser Vision Correction Services Discount** --      |
| Laser Vision Correction up to 25% off usual and customary fee         |
| (in-network only). Telephone: 1-800-584-2866 (refer to client control |
| number 7810). Web site:                                               |
| [www.davisvision.com](http://www.davisvision.com/).                   |
|                                                                       |
| **Davis Vision Affinity Discount Program** -- Significant discounts   |
| on examinations, eyewear and contact lenses (in-network only) up to   |
| 20% savings. Telephone: 1-877-92DAVIS (refer to client control number |
| 7810). Web site: [www.davisvision.com](http://www.davisvision.com/).  |
|                                                                       |
| **American Specialty Health Networks (ASHN)** --                      |
|                                                                       |
| **Acupuncture Therapy Discount Access Program** -- Significant        |
| savings on acupuncture therapy services.                              |
|                                                                       |
| **Massage Therapy Discount Access Program** - Significant savings on  |
| acupuncture therapy services.                                         |
|                                                                       |
| **Registered Dietician Discount Program** -- Significant savings up   |
| to 25% discount.                                                      |
|                                                                       |
| Telephone: 1-877-327-2746. Web site:                                  |
| [www.healthyroads.com](http://www.healthyroads.com/)                  |
|                                                                       |
| **HEARx** -- Hearing Aid and Product Discount -- Complimentary        |
| hearing screening, extended family member discounts, a \$200 discount |
| off the price of any single hearing aid. Telephone: 1-800-323-3277.   |
| Web site: [www.hearx.com](http://www.hearx.com/).                     |
|                                                                       |
| **CARExpress Benefits Network Discount Health Programs** -- Discount  |
| program for prescription drugs, vision, and dental care, medical      |
| supplies and home nursing care (in-network only). Telephone:          |
| 1-866-305-7283. Web site:                                             |
| [www.carexpress.org](http://www.carexpress.org/).                     |
+-----------------------------------------------------------------------+

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

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

We do not cover the following:

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

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

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

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

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

-   Services, drugs, or supplies related to abortions, 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 related to the professional fee for treatment of cavities
    and extractions, care of gums or bones supporting the teeth,
    orthodontia, false teeth, odontoma (tumors that are of dental origin
    and comprised of hard dental tissue), or any other dental services;
    or

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

# Section 7. Filing a claim for covered services

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

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

+-----------------------+----------------------------------------------+
| Medical, hospital &   | In most cases, providers and facilities file |
| drug benefits         | claims for you. Physicians must file on the  |
|                       | form HCFA-1500, Health Insurance Claim Form. |
|                       | Facilities will file on the UB-92 form. For  |
|                       | claims questions and assistance, call us at  |
|                       | 1-877-244-4466.                              |
|                       |                                              |
|                       | When you must file a claim \-- such as for   |
|                       | services you receive outside of the Plan\'s  |
|                       | service area \-- submit it on the HCFA-1500  |
|                       | or a claim form that includes the following  |
|                       | information shown below. Bills and receipts  |
|                       | should be itemized and show:                 |
|                       |                                              |
|                       | -   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: GHI HMO Claims      |
|                       | Department**                                 |
|                       |                                              |
|                       | **PO Box 4141**                              |
|                       |                                              |
|                       | **Kingston, NY 12402**                       |
+-----------------------+----------------------------------------------+
| Deadline for filing   | Send us all of the documents for your claim  |
| your claim            | as soon as possible. You must submit the     |
|                       | claim by December 31 of the year after the   |
|                       | year you received the service, unless timely |
|                       | filing was prevented by administrative       |
|                       | operations of Government or legal            |
|                       | incapacity, provided the claim was submitted |
|                       | as soon as reasonably possible.              |
|                       |                                              |
|                       | If a claim is denied, you will receive       |
|                       | notice of the decision, including reasons    |
|                       | for the denial and the provisions of the     |
|                       | contract on which the denial was based. If   |
|                       | you disagree with the plans decision, you    |
|                       | may request reconsideration in accordance    |
|                       | with the disputed claims procedure described |
|                       | on page 53.                                  |
+-----------------------+----------------------------------------------+
| When we need more     | Please reply promptly when we ask for        |
| information           | additional information. We may delay         |
|                       | processing or deny your claim if you do not  |
|                       | respond.                                     |
+-----------------------+----------------------------------------------+

# Section 8. The disputed claims process

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

+---+---+-----------------------------------------------------------------+
| S |   | Description                                                     |
| t |   |                                                                 |
| e |   |                                                                 |
| p |   |                                                                 |
+---+---+-----------------------------------------------------------------+
| 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: GHI HMO, PO Box 4332, Kingston, |
|   |   |     NY 12402; 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: United States Office of Personnel Management,  |
|   |   | Insurance Services Programs, Health Insurance Group 3, 1900 E   |
|   |   | Street, NW, Washington, D.C. 20415-3630.                        |
+---+---+-----------------------------------------------------------------+
| T |   |                                                                 |
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| * |   |                                                                 |
+---+---+-----------------------------------------------------------------+
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|   | d |                                                                 |
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|   | s |                                                                 |
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|   | m |                                                                 |
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|   | p |                                                                 |
|   | a |                                                                 |
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|   | d |                                                                 |
|   | . |                                                                 |
+---+---+-----------------------------------------------------------------+
|   | Y |                                                                 |
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|   | d |                                                                 |
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|   | m |                                                                 |
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|   | a |                                                                 |
|   | m |                                                                 |
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|   | o |                                                                 |
|   | f |                                                                 |
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|   | n |                                                                 |
|   | e |                                                                 |
|   | f |                                                                 |
|   | i |                                                                 |
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|   | s |                                                                 |
|   | i |                                                                 |
|   | n |                                                                 |
|   | d |                                                                 |
|   | i |                                                                 |
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|   | . |                                                                 |
+---+---+-----------------------------------------------------------------+

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

a)  We haven\'t responded yet to your initial request for care or
    preauthorization/prior approval, then call us at 1-877-244-4466 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 Insurance Group 3 at 202/606-0737 between
    8 a.m. and 5 p.m. eastern time.

# Section 9. Coordinating benefits with other coverage

+---------------------+------------------------------------------------+
| #                   | You must tell us if you or a covered family    |
| ## When you have ot | member have coverage under another group       |
| her health coverage | health plan or have automobile insurance that  |
|                     | pays health care expenses without regard to    |
|                     | fault. This is called "double coverage."       |
|                     |                                                |
|                     | When you have double coverage, one plan        |
|                     | normally pays its benefits in full as the      |
|                     | primary payer and the other plan pays a        |
|                     | reduced benefit as the secondary payer. We,    |
|                     | like other insurers, determine which coverage  |
|                     | is primary according to the National           |
|                     | Association of Insurance Commissioners\'       |
|                     | guidelines.                                    |
|                     |                                                |
|                     | 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.               |
+---------------------+------------------------------------------------+
| ##                  | Medicare is a Health Insurance Program for:    |
| # What is Medicare? |                                                |
|                     | -   People 65 years of age and older           |
|                     |                                                |
|                     | -   Some people with disabilities, under 65    |
|                     |     years of age                               |
|                     |                                                |
|                     | -   People with End-Stage Renal Disease        |
|                     |     (permanent kidney failure requiring        |
|                     |     dialysis or a transplant).                 |
|                     |                                                |
|                     | Medicare has two parts:                        |
|                     |                                                |
|                     | -   Part A (Hospital Insurance). Most people   |
|                     |     do not have to pay for Part A. If you or   |
|                     |     your spouse worked for at least 10 years   |
|                     |     in Medicare-covered employment, you should |
|                     |     be able to qualify for premium-free Part A |
|                     |     insurance. (Someone who was a Federal      |
|                     |     employee on January 1, 1983 or since       |
|                     |     automatically qualifies.) Otherwise, if    |
|                     |     you are age 65 or older, you may be able   |
|                     |     to buy it. Contact 1-800-MEDICARE for more |
|                     |     information.                               |
|                     |                                                |
|                     | -   Part B (Medical Insurance). Most people    |
|                     |     pay monthly for Part B. Generally, Part B  |
|                     |     premiums are withheld from your monthly    |
|                     |     Social Security check or your retirement   |
|                     |     check.                                     |
+---------------------+------------------------------------------------+
| #### Should I       | The decision to enroll in Medicare is yours.   |
| enroll in Medicare? | We encourage you to apply for Medicare         |
|                     | benefits 3 months before you turn age 65. It's |
|                     | easy. Just call the Social Security            |
|                     | Administration toll-free number 1-800-772-1213 |
|                     | to set up an appointment to apply. If you do   |
|                     | not apply for one or both Parts of Medicare,   |
|                     | you can still be covered under the FEHB        |
|                     | Program.                                       |
|                     |                                                |
|                     | If you can get premium-free Part A coverage,   |
|                     | we advise you to enroll in it. Most Federal    |
|                     | employees and annuitants are entitled to       |
|                     | Medicare Part A at age 65 **without cost**.    |
|                     | 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 Ori        | The Original Medicare Plan (Original Medicare) |
| ginal Medicare Plan | is available everywhere in the United States.  |
|  (Part A or Part B) | It is the way everyone used to get Medicare    |
|                     | benefits and is the way most people get their  |
|                     | Medicare Part A and Part B benefits now. You   |
|                     | may go to any doctor, specialist, or hospital  |
|                     | that accepts Medicare. The Original Medicare   |
|                     | Plan pays its share and you pay your share.    |
|                     | Some things are not covered under Original     |
|                     | Medicare, like prescription drugs (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. Your care must continue to be       |
|                     | authorized and arranged by your Plan PCP.      |
+---------------------+------------------------------------------------+
| ####  {#sect        | **Claims process when you have the Original    |
| ion-14 .unnumbered} | Medicare Plan**\--You probably will never have |
|                     | to file a claim 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 claims will be  |
|                     |     coordinated automatically and we will pay  |
|                     |     the balance of covered charges. You will   |
|                     |     not need to do anything. To find out if    |
|                     |     you need to do something about filing your |
|                     |     claims, call us at 1-877-244-4466 or visit |
|                     |     our website at                             |
|                     |     [www.ghi.com](http://www.ghihmo.com/).     |
|                     |                                                |
|                     | **We do not waive any costs if the Original    |
|                     | Medicare Plan is your primary payer**.         |
|                     |                                                |
|                     | *(Primary payer chart begins on next page.)*   |
+---------------------+------------------------------------------------+

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

+----------------------------------------------------+-------+--------+
| > **Primary Payer Chart**                          |       |        |
+----------------------------------------------------+-------+--------+
| **A. When you - or your covered spouse - are age   | **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       |
|                        | [w                                          |
|                        | ww.medicare.gov](http://www.medicare.gov/). |
|                        |                                             |
|                        | If you enroll in a Medicare managed care    |
|                        | plan, the following options are available   |
|                        | to you:                                     |
|                        |                                             |
|                        | **This Plan and 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 is primary, even out of the       |
|                        | managed care plan\'s network and/or service |
|                        | area (if you use our Plan providers), but   |
|                        | we will not waive any of our copayments or  |
|                        | coinsurance. If you enroll in a Medicare    |
|                        | 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.                                       |
+------------------------+---------------------------------------------+
| #                      | TRICARE is the health care program for      |
| ## TRICARE 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 a one of    |
|                        | these programs, eliminating your FEHB       |
|                        | premium. (OPM does not contribute to any    |
|                        | applicable plan premiums.) For information  |
|                        | on suspending your FEHB enrollment, contact |
|                        | your retirement office. If you later want   |
|                        | to re-enroll in the FEHB Program, generally |
|                        | you may do so only at the next Open Season  |
|                        | unless you involuntarily lose coverage      |
|                        | under the program.                          |
+------------------------+---------------------------------------------+
| ###                    | We do not cover services that:              |
|  Workers' 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. You must use our      |
|                        | providers.                                  |
+------------------------+---------------------------------------------+
| ### Medicaid           | When you have this Plan and Medicaid, we    |
|                        | pay first.                                  |
|                        |                                             |
|                        | **Suspended FEHB coverage to enroll in      |
|                        | Medicaid or a similar State-sponsored       |
|                        | program of medical assistance:** If you are |
|                        | an annuitant or former spouse, you can      |
|                        | suspend your FEHB coverage to enroll in a   |
|                        | one of these State programs, eliminating    |
|                        | your FEHB premium. For information on       |
|                        | suspending your FEHB enrollment, contact    |
|                        | your retirement office. If you later want   |
|                        | to re-enroll in the FEHB Program, generally |
|                        | you may do so only at the next Open Season  |
|                        | unless you involuntarily lose coverage      |
|                        | under the State program.                    |
+------------------------+---------------------------------------------+
| ### When other Gover   | We do not cover services and supplies when  |
| nment agencies are res | a local, State, or Federal Government       |
| ponsible for your care | agency directly or indirectly pays for      |
|                        | them.                                       |
+------------------------+---------------------------------------------+
| ### When others are re | When you receive money to compensate you    |
| sponsible for injuries | for medical or hospital care for injuries   |
|                        | or illness caused by another person, you    |
|                        | must reimburse us for any expenses we paid. |
|                        | However, we will cover the cost of          |
|                        | treatment that exceeds the amount you       |
|                        | received in the settlement.                 |
|                        |                                             |
|                        | If you do not seek damages you must agree   |
|                        | to let us try. This is called subrogation.  |
|                        | You must assist us in receiving our excess  |
|                        | payment, for example, by completing and     |
|                        | filing claim forms with other Health Plans  |
|                        | and endorsing checks over to us. If you     |
|                        | need more information, contact us for our   |
|                        | subrogation procedures.                     |
+------------------------+---------------------------------------------+

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

+---------------------+------------------------------------------------+
| Calendar year       | January 1 through December 31 of the same      |
|                     | year. For new enrollees, the calendar year     |
|                     | begins on the effective date of their          |
|                     | enrollment and ends on December 31 of the same |
|                     | year.                                          |
+---------------------+------------------------------------------------+
| Coinsurance         | Coinsurance is the percentage of our allowance |
|                     | that you must pay for your care. See page 13.  |
+---------------------+------------------------------------------------+
| Copayment           | A copayment is a fixed amount of money you pay |
|                     | when you receive covered services. See page    |
|                     | 13.                                            |
+---------------------+------------------------------------------------+
| Covered services    | Care we provide benefits for, as described in  |
|                     | this brochure.                                 |
+---------------------+------------------------------------------------+
| Custodial care      | Any service which can be learned and provided  |
|                     | by an average individual who does not have     |
|                     | medical training. Examples of Custodial Care   |
|                     | include:                                       |
|                     |                                                |
|                     | -   Assistance in meeting activities of daily  |
|                     |     living such as feeding, dressing and       |
|                     |     personal hygiene;                          |
|                     |                                                |
|                     | -   Administration of oral medications,        |
|                     |     routine changing of dressing, or           |
|                     |     preparation of special diets;              |
|                     |                                                |
|                     | -   Assistance in walking or getting out of    |
|                     |     bed;                                       |
|                     |                                                |
|                     | -   Child care necessitated by the incapacity  |
|                     |     of a parent; or                            |
|                     |                                                |
|                     | -   Respite Care                               |
|                     |                                                |
|                     | Custodial care that last 90 days or more is    |
|                     | sometimes know as Long term care.              |
+---------------------+------------------------------------------------+
| Experimental or     | Any drug, device or medical treatment or       |
| investigational     | procedure is experimental or investigational:  |
| services            |                                                |
|                     | -   If the drug or device has not been         |
|                     |     approved by the Food and Drug              |
|                     |     Administration (FDA)                       |
|                     |                                                |
|                     | -   If reliable evidence, (reports in          |
|                     |     respected medical and scientific           |
|                     |     literature) shows that the opinion of      |
|                     |     experts is that further study is needed to |
|                     |     decide how a drug, device or medical       |
|                     |     treatments or procedures compares with the |
|                     |     standard method of treatment or diagnosis. |
+---------------------+------------------------------------------------+
| Medical necessity   | Medically necessary health care services are   |
|                     | those necessary to preserve and maintain an    |
|                     | Enrollee's health in accordance with           |
|                     | acceptable standards of medical practice and   |
|                     | received in an appropriate setting. The GHI    |
|                     | HMO Medical Director shall determine whether a |
|                     | particular health care service rendered to an  |
|                     | Enrollee is Medical Necessary for the purpose  |
|                     | of determining whether such health care        |
|                     | services are covered services and not for the  |
|                     | purpose of practicing medicine or determining  |
|                     | a course of treatment, which course is to be   |
|                     | determined by the Participating Physician      |
+---------------------+------------------------------------------------+
| Plan allowance      | The plan allowance is a fee negotiated between |
|                     | the providers of service and the plan. These   |
|                     | agreed upon fees are considered to be payment  |
|                     | in full for services rendered by all           |
|                     | participating providers. Your coinsurance (20% |
|                     | for durable medical equipment) will be applied |
|                     | to these negotiated fees.                      |
+---------------------+------------------------------------------------+
| Us/We               | Us and we refer to GHI HMO                     |
+---------------------+------------------------------------------------+
| You                 | You refers to the enrollee and each covered    |
|                     | family member.                                 |
+---------------------+------------------------------------------------+

# Section 11. FEHB Facts

### Coverage Information

+---------------------+------------------------------------------------+
| ###                 | We will not refuse to cover the treatment of a |
| # No pre-existing c | condition that you had before you enrolled in  |
| ondition limitation | this Plan solely because you had the condition |
|                     | before you enrolled.                           |
+---------------------+------------------------------------------------+
| #### Where yo       | See                                            |
| u can get informati | [www.opm.gov/insure](../www.opm.gov/insure).   |
| on about enrolling  | Also, your employing or retirement office can  |
| in the FEHB Program | answer your questions, and give you a *Guide   |
|                     | to Federal Employees Health Benefits Plans,*   |
|                     | brochures for other plans, and other materials |
|                     | you need to make an informed decision about    |
|                     | your FEHB coverage. These materials tell you:  |
|                     |                                                |
|                     | -   When you may change your enrollment;       |
|                     |                                                |
|                     | -   How you can cover your family members;     |
|                     |                                                |
|                     | -   What happens when you transfer to another  |
|                     |     Federal agency, go on leave without pay,   |
|                     |     enter military service, or retire;         |
|                     |                                                |
|                     | -   When your enrollment ends; and             |
|                     |                                                |
|                     | -   When the next open season for enrollment   |
|                     |     begins.                                    |
|                     |                                                |
|                     | We don't determine who is eligible for         |
|                     | coverage and, in most cases, cannot change     |
|                     | your enrollment status without information     |
|                     | from your employing or retirement office.      |
+---------------------+------------------------------------------------+
| #### Types of cove  | Self Only coverage is for you alone. Self and  |
| rage available for  | Family coverage is for you, your spouse, and   |
| you and your family | your unmarried dependent children under age    |
|                     | 22, including any foster children or           |
|                     | stepchildren your employing or retirement      |
|                     | office authorizes coverage for. Under certain  |
|                     | circumstances, you may also continue coverage  |
|                     | for a disabled child 22 years of age or older  |
|                     | who is incapable of self-support.              |
|                     |                                                |
|                     | If you have a Self Only enrollment, you may    |
|                     | change to a Self and Family enrollment if you  |
|                     | marry, give birth, or add a child to your      |
|                     | family. You may change your enrollment 31 days |
|                     | before to 60 days after that event. The Self   |
|                     | and Family enrollment begins on the first day  |
|                     | of the pay period in which the child is born   |
|                     | or becomes an eligible family member. When you |
|                     | change to Self and Family because you marry,   |
|                     | the change is effective on the first day of    |
|                     | the pay period that begins after your          |
|                     | employing office receives your enrollment      |
|                     | form; benefits will not be available to your   |
|                     | spouse until you marry.                        |
|                     |                                                |
|                     | Your employing or retirement office will       |
|                     | **not** notify you when a family member is no  |
|                     | longer eligible to receive health benefits,    |
|                     | nor will we. Please tell us immediately when   |
|                     | you add or remove family members from your     |
|                     | coverage for any reason, including divorce, or |
|                     | when your child under age 22 marries or turns  |
|                     | 22.                                            |
|                     |                                                |
|                     | If you or one of your family members is        |
|                     | enrolled in one FEHB plan, that person may not |
|                     | be enrolled in or covered as a family member   |
|                     | by another FEHB plan.                          |
+---------------------+------------------------------------------------+
| #### Chi            | OPM has implemented the Federal Employees      |
| ldren\'s Equity Act | Health Benefits Children\'s Equity Act of      |
|                     | 2000. This law mandates that you be enrolled   |
|                     | for Self and Family coverage in the Federal    |
|                     | Employees Health Benefits (FEHB) Program, if   |
|                     | you are an employee subject to a court or      |
|                     | administrative order requiring you to provide  |
|                     | health benefits for your child(ren).           |
|                     |                                                |
|                     | If this law applies to you, you must enroll    |
|                     | for Self and Family coverage in a health plan  |
|                     | that provides full benefits in the area where  |
|                     | your children live or provide documentation to |
|                     | your employing office that you have obtained   |
|                     | other health benefits coverage for your        |
|                     | children. If you do not do so, your employing  |
|                     | office will enroll you involuntarily as        |
|                     | follows:                                       |
|                     |                                                |
|                     | -   If you have no FEHB coverage, your         |
|                     |     employing office will enroll you for Self  |
|                     |     and Family coverage in the Blue Cross and  |
|                     |     Blue Shield Service Benefit Plan\'s Basic  |
|                     |     Option,                                    |
|                     |                                                |
|                     | -   If you have a Self Only enrollment in a    |
|                     |     fee-for-service plan or in an HMO that     |
|                     |     serves the area where your children live,  |
|                     |     your employing office will change your     |
|                     |     enrollment to Self and Family in the same  |
|                     |     option of the same plan; or                |
|                     |                                                |
|                     | -   If you are enrolled in an HMO that does    |
|                     |     not serve the area where the children      |
|                     |     live, your employing office will change    |
|                     |     your enrollment to Self and Family in the  |
|                     |     Blue Cross and Blue Shield Service Benefit |
|                     |     Plan\'s Basic Option.                      |
|                     |                                                |
|                     | As long as the court/administrative order is   |
|                     | in effect, and you have at least one child     |
|                     | identified in the order who is still eligible  |
|                     | under the FEHB Program, you cannot cancel your |
|                     | enrollment, change to Self Only, or change to  |
|                     | a plan that doesn\'t serve the area in which   |
|                     | your children live, unless you provide         |
|                     | documentation that you have other coverage for |
|                     | the children. If the court/administrative      |
|                     | order is still in effect when you retire, and  |
|                     | you have at least one child still eligible for |
|                     | FEHB coverage, you must continue your FEHB     |
|                     | coverage into retirement (if eligible) and     |
|                     | cannot cancel your coverage, change to Self    |
|                     | Only, or change to a plan that doesn't serve   |
|                     | the area in which your children live as long   |
|                     | as the court/administrative order is in        |
|                     | effect. Contact you employing office for       |
|                     | further information.                           |
+---------------------+------------------------------------------------+
| #### When benefits  | The benefits in this brochure are effective on |
|  and premiums start | January 1. If you joined this Plan during Open |
|                     | Season, your coverage begins on the first day  |
|                     | of your first pay period that starts on or     |
|                     | after January 1. If you changed plans or plan  |
|                     | options during Open Season and you receive     |
|                     | care between January 1 and the effective date  |
|                     | of coverage under your new plan or option,     |
|                     | your claims will be paid according to the 2005 |
|                     | benefits of your old plan or option. However,  |
|                     | if your old plan left the FEHB Program at the  |
|                     | end of the year, you are covered under that    |
|                     | plan's 2003 benefits until the effective date  |
|                     | of your coverage with your new plan.           |
|                     | Annuitants' coverage and premiums begin on     |
|                     | January 1. If you joined at any other time     |
|                     | during the year, your employing office will    |
|                     | tell you the effective date of coverage.       |
+---------------------+------------------------------------------------+
| #                   | When you retire, you can usually stay in the   |
| ### When you retire | FEHB Program. Generally, you must have been    |
|                     | enrolled in the FEHB Program for the last five |
|                     | years of your Federal service. If you do not   |
|                     | meet this requirement, you may be eligible for |
|                     | other forms of coverage, such as Temporary     |
|                     | Continuation of Coverage (TCC).                |
+---------------------+------------------------------------------------+

### When you lose benefits

+--------------------+-------------------------------------------------+
| #### When F        | You will receive an additional 31 days of       |
| EHB 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).                                        |
+--------------------+-------------------------------------------------+
| #### Spou          | If you are divorced from a Federal employee or  |
| se 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 supply health coverage to you. |
|                    | But, you may be eligible for your own FEHB      |
|                    | coverage under the spouse equity law or         |
|                    | Temporary Continuation of Coverage (TCC). If    |
|                    | you are recently divorced or are anticipating a |
|                    | divorce, contact your ex-spouse's employing or  |
|                    | retirement office to get RI 70-5, the *Guide to |
|                    | Federal Employees Health Benefits Plans for     |
|                    | Temporary Continuation of Coverage and Former   |
|                    | Spouse Enrollees*, or other information about   |
|                    | your coverage choices. You can also download    |
|                    | the guide from OPM\'s website,                  |
|                    | [www.opm.gov/insure](../www.opm.gov/insure).    |
+--------------------+-------------------------------------------------+
| #### Temp          | If you leave Federal service, or if you lose    |
| orary Continuation | coverage because you no longer qualify as a     |
|  of 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 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.      |
+--------------------+-------------------------------------------------+
| ##                 | You may convert to a non-FEHB individual policy |
| ## Converting to i | if:                                             |
| ndividual 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.   |
+--------------------+-------------------------------------------------+
| ##                 | The Health Insurance Portability and            |
| ## Getting a Certi | Accountability Act of 1996 (HIPAA) is a Federal |
| ficate of Group He | law that offers limited Federal protections for |
| alth 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. []{.mark}                     |
|                    |                                                 |
|                    | For more information, get OPM pamphlet RI       |
|                    | 79-27, Temporary Continuation of Coverage (TCC) |
|                    | under the FEHB Program. See also the FEHB web   |
|                    | site                                            |
|                    | ([www.opm.gov/insur                             |
|                    | e/health);](http://www.opm.gov/insure/health);) |
|                    | refer to the \"TCC and HIPAA\" frequently asked |
|                    | question. These highlight HIPAA rules, such as  |
|                    | the requirement that Federal employees must     |
|                    | exhaust any TCC eligibility as one condition    |
|                    | for guaranteed access to individual health      |
|                    | coverage under HIPAA, and have 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 than that of a |         |        |
|                  |     "family member" than is   |         |        |
|                  |     used under the FEHB       |         |        |
|                  |     Program to provide        |         |        |
|                  |     benefits by your FEHB     |         |        |
|                  |     Plan.                     |         |        |
|                  |                               |         |        |
|                  | -   The maximum amount that   |         |        |
|                  |     can be allotted for the   |         |        |
|                  |     HCFSA is \$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, or 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  |         |        |
|                  |     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 that can be   |         |        |
|                  |     allotted for the DCFSA is |         |        |
|                  |     \$5,000 annually. 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       | to enroll in an FSA during    |         |        |
|     Open**       | the 2005 FEHB Open Season.    |         |        |
|     S**eason**   | Even if you enrolled during   |         |        |
|                  | 2004, you must make a new     |         |        |
|                  | election to continue          |         |        |
|                  | participating in 2005.        |         |        |
|                  | Enrollment is easy!           |         |        |
|                  |                               |         |        |
|                  | -   Online: visit             |         |        |
|                  |     **[www.fsafeds.co         |         |        |
|                  | m](http://www.fsafeds.com/)** |         |        |
|                  |     and click on              |         |        |
|                  |     [Enroll]{.underline}.     |         |        |
|                  |                               |         |        |
|                  | -   Telephone: call an        |         |        |
|                  |     FSAFEDS Benefit Counselor |         |        |
|                  |     toll--free at             |         |        |
|                  |     1-877-FSAFEDS (372-3337), |         |        |
|                  |     Monday through Friday,    |         |        |
|                  |     from 9 a.m. until 9 p.m.  |         |        |
|                  |     Eastern Time. TYY:        |         |        |
|                  |     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 will be 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 |         |        |
|                  | (HSAA), you are not eligible  |         |        |
|                  | to participate in an HCFSA.   |         |        |
|                  |                               |         |        |
|                  | Almost all Federal employees  |         |        |
|                  | are eligible to enroll for    |         |        |
|                  | the 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     |         |        |
|                  | 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 expense         |         |        |
|                  | incurred from January through |         |        |
|                  | 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   | Every FEHB plan includes cost |         |        |
|     my 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. The out-of-pocket   |         |        |
|                  | costs are summarized on page  |         |        |
|                  | 13 and detailed throughout    |         |        |
|                  | this brochure. Your HCFSA     |         |        |
|                  | will reimburse you when those |         |        |
|                  | costs are for medical care    |         |        |
|                  | that you, your spouse and/or  |         |        |
|                  | your dependents receive that  |         |        |
|                  | is NOT covered by this FEHB   |         |        |
|                  | Plan or any other coverage    |         |        |
|                  | that you have.                |         |        |
|                  |                               |         |        |
|                  | Under the High Option and     |         |        |
|                  | Standard Option of this Plan, |         |        |
|                  | typical out-of-pocket         |         |        |
|                  | expenses include: The most    |         |        |
|                  | frequent/significant expenses |         |        |
|                  | are, Physician Visits         |         |        |
|                  | Copayments, Prescription Drug |         |        |
|                  | Copayments and Emergency Room |         |        |
|                  | Copayments. The common but    |         |        |
|                  | significant expenses that are |         |        |
|                  | not covered under this plan   |         |        |
|                  | are, Eyeglasses/Contact       |         |        |
|                  | Lenses, Fertility Drugs and   |         |        |
|                  | Dental.                       |         |        |
|                  |                               |         |        |
|                  | 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.i                 |         |        |
|                  | rs.gov/pub/irs-pdf/p502.pdf>. |         |        |
|                  | The FSAFEDS Web site also has |         |        |
|                  | a comprehensive list of       |         |        |
|                  | eligible expenses at:         |         |        |
|                  | [w                            |         |        |
|                  | ww.fsafeds.com/fsafeds/eligib |         |        |
|                  | leexpenses.asp](http://www.ir |         |        |
|                  | s.gov/pub/irs-pdf/p502.pdf).  |         |        |
|                  | If you do not see your        |         |        |
|                  | service or expense listed ,   |         |        |
|                  | please call a FSAFEDS Benefit |         |        |
|                  | Counselor at 1-877-FSAFEDS    |         |        |
|                  | (372-3337), who will be able  |         |        |
|                  | to answer your specific       |         |        |
|                  | questions.                    |         |        |
+------------------+-------------------------------+---------+--------+
| -   **Tax        | An FSA lets you allot money   |         |        |
|     savings with | for eligible expenses         |         |        |
|     an FSA**     | ***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          | **With  | **W    |
|                  | Example**                     | FSA**   | ithout |
|                  |                               |         | FSA**  |
+------------------+-------------------------------+---------+--------+
|                  | If your taxable income is:    | \       | \$     |
|                  |                               | $50,000 | 50,000 |
+------------------+-------------------------------+---------+--------+
|                  | And you deposit this amount   | \$      | -\$0-  |
|                  | into a 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        | -\$0-   | \$     |
|                  | dollars for expense:          |         | 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 in which      |         |        |
|                  | retirement system 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        | You *cannot* claim expenses   |         |        |
|     credits and  | on your Federal income tax    |         |        |
|     deductions** | return 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 the HCFSA  |         |        |
|                  | at any time during the year   |         |        |
|                  | for expenses up to the annual |         |        |
|                  | amount you\'ve elected to     |         |        |
|                  | contribute.                   |         |        |
|                  |                               |         |        |
|                  | Only health care expenses     |         |        |
|                  | exceeding 7.5% of your        |         |        |
|                  | adjusted gross income are     |         |        |
|                  | eligible to be deducted on    |         |        |
|                  | your Federal Income Tax       |         |        |
|                  | return. Using the example     |         |        |
|                  | listed in the above chart,    |         |        |
|                  | only health care expenses     |         |        |
|                  | exceeding \$3,750 (7.5% of    |         |        |
|                  | \$50,000) would be eligible   |         |        |
|                  | to be deducted on your        |         |        |
|                  | Federal Income Tax return. In |         |        |
|                  | addition, money set aside     |         |        |
|                  | through a HCFSA is also       |         |        |
|                  | exempt from FICA taxes. This  |         |        |
|                  | exemption is not available on |         |        |
|                  | your Federal Income Tax       |         |        |
|                  | return.                       |         |        |
+------------------+-------------------------------+---------+--------+
| Dependent care   | 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    | No. Section 1127 of the       |         |        |
|     cost me      | National Defense              |         |        |
|     anything to  | Authorization Act (Public Law |         |        |
|     participate  | 108-136) requires agencies    |         |        |
|     in           | that offer FSAFEDS to         |         |        |
|     FSAFEDS?**   | 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    | To learn more or to enroll,   |         |        |
|     us**         | 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 from Monday     |         |        |
|                  | through Friday, from 9:00     |         |        |
|                  | a.m. until 9:00 p.m. Eastern  |         |        |
|                  | Time.                         |         |        |
|                  |                               |         |        |
|                  | -   E-mail:                   |         |        |
|                  |     <fsafeds@shps.net>        |         |        |
|                  |                               |         |        |
|                  | -   Telephone: 1-877-FSAFEDS  |         |        |
|                  |     (372-3337)                |         |        |
|                  |                               |         |        |
|                  | -   TTY: 1-800-952-0450       |         |        |
+------------------+-------------------------------+---------+--------+

### 

### 

### 

### 

### The Federal Long Term Care Insurance Program

+-------------------+--------------------------------------------------+
| -   **It's        | Why should you consider enrolling in the Federal |
|     important     | Long Term Care Insurance Program (FLTCIP)?       |
|     protection**  |                                                  |
|                   | -   **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

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

Accidental injury 49

Allergy tests 21

Allogenic (donor) bone marrow transplants 32

Alternative treatments 27

Ambulance 37, 40

Ambulatory surgical center 36, 37

Anesthesia 33

Autologous bone marrow transplants 32

Biopsy 28

Blood and blood plasma 36

Catastrophic protection out-of-pocket maximum 13

Changes for 2005 9

Chemotherapy 22

Chiropractic 27

Cholesterol tests 18

Circumcision 19

Claims 43

Coinsurance 13

Colorectal Cancer Screening 18

Congenital anomalies 30

Contraceptive drugs and devices 46

Copayments 13

Crutches 26

Deductible 13

Definitions 60

Dental 49

Diabetic supplies and equipment 21

Diagnostic Tests 42

Dialysis 22

Disputed claims process 53

Donor expenses 33

Durable medical equipment 26

Educational classes and programs 27

Effective date of coverage 63

Emergency services 38

Experimental or investigational 51

Family planning 20

Fecal occult blood test 18

Fraud 3

General exclusions 51

Hearing services 23

Home health services 26

Hospice care 36

Immunizations 18, 19

Infertility services 20, 21

Inpatient hospital 34

Insulin 46

Lab Services 17

Mail Order Prescriptions 44

Mammogram 16, 18

Maternity care 19

Medicaid 59

Medical necessity 60

Medicare 55

Mental health and substance abuse benefits 41

Newborn care 19

Non-FEHB benefits 50

Occupational therapies 23

Oral and maxillofacial surgery 31

Outpatient hospital 36

Oxygen 26

Pap test 16, 18

Physical therapy 23

Preauthorization 43

Prescription drug benefits 44

Preventive care, adult 18

Preventive care, children 19

Prior approval 12

Prosthetic devices 25

Psychiatrist 41

Psychologist 41

Radiation therapy 22

Reconstructive surgery 30

Room and board 34

Second surgical opinion 17

Skilled nursing facility 36

Smoking cessation 27

Speech therapy 23

Subrogation 59

Substance abuse benefits 41

Surgery 28

Syringes 21, 46

Temporary Continuation of Coverage (TCC) 64

Transplants 32

Vision services 24

Wheelchairs 26

Workers' Compensation 58

X-ray and other diagnostic tests 17

#  {#section-20 .unnumbered}

# Summary of benefits for GHI HMO - 2005

-   **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**                            | **High   | **       | **Pa |
|                                         | Plan**   | Standard | ge** |
|                                         |          | Plan**   |      |
|                                         | **You    |          |      |
|                                         | Pay**    | **You    |      |
|                                         |          | Pay**    |      |
+-----------------------------------------+----------+----------+------+
| Medical services provided by            | Office   | Office   | 16   |
| physicians:                             | visit    | visit    |      |
|                                         | copay:   | copay    |      |
| -   Diagnostic and treatment services   | \$10     | \$20     |      |
|     provided in the office...           | primary  | primary  |      |
|                                         | care;    | care;    |      |
|                                         | \$10     | \$20     |      |
|                                         | sp       | spe      |      |
|                                         | ecialist | cialist. |      |
|                                         |          |          |      |
|                                         |          | Nothing  |      |
|                                         |          | for      |      |
|                                         |          | children |      |
|                                         |          | (up to   |      |
|                                         |          | age 18)  |      |
+-----------------------------------------+----------+----------+------+
| Services provided by a hospital:        | Nothing  | Nothing  | 34   |
|                                         |          |          |      |
| -   Inpatient                           | Nothing  | Nothing  |      |
|     .....................               |          |          |      |
| ....................................... | Nothing  | Nothing  |      |
|                                         |          |          |      |
| -   Outpatient....................      | \$10     | \$20     |      |
| ....................................... | copay    | copay    |      |
|                                         |          |          |      |
| -   Lab                                 |          |          |      |
|     ...........................         |          |          |      |
| ....................................... |          |          |      |
|                                         |          |          |      |
| -   X-Ray........................       |          |          |      |
| ....................................... |          |          |      |
+-----------------------------------------+----------+----------+------+
| Emergency benefits:                     | \$35 per | \$50 per | 38   |
|                                         | visit    | visit    |      |
| -   In-area........................     |          |          |      |
| ....................................... | \$35 per | \$50 per |      |
|                                         | visit    | visit    |      |
| -   Out-of-area...................      |          |          |      |
| ....................................... |          |          |      |
+-----------------------------------------+----------+----------+------+
| Mental health and substance abuse       | Regular  |          | 41   |
| treatment .....................         | cost     |          |      |
|                                         | sharing  |          |      |
+-----------------------------------------+----------+----------+------+
| Prescription                            | Retail   |          | 44   |
| drugs..............                     | P        |          |      |
| ....................................... | harmacy: |          |      |
|                                         |          |          |      |
|                                         | \$10 co  |          |      |
|                                         | pay -    |          |      |
|                                         | generic  |          |      |
|                                         |          |          |      |
|                                         | \$20 co  |          |      |
|                                         | pay --   |          |      |
|                                         | p        |          |      |
|                                         | referred |          |      |
|                                         | brand    |          |      |
|                                         |          |          |      |
|                                         | \$30 co  |          |      |
|                                         | pay --   |          |      |
|                                         | non-p    |          |      |
|                                         | referred |          |      |
|                                         | brand    |          |      |
|                                         |          |          |      |
|                                         | Mail     |          |      |
|                                         | Order:   |          |      |
|                                         |          |          |      |
|                                         | \$20 co  |          |      |
|                                         | pay --   |          |      |
|                                         | generic  |          |      |
|                                         |          |          |      |
|                                         | \$40 co  |          |      |
|                                         | pay --   |          |      |
|                                         | p        |          |      |
|                                         | referred |          |      |
|                                         | brand    |          |      |
|                                         |          |          |      |
|                                         | \$50     |          |      |
|                                         | copay -- |          |      |
|                                         | non-p    |          |      |
|                                         | referred |          |      |
|                                         | brand    |          |      |
+-----------------------------------------+----------+----------+------+

+-----------------------------------------+----------+----------+------+
| Dental                                  | Ac       |          | 49   |
| Care......................              | cidental |          |      |
| ....................................... | injury   |          |      |
|                                         | to sound |          |      |
|                                         | natural  |          |      |
|                                         | teeth    |          |      |
|                                         | only.    |          |      |
|                                         | You pay  |          |      |
|                                         | nothing  |          |      |
+-----------------------------------------+----------+----------+------+
| Vision                                  | One      | One      | 24   |
| Care......................              | re       | re       |      |
| ....................................... | fraction | fraction |      |
|                                         | a        | a        |      |
|                                         | nnually. | nnually. |      |
|                                         | You pay  | You pay  |      |
|                                         | \$10     | \$20     |      |
|                                         | copay    | copay    |      |
|                                         | per      | per      |      |
|                                         | office   | office   |      |
|                                         | visit    | visit    |      |
+-----------------------------------------+----------+----------+------+
| Special features:                       |          |          | 48   |
|                                         |          |          |      |
| -   Services for deaf and hearing       |          |          |      |
|     impaired                            |          |          |      |
|                                         |          |          |      |
| -   Centers of Excellence for           |          |          |      |
|     transplants/heart surgeries         |          |          |      |
|                                         |          |          |      |
| -   PHIP -- Personal Health Improvement |          |          |      |
|     Project                             |          |          |      |
+-----------------------------------------+----------+----------+------+
| Protection against catastrophic costs   | Your     |          | 13   |
|                                         | out-o    |          |      |
| (your catastrophic protection           | f-pocket |          |      |
| out-of-pocket maximum)                  | expenses |          |      |
|                                         | for      |          |      |
|                                         | benefits |          |      |
|                                         | under    |          |      |
|                                         | this     |          |      |
|                                         | Plan are |          |      |
|                                         | limited  |          |      |
|                                         | to the   |          |      |
|                                         | stated   |          |      |
|                                         | co       |          |      |
|                                         | payments |          |      |
|                                         | which    |          |      |
|                                         | are      |          |      |
|                                         | required |          |      |
|                                         | for few  |          |      |
|                                         | benefits |          |      |
+-----------------------------------------+----------+----------+------+

# 2005 Rate Information for GHI HMO 

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

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

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

+--------------+-----+-------+-------+-------+-------+-------+-------+
|              |     | ***   |       |       |       | ***P  |       |
|              |     | Non-P |       |       |       | ostal |       |
|              |     | ostal |       |       |       | Premi |       |
|              |     | Premi |       |       |       | um*** |       |
|              |     | um*** |       |       |       |       |       |
+--------------+-----+-------+-------+-------+-------+-------+-------+
|              |     | *     |       | **[Mo |       | *     |       |
|              |     | *[Biw |       | nthly |       | *[Biw |       |
|              |     | eekly |       | ]{.un |       | eekly |       |
|              |     | ]{.un |       | derli |       | ]{.un |       |
|              |     | derli |       | ne}** |       | derli |       |
|              |     | ne}** |       |       |       | ne}** |       |
+--------------+-----+-------+-------+-------+-------+-------+-------+
| **Type of**  | **  | **Go  | **Y   | **Go  | **Y   | **U   | **Y   |
|              | Cod | v't** | our** | v't** | our** | SPS** | our** |
| **           | e** |       |       |       |       |       |       |
| Enrollment** |     | **Sh  | **Sh  | **Sh  | **Sh  | **Sh  | **Sh  |
|              |     | are** | are** | are** | are** | are** | are** |
+--------------+-----+-------+-------+-------+-------+-------+-------+

Bronx/Brooklyn/Manhattan/Nassau/Queens/Richmond/Suffolk/Westchester

+--------------+-----+-------+-------+-------+-------+-------+-------+
| **High       | *   | **    | *     | **    | **    | **    | *     |
| Option**     | *6V | \$131 | *\$52 | \$284 | \$114 | \$154 | *\$29 |
|              | 1** | .08** | .67** | .01** | .12** | .74** | .01** |
| **Self       |     |       |       |       |       |       |       |
| Only**       |     |       |       |       |       |       |       |
+--------------+-----+-------+-------+-------+-------+-------+-------+
| **High       | *   | **    | **    | **    | **    | **    | **    |
| Option**     | *6V | \$298 | \$169 | \$646 | \$367 | \$352 | \$115 |
|              | 2** | .23** | .55** | .17** | .35** | .08** | .70** |
| **Self and   |     |       |       |       |       |       |       |
| Family**     |     |       |       |       |       |       |       |
+--------------+-----+-------+-------+-------+-------+-------+-------+

+--------------+-----+-------+-------+-------+-------+-------+-------+
| **Standard   | *   | **    | *     | **    | *     | **    | *     |
| Option**     | *6V | \$118 | *\$39 | \$256 | *\$85 | \$139 | *\$17 |
|              | 4** | .28** | .42** | .26** | .42** | .96** | .74** |
| **Self       |     |       |       |       |       |       |       |
| Only**       |     |       |       |       |       |       |       |
+--------------+-----+-------+-------+-------+-------+-------+-------+
| **Standard   | *   | **    | **    | **    | **    | **    | *     |
| Option**     | *6V | \$298 | \$103 | \$646 | \$223 | \$352 | *\$49 |
|              | 5** | .23** | .23** | .17** | .66** | .08** | .38** |
| **Self and   |     |       |       |       |       |       |       |
| Family**     |     |       |       |       |       |       |       |
+--------------+-----+-------+-------+-------+-------+-------+-------+

Albany/Broome/Columbia/Delaware/Dutchess/Fulton/Greene/Montgomery/Orange/Otsego/Putnam/RensselaerRockland/Saratoga/Schenectday/Schoharie/Sullivan/Ulster/Warrren/Washington

+--------------+-----+-------+-------+-------+-------+-------+-------+
| **High       | *   | **    | *     | **    | *     | **    | *     |
| Option**     | *X4 | \$127 | *\$42 | \$275 | *\$91 | \$150 | *\$19 |
|              | 1** | .31** | .44** | .84** | .95** | .65** | .10** |
| **Self       |     |       |       |       |       |       |       |
| Only**       |     |       |       |       |       |       |       |
+--------------+-----+-------+-------+-------+-------+-------+-------+
| **High       | *   | **    | **    | **    | **    | **    | *     |
| Option**     | *X4 | \$298 | \$139 | \$646 | \$301 | \$352 | *\$85 |
|              | 2** | .23** | .26** | .17** | .73** | .08** | .41** |
| **Self and   |     |       |       |       |       |       |       |
| Family**     |     |       |       |       |       |       |       |
+--------------+-----+-------+-------+-------+-------+-------+-------+

+--------------+-----+-------+-------+-------+-------+-------+-------+
| **Standard   | *   | **    | *     | **    | *     | **    | *     |
| Option**     | *X4 | \$115 | *\$38 | \$250 | *\$83 | \$136 | *\$17 |
|              | 4** | .76** | .59** | .82** | .61** | .99** | .36** |
| **Self       |     |       |       |       |       |       |       |
| Only**       |     |       |       |       |       |       |       |
+--------------+-----+-------+-------+-------+-------+-------+-------+
| **Standard   | *   | **    | *     | **    | **    | **    | *     |
| Option**     | *X4 | \$292 | *\$97 | \$634 | \$211 | \$346 | *\$43 |
|              | 5** | .73** | .57** | .24** | .41** | .39** | .91** |
| **Self and   |     |       |       |       |       |       |       |
| Family**     |     |       |       |       |       |       |       |
+--------------+-----+-------+-------+-------+-------+-------+-------+