# ![](media/image1.jpeg){width="7.486111111111111in" height="9.677777777777777in"} 

# ![](media/image2.png){width="4.872222222222222in" height="1.257638888888889in"}

Dear Federal Employees Health Benefits Program Participant:

I am pleased to present this 2004 Federal Employees Health Benefits
(FEHB) Program plan brochure. The brochure describes the benefits this
plan offers you for 2004. Because benefits vary from year to year, you
should review your plan's brochure every Open Season -- especially
Section 2, which explains how the plan changed.

It takes a lot of information to help a consumer make wise healthcare
decisions. The information in this brochure, our FEHB Guide, and our
web-based resources, make it easier than ever to get information about
plans, to compare benefits and to read customer service satisfaction
ratings for the national and local plans that may be of interest. Just
click on [www.opm.gov/insure](http://www.opm.gov/insure)!

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

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

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

> Sincerely,
>
> ![](media/image3.png){width="2.5833333333333335in"
> height="0.7291666666666666in"}
>
> Kay Coles James
>
> Director

![](media/image4.png){width="0.875in" height="0.875in"} Notice of the
Office of Personnel Management's
![](media/image5.png){width="1.1555555555555554in"
height="0.8201388888888889in"}

#  Privacy Notice

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

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

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

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

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

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

-   Where required by law.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

-   Get a separate paper copy of this notice.

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

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

Privacy Complaints

United States Office of Personnel Management

P.O. Box 707

Washington, DC 20004-0707

Filing a complaint will not affect your benefits under the FEHB Program.
You also may file a complaint with the Secretary of the 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............................................................................
4

Plain Language 4

Stop Health Care Fraud! 4

Preventing Medical Mistakes 5

Section 1. Facts about this HMO Plan 7

How we pay physicians, health care practitioners and facilities 7

Your Rights 7

Service Area 7

Section 2. How we change for 2004 9

Program-wide changes 9

Changes to this Plan 9

Section 3. How you get care 10

Health plan identification cards 10

Where you get covered care 10

> • Plan physicians and health care practitioners 10
>
> • Plan facilities 10

What you must do to get covered care 10

> • Primary care 11
>
> • Specialty care 11
>
> • Hospital care 12

Circumstances beyond our control 12

Services requiring our prior approval 13

Section 4. Your costs for covered services 14

-   Copayments 14

-   Deductible 14

-   Coinsurance 14

-   Your catastrophic protection out-of-pocket maximum 14

Section 5. Benefits 15

Overview 15

> \(a\) Medical services and supplies provided by physicians and other
> health care professionals 16
>
> \(b\) Surgical and anesthesia services provided by physicians and
> other health care professionals 26
>
> \(c\) Services provided by a hospital or other facility, and ambulance
> services 29
>
> \(d\) Emergency services/accidents 32
>
> \(e\) Mental health and substance abuse benefits 34
>
> \(f\) Prescription drug benefits 36
>
> \(g\) Special features 39
>
> • Flexible benefits option 39
>
> • Centers for Cardiac Surgery, Transplants and Joint Replacement 39
>
> • WeeCall Program 39
>
> • Plan Publications 39
>
> • Health Education and Disease Management Programs 39
>
> \(h\) Dental benefits 40
>
> \(i\) Non-FEHB benefits available to Plan members 43

Section 6. General exclusions -- things we don\'t cover 44

Section 7. Filing a claim for covered services 45

Section 8. The disputed claims process 46

Section 9. Coordinating benefits with other coverage 48

When you have other health coverage 48

-   What is Medicare? 48

-   Should I enroll in Medicare? 48

-   Original Medicare Plan 49

-   Medicare + Choice 51

-   TRICARE and CHAMPVA 51

-   Workers\' Compensation 51

-   Medicaid 52

-   Other Government agencies 52

-   When others are responsible for injuries 52

Section 10. Definitions of terms we use in this brochure 53

Section 11. FEHB facts 55

Coverage information 55

> • No pre-existing condition limitation 55
>
> • Where you can get information about enrolling in the FEHB Program 55
>
> • Types of coverage available for you and your family 55
>
> • Children's Equity Act 55
>
> • When benefits and premiums start 56
>
> • When you retire 56
>
> When you lose benefits 56
>
> • When FEHB coverage ends 56
>
> • Spouse equity coverage 57
>
> • Temporary Continuation of Coverage (TCC) 57
>
> • Converting to individual coverage 57
>
> • Getting a Certificate of Group Health Plan Coverage 58

Two new Federal Programs complement FEHB benefits 59

The Federal Flexible Spending Account
Program-*FSAFEDS*......................................................................59

The Federal Long Term Care Insurance
Program.................................................................................\....62

Index 63

Summary of benefits 64

Rates Back cover

+-----------------------------------------------------------------------+
| # Introduction                                                        |
+-----------------------------------------------------------------------+

This brochure describes the benefits of M.D.IPA under our contract (CS
1935) with the United States Office of Personnel Management (OPM), as
authorized by the Federal Employees Health Benefits law. The address for
M.D.IPA's administrative offices is:

MD-Individual Practice Association, Inc. (M.D. IPA)

4 Taft Court

Rockville, MD 20850

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

If you are enrolled in this Plan, you are entitled to the benefits
described in this brochure. If you are enrolled in Self and Family
coverage, each eligible family member is also entitled to these
benefits. You do not have a right to benefits that were available before
January 1, 2004, unless those benefits are also shown in this brochure

OPM negotiates benefits and rates with each plan annually. Benefit
changes are effective January 1, 2004, and changes are summarized on
page 9. Rates are shown on the back cover of this brochure.

+-----------------------------------------------------------------------+
| ## **Plain Language**                                                 |
+-----------------------------------------------------------------------+

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

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

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

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

If you have comments or suggestions about how to improve the structure
of this brochure, let OPM know. Visit OPM\'s \"Rate Us\" feedback area
at [www.opm.gov/insure](http://www.opm.gov/reitre) 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.

```{=html}
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```
-   Let only the appropriate medical professionals review your medical
    record or recommend services.

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

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

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

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

```{=html}
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```
-   Call the physician or health care practitioner and ask for an
    explanation. There may be an error.

-   If the physician or health care practitioner does not resolve the
    matter, call us at 301-360-8080 or 1-800-251-0956 and explain the
    situation.

-   If we do not resolve the issue:

```{=html}
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```
-   Do not maintain as a family member on your policy:

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

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

```{=html}
<!-- -->
```
-   If you have any questions about the eligibility of a dependent,
    check with your personnel office if you are employed, with your
    retirement office (such as OPM) if you are retired, or with the
    National Finance Center if you are enrolled under Temporary
    Continuation of Coverage.

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

  -----------------------------------------------------------------------
  Preventing Medical Mistakes

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

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

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

-   Ask questions and make sure you understand the answers.

-   Choose a doctor with whom you feel comfortable talking.

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

1.  **Keep and bring a list of all the medicines you take.**

-   Give your doctor and pharmacist a list of all the medicines that you
    take, including non-prescription medicines.

-   Tell them about any drug allergies you have.

-   Ask about side effects and what to avoid while taking the medicine.

-   Read the label when you get your medicine, including all warnings.

-   Make sure your medicine is what the doctor ordered and know how to
    use it.

-   Ask the pharmacist about your medicine if it looks different than
    you expected.

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

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

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

-   Call your doctor and ask for your results.

-   Ask what the results mean for your care.

3.  **Talk to your doctor about which hospital is best for your health
    needs.**

-   Ask your doctor about which hospital has the best care and results
    for your condition if you have more than one hospital to choose from
    to get the health care you need.

-   Be sure you understand the instructions you get about follow-up care
    when you leave the hospital.

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

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

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

-   Ask your surgeon:

    Exactly what will you be doing?

    About how long will it take?

    What will happen after surgery?

    How can I expect to feel during recovery?

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

    Want more information on patient safety?

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

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

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

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

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

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

+-----------------------------------------------------------------------+
| # Section 1. Facts about this HMO Plan                                |
+-----------------------------------------------------------------------+

This Plan is a health maintenance organization (HMO). We require you to
see specific physicians, hospitals, facilities and other health care
practitioners who contract with us. These Plan physicians and health
care practitioners coordinate your health care services. The Plan is
solely responsible for the selection of these providers in your area.
Contact the Plan at 301-360-8080 or at 1-800-251-0956 ( TTY:
301-360-8111 or 1-800-553-7109) for a copy of their most recent
*Directory of Health Care Professionals* or visit our website,
www.mamsi.com/federal.

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 physicians and health care practitioners follow
generally accepted medical practice when prescribing any course of
treatment.

When you receive services from Plan physicians and health care
practitioners, 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 physicians and health care
practitioners, you may have to submit claim forms.

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

### How we pay physicians, health care practitioners and facilities

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

### 

### Your Rights

OPM requires that all FEHB Plans to provide certain information to their
FEHB members. You may get information about us, our networks of
physicians, health care practitioners and facilities. OPM's FEHB Web
site ([www.opm.gov/insure](http://www.opm.gov/insure)) lists the
specific types of information that we must make available to you.

If you want more information about us, call M.D. IPA's Member Services
Department at 301-360-8080 or at 1-800-251-0956 (TTY: 301-360-8111 or
1-800-553-7109), or write to P.O. Box 933, Frederick, MD 21705. You may
also contact us by fax at 301-360-8907 or visit our Web site,
[www.mamsi.com/federal](http://www.mamsi.com/federal)[.]{.underline}

### Service Area

To enroll in this Plan, you must live in or work in our service area.
This is where our physicians and health care practitioners practice.

Our service area is:

> **Washington, D.C.**
>
> **Maryland (the entire state)**
>
> **Virginia**
>
> **Cities of:**
>
> Alexandria, Charlottesville, Chesapeake, Clifton Forge, Colonial
> Heights, Covington, Emporia, Fairfax, Falls Church, Franklin,
> Fredericksburg, Hampton, Harrisonburg, Hopewell, Manassas, Manassas
> Park, Newport News, Norfolk, Norton, Petersburg, Poquoson, Portsmouth,
> Radford, Richmond, Roanoke, Salem, Staunton, Suffolk, Virginia Beach,
> Waynesboro and Williamsburg
>
> **Counties of:**
>
> Accomack, Albemarle, Alleghany, Amelia, Arlington, Augusta, Bath,
> Bedford, Bland, Botetourt, Buchanan, Buckingham, Caroline, Charles
> City, Charlotte, Chesterfield, Clarke, Craig, Culpeper, Cumberland,
> Dinwiddie, Fairfax, Fauquier, Floyd, Fluvanna, Franklin, Giles,
> Goochland, Gloucester, Greene, Greensville, Hanover, Henrico, Isle of
> Wight, James City, King George, King William, King and Queen, Loudoun,
> Louisa, Lunenburg, Madison, Mathews, Middlesex, Montgomery, Nelson,
> New Kent, Northampton, Nottoway, Orange, Page, Patrick, Powhatan,
> Prince Edward, Prince George, Prince William, Pulaski, Rappahannock,
> Roanoke, Rockingham, Russell, Southampton, Spotsylvania, Stafford,
> Surry, Sussex, Tazewell, Westmoreland, Wise, Wythe, and York.

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

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

+-----------------------------------------------------------------------+
| # Section 2. How we change for 2004                                   |
+-----------------------------------------------------------------------+

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

### Program-wide changes

-   We added information regarding two new Federal Programs that
    complement FEHB benefits, the Federal Flexible Spending Account
    Program - *FSAFEDS* and the Federal Long Term Care Insurance
    Program. See page 59.

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

-   We added information regarding enrolling in Medicare. See page 48.

-   We revised the Medicare Primary Payer Chart. See page 50.

### Changes to this Plan

-   Your share of the non-Postal premium will increase by 5.8% for Self
    Only coverage or 5.4% for Self and Family coverage.

-   **Prescription drugs**--You now pay \$20 per brand name drug on the
    Plan's formulary, and \$35 per brand name drug not on the Plan's
    formulary. The copayments for generic and injectable drugs remain
    the same.

-   **Prescription drugs** -- You now pay one copayment for up to a 90
    day supply for contraceptive drugs purchased through a Plan retail
    pharmacy or the Plan's mail order program.

-   **Inpatient hospitalization**--You now pay a \$100 copayment for
    each inpatient hospital admission.

-   **Service area expansion** -- We have expanded our service area in
    the State of Virginia to include the City of Harrisonburg and the
    counties of Fluvanna, Charlotte, Rockingham, Lunenburg, and Prince
    Edward.

+--------------------------+-------------------------------------------+
| #### Sec                 |                                           |
| tion 3. How you get care |                                           |
+--------------------------+-------------------------------------------+
| ###                      |                                           |
+--------------------------+-------------------------------------------+
| ### Identification cards | We will send you a health Plan            |
|                          | identification (ID) card. You should      |
|                          | carry your ID card with you at all times. |
|                          | You must show it whenever you receive     |
|                          | services from a Plan physician or health  |
|                          | care practitioner, or fill a prescription |
|                          | at a Plan pharmacy. Until you receive     |
|                          | your health Plan 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 301-360-8080 or         |
|                          | 1-800-251-0956 or write to us at P.O. Box |
|                          | 943, Frederick, MD 21705. You may also    |
|                          | request replacement cards through our     |
|                          | website at www.mamsi.com/federal.         |
+--------------------------+-------------------------------------------+
| ### Wh                   | You get care from "Plan providers" and    |
| ere you get covered care | "Plan facilities." You will only pay      |
|                          | copayments and/or coinsurance and you     |
|                          | will not have to file claims.             |
+--------------------------+-------------------------------------------+
| #                        | Plan physicians and other licensed health |
| ## Plan physicians and h | care professionals in our service area    |
| ealth care practitioners | contract with us to provide covered       |
|                          | services to our members.                  |
|                          |                                           |
|                          | All of our physicians are credentialed in |
|                          | accordance with the standards set by the  |
|                          | National Committee for Quality Assurance  |
|                          | (NCQA). For further information on our    |
|                          | credentialing procedures, please contact  |
|                          | our Member Services Department at         |
|                          | 301-360-8080 or 1-800-251-0956.           |
|                          |                                           |
|                          | We list Plan physicians and health care   |
|                          | practitioners in our *Directory of Health |
|                          | Care Professionals*. The list is also on  |
|                          | our website, www.mamsi.com/federal, which |
|                          | we update periodically. Information in    |
|                          | the directory is subject to change. For   |
|                          | this reason, we recommend that you access |
|                          | our website to look up the most           |
|                          | up-to-date information.                   |
+--------------------------+-------------------------------------------+
| ### Plan facilities      | Plan facilities are hospitals and other   |
|                          | facilities in our service area that we    |
|                          | contract with to provide covered services |
|                          | to our members. We list these in our      |
|                          | *Directory of Health Care Professionals*. |
|                          | The list is also on our website,          |
|                          | www.mamsi.com/federal. Information in the |
|                          | directory is subject to change. For this  |
|                          | reason, we recommend that you access our  |
|                          | website to look up the most up-to-date    |
|                          | information.                              |
+--------------------------+-------------------------------------------+
| ###                      | It depends on the type of care you need.  |
| What you must do to get  | First, you and each family member must    |
|                          | choose a Primary Care Physician (PCP).    |
| ### covered care         | This decision is important since your PCP |
|                          | provides or arranges for most of your     |
|                          | health care. **Please see pages** **34**  |
|                          | **and** **35** **for information on       |
|                          | accessing Mental Health and Substance     |
|                          | Abuse benefits.**                         |
|                          |                                           |
|                          | To choose a PCP check our *Directory of   |
|                          | Health Care Professionals* or our         |
|                          | website,                                  |
|                          | [www.mamsi.com/federal]{.underline}. You  |
|                          | may call the Member Services Department   |
|                          | at 301-360-8080 or 1-800-251-0956 and we  |
|                          | will make the change for you over the     |
|                          | phone. Or, if you wish, you may complete  |
|                          | the "Federal Information Form" included   |
|                          | in your open season information packet    |
|                          | and mail it to us at P.O. Box 943,        |
|                          | Frederick, MD 21705.                      |
+--------------------------+-------------------------------------------+

+-------------------------+---+---+---+--------------------------------------------+---+---+
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+-------------------------+---+---+---+--------------------------------------------+---+---+
| ### Specialty care      |   |   |   | Your Primary Care Physician (PCP) will     |   |   |
|                         |   |   |   | refer you to a participating specialist    |   |   |
|                         |   |   |   | for needed care.  Your referral is valid   |   |   |
|                         |   |   |   | for one visit/consultation unless your PCP |   |   |
|                         |   |   |   | authorized a certain number of visits      |   |   |
|                         |   |   |   | without additional referrals. If you are   |   |   |
|                         |   |   |   | changing your PCP and currently have in    |   |   |
|                         |   |   |   | effect a referral to a Specialist, it will |   |   |
|                         |   |   |   | be necessary to request a new referral     |   |   |
|                         |   |   |   | from your new PCP. All follow-up care must |   |   |
|                         |   |   |   | be authorized by your PCP issuing you a    |   |   |
|                         |   |   |   | new referral, or by approving a Consultant |   |   |
|                         |   |   |   | Treatment Plan (CTP) submitted by the      |   |   |
|                         |   |   |   | specialist. Female members may see a       |   |   |
|                         |   |   |   | participating obstetrician or              |   |   |
|                         |   |   |   | gynecologist, or a participating Certified |   |   |
|                         |   |   |   | Nurse Midwife, for obstetrical and         |   |   |
|                         |   |   |   | gynecological care without a referral.     |   |   |
|                         |   |   |   | Obstetrical and gynecological services     |   |   |
|                         |   |   |   | include routine care and follow-up         |   |   |
|                         |   |   |   | services, as well as medically necessary   |   |   |
|                         |   |   |   | services. Eye refraction exams and dental  |   |   |
|                         |   |   |   | care are also available from Plan          |   |   |
|                         |   |   |   | physicians and health care practitioners   |   |   |
|                         |   |   |   | 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 PCP will develop a treatment plan |   |   |
|                         |   |   |   |     that allows you to see your specialist |   |   |
|                         |   |   |   |     for a certain number of visits without |   |   |
|                         |   |   |   |     additional referrals. Your PCP will    |   |   |
|                         |   |   |   |     use our criteria when creating your    |   |   |
|                         |   |   |   |     treatment plan (the physician may have |   |   |
|                         |   |   |   |     to get an authorization or approval    |   |   |
|                         |   |   |   |     beforehand).                           |   |   |
|                         |   |   |   |                                            |   |   |
|                         |   |   |   | ```{=html}                                 |   |   |
|                         |   |   |   | <!-- -->                                   |   |   |
|                         |   |   |   | ```                                        |   |   |
|                         |   |   |   | -   If you are seeing a specialist when    |   |   |
|                         |   |   |   |     you enroll in our Plan, talk to your   |   |   |
|                         |   |   |   |     PCP. He or she will decide what        |   |   |
|                         |   |   |   |     treatment you need. If he or she       |   |   |
|                         |   |   |   |     decides to refer you to a specialist,  |   |   |
|                         |   |   |   |     ask if you can see your current        |   |   |
|                         |   |   |   |     specialist. If your current specialist |   |   |
|                         |   |   |   |     does not participate with us, you must |   |   |
|                         |   |   |   |     receive treatment from a specialist    |   |   |
|                         |   |   |   |     who does. Generally, we will not pay   |   |   |
|                         |   |   |   |     for you to see a specialist who does   |   |   |
|                         |   |   |   |     not participate with our Plan.         |   |   |
|                         |   |   |   |                                            |   |   |
|                         |   |   |   | ```{=html}                                 |   |   |
|                         |   |   |   | <!-- -->                                   |   |   |
|                         |   |   |   | ```                                        |   |   |
|                         |   |   |   | -   If you are seeing a specialist and     |   |   |
|                         |   |   |   |     your specialist leaves the Plan, call  |   |   |
|                         |   |   |   |     your PCP, who will arrange for you to  |   |   |
|                         |   |   |   |     see another specialist. You may        |   |   |
|                         |   |   |   |     receive services from your current     |   |   |
|                         |   |   |   |     specialist until we can make           |   |   |
|                         |   |   |   |     arrangements for you to see someone    |   |   |
|                         |   |   |   |     else.                                  |   |   |
|                         |   |   |   |                                            |   |   |
|                         |   |   |   | -   If you have a chronic or disabling     |   |   |
|                         |   |   |   |     condition and lose access to your      |   |   |
|                         |   |   |   |     specialist because we:                 |   |   |
|                         |   |   |   |                                            |   |   |
|                         |   |   |   | -   terminate our contract with your       |   |   |
|                         |   |   |   |     specialist for other than cause;or     |   |   |
|                         |   |   |   |                                            |   |   |
|                         |   |   |   | ```{=html}                                 |   |   |
|                         |   |   |   | <!-- -->                                   |   |   |
|                         |   |   |   | ```                                        |   |   |
|                         |   |   |   | -   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.                                   |   |   |
+-------------------------+---+---+---+--------------------------------------------+---+---+
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|                         |   |   | v |                                            |   |   |
|                         |   |   | i |                                            |   |   |
|                         |   |   | d |                                            |   |   |
|                         |   |   | e |                                            |   |   |
|                         |   |   | y |                                            |   |   |
|                         |   |   | o |                                            |   |   |
|                         |   |   | u |                                            |   |   |
|                         |   |   | w |                                            |   |   |
|                         |   |   | i |                                            |   |   |
|                         |   |   | t |                                            |   |   |
|                         |   |   | h |                                            |   |   |
|                         |   |   | t |                                            |   |   |
|                         |   |   | h |                                            |   |   |
|                         |   |   | e |                                            |   |   |
|                         |   |   | n |                                            |   |   |
|                         |   |   | e |                                            |   |   |
|                         |   |   | c |                                            |   |   |
|                         |   |   | e |                                            |   |   |
|                         |   |   | s |                                            |   |   |
|                         |   |   | s |                                            |   |   |
|                         |   |   | a |                                            |   |   |
|                         |   |   | r |                                            |   |   |
|                         |   |   | y |                                            |   |   |
|                         |   |   | c |                                            |   |   |
|                         |   |   | a |                                            |   |   |
|                         |   |   | r |                                            |   |   |
|                         |   |   | e |                                            |   |   |
|                         |   |   | . |                                            |   |   |
+-------------------------+---+---+---+--------------------------------------------+---+---+

+-------------------------+--------------------------------------------+
| ### Servi               | Your Primary Care Physician (PCP) has      |
| ces requiring our prior | authority to refer you for most services.  |
|                         | For certain services, however, your        |
| ### approval            | physician must obtain approval from us.    |
|                         | All care must be arranged with Plan        |
|                         | providers except for emergencies. Before   |
|                         | giving approval, we consider if the        |
|                         | service is covered, medically necessary,   |
|                         | and follows generally accepted medical     |
|                         | practice.                                  |
|                         |                                            |
|                         | We call this review and approval process   |
|                         | precertification. Your physician must      |
|                         | obtain precertification for some services  |
|                         | such as, but not limited to the following: |
|                         |                                            |
|                         | -   Acupuncture                            |
|                         |                                            |
|                         | -   Biofeedback                            |
|                         |                                            |
|                         | -   Breast Reduction                       |
|                         |                                            |
|                         | -   Reconstructive surgery                 |
|                         |                                            |
|                         | -   Growth Hormone Therapy (GHT)           |
|                         |                                            |
|                         | -   Infertility Services                   |
|                         |                                            |
|                         | -   Morbid Obesity Surgery                 |
|                         |                                            |
|                         | -   Rhinoplasty                            |
|                         |                                            |
|                         | -   Therapies (Physical Therapy,           |
|                         |     Occupational Therapy and Speech        |
|                         |                                            |
|                         |     Therapy)                               |
|                         |                                            |
|                         |     -- precertification is required for    |
|                         |     physical therapy and occupational      |
|                         |     therapy after the eighth (8^th^) visit |
|                         |     for all members                        |
|                         |                                            |
|                         |     -- precertification is required for    |
|                         |     speech therapy from the first (1^st^)  |
|                         |     visit, but only for members under age  |
|                         |     10                                     |
|                         |                                            |
|                         | -   Temporomandibular Joint (TMJ) Pain     |
|                         |     Dysfunction and/or related             |
|                         |                                            |
|                         |     Myofascial Pain Dysfunction (MPD)      |
|                         |     treatment                              |
|                         |                                            |
|                         | -   Transplants                            |
|                         |                                            |
|                         | -   Uvulopalatopharyngoplasty              |
|                         |                                            |
|                         | -   Durable Medical Equipment, Orthopedic  |
|                         |     and Prosthetic Devices                 |
|                         |                                            |
|                         | -   Certain Mental Health and Substance    |
|                         |     Abuse services. See page 34            |
|                         |                                            |
|                         | In addition, your admitting physician and  |
|                         | facility must also preauthorize any        |
|                         | elective inpatient stays.                  |
|                         |                                            |
|                         | It is your PCP's or specialist's           |
|                         | responsibility to obtain precertification  |
|                         | for the procedures listed above before     |
|                         | performing them. If the PCP or specialist  |
|                         | does not do this, you will not be liable   |
|                         | for the cost of covered services.          |
|                         |                                            |
|                         | We will decide whether or not to           |
|                         | precertify a procedure within two working  |
|                         | days of the receipt of the information we  |
|                         | need to make a decision.                   |
|                         |                                            |
|                         | If we deny the request or if you wish to   |
|                         | extend the number of authorized visits,    |
|                         | your PCP or specialist may ask us to       |
|                         | reevaluate our decision or extend the      |
|                         | number of authorized visits at any time. A |
|                         | decision will be made within one working   |
|                         | day of receiving all of the information we |
|                         | need to make the decision.                 |
|                         |                                            |
|                         | If you are not satisfied with our          |
|                         | decision, you, or your PCP or specialist   |
|                         | on your behalf, may appeal the decision.   |
+-------------------------+--------------------------------------------+

### 

+--------------------------+--------------------------------------------+
| Section 4. Your costs    |                                            |
| for covered services     |                                            |
+--------------------------+--------------------------------------------+
| ###                      | ###                                        |
|                          |                                            |
| You must share the cost  | You are responsible for:                   |
| of some services.        |                                            |
+--------------------------+--------------------------------------------+
| ### Copayment            | ### A copayment is a                       |
|                          |  fixed amount of money you pay to the phys |
|                          | ician, health care practitioner, facility, |
|                          |  pharmacy, etc. when you receive services. |
|                          |                                            |
|                          | Example: When you see your Primary Care    |
|                          | Physician you pay a copayment of \$10 per  |
|                          | office visit and when you are admitted to  |
|                          | the hospital, you pay a copayment of \$100 |
|                          | per admission.                             |
+--------------------------+--------------------------------------------+
| ### Deductible           | We do not have a deductible*.*             |
+--------------------------+--------------------------------------------+
| ### Coinsurance          | ### C                                      |
|                          | oinsurance is the percentage of our negoti |
|                          | ated fee that you must pay for your care.  |
|                          |                                            |
|                          | Example: In our Plan, you pay 50% of our   |
|                          | allowance for most infertility services    |
|                          | and durable medical equipment.             |
+--------------------------+--------------------------------------------+
| ### Your                 | ### After y                                |
| catastrophic protection  | our copayment and/or coinsurance total \$1 |
|                          | ,800 per person or \$4,800 per family enro |
| #                        | llment in any calendar year, you do not ha |
| ## out-of-pocket maximum | ve to pay any more for covered services. H |
|                          | owever, copayments and coinsurance for the |
| **for coinsurance and    |  following services do not count toward yo |
| copayments**             | ur catastrophic protection out-of-pocket m |
|                          | aximum, and you must continue to pay copay |
|                          | ments and coinsurance for these services:  |
|                          |                                            |
|                          | -   Prescription drugs                     |
|                          |                                            |
|                          | -   Dental Discount Benefits               |
|                          |                                            |
|                          | -   Eyeglasses or contact lenses           |
|                          |                                            |
|                          | -   In-vitro fertilization                 |
|                          |                                            |
|                          | Be sure to keep accurate records of your   |
|                          | copayments and coinsurance since you are   |
|                          | responsible for informing us when you      |
|                          | reach the maximum.                         |
+--------------------------+--------------------------------------------+

+-----------------------------------+--------------------------------+---+
| ###                               |                                |   |
| # Section 5. Benefits -- OVERVIEW |                                |   |
|                                   |                                |   |
| **(*See page 9*** ***for how our  |                                |   |
| benefits changed this year and    |                                |   |
| page*** ***64*** ***for a         |                                |   |
| benefits summary)***              |                                |   |
+-----------------------------------+--------------------------------+---+
| **Note:** This benefits section   |                                |   |
| is divided into subsections.      |                                |   |
| Please read the important things  |                                |   |
| you should keep in mind at the    |                                |   |
| beginning of each subsection.     |                                |   |
| Also read the General Exclusions  |                                |   |
| in Section 6; they apply to the   |                                |   |
| benefits in the subsections. To   |                                |   |
| obtain claims forms, claims       |                                |   |
| filing advice, or more            |                                |   |
| information about our benefits,   |                                |   |
| contact us at                     |                                |   |
|                                   |                                |   |
| 301-360-8080 or 1-800-251-0956 (  |                                |   |
| TTY: 301-360-8111 or              |                                |   |
| 1-800-553-7109) ,or at our        |                                |   |
| website, www.mamsi.com/federal..  |                                |   |
+-----------------------------------+--------------------------------+---+
| (a) Medical services and supplies |                                |   |
|     provided by physicians and    |                                |   |
|     other health care             |                                |   |
|     professionals 16-25           |                                |   |
+-----------------------------------+--------------------------------+---+
| -   Diagnostic and treatment      | -   Speech therapy             |   |
|     services                      |                                |   |
|                                   | -   Habilitative therapies     |   |
| -   Laboratory, X-ray, and other  |                                |   |
|     diagnostic tests              | -   Hearing services (testing, |   |
|                                   |     treatment, and supplies)   |   |
| -   Preventive care, adult        |                                |   |
|                                   | -   Vision services (testing,  |   |
| -   Preventive care, children     |     treatment, and supplies)   |   |
|                                   |                                |   |
| -   Maternity care                | -   Foot care                  |   |
|                                   |                                |   |
| -   Family planning               | -   Orthopedic and prosthetic  |   |
|                                   |     devices                    |   |
| -   Infertility services          |                                |   |
|                                   | -   Durable medical equipment  |   |
| -   Allergy care                  |     (DME)                      |   |
|                                   |                                |   |
| -   Treatment therapies           | -   Home health services       |   |
|                                   |                                |   |
| -   Physical, cardiac and         | -   Chiropractic               |   |
|     occupational therapies        |                                |   |
|                                   | -   Alternative treatments     |   |
|                                   |                                |   |
|                                   | -   Educational classes and    |   |
|                                   |     programs                   |   |
+-----------------------------------+--------------------------------+---+
| (b) Surgical and anesthesia       |                                |   |
|     services provided by          |                                |   |
|     physicians and other health   |                                |   |
|     care professionals 26-28      |                                |   |
+-----------------------------------+--------------------------------+---+
| -   Surgical procedures           | -   Oral and maxillofacial     |   |
|                                   |     surgery                    |   |
| -   Reconstruction surgery        |                                |   |
|                                   | -   Organ/tissue transplants   |   |
|                                   |                                |   |
|                                   | -   Anesthesia                 |   |
+-----------------------------------+--------------------------------+---+
| (c) Services provided by a        |                                |   |
|     hospital or other facility,   |                                |   |
|     and ambulance services 29-31  |                                |   |
+-----------------------------------+--------------------------------+---+
| -   Inpatient hospital            | -   Extended care              |   |
|                                   |     benefits/skilled nursing   |   |
| -   Outpatient hospital or        |     care facility benefits     |   |
|     ambulatory surgical center    |                                |   |
|                                   | -   Hospice care               |   |
|                                   |                                |   |
|                                   | -   Ambulance                  |   |
+-----------------------------------+--------------------------------+---+
| (d) Emergency services/accidents  |                                |   |
|     32-33                         |                                |   |
+-----------------------------------+--------------------------------+---+
| -   Medical emergency             | -   Ambulance                  |   |
+-----------------------------------+--------------------------------+---+
| (e) Mental health and substance   |                                |   |
|     abuse benefits 34-35          |                                |   |
+-----------------------------------+--------------------------------+---+
| (f) Prescription drug benefits    |                                |   |
|     36-38                         |                                |   |
+-----------------------------------+--------------------------------+---+
| (g) Special features 39           |                                |   |
|                                   |                                |   |
| -   Flexible benefits option      |                                |   |
|                                   |                                |   |
| ```{=html}                        |                                |   |
| <!-- -->                          |                                |   |
| ```                               |                                |   |
| -   Centers for Cardiac Surgery,  |                                |   |
|     Transplants and Joint         |                                |   |
|     Replacement                   |                                |   |
|                                   |                                |   |
| -   Health Education and Disease  |                                |   |
|     Management Programs           |                                |   |
+-----------------------------------+--------------------------------+---+
| \(h\) Dental benefits 40-42       |                                |   |
+-----------------------------------+--------------------------------+---+
| \(i\) Non-FEHB benefits available |                                |   |
| to Plan members 43                |                                |   |
+-----------------------------------+--------------------------------+---+
| Summary of benefits 64            |                                |   |
+-----------------------------------+--------------------------------+---+

+---+---+----------------------------------------+---------------+---+---+
| # |   |                                        |               |   |   |
| # |   |                                        |               |   |   |
| # |   |                                        |               |   |   |
| # |   |                                        |               |   |   |
| # |   |                                        |               |   |   |
| # |   |                                        |               |   |   |
|   |   |                                        |               |   |   |
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| n |   |                                        |               |   |   |
|   |   |                                        |               |   |   |
| 5 |   |                                        |               |   |   |
| ( |   |                                        |               |   |   |
| a |   |                                        |               |   |   |
| ) |   |                                        |               |   |   |
| . |   |                                        |               |   |   |
|   |   |                                        |               |   |   |
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|   |   |                                        |               |   |   |
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| d |   |                                        |               |   |   |
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| d |   |                                        |               |   |   |
|   |   |                                        |               |   |   |
| b |   |                                        |               |   |   |
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|   |   |                                        |               |   |   |
| p |   |                                        |               |   |   |
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| c |   |                                        |               |   |   |
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| n |   |                                        |               |   |   |
| s |   |                                        |               |   |   |
|   |   |                                        |               |   |   |
| a |   |                                        |               |   |   |
| n |   |                                        |               |   |   |
| d |   |                                        |               |   |   |
|   |   |                                        |               |   |   |
| o |   |                                        |               |   |   |
| t |   |                                        |               |   |   |
| h |   |                                        |               |   |   |
| e |   |                                        |               |   |   |
| r |   |                                        |               |   |   |
|   |   |                                        |               |   |   |
| h |   |                                        |               |   |   |
| e |   |                                        |               |   |   |
| a |   |                                        |               |   |   |
| l |   |                                        |               |   |   |
| t |   |                                        |               |   |   |
| h |   |                                        |               |   |   |
|   |   |                                        |               |   |   |
| c |   |                                        |               |   |   |
| a |   |                                        |               |   |   |
| r |   |                                        |               |   |   |
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|   |   |                                        |               |   |   |
| p |   |                                        |               |   |   |
| r |   |                                        |               |   |   |
| o |   |                                        |               |   |   |
| f |   |                                        |               |   |   |
| e |   |                                        |               |   |   |
| s |   |                                        |               |   |   |
| s |   |                                        |               |   |   |
| i |   |                                        |               |   |   |
| o |   |                                        |               |   |   |
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| a |   |                                        |               |   |   |
| l |   |                                        |               |   |   |
| s |   |                                        |               |   |   |
+---+---+----------------------------------------+---------------+---+---+
|   | * | **Here are some important things to    |               | # |   |
|   | * | keep in mind about these benefits:**   |               | # |   |
|   | I |                                        |               | # |   |
|   | M | -   Please remember that all benefits  |               |   |   |
|   | * |     are subject to the definitions,    |               | I |   |
|   | * |     limitations and exclusions in this |               |   |   |
|   |   |     brochure and are payable only when |               | * |   |
|   | * |     we determine they are medically    |               | * |   |
|   | * |     necessary.                         |               | M |   |
|   | P |                                        |               | * |   |
|   | * | -   Plan physicians must provide or    |               | * |   |
|   | * |     arrange your care.                 |               |   |   |
|   |   |                                        |               | * |   |
|   | * | -   We have no calendar year           |               | * |   |
|   | * |     deductible.                        |               | P |   |
|   | 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       |               | O |   |
|   | R |     benefits with other coverage,      |               | * |   |
|   | * |     including with Medicare.           |               | * |   |
|   | * |                                        |               |   |   |
|   |   | -   **YOUR PHYSICIAN MUST GET          |               | * |   |
|   | * |     PRECERTIFICATION FOR SOME SERVICES |               | * |   |
|   | * |     AND/OR** **PROCEDURES.** Please    |               | R |   |
|   | T |     refer to the precertification      |               | * |   |
|   | * |     information shown in Section 3 to  |               | * |   |
|   | * |     be sure which services require     |               |   |   |
|   |   |     precertification.                  |               | * |   |
|   | * |                                        |               | * |   |
|   | * |                                        |               | T |   |
|   | A |                                        |               | * |   |
|   | * |                                        |               | * |   |
|   | * |                                        |               |   |   |
|   |   |                                        |               | * |   |
|   | * |                                        |               | * |   |
|   | * |                                        |               | A |   |
|   | N |                                        |               | * |   |
|   | * |                                        |               | * |   |
|   | * |                                        |               |   |   |
|   |   |                                        |               | * |   |
|   | * |                                        |               | * |   |
|   | * |                                        |               | N |   |
|   | T |                                        |               | * |   |
|   | * |                                        |               | * |   |
|   | * |                                        |               |   |   |
|   |   |                                        |               | * |   |
|   |   |                                        |               | * |   |
|   |   |                                        |               | T |   |
|   |   |                                        |               | * |   |
|   |   |                                        |               | * |   |
+---+---+----------------------------------------+---------------+---+---+
| B |   |                                        | You pay       |   |   |
| e |   |                                        |               |   |   |
| n |   |                                        |               |   |   |
| e |   |                                        |               |   |   |
| f |   |                                        |               |   |   |
| i |   |                                        |               |   |   |
| t |   |                                        |               |   |   |
| D |   |                                        |               |   |   |
| e |   |                                        |               |   |   |
| s |   |                                        |               |   |   |
| c |   |                                        |               |   |   |
| r |   |                                        |               |   |   |
| i |   |                                        |               |   |   |
| p |   |                                        |               |   |   |
| t |   |                                        |               |   |   |
| i |   |                                        |               |   |   |
| o |   |                                        |               |   |   |
| n |   |                                        |               |   |   |
+---+---+----------------------------------------+---------------+---+---+
| > |   |                                        |               |   |   |
|   |   |                                        |               |   |   |
| 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 |   |                                        |               |   |   |
+---+---+----------------------------------------+---------------+---+---+
| > |   |                                        | \$10 per      |   |   |
|   |   |                                        | office visit  |   |   |
| P |   |                                        | to your       |   |   |
| r |   |                                        | Primary Care  |   |   |
| o |   |                                        | Physician     |   |   |
| f |   |                                        |               |   |   |
| e |   |                                        | \$20 per      |   |   |
| s |   |                                        | office visit  |   |   |
| s |   |                                        | to a          |   |   |
| i |   |                                        | specialist    |   |   |
| o |   |                                        |               |   |   |
| n |   |                                        |               |   |   |
| a |   |                                        |               |   |   |
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+---+---+----------------------------------------+---------------+---+---+
| > |   |                                        | \$10 per      |   |   |
|   |   |                                        | visit from    |   |   |
| A |   |                                        | your Primary  |   |   |
| t |   |                                        | Care          |   |   |
| > |   |                                        | Physician     |   |   |
|   |   |                                        |               |   |   |
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| o |   |                                        | visit from a  |   |   |
| m |   |                                        | specialist    |   |   |
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+---+---+----------------------------------------+---------------+---+---+
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+---+---+----------------------------------------+---------------+---+---+
| T |   |                                        | Nothing if    |   |   |
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| t |   |                                        | services      |   |   |
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| : |   |                                        |               |   |   |
|   |   |                                        | \$50 per      |   |   |
| - |   |                                        | outpatient    |   |   |
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|   |   |                                        |               |   |   |
| a |   |                                        |               |   |   |
| n |   |                                        |               |   |   |
| d |   |                                        |               |   |   |
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| E |   |                                        |               |   |   |
| E |   |                                        |               |   |   |
| G |   |                                        |               |   |   |
+---+---+----------------------------------------+---------------+---+---+

+----------------------------------------------+-----------------------+
| > Preventive care, adult                     | You pay               |
+----------------------------------------------+-----------------------+
| > Routine screenings, such as:               | \$10 per office visit |
|                                              | to your Primary Care  |
| -   Total Blood Cholesterol                  | Physician             |
|                                              |                       |
| -   Colorectal Cancer Screening, including:  | \$20 per office visit |
|                                              | to a specialist       |
| ```{=html}                                   |                       |
| <!-- -->                                     |                       |
| ```                                          |                       |
| -   Fecal occult blood test                  |                       |
|                                              |                       |
| ```{=html}                                   |                       |
| <!-- -->                                     |                       |
| ```                                          |                       |
| -   Sigmoidoscopy screening -- every five    |                       |
|     years starting at age 50                 |                       |
+----------------------------------------------+-----------------------+
| > Routine Prostate Specific Antigen (PSA)    | \$10 per office visit |
| > test-- one annually for men age 40 and     | to your Primary Care  |
| > older                                      | Physician             |
|                                              |                       |
|                                              | \$20 per office visit |
|                                              | to a specialist       |
+----------------------------------------------+-----------------------+
| > Routine pap test                           | \$10 per office visit |
| >                                            | to your Primary Care  |
| > Note: The office visit is covered if pap   | Physician             |
| > test is received on the same day; see      |                       |
| > *Diagnostic and Treatment services*,       | \$20 per office visit |
| > above.                                     | to a specialist       |
|                                              |                       |
|                                              | Nothing per visit to  |
|                                              | a Certified Nurse     |
|                                              | Midwife               |
+----------------------------------------------+-----------------------+
| > Routine mammogram -- covered for women age | \$10 per office visit |
| > 35 and older, as follows:                  | to your Primary Care  |
|                                              | Physician             |
| -   From age 35 through 39, one during this  |                       |
|     five year period                         | \$20 per office visit |
|                                              | to a specialist       |
| -   From age 40 through 64, one every        |                       |
|     calendar year                            | \$50 per outpatient   |
|                                              | hospital visit        |
| -   At age 65 and older, one every two       |                       |
|     consecutive calendar years               |                       |
+----------------------------------------------+-----------------------+
| > Routine immunizations limited to:          | \$10 per office visit |
|                                              | to your Primary Care  |
| -   Tetanus-diphtheria (Td) booster -- once  | Physician             |
|     every 10 years, ages 19 and over (except |                       |
|     as provided for under Childhood          | \$20 per office visit |
|     immunizations.)                          | to a specialist       |
|                                              |                       |
| -   Influenza vaccine, annually, age 50 and  |                       |
|     over                                     |                       |
|                                              |                       |
| -   Pneumococcal vaccine, once at age 65 or  |                       |
|     older                                    |                       |
+----------------------------------------------+-----------------------+
| *Not covered: Physical exams and             | *All charges*         |
| immunizations required for obtaining or      |                       |
| continuing employment or insurance,          |                       |
| attending schools or camp, or travel.*       |                       |
+----------------------------------------------+-----------------------+

+----------------------------------------------+-----------------------+
| > Preventive care, children                  | You pay               |
+----------------------------------------------+-----------------------+
| -   Childhood immunizations recommended by   | \$10 per office visit |
|     the American Academy of Pediatrics       | to your Primary Care  |
|     (AAP), American Academy of Family        | Physician             |
|     Physicians (AAFP), and the Advisory      |                       |
|     Committee on Immunization Practices      | \$20 per office visit |
|     (ACIP)                                   | to a specialist       |
+----------------------------------------------+-----------------------+
| -   Well-child care for routine              | \$10 per office visit |
|     examinations, immunizations and care (up | to your Primary Care  |
|     to age 22)                               | Physician             |
|                                              |                       |
| ```{=html}                                   | \$20 per office visit |
| <!-- -->                                     | to a specialist       |
| ```                                          |                       |
| -   Examinations, such as:                   |                       |
|                                              |                       |
| ```{=html}                                   |                       |
| <!-- -->                                     |                       |
| ```                                          |                       |
| -   Ear exams to determine the need for      |                       |
|     hearing correction                       |                       |
|                                              |                       |
| -   Examinations done on the day of          |                       |
|     immunizations (up to age 22)             |                       |
+----------------------------------------------+-----------------------+
| > Eye exams to determine the need for vision | \$25 per office visit |
| > correction                                 | to a specialist       |
+----------------------------------------------+-----------------------+
| > Maternity Care                             |                       |
+----------------------------------------------+-----------------------+
| > Complete maternity (obstetrical) care,     | \$10 per office visit |
| > such as:                                   | to your Primary Care  |
|                                              | Physician             |
| -   Prenatal care                            |                       |
|                                              | \$20 per office visit |
| -   Delivery                                 | to a specialist       |
|                                              |                       |
| -   Postnatal care                           | Nothing per visit to  |
|                                              | a Certified Nurse     |
| > **Note**: Here are some things to keep in  | Midwife               |
| > mind:                                      |                       |
|                                              |                       |
| -   Office visit copayments for routine      |                       |
|     obstetrical care are waived after the    |                       |
|     first maternity care visit.              |                       |
|                                              |                       |
| ```{=html}                                   |                       |
| <!-- -->                                     |                       |
| ```                                          |                       |
| -   Routine care includes office visits, one |                       |
|     office sonogram (as part of prenatal     |                       |
|     care) and laboratory work                |                       |
|                                              |                       |
| -   You do not have to obtain a referral to  |                       |
|     see a participating obstetrician or      |                       |
|     gynecologist, or a participating         |                       |
|     Certified Nurse Midwife, for obstetrical |                       |
|     and gynecological care. Obstetrical and  |                       |
|     gynecological services include routine   |                       |
|     care and follow-up services, as well as  |                       |
|     medically necessary services. A          |                       |
|     participating obstetrician/gynecologist  |                       |
|     may issue referrals for                  |                       |
|     pregnancy-related illnesses through the  |                       |
|     postpartum period.                       |                       |
|                                              |                       |
| -   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.                               |                       |
|                                              |                       |
| ```{=html}                                   |                       |
| <!-- -->                                     |                       |
| ```                                          |                       |
| -   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.                       |                       |
|                                              |                       |
| -   Circumcisions are covered 100% during    |                       |
|     newborn stay. Note: Medically necessary  |                       |
|     circumcisions following the newborn stay |                       |
|     are covered under the surgical benefit   |                       |
|     at the applicable copayment              |                       |
|                                              |                       |
| ```{=html}                                   |                       |
| <!-- -->                                     |                       |
| ```                                          |                       |
| -   We pay hospitalization and surgeon       |                       |
|     services (delivery) the same as for      |                       |
|     illness and injury. See Hospital         |                       |
|     benefits (Section 5c) and Surgery        |                       |
|     benefits (Section 5b).                   |                       |
|                                              |                       |
| -   We cover delivery services by a midwife  |                       |
|     only at accredited birthing centers and  |                       |
|     hospitals                                |                       |
+----------------------------------------------+-----------------------+

+----------------------------------------------+-----------------------+
| > Family planning                            | You pay               |
+----------------------------------------------+-----------------------+
| > A broad range of voluntary family planning | \$10 per office visit |
| > services, limited to:                      | to your Primary Care  |
|                                              | Physician             |
| -   Voluntary sterilization (See Surgical    |                       |
|     procedures 5 (b))                        | \$20 per office visit |
|                                              | to a specialist       |
| ```{=html}                                   |                       |
| <!-- -->                                     | \$50 per outpatient   |
| ```                                          | hospital visit        |
| -   Surgically implanted contraceptives      |                       |
|                                              |                       |
| -   Administration of injectable             |                       |
|     contraceptive drugs (such as Depo        |                       |
|     provera)                                 |                       |
|                                              |                       |
| -   Intrauterine devices (IUDs)              |                       |
|                                              |                       |
| -   Diaphragms                               |                       |
|                                              |                       |
| > **Note**: We cover oral and injectable     |                       |
| > contraceptives under the prescription drug |                       |
| > benefit.                                   |                       |
+----------------------------------------------+-----------------------+
| > *Not covered: reversal of voluntary        | *All charges*         |
| > surgical sterilization*                    |                       |
+----------------------------------------------+-----------------------+
| **Infertility services**                     |                       |
+----------------------------------------------+-----------------------+
| Diagnosis and treatment of infertility, such | \$10 per office visit |
| as:                                          | to your Primary Care  |
|                                              | Physician             |
| -   Artificial insemination:                 |                       |
|                                              | 50% per office visit  |
| ```{=html}                                   | to other Plan         |
| <!-- -->                                     | physicians or health  |
| ```                                          | care practitioners    |
| -   intravaginal insemination (IVI)          |                       |
|                                              |                       |
| -   intracervical insemination (ICI)         |                       |
|                                              |                       |
| -   intrauterine insemination (IUI)          |                       |
|                                              |                       |
| ```{=html}                                   |                       |
| <!-- -->                                     |                       |
| ```                                          |                       |
| -   In-vitro fertilization is covered for    |                       |
|     married members when the following       |                       |
|     criteria is met:                         |                       |
|                                              |                       |
| ```{=html}                                   |                       |
| <!-- -->                                     |                       |
| ```                                          |                       |
| -   your oocytes are fertilized with your    |                       |
|     spouse's sperm                           |                       |
|                                              |                       |
| -   you and your spouse have a history of    |                       |
|     infertility of at least 2 years, or      |                       |
|                                              |                       |
| -   your infertility is associated with      |                       |
|     endometriosis, or exposure in-utero to   |                       |
|     diethylstilbestrol (DES), or blockage    |                       |
|     of, or surgical removal of one or both   |                       |
|     fallopian tubes (not due to voluntary    |                       |
|     sterilization), or abnormal male         |                       |
|     factors, including oligospermia,         |                       |
|     contributing to the infertility          |                       |
|                                              |                       |
| -   you have been unable to attain a         |                       |
|     successful pregnancy through a less      |                       |
|     costly treatment that is covered by the  |                       |
|     Plan                                     |                       |
|                                              |                       |
| In-vitro fertilization is limited to three   |                       |
| (3) in-vitro attempts per live birth and a   |                       |
| maximum lifetime benefit of \$100,000,       |                       |
| except drugs (an attempt is counted toward   |                       |
| this limit when injectable medications are   |                       |
| started).                                    |                       |
+----------------------------------------------+-----------------------+
| **Note:** We cover injectable and oral       |                       |
| fertility drugs for covered in-vitro         |                       |
| fertilization services. We cover Clomid      |                       |
| (clomiphene) for other infertility services. |                       |
| When covered, all infertility drugs are      |                       |
| covered under the prescription drug benefit. |                       |
+----------------------------------------------+-----------------------+
| > *Not covered:*                             | *All charges*         |
|                                              |                       |
| -   *Assisted reproductive technology (ART)  |                       |
|     procedures, such as:*                    |                       |
|                                              |                       |
| ```{=html}                                   |                       |
| <!-- -->                                     |                       |
| ```                                          |                       |
| -   *embryo transplant, gamete               |                       |
|     intrafallopian transfer (GIFT), zygote   |                       |
|     intrafallopian transfer (ZIFT), sex      |                       |
|     selection, surrogacy, host uterus, gene  |                       |
|     therapy, cryopreservation, and           |                       |
|     pre-implantation genetic diagnosis*      |                       |
|                                              |                       |
| ```{=html}                                   |                       |
| <!-- -->                                     |                       |
| ```                                          |                       |
| -   *Other services and supplies related to  |                       |
|     ART procedures*                          |                       |
|                                              |                       |
| ```{=html}                                   |                       |
| <!-- -->                                     |                       |
| ```                                          |                       |
| -   *Cost of donor sperm, donor eggs, and    |                       |
|     related costs*                           |                       |
|                                              |                       |
| -   *Infertility services after reversal of  |                       |
|     voluntary sterilization*                 |                       |
+----------------------------------------------+-----------------------+

+-----------------------------------------------+----------------------+
| > Allergy care                                | You pay              |
+-----------------------------------------------+----------------------+
| > Testing and treatment                       | \$10 per office      |
| >                                             | visit to your        |
| > Allergy injections                          | Primary Care         |
|                                               | Physician            |
|                                               |                      |
|                                               | \$20 per office      |
|                                               | visit to a           |
|                                               | specialist           |
+-----------------------------------------------+----------------------+
| > Allergy serum                               | Nothing              |
+-----------------------------------------------+----------------------+
| *Not covered: provocative food testing and    | *All charges*        |
| sublingual allergy desensitization.*          |                      |
+-----------------------------------------------+----------------------+
| **Treatment therapies**                       |                      |
+-----------------------------------------------+----------------------+
| -   Chemotherapy and radiation therapy        | \$10 per office      |
|                                               | visit to your        |
| > Note: High dose chemotherapy in association | Primary Care         |
| > with autologous bone marrow transplants is  | Physician            |
| > limited to those transplants listed under   |                      |
| > Organ/Tissue Transplants on page 28.        | \$20 per office      |
|                                               | visit to a           |
| -   Respiratory and inhalation therapy        | specialist           |
|                                               |                      |
| -   Dialysis -- hemodialysis and peritoneal   | \$50 per outpatient  |
|     dialysis                                  | hospital visit       |
|                                               |                      |
| -   Intravenous (IV)/Infusion Therapy -- Home |                      |
|     IV and antibiotic therapy                 |                      |
|                                               |                      |
| -   Growth hormone therapy (GHT)              |                      |
|                                               |                      |
| > **Note**: Growth hormone is covered under   |                      |
| > the prescription drug benefit. We will only |                      |
| > cover GHT when we preauthorize the          |                      |
| > treatment. See *Services requiring our      |                      |
| > prior approval* in Section 3.               |                      |
+-----------------------------------------------+----------------------+
| > **Physical, cardiac and occupational        |                      |
| > therapies**                                 |                      |
+-----------------------------------------------+----------------------+
| Up to two months or 60 visits (whichever is   | \$20 per office      |
| more) per condition, for the services of the  | visit to a           |
| following:                                    | specialist           |
|                                               |                      |
| -   qualified physical therapists and         | \$50 per outpatient  |
|                                               | hospital visit       |
| -   occupational therapists.                  |                      |
|                                               | Nothing per visit    |
| > **Note**: We only cover therapy to restore  | during covered       |
| > bodily function when there has been a total | inpatient admission  |
| > or partial loss of bodily function due to   |                      |
| > illness or injury.                          |                      |
| >                                             |                      |
| > Cardiac rehabilitation following a heart    |                      |
| > transplant, bypass surgery or a myocardial  |                      |
| > infarction, is provided for up to two       |                      |
| > months or 60 visits (whichever is more) per |                      |
| > condition.                                  |                      |
+-----------------------------------------------+----------------------+
| Not covered:                                  | *All charges*        |
|                                               |                      |
| -   *long-term rehabilitative therapy*        |                      |
|                                               |                      |
| ```{=html}                                    |                      |
| <!-- -->                                      |                      |
| ```                                           |                      |
| -   exercise programs, gym or pool            |                      |
|     memberships                               |                      |
|                                               |                      |
| -   work hardening/functional capacity        |                      |
|     programs or evaluations                   |                      |
+-----------------------------------------------+----------------------+
| Speech therapy                                |                      |
+-----------------------------------------------+----------------------+
| Up to two months or 60 visits (whichever is   | \$20 per office      |
| more) per condition                           | visit to a           |
|                                               | specialist           |
|                                               |                      |
|                                               | \$50 per outpatient  |
|                                               | hospital visit       |
|                                               |                      |
|                                               | Nothing per visit    |
|                                               | during covered       |
|                                               | inpatient admission  |
+-----------------------------------------------+----------------------+

+-----------------------------------------------+----------------------+
| > Habilitative Therapies                      | You pay              |
+-----------------------------------------------+----------------------+
| > Habilitative services for children under    | \$20 per office      |
| > age 19 with congenital or genetic birth     | visit to a           |
| > defects. Treatment is provided to enhance   | specialist           |
| > the child's ability to function. Services   |                      |
| > include:                                    | \$50 per outpatient  |
|                                               | hospital visit       |
| -   Speech therapy                            |                      |
|                                               |                      |
| ```{=html}                                    |                      |
| <!-- -->                                      |                      |
| ```                                           |                      |
| -   Occupational therapy; and                 |                      |
|                                               |                      |
| -   Physical therapy                          |                      |
|                                               |                      |
| > **Note**: No day or visit limits apply to   |                      |
| > these services. A congenital disorder means |                      |
| > a significant structural or functional      |                      |
| > abnormality that was present from birth.    |                      |
|                                               |                      |
| Includes medically necessary habilitative     |                      |
| services coverage for children with Autism,   |                      |
| an Autism Spectrum disorder, or Cerebral      |                      |
| Palsy                                         |                      |
+-----------------------------------------------+----------------------+
| > Hearing services (testing, treatment, and   |                      |
| > supplies)                                   |                      |
+-----------------------------------------------+----------------------+
| -   Hearing testing                           | \$10 per office      |
|                                               | visit to your        |
| -   Hearing aid examinations for children     | Primary Care         |
|     under 19; hearing aids covered under      | Physician            |
|     *Durable Medical Equipment.*              |                      |
|                                               | \$20 per office      |
|                                               | visit to a           |
|                                               | specialist           |
+-----------------------------------------------+----------------------+
| > *Not covered:*                              | *All charges*        |
|                                               |                      |
| -   *Hearing aids, except as covered for      |                      |
|     children under age 19 under Durable       |                      |
|     Medical Equipment in this section*        |                      |
+-----------------------------------------------+----------------------+
| > Vision services (testing, treatment, and    |                      |
| > supplies)                                   |                      |
+-----------------------------------------------+----------------------+
| -   Diagnosis and treatment of diseases of    | \$10 per office      |
|     the eye                                   | visit to your        |
|                                               | Primary Care         |
|                                               | Physician            |
|                                               |                      |
|                                               | \$20 per office      |
|                                               | visit to a           |
|                                               | specialist           |
+-----------------------------------------------+----------------------+
| -   One pair of eyeglasses or contact lenses  | 50% of charges       |
|     per lifetime to correct an impairment     |                      |
|     directly caused by accidental ocular      |                      |
|     injury or intraocular surgery (such as    |                      |
|     for cataracts)                            |                      |
+-----------------------------------------------+----------------------+
| -   Annual eye refraction exams to provide a  | \$25 per office      |
|     written lens prescription                 | visit to a           |
|                                               | specialist           |
| > You do not have to obtain a referral from   |                      |
| > your Primary Care Physician for this        |                      |
| > service                                     |                      |
+-----------------------------------------------+----------------------+
| > *Not covered:*                              | *All charges*        |
|                                               |                      |
| -   *Eyeglasses or contact lenses*            |                      |
|                                               |                      |
| -   *Eye exercises and orthoptics*            |                      |
|                                               |                      |
| -   *Radial keratotomy and other refractive   |                      |
|     surgery*                                  |                      |
+-----------------------------------------------+----------------------+

+-----------------------------------------------+----------------------+
| > **Foot Care**                               | You pay              |
+-----------------------------------------------+----------------------+
| > Routine foot care when you are under active | \$10 per office      |
| > treatment for a metabolic or peripheral     | visit to your        |
| > vascular disease, such as diabetes.         | Primary Care         |
| >                                             | Physician            |
| > See orthopedic and prosthetic devices for   |                      |
| > information on podiatric shoe inserts.      | \$20 per office      |
|                                               | visit to a           |
|                                               | specialist           |
|                                               |                      |
|                                               | \$50 per outpatient  |
|                                               | hospital visit       |
+-----------------------------------------------+----------------------+
| > *Not covered:*                              | *All charges*        |
|                                               |                      |
| -   *Cutting, trimming or removal of corns,   |                      |
|     calluses, or the free edge of toenails,   |                      |
|     and similar routine treatment of          |                      |
|     conditions of the foot, except as stated  |                      |
|     above*                                    |                      |
|                                               |                      |
| -   *Treatment of weak, strained or flat feet |                      |
|     or bunions or spurs; and of any           |                      |
|     instability, imbalance or subluxation of  |                      |
|     the foot (unless the treatment is by open |                      |
|     cutting surgery)*                         |                      |
+-----------------------------------------------+----------------------+
| > Orthopedic and prosthetic devices           |                      |
+-----------------------------------------------+----------------------+
| > Orthopedic devices, such as:                | 50% of charges       |
|                                               |                      |
| -   Artificial limbs and eyes; stump hose     |                      |
|                                               |                      |
| -   External lenses following cataract        |                      |
|     removal                                   |                      |
|                                               |                      |
| -   Externally worn breast prostheses and     |                      |
|     surgical bras, including necessary        |                      |
|     replacements, following a mastectomy      |                      |
|                                               |                      |
| -   Enteral equipment and supplies            |                      |
|                                               |                      |
| -   Ostomy supplies except deodorants,        |                      |
|     filters, lubricants, tape, appliance      |                      |
|     cleaners, adhesive and adhesive removers  |                      |
|                                               |                      |
| -   Orthotic braces and splints not available |                      |
|     over-the-counter                          |                      |
|                                               |                      |
| -   Surgical dressings not available          |                      |
|     over-the-counter; (see Durable Medical    |                      |
|     Equipment)                                |                      |
|                                               |                      |
| -   A hair prosthesis for hair loss resulting |                      |
|     from chemotherapy or radiation treatment  |                      |
|     for cancer. There is a limit of one hair  |                      |
|     prosthesis per lifetime, with a maximum   |                      |
|     cost of \$350.                            |                      |
|                                               |                      |
| -   Corrective orthopedic appliances for      |                      |
|     non-dental treatment of temporomandibular |                      |
|     joint (TMJ) pain dysfunction syndrome.    |                      |
|                                               |                      |
| -   Internal prosthetic devices, such as      |                      |
|     artificial joints, pacemakers, cochlear   |                      |
|     implants, and surgically implanted breast |                      |
|     implants following mastectomy.            |                      |
|                                               |                      |
| > **Note**: Most orthopedic and prosthetic    |                      |
| > devices must be preauthorized**.** Call us  |                      |
| > at 301-360-8080 or 1-800-251-0956 if your   |                      |
| > Plan physician prescribes this and you need |                      |
| > assistance locating a health care physician |                      |
| > or health care practitioner to sell or rent |                      |
| > you orthopedic or prosthetic equipment. You |                      |
| > may also call us to determine if a certain  |                      |
| > device is covered. We pay internal          |                      |
| > prosthetic devices as hospital benefits;    |                      |
| > see Section 5(c) for payment information.   |                      |
| > See 5(b) for coverage of the surgery to     |                      |
| > insert the device.                          |                      |
+-----------------------------------------------+----------------------+
| > *Not covered:*                              | *All charges*        |
|                                               |                      |
| -   *orthopedic and corrective shoes*         |                      |
|                                               |                      |
| -   *shoes and foot orthotics, including heel |                      |
|     pads, heel cups and arch supports*        |                      |
|                                               |                      |
| -   *lumbosacral supports*                    |                      |
|                                               |                      |
| -   *corsets trusses, elastic stockings,      |                      |
|     support hose, and other supportive        |                      |
|     devices*                                  |                      |
|                                               |                      |
| -   *prosthetic replacements provided less    |                      |
|     than 5 years after the last one we        |                      |
|     covered (except as needed to accommodate  |                      |
|     growth in children or for socket          |                      |
|     replacement for members with significant  |                      |
|     residual limb volume or weight changes)*  |                      |
|                                               |                      |
| ```{=html}                                    |                      |
| <!-- -->                                      |                      |
| ```                                           |                      |
| -   *external penile devices*                 |                      |
|                                               |                      |
| ```{=html}                                    |                      |
| <!-- -->                                      |                      |
| ```                                           |                      |
| -   *speech prosthetics (except               |                      |
|     electrolarynx)*                           |                      |
+-----------------------------------------------+----------------------+
| > Durable medical equipment (DME)             | You pay              |
+-----------------------------------------------+----------------------+
| > Rental or purchase, at our option,          | 50% of charges       |
| > including repair and adjustment, of durable |                      |
| > medical equipment prescribed by your Plan   |                      |
| > physician, such as oxygen and dialysis      |                      |
| > equipment. Under this benefit, we also      |                      |
| > cover:                                      |                      |
|                                               |                      |
| -   hospital beds;                            |                      |
|                                               |                      |
| -   wheelchairs;                              |                      |
|                                               |                      |
| -   crutches;                                 |                      |
|                                               |                      |
| -   walkers;                                  |                      |
|                                               |                      |
| -   blood glucose monitors; and               |                      |
|                                               |                      |
| -   insulin pumps and insulin pump supplies   |                      |
|                                               |                      |
| -   surgical dressings not available          |                      |
|     over-the-counter                          |                      |
|                                               |                      |
| > **Note**: Most durable medical equipment    |                      |
| > must be preauthorized. Call us at           |                      |
| > 301-360-8080 or 1-800-251-0956 if your Plan |                      |
| > physician prescribes this equipment and you |                      |
| > need assistance locating a health care      |                      |
| > physician or health care practitioner to    |                      |
| > rent or sell you durable medical            |                      |
| > equipment*.* You may also call us to see if |                      |
| > a certain piece of equipment is covered.    |                      |
+-----------------------------------------------+----------------------+
| > Hearing aids for children under age 19,     | 50% of charges up to |
| > prescribed, fitted and dispensed by a       | \$1,400 per ear      |
| > licensed audiologist                        | every 36 months      |
+-----------------------------------------------+----------------------+
| > *Not covered:*                              | *All charges*        |
|                                               |                      |
| -   *Power-operated vehicles*                 |                      |
|                                               |                      |
| -   *Duplicate or backup equipment*           |                      |
|                                               |                      |
| -   *Parts and labor costs for supplies and   |                      |
|     accessories replaced due to wear and tear |                      |
|     such as wheelchair tires and tubes*       |                      |
|                                               |                      |
| -   *Educational, vocational, or              |                      |
|     environmental equipment*                  |                      |
|                                               |                      |
| -   *Deluxe or upgraded equipment and         |                      |
|     supplies*                                 |                      |
|                                               |                      |
| -   *Home or vehicle modifications, seat      |                      |
|     lifts*                                    |                      |
|                                               |                      |
| -   *Over-the-counter medical equipment and   |                      |
|     supplies*                                 |                      |
|                                               |                      |
| -   *Activities of daily living aids (such as |                      |
|     grab bars and utensil holders)*           |                      |
|                                               |                      |
| -   *Personal hygiene equipment*              |                      |
|                                               |                      |
| -   *Paraffin baths, whirlpools, and cold     |                      |
|     therapy*                                  |                      |
|                                               |                      |
| -   *Augmentative communication devices*      |                      |
|                                               |                      |
| -   *Infertility monitors*                    |                      |
|                                               |                      |
| -   *Physical fitness equipment*              |                      |
|                                               |                      |
| -   *Hearing aids for those over 19 years     |                      |
|     old*                                      |                      |
|                                               |                      |
| -   *Continuous pulse oximetry unless skilled |                      |
|     nursing is involved in home care and it   |                      |
|     is part of their medically necessary      |                      |
|     equipment*                                |                      |
+-----------------------------------------------+----------------------+

+-----------------------------------------------+---+----------------------+
| > Home health services                        | Y |                      |
|                                               | o |                      |
|                                               | u |                      |
|                                               | p |                      |
|                                               | a |                      |
|                                               | y |                      |
+-----------------------------------------------+---+----------------------+
| -   Medically necessary home health care      | N |                      |
|     ordered by a Plan physician and provided  | o |                      |
|     by a registered nurse (R.N.), licensed    | t |                      |
|     practical nurse (L.P.N.), licensed        | h |                      |
|     vocational nurse (L.V.N.), or home health | i |                      |
|     aide. Services include administration of  | n |                      |
|     oxygen therapy, intravenous therapy and   | g |                      |
|     medications.                              |   |                      |
|                                               |   |                      |
| ```{=html}                                    |   |                      |
| <!-- -->                                      |   |                      |
| ```                                           |   |                      |
| -   Medical foods prescribed by a physician   |   |                      |
|     when determined to be your sole source of |   |                      |
|     nutrition                                 |   |                      |
|                                               |   |                      |
| -   Foods used to treat inherited metabolic   |   |                      |
|     diseases                                  |   |                      |
+-----------------------------------------------+---+----------------------+
| > Not covered:                                | A |                      |
|                                               | l |                      |
| -   nursing care requested by, or for the     | l |                      |
|     convenience of, the patient or the        | c |                      |
|     patient's family;                         | h |                      |
|                                               | a |                      |
| -   home care primarily for personal          | r |                      |
|     assistance that does not include a        | g |                      |
|     medical component and is not diagnostic,  | e |                      |
|     therapeutic, or rehabilitative;           | s |                      |
+-----------------------------------------------+---+----------------------+
| > Chiropractic                                |   |                      |
+-----------------------------------------------+---+----------------------+
| -   Chiropractic services are covered up to a |   | 50% of charges up to |
|     maximum benefit of \$500                  |   | the maximum benefit  |
|                                               |   | and all charges      |
|                                               |   | thereafter.          |
+-----------------------------------------------+---+----------------------+
| **Alternative treatments**                    |   |                      |
+-----------------------------------------------+---+----------------------+
| -   Acupuncture -- up to twelve (12) visits   |   | \$20 per office      |
|     per calendar year for postoperative and   |   | visit to a           |
|     chemotherapy nausea and vomiting, nausea  |   | specialist           |
|     of pregnancy, postoperative dental pain   |   |                      |
|     and as part of a comprehensive treatment  |   | \$50 per outpatient  |
|     program for chronic pain                  |   | hospital visit       |
|                                               |   |                      |
| -   Biofeedback -- for pain management,       |   |                      |
|     migraine treatment, bowel training and    |   |                      |
|     pelvic floor training for urinary         |   |                      |
|     incontinence                              |   |                      |
+-----------------------------------------------+---+----------------------+
| > *Not covered:*                              |   | *All charges*        |
|                                               |   |                      |
| -   *naturopathic services*                   |   |                      |
|                                               |   |                      |
| -   *hypnotherapy*                            |   |                      |
|                                               |   |                      |
| -   *massage therapy*                         |   |                      |
|                                               |   |                      |
| -   *herbal medicine*                         |   |                      |
|                                               |   |                      |
| -   *homeopathy*                              |   |                      |
+-----------------------------------------------+---+----------------------+

+-----------------------------------------------+----------------------+
| > Educational classes and programs            | You pay              |
+-----------------------------------------------+----------------------+
| -   Childbirth education classes:             | All charges -- we    |
|                                               | will reimburse up to |
| When you complete the childbirth education    | \$50 for childbirth  |
| class, submit a copy of the certificate of    | education classes    |
| completion with the dates attended, as well   |                      |
| as a copy of your canceled check or receipt   |                      |
| to P.O. Box 948, Frederick, MD 21705.         |                      |
+-----------------------------------------------+----------------------+
| -   Smoking cessation program                 | All charges -- we    |
|                                               | will reimburse up to |
| When you complete the smoking cessation       | \$100 for the        |
| program, submit a copy of the certificate of  | smoking cessation    |
| completion with the dates attended, as well   | program              |
| as a copy of your canceled check or receipt   |                      |
| to P.O. Box 948, Frederick, MD 21705.         |                      |
+-----------------------------------------------+----------------------+
| -   Diabetes self-management classes          | \$10 per office      |
|                                               | visit to your        |
|                                               | Primary Care         |
|                                               | Physician            |
|                                               |                      |
|                                               | \$20 per office      |
|                                               | visit to a           |
|                                               | specialist           |
|                                               |                      |
|                                               | \$50 per outpatient  |
|                                               | hospital visit       |
+-----------------------------------------------+----------------------+

+---+---+----------------------------------------+---------------+---+---+
| # |   |                                        |               |   |   |
| # |   |                                        |               |   |   |
| # |   |                                        |               |   |   |
| # |   |                                        |               |   |   |
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|   |   |                                        |               |   |   |
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| d |   |                                        |               |   |   |
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| l |   |                                        |               |   |   |
| s |   |                                        |               |   |   |
+---+---+----------------------------------------+---------------+---+---+
|   | * | **Here are some important things to    |               | * |   |
|   | * | keep in mind about these benefits:**   |               | * |   |
|   | I |                                        |               | I |   |
|   | M | -   Please remember that all benefits  |               | \ |   |
|   | * |     are subject to the definitions,    |               | M |   |
|   | * |     limitations and exclusions in this |               | * |   |
|   |   |     brochure and are payable only when |               | * |   |
|   | * |     we determine they are medically    |               |   |   |
|   | * |     necessary.                         |               | * |   |
|   | P |                                        |               | * |   |
|   | * | -   Plan physicians must provide or    |               | P |   |
|   | * |     arrange your care.                 |               | * |   |
|   |   |                                        |               | * |   |
|   | * | -   We have no calendar year           |               |   |   |
|   | * |     deductible.                        |               | * |   |
|   | O |                                        |               | * |   |
|   | * | -   Be sure to read Section 4, *Your   |               | O |   |
|   | * |     costs for covered services,* for   |               | * |   |
|   |   |     valuable information about how     |               | * |   |
|   | * |     cost sharing works. Also read      |               |   |   |
|   | * |     Section 9 about coordinating       |               | * |   |
|   | R |     benefits with other coverage,      |               | * |   |
|   | * |     including with Medicare.           |               | R |   |
|   | * |                                        |               | * |   |
|   |   | -   In certain geographic areas, the   |               | * |   |
|   | * |     Health Plan has designated Centers |               |   |   |
|   | * |     for Cardiac Surgery, Ambulatory    |               | * |   |
|   | T |     Surgery, Transplants and Joint     |               | * |   |
|   | * |     Replacement.                       |               | T |   |
|   | * |                                        |               | * |   |
|   |   | -   The amounts listed below are for   |               | * |   |
|   | * |     the charges billed by a physician  |               |   |   |
|   | * |     or other health care professional  |               | * |   |
|   | A |     for your surgical care. Look in    |               | * |   |
|   | * |     Section 5(c) for charges           |               | A |   |
|   | * |     associated with the facility.      |               | * |   |
|   |   |                                        |               | * |   |
|   | * | ```{=html}                             |               |   |   |
|   | * | <!-- -->                               |               | * |   |
|   | N | ```                                    |               | * |   |
|   | * | -   **YOUR PHYSICIAN MUST GET          |               | N |   |
|   | * |     PRECERTIFICATION FOR SOME SURGICAL |               | * |   |
|   |   |     PROCEDURES**. Please refer to the  |               | * |   |
|   | * |     precertification information shown |               |   |   |
|   | * |     in Section 3 to be sure which      |               | * |   |
|   | T |     services require precertification. |               | * |   |
|   | * |                                        |               | T |   |
|   | * |                                        |               | * |   |
|   |   |                                        |               | * |   |
+---+---+----------------------------------------+---------------+---+---+
| B |   |                                        | You pay       |   |   |
| e |   |                                        |               |   |   |
| n |   |                                        |               |   |   |
| e |   |                                        |               |   |   |
| f |   |                                        |               |   |   |
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| r |   |                                        |               |   |   |
| i |   |                                        |               |   |   |
| p |   |                                        |               |   |   |
| t |   |                                        |               |   |   |
| i |   |                                        |               |   |   |
| o |   |                                        |               |   |   |
| n |   |                                        |               |   |   |
+---+---+----------------------------------------+---------------+---+---+
| > |   |                                        |               |   |   |
|   |   |                                        |               |   |   |
| S |   |                                        |               |   |   |
| u |   |                                        |               |   |   |
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| g |   |                                        |               |   |   |
| i |   |                                        |               |   |   |
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| a |   |                                        |               |   |   |
| l |   |                                        |               |   |   |
| > |   |                                        |               |   |   |
|   |   |                                        |               |   |   |
| p |   |                                        |               |   |   |
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| e |   |                                        |               |   |   |
| s |   |                                        |               |   |   |
+---+---+----------------------------------------+---------------+---+---+
| > |   |                                        | \$10 per      |   |   |
|   |   |                                        | office visit  |   |   |
| A |   |                                        | to your       |   |   |
| > |   |                                        | Primary Care  |   |   |
|   |   |                                        | Physician     |   |   |
| c |   |                                        |               |   |   |
| o |   |                                        | \$20 per      |   |   |
| m |   |                                        | office visit  |   |   |
| p |   |                                        | to a          |   |   |
| r |   |                                        | specialist    |   |   |
| e |   |                                        |               |   |   |
| h |   |                                        | \$50 per      |   |   |
| e |   |                                        | outpatient    |   |   |
| n |   |                                        | hospital      |   |   |
| s |   |                                        | visit         |   |   |
| i |   |                                        |               |   |   |
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|   |   |                                        |               |   |   |
| i |   |                                        |               |   |   |
| n |   |                                        |               |   |   |
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| e |   |                                        |               |   |   |
| r |   |                                        |               |   |   |
| t |   |                                        |               |   |   |
| i |   |                                        |               |   |   |
| o |   |                                        |               |   |   |
| n |   |                                        |               |   |   |
| > |   |                                        |               |   |   |
|   |   |                                        |               |   |   |
| o |   |                                        |               |   |   |
| f |   |                                        |               |   |   |
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|   |   |                                        |               |   |   |
| t |   |                                        |               |   |   |
| h |   |                                        |               |   |   |
| e |   |                                        |               |   |   |
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+---+---+----------------------------------------+---------------+---+---+
| * |   |                                        | *All charges* |   |   |
| N |   |                                        |               |   |   |
| o |   |                                        |               |   |   |
| t |   |                                        |               |   |   |
| C |   |                                        |               |   |   |
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| d |   |                                        |               |   |   |
| * |   |                                        |               |   |   |
|   |   |                                        |               |   |   |
| - |   |                                        |               |   |   |
|   |   |                                        |               |   |   |
|   |   |                                        |               |   |   |
|   |   |                                        |               |   |   |
| * |   |                                        |               |   |   |
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| e |   |                                        |               |   |   |
| v |   |                                        |               |   |   |
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| s |   |                                        |               |   |   |
| a |   |                                        |               |   |   |
| l |   |                                        |               |   |   |
|   |   |                                        |               |   |   |
|   |   |                                        |               |   |   |
|   |   |                                        |               |   |   |
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| f |   |                                        |               |   |   |
|   |   |                                        |               |   |   |
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|   |   |                                        |               |   |   |
|   |   |                                        |               |   |   |
| v |   |                                        |               |   |   |
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| u |   |                                        |               |   |   |
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| t |   |                                        |               |   |   |
| a |   |                                        |               |   |   |
| r |   |                                        |               |   |   |
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|   |   |                                        |               |   |   |
|   |   |                                        |               |   |   |
|   |   |                                        |               |   |   |
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| s |   |                                        |               |   |   |
| t |   |                                        |               |   |   |
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| l |   |                                        |               |   |   |
| i |   |                                        |               |   |   |
| z |   |                                        |               |   |   |
| a |   |                                        |               |   |   |
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| n |   |                                        |               |   |   |
| * |   |                                        |               |   |   |
+---+---+----------------------------------------+---------------+---+---+

+----------------------------------------------+-----------------------+
| > Reconstructive surgery                     | > You pay             |
+----------------------------------------------+-----------------------+
| -   Surgery to correct a functional defect   | \$10 per office visit |
|                                              | to your Primary Care  |
| -   Surgery to correct a condition caused by | Physician             |
|     injury or illness if:                    |                       |
|                                              | \$20 per office visit |
| ```{=html}                                   | to a specialist       |
| <!-- -->                                     |                       |
| ```                                          | \$50 per outpatient   |
| -   the condition produced a major effect on | hospital visit        |
|     the member's appearance, and             |                       |
|                                              |                       |
| -   the condition can reasonably be expected |                       |
|     to be corrected by such surgery          |                       |
|                                              |                       |
| ```{=html}                                   |                       |
| <!-- -->                                     |                       |
| ```                                          |                       |
| -   Surgery to correct a condition that      |                       |
|     existed at or from birth and is a        |                       |
|     significant deviation from the common    |                       |
|     form or norm. Examples of congenital     |                       |
|     anomalies are: protruding ear            |                       |
|     deformities; cleft lip; cleft palate;    |                       |
|     birth marks; webbed fingers; and webbed  |                       |
|     toes. Your physician must precertify     |                       |
|     repair of congenital anomalies.          |                       |
|                                              |                       |
| -   All stages of breast reconstruction      |                       |
|     surgery following a mastectomy for       |                       |
|     cancer, such as:                         |                       |
|                                              |                       |
| ```{=html}                                   |                       |
| <!-- -->                                     |                       |
| ```                                          |                       |
| -   surgery to produce a symmetrical         |                       |
|     appearance on the other breast;          |                       |
|                                              |                       |
| -   treatment of any physical complications, |                       |
|     such as lymphedemas;                     |                       |
|                                              |                       |
| -   breast prostheses and surgical bras and  |                       |
|     replacements (see Prosthetic devices)    |                       |
|                                              |                       |
| > **Note**: If you need a mastectomy, you    |                       |
| > may choose to have the procedure performed |                       |
| > on an inpatient basis and remain in the    |                       |
| > hospital up to 48 hours after the          |                       |
| > procedure.                                 |                       |
+----------------------------------------------+-----------------------+
| > Not covered:                               | All charges           |
|                                              |                       |
| -   Cosmetic surgery -- any surgical         |                       |
|     procedure (or any portion of a           |                       |
|     procedure) performed primarily to        |                       |
|     improve physical appearance through      |                       |
|     change in bodily form, except repair of  |                       |
|     accidental injury                        |                       |
|                                              |                       |
| -   Surgeries related to sex transformation  |                       |
+----------------------------------------------+-----------------------+
| > Oral and maxillofacial surgery             |                       |
+----------------------------------------------+-----------------------+
| > Oral surgical procedures, limited to:      | \$10 per office visit |
|                                              | to your Primary Care  |
| -   Reduction of fractures of the jaws or    | Physician             |
|     facial bones;                            |                       |
|                                              | \$20 per office visit |
| -   Surgical correction of cleft lip, cleft  | to a specialist       |
|     palate or severe functional              |                       |
|     malocclusion; facial defects due to      | \$50 per outpatient   |
|     congenital syndromes such as cleft       | hospital visit        |
|     lip/cleft palate, Crouzon's and          |                       |
|     Pierre-Robin's.                          |                       |
|                                              |                       |
| -   Removal of stones from salivary ducts;   |                       |
|                                              |                       |
| -   Excision of leukoplakia or malignancies; |                       |
|                                              |                       |
| -   Excision of cysts and incision of        |                       |
|     abscesses when done as independent       |                       |
|     procedures; and                          |                       |
|                                              |                       |
| -                                            |                       |
|                                              |                       |
| -   Other surgical procedures that do not    |                       |
|     involve the teeth or their supporting    |                       |
|     structures                               |                       |
|                                              |                       |
| -   Medically necessary and appropriate      |                       |
|     services for the treatment of            |                       |
|     Temporomandibular Joint (TMJ) Pain       |                       |
|     Dysfunction and/or related Myofacial     |                       |
|     Pain Dysfunction (MPD). Note: We will    |                       |
|     only cover these services when we        |                       |
|     preauthorize the treatment. See          |                       |
|     *Services requiring our prior approval*  |                       |
|     in Section 3.                            |                       |
+----------------------------------------------+-----------------------+
| *Not covered:*                               | *All charges*         |
|                                              |                       |
| -   *Oral implants and transplants*          |                       |
|                                              |                       |
| ```{=html}                                   |                       |
| <!-- -->                                     |                       |
| ```                                          |                       |
| -   *Procedures that involve the teeth or    |                       |
|     their supporting structures (such as the |                       |
|     periodontal membrane, gingival, and      |                       |
|     alveolar bone)*                          |                       |
+----------------------------------------------+-----------------------+

+----------------------------------------------+-----------------------+
| > Organ/tissue transplants                   | > You pay             |
+----------------------------------------------+-----------------------+
| > Limited to:                                | \$10 per office visit |
|                                              | to your Primary Care  |
| -   Cornea                                   | Physician             |
|                                              |                       |
| -   Heart                                    | \$20 per office visit |
|                                              | to a specialist       |
| -   Heart/lung                               |                       |
|                                              | \$50 per outpatient   |
| -   Kidney                                   | hospital visit        |
|                                              |                       |
| -   Liver                                    |                       |
|                                              |                       |
| -   Lung: Single-Double                      |                       |
|                                              |                       |
| -   Pancreas                                 |                       |
|                                              |                       |
| -   Allogeneic (donor) bone marrow           |                       |
|     transplants                              |                       |
|                                              |                       |
| -   Autologous bone marrow transplants       |                       |
|     (autologous stem cell and peripheral     |                       |
|     stem cell support) for the following     |                       |
|     conditions: acute lymphocytic or         |                       |
|     non-lymphocytic leukemia; advanced       |                       |
|     Hodgkins 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 |                       |
|     at a Medicare approved center.           |                       |
|                                              |                       |
| 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 for Cardiac Surgery,  |                       |
| Transplants and Joint Replacement and if     |                       |
| approved by the Plan's medical director in   |                       |
| accordance with the Plan's protocols.        |                       |
|                                              |                       |
| > **Note**: We cover related medical and     |                       |
| > hospital expenses of the donor when we     |                       |
| > cover the recipient.                       |                       |
+----------------------------------------------+-----------------------+
| > *Not covered:*                             | *All charges*         |
|                                              |                       |
| -   Donor screening tests and donor search   |                       |
|     expenses, except those performed for the |                       |
|     actual donor                             |                       |
|                                              |                       |
| -   Implants of artificial organs            |                       |
|                                              |                       |
| -   Transplants not listed as covered        |                       |
|                                              |                       |
| -   All services related to non-covered      |                       |
|     transplants                              |                       |
|                                              |                       |
| -   All services associated with             |                       |
|     complications resulting from the removal |                       |
|     of an organ from a non-member            |                       |
+----------------------------------------------+-----------------------+
| **Anesthesia**                               |                       |
+----------------------------------------------+-----------------------+
| > Professional services provided in:         | Nothing               |
|                                              |                       |
| -   Hospital (inpatient)                     |                       |
|                                              |                       |
| -   Hospital outpatient department           |                       |
|                                              |                       |
| -   Skilled nursing facility                 |                       |
|                                              |                       |
| -   Ambulatory surgical center               |                       |
|                                              |                       |
| -   Office                                   |                       |
+----------------------------------------------+-----------------------+

+---+---+----------------------------------------+---------------+---+---+
| # |   |                                        |               |   |   |
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+---+---+----------------------------------------+---------------+---+---+
|   | * | **Here are some important things to    |               | * |   |
|   | * | keep in mind about these benefits:**   |               | * |   |
|   | I |                                        |               | I |   |
|   | M | -   Please remember that all benefits  |               | * |   |
|   | * |     are subject to the definitions,    |               | * |   |
|   | * |     limitations and exclusions in this |               |   |   |
|   |   |     brochure and are payable only when |               | * |   |
|   | * |     we determine they are medically    |               | * |   |
|   | * |     necessary.                         |               | M |   |
|   | P |                                        |               | * |   |
|   | * | -   Plan physicians must provide or    |               | * |   |
|   | * |     arrange your care and you must be  |               |   |   |
|   |   |     hospitalized in a Plan facility.   |               | * |   |
|   | * |                                        |               | * |   |
|   | * | -   We have no calendar year           |               | P |   |
|   | O |     deductible.                        |               | * |   |
|   | * |                                        |               | * |   |
|   | * | -   Be sure to read Section 4, *Your   |               |   |   |
|   |   |     costs for covered services,* for   |               | * |   |
|   | * |     valuable information about how     |               | * |   |
|   | * |     cost sharing works. Also, read     |               | O |   |
|   | R |     Section 9 about coordinating       |               | * |   |
|   | * |     benefits with other coverage,      |               | * |   |
|   | * |     including with Medicare.           |               |   |   |
|   |   |                                        |               | * |   |
|   | * | -   The amounts listed below are for   |               | * |   |
|   | * |     the charges billed by the facility |               | R |   |
|   | T |     (i.e., hospital or surgical        |               | * |   |
|   | * |     center) or ambulance service for   |               | * |   |
|   | * |     your surgery or care. Any costs    |               |   |   |
|   |   |     associated with the professional   |               | * |   |
|   | * |     charge (i.e., physicians, etc.)    |               | * |   |
|   | * |     are covered in Sections 5(a) or    |               | T |   |
|   | A |     (b).                               |               | * |   |
|   | * |                                        |               | * |   |
|   | * | -   **YOUR ATTENDING PHYSICIAN MUST    |               |   |   |
|   |   |     GET PREAUTHORIZATION FOR ELECTIVE  |               | * |   |
|   | * |     HOSPITAL STAYS.**                  |               | * |   |
|   | * |                                        |               | A |   |
|   | N |                                        |               | * |   |
|   | * |                                        |               | * |   |
|   | * |                                        |               |   |   |
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|   |   |                                        |               | * |   |
|   |   |                                        |               | T |   |
|   |   |                                        |               | * |   |
|   |   |                                        |               | * |   |
+---+---+----------------------------------------+---------------+---+---+
| B |   |                                        | You pay       |   |   |
| e |   |                                        |               |   |   |
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+---+---+----------------------------------------+---------------+---+---+
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+---+---+----------------------------------------+---------------+---+---+
| > |   |                                        | \$100 per     |   |   |
|   |   |                                        | admission     |   |   |
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| > |   |                                        | *All charges* |   |   |
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| s |   |                                        |               |   |   |
+---+---+----------------------------------------+---------------+---+---+

+----------------------------------------------+-----------------------+
| > Hospice Care                               | > You pay             |
+----------------------------------------------+-----------------------+
| > Supportive or palliative care for a        | Nothing               |
| > terminally ill member in the home or       |                       |
| > hospice facility. These services are       |                       |
| > provided under the direction of a Plan     |                       |
| > physician who certifies that you are in    |                       |
| > the terminal stages of illness, with a     |                       |
| > life expectancy of approximately six (6)   |                       |
| > months or less.                            |                       |
| >                                            |                       |
| > Services include:                          |                       |
|                                              |                       |
| -   In home care or hospice facility         |                       |
|                                              |                       |
| -   Family counseling                        |                       |
+----------------------------------------------+-----------------------+
| > *Not covered: Independent nursing, private | *All charges*         |
| > duty nursing, homemaker services*          |                       |
+----------------------------------------------+-----------------------+
| > Ambulance                                  |                       |
+----------------------------------------------+-----------------------+
| -   Professional ambulance service when      | Nothing               |
|     medically appropriate                    |                       |
+----------------------------------------------+-----------------------+

+---+---+---------------------------------------------------------+---+---+
| # |   |                                                         |   |   |
| # |   |                                                         |   |   |
| # |   |                                                         |   |   |
| # |   |                                                         |   |   |
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| # |   |                                                         |   |   |
|   |   |                                                         |   |   |
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| n |   |                                                         |   |   |
|   |   |                                                         |   |   |
| 5 |   |                                                         |   |   |
| ( |   |                                                         |   |   |
| d |   |                                                         |   |   |
| ) |   |                                                         |   |   |
|   |   |                                                         |   |   |
| E |   |                                                         |   |   |
| m |   |                                                         |   |   |
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| r |   |                                                         |   |   |
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| c |   |                                                         |   |   |
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|   |   |                                                         |   |   |
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| c |   |                                                         |   |   |
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| s |   |                                                         |   |   |
| / |   |                                                         |   |   |
| a |   |                                                         |   |   |
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| t |   |                                                         |   |   |
| s |   |                                                         |   |   |
+---+---+---------------------------------------------------------+---+---+
|   | * | **Here are some important things to keep in mind about  | * |   |
|   | * | these benefits:**                                       | * |   |
|   | I |                                                         | I |   |
|   | M | -   Please remember that all benefits are subject to    | * |   |
|   | * |     the definitions, limitations and exclusions in this | * |   |
|   | * |     brochure and are payable only when we determine     |   |   |
|   |   |     they are medically necessary.                       | * |   |
|   | * |                                                         | * |   |
|   | * | -   We have no calendar year deductible.                | M |   |
|   | P |                                                         | * |   |
|   | * | -   Be sure to read Section 4, *Your costs for covered  | * |   |
|   | * |     services,* for valuable information about how cost  |   |   |
|   |   |     sharing works. Also read Section 9 about            | * |   |
|   | * |     coordinating benefits with other coverage,          | * |   |
|   | * |     including with Medicare.                            | P |   |
|   | O |                                                         | * |   |
|   | * |                                                         | * |   |
|   | * |                                                         |   |   |
|   |   |                                                         | * |   |
|   | * |                                                         | * |   |
|   | * |                                                         | O |   |
|   | R |                                                         | * |   |
|   | * |                                                         | * |   |
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|   |   |                                                         | * |   |
|   | * |                                                         | * |   |
|   | * |                                                         | R |   |
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|   | * |                                                         | * |   |
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|   | * |                                                         | T |   |
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|   | * |                                                         | * |   |
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|   |   |                                                         | T |   |
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|   |   |                                                         | * |   |
+---+---+---------------------------------------------------------+---+---+
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| d |   |                                                         |   |   |
| f |   |                                                         |   |   |
| o |   |                                                         |   |   |
| r |   |                                                         |   |   |
| q |   |                                                         |   |   |
| u |   |                                                         |   |   |
| i |   |                                                         |   |   |
| c |   |                                                         |   |   |
| k |   |                                                         |   |   |
| a |   |                                                         |   |   |
| c |   |                                                         |   |   |
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| . |   |                                                         |   |   |
+---+---+---------------------------------------------------------+---+---+

+-----------------------------------------------------------------------+
| ### What to do in case of emergency:                                  |
|                                                                       |
| **Emergencies within or outside our service area*: ***                |
|                                                                       |
| If you are in an emergency situation, please call your Primary Care   |
| Physician. In extreme emergencies, if you are unable to contact your  |
| physician, contact the local emergency system (e.g., the 911          |
| telephone system) or go to the nearest hospital emergency room. Be    |
| sure to tell the emergency room personnel that you are a Plan member  |
| so they can notify the Plan. You or a family member should notify the |
| Plan or Primary Care Physician within 48 hours, unless it was not     |
| reasonably possible to notify us within that time. It is your         |
| responsibility to ensure that the Plan has been timely notified.      |
|                                                                       |
| If you need to be hospitalized, the Plan must be notified within 48   |
| hours or on the first working day following your admission, unless it |
| was not reasonably possible to notify us within that time. If you are |
| hospitalized in a non-Plan facility and Plan physicians believe care  |
| can be better provided in a Plan hospital, you will be transferred    |
| when medically feasible with any ambulance charges covered in full.   |
| Benefits are available for care from non-Plan physicians or health    |
| care practitioners in a medical emergency only if delay in reaching a |
| Plan physician or health care practitioner would result in death,     |
| disability or significant jeopardy to your condition. To be covered   |
| by this Plan, any follow-up care recommended by non-Plan physicians   |
| or health care practitioners must be approved by the Plan or provided |
| by Plan physicians or health care practitioners.                      |
+-----------------------------------------------------------------------+

+----------------------------------------------+----------------------+---+
| Benefit Description                          | You pay              |   |
+----------------------------------------------+----------------------+---+
| > Emergency within or outside our service    |                      |   |
| > area                                       |                      |   |
+----------------------------------------------+----------------------+---+
| -   Emergency care at a physician's office   | \$10 per office      |   |
|                                              | visit to your        |   |
|                                              | Primary Care         |   |
|                                              | Physician            |   |
|                                              |                      |   |
|                                              | \$20 per office      |   |
|                                              | visit to a           |   |
|                                              | specialist           |   |
+----------------------------------------------+----------------------+---+
| -   Emergency care at an urgent care center  | \$25 per visit       |   |
+----------------------------------------------+----------------------+---+
| -   Emergency care at an emergency room.     | \$50 per visit,      |   |
|                                              | waived if admitted,  |   |
|                                              | then the inpatient   |   |
|                                              | hospital copayment   |   |
|                                              | applies              |   |
+----------------------------------------------+----------------------+---+
| > *Not covered:*                             | *All charges*        |   |
|                                              |                      |   |
| -   Elective care or non-emergency care      |                      |   |
|                                              |                      |   |
| -   Emergency care provided outside the      |                      |   |
|     service area if the need for care could  |                      |   |
|     have been foreseen before leaving the    |                      |   |
|     service area                             |                      |   |
|                                              |                      |   |
| -   Medical and hospital costs resulting     |                      |   |
|     from a normal full-term delivery of a    |                      |   |
|     baby outside the service area.           |                      |   |
+----------------------------------------------+----------------------+---+
| > Ambulance                                  |                      |   |
+----------------------------------------------+----------------------+---+
| > Professional ambulance service, including  | Nothing              |   |
| > air ambulance, when medically appropriate. |                      |   |
| >                                            |                      |   |
| > See 5(c) for non-emergency service.        |                      |   |
+----------------------------------------------+----------------------+---+

+---+---+----------------------------------------+---------------+---+---+
| * |   |                                        |               |   |   |
| * |   |                                        |               |   |   |
| S |   |                                        |               |   |   |
| e |   |                                        |               |   |   |
| c |   |                                        |               |   |   |
| t |   |                                        |               |   |   |
| i |   |                                        |               |   |   |
| o |   |                                        |               |   |   |
| n |   |                                        |               |   |   |
| 5 |   |                                        |               |   |   |
| ( |   |                                        |               |   |   |
| e |   |                                        |               |   |   |
| ) |   |                                        |               |   |   |
| . |   |                                        |               |   |   |
| M |   |                                        |               |   |   |
| e |   |                                        |               |   |   |
| n |   |                                        |               |   |   |
| t |   |                                        |               |   |   |
| a |   |                                        |               |   |   |
| l |   |                                        |               |   |   |
| h |   |                                        |               |   |   |
| e |   |                                        |               |   |   |
| a |   |                                        |               |   |   |
| l |   |                                        |               |   |   |
| t |   |                                        |               |   |   |
| h |   |                                        |               |   |   |
| a |   |                                        |               |   |   |
| n |   |                                        |               |   |   |
| d |   |                                        |               |   |   |
| s |   |                                        |               |   |   |
| u |   |                                        |               |   |   |
| b |   |                                        |               |   |   |
| s |   |                                        |               |   |   |
| t |   |                                        |               |   |   |
| a |   |                                        |               |   |   |
| n |   |                                        |               |   |   |
| c |   |                                        |               |   |   |
| e |   |                                        |               |   |   |
| a |   |                                        |               |   |   |
| b |   |                                        |               |   |   |
| u |   |                                        |               |   |   |
| s |   |                                        |               |   |   |
| e |   |                                        |               |   |   |
| b |   |                                        |               |   |   |
| e |   |                                        |               |   |   |
| n |   |                                        |               |   |   |
| e |   |                                        |               |   |   |
| f |   |                                        |               |   |   |
| i |   |                                        |               |   |   |
| t |   |                                        |               |   |   |
| s |   |                                        |               |   |   |
| * |   |                                        |               |   |   |
| * |   |                                        |               |   |   |
+---+---+----------------------------------------+---------------+---+---+
|   | * | When you get our approval for services |               | * |   |
|   | * | and follow a treatment plan we         |               | * |   |
|   | I | approve, cost-sharing and limitations  |               | I |   |
|   | M | for Plan mental health and substance   |               | * |   |
|   | * | abuse benefits will be no greater than |               | * |   |
|   | * | for similar benefits for other         |               |   |   |
|   |   | illnesses and conditions.              |               | * |   |
|   | * |                                        |               | * |   |
|   | * | Here are some important things to keep |               | M |   |
|   | P | in mind about these benefits:          |               | * |   |
|   | * |                                        |               | * |   |
|   | * | -   All benefits are subject to the    |               |   |   |
|   |   |     definitions, limitations and       |               | * |   |
|   | * |     exclusions in this brochure and    |               | * |   |
|   | * |     are payable only when we determine |               | P |   |
|   | O |     they are medically necessary.      |               | * |   |
|   | * |                                        |               | * |   |
|   | * | -   We have no calendar year           |               |   |   |
|   |   |     deductible.                        |               | * |   |
|   | * |                                        |               | * |   |
|   | * | -   Be sure to read Section 4, *Your   |               | O |   |
|   | R |     costs for covered services*, for   |               | * |   |
|   | * |     valuable information about how     |               | * |   |
|   | * |     cost sharing works. Also read      |               |   |   |
|   |   |     Section 9 about coordinating       |               | * |   |
|   | * |     benefits with other coverage,      |               | * |   |
|   | * |     including with Medicare.           |               | R |   |
|   | T |                                        |               | * |   |
|   | * | -   **YOU MUST GET PREAUTHORIZATION    |               | * |   |
|   | * |     FOR THESE SERVICES.** See the      |               |   |   |
|   |   |     instructions after the benefits    |               | * |   |
|   | * |     description below.                 |               | * |   |
|   | * |                                        |               | T |   |
|   | A |                                        |               | * |   |
|   | * |                                        |               | * |   |
|   | * |                                        |               |   |   |
|   |   |                                        |               | * |   |
|   | * |                                        |               | * |   |
|   | * |                                        |               | A |   |
|   | N |                                        |               | * |   |
|   | * |                                        |               | * |   |
|   | * |                                        |               |   |   |
|   |   |                                        |               | * |   |
|   | * |                                        |               | * |   |
|   | * |                                        |               | N |   |
|   | T |                                        |               | * |   |
|   | * |                                        |               | * |   |
|   | * |                                        |               |   |   |
|   |   |                                        |               | * |   |
|   |   |                                        |               | * |   |
|   |   |                                        |               | T |   |
|   |   |                                        |               | * |   |
|   |   |                                        |               | * |   |
+---+---+----------------------------------------+---------------+---+---+
| B |   |                                        | You pay       |   |   |
| e |   |                                        |               |   |   |
| n |   |                                        |               |   |   |
| e |   |                                        |               |   |   |
| f |   |                                        |               |   |   |
| i |   |                                        |               |   |   |
| t |   |                                        |               |   |   |
| D |   |                                        |               |   |   |
| e |   |                                        |               |   |   |
| s |   |                                        |               |   |   |
| c |   |                                        |               |   |   |
| r |   |                                        |               |   |   |
| i |   |                                        |               |   |   |
| p |   |                                        |               |   |   |
| t |   |                                        |               |   |   |
| i |   |                                        |               |   |   |
| o |   |                                        |               |   |   |
| n |   |                                        |               |   |   |
+---+---+----------------------------------------+---------------+---+---+
| > |   |                                        |               |   |   |
|   |   |                                        |               |   |   |
| M |   |                                        |               |   |   |
| e |   |                                        |               |   |   |
| n |   |                                        |               |   |   |
| t |   |                                        |               |   |   |
| a |   |                                        |               |   |   |
| l |   |                                        |               |   |   |
| > |   |                                        |               |   |   |
|   |   |                                        |               |   |   |
| h |   |                                        |               |   |   |
| e |   |                                        |               |   |   |
| a |   |                                        |               |   |   |
| l |   |                                        |               |   |   |
| t |   |                                        |               |   |   |
| h |   |                                        |               |   |   |
| > |   |                                        |               |   |   |
|   |   |                                        |               |   |   |
| a |   |                                        |               |   |   |
| n |   |                                        |               |   |   |
| d |   |                                        |               |   |   |
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+---+---+----------------------------------------+---------------+---+---+
| > |   |                                        | Your cost     |   |   |
|   |   |                                        | sharing       |   |   |
| A |   |                                        | res           |   |   |
| l |   |                                        | ponsibilities |   |   |
| l |   |                                        | are no        |   |   |
| > |   |                                        | greater than  |   |   |
|   |   |                                        | for other     |   |   |
| d |   |                                        | illness or    |   |   |
| i |   |                                        | conditions    |   |   |
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+---+---+----------------------------------------+---------------+---+---+
| - |   |                                        | \$20 per      |   |   |
|   |   |                                        | office visit  |   |   |
|   |   |                                        | to a          |   |   |
|   |   |                                        | specialist    |   |   |
| P |   |                                        |               |   |   |
| r |   |                                        | \$50 per      |   |   |
| o |   |                                        | outpatient    |   |   |
| f |   |                                        | hospital      |   |   |
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+---+---+----------------------------------------+---------------+---+---+
| - |   |                                        | \$20 per      |   |   |
|   |   |                                        | office visit  |   |   |
|   |   |                                        | to a          |   |   |
|   |   |                                        | specialist    |   |   |
| D |   |                                        |               |   |   |
| i |   |                                        | \$50 per      |   |   |
| a |   |                                        | outpatient    |   |   |
| g |   |                                        | hospital      |   |   |
| n |   |                                        | visit         |   |   |
| o |   |                                        |               |   |   |
| s |   |                                        |               |   |   |
| t |   |                                        |               |   |   |
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+---+---+----------------------------------------+---------------+---+---+
| - |   |                                        | \$100 per     |   |   |
|   |   |                                        | admission     |   |   |
|   |   |                                        |               |   |   |
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+---+---+----------------------------------------+---------------+---+---+
| - |   |                                        | \$50 per      |   |   |
|   |   |                                        | outpatient    |   |   |
|   |   |                                        | hospital      |   |   |
|   |   |                                        | visit         |   |   |
| S |   |                                        |               |   |   |
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| y |   |                                        |               |   |   |
| > |   |                                        |               |   |   |
|   |   |                                        |               |   |   |
| C |   |                                        |               |   |   |
| a |   |                                        |               |   |   |
| r |   |                                        |               |   |   |
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| > |   |                                        |               |   |   |
|   |   |                                        |               |   |   |
| P |   |                                        |               |   |   |
| h |   |                                        |               |   |   |
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| n |   |                                        |               |   |   |
| . |   |                                        |               |   |   |
+---+---+----------------------------------------+---------------+---+---+

+-----------------------+----------------------+-----------------------+
| > Mental health and   |                      | > You pay             |
| > substance abuse     |                      |                       |
| > benefits            |                      |                       |
| > *(Continued)*       |                      |                       |
+-----------------------+----------------------+-----------------------+
| > Not covered:        |                      | All charges           |
|                       |                      |                       |
| -   Services we have  |                      |                       |
|     not approved      |                      |                       |
|                       |                      |                       |
| -   Psychiatric       |                      |                       |
|     evaluation or     |                      |                       |
|     therapy on court  |                      |                       |
|     order or as a     |                      |                       |
|     condition of      |                      |                       |
|     parole or         |                      |                       |
|     probation, unless |                      |                       |
|     determined by a   |                      |                       |
|     Plan physician to |                      |                       |
|     be necessary and  |                      |                       |
|     appropriate       |                      |                       |
|                       |                      |                       |
| -   Services and      |                      |                       |
|     supplies when     |                      |                       |
|     paid for directly |                      |                       |
|     or indirectly by  |                      |                       |
|     a local, State,   |                      |                       |
|     or Federal        |                      |                       |
|     Government agency |                      |                       |
|                       |                      |                       |
|     **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 once   |                      |                       |
|     clinically        |                      |                       |
|     appropriate       |                      |                       |
|     treatment plan in |                      |                       |
|     favor of another. |                      |                       |
+-----------------------+----------------------+-----------------------+
| >                     | -   To be eligible   |                       |
|  **Preauthorization** |     to receive these |                       |
|                       |     benefits you     |                       |
|                       |     must follow your |                       |
|                       |     treatment plan   |                       |
|                       |     and your         |                       |
|                       |     participating    |                       |
|                       |     behavioral       |                       |
|                       |     health care      |                       |
|                       |     practitioner     |                       |
|                       |     must obtain      |                       |
|                       |     preauthorization |                       |
|                       |     for some         |                       |
|                       |     services,        |                       |
|                       |     including, but   |                       |
|                       |     not limited to   |                       |
|                       |     the following:   |                       |
|                       |                      |                       |
|                       | -   All substance    |                       |
|                       |     abuse treatments |                       |
|                       |                      |                       |
|                       | ```{=html}           |                       |
|                       | <!-- -->             |                       |
|                       | ```                  |                       |
|                       | -   Psychological    |                       |
|                       |     testing,         |                       |
|                       |                      |                       |
|                       |   Neuropsychological |                       |
|                       |     testing and      |                       |
|                       |     Extended         |                       |
|                       |     Developmental    |                       |
|                       |     testing          |                       |
|                       |                      |                       |
|                       | -   Partial          |                       |
|                       |     hospitalization  |                       |
|                       |                      |                       |
|                       | -   Intensive        |                       |
|                       |     outpatient       |                       |
|                       |     treatment        |                       |
|                       |                      |                       |
|                       | -                    |                       |
|                       |   Electro-convulsive |                       |
|                       |     therapy (ECT)    |                       |
|                       |                      |                       |
|                       |     Your             |                       |
|                       |     participating    |                       |
|                       |     behavioral       |                       |
|                       |     health           |                       |
|                       |     practitioner     |                       |
|                       |     must also use    |                       |
|                       |     the following    |                       |
|                       |     authorization    |                       |
|                       |     processes:       |                       |
|                       |                      |                       |
|                       | -   Once you have    |                       |
|                       |     been referred    |                       |
|                       |     for mental       |                       |
|                       |     health services, |                       |
|                       |     **you must be    |                       |
|                       |     evaluated by a   |                       |
|                       |     participating    |                       |
|                       |     Psychiatric      |                       |
|                       |     Physician**.     |                       |
|                       |     This physician   |                       |
|                       |     will discuss     |                       |
|                       |     with you a       |                       |
|                       |     recommended      |                       |
|                       |     course of        |                       |
|                       |     treatment at the |                       |
|                       |     appropriate      |                       |
|                       |     provider level.  |                       |
|                       |                      |                       |
|                       | -   We list mental   |                       |
|                       |     health and       |                       |
|                       |     substance abuse  |                       |
|                       |     physicians and   |                       |
|                       |     health care      |                       |
|                       |     practitioners in |                       |
|                       |     our *Directory   |                       |
|                       |     of Health Care   |                       |
|                       |     Professionals* , |                       |
|                       |     which we update  |                       |
|                       |     periodically.    |                       |
|                       |     The list is also |                       |
|                       |     on our website,  |                       |
|                       |     [www.ma          |                       |
|                       | msi.com](http://www. |                       |
|                       | mamsi.com/)/federal. |                       |
|                       |     Information in   |                       |
|                       |     the directory is |                       |
|                       |     subject to       |                       |
|                       |     change; for this |                       |
|                       |     reason, we       |                       |
|                       |     recommend that   |                       |
|                       |     you access our   |                       |
|                       |     website to look  |                       |
|                       |     up the most      |                       |
|                       |     up-to-date       |                       |
|                       |     information.     |                       |
+-----------------------+----------------------+-----------------------+
| > **Limitation**      | We may limit your    |                       |
|                       | benefits if you do   |                       |
|                       | not obtain and       |                       |
|                       | follow a treatment   |                       |
|                       | plan.                |                       |
+-----------------------+----------------------+-----------------------+

+---+---+----------------------------------------------------------+---+---+
| * |   |                                                          |   |   |
| * |   |                                                          |   |   |
| S |   |                                                          |   |   |
| e |   |                                                          |   |   |
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| t |   |                                                          |   |   |
| i |   |                                                          |   |   |
| o |   |                                                          |   |   |
| n |   |                                                          |   |   |
| 5 |   |                                                          |   |   |
| ( |   |                                                          |   |   |
| f |   |                                                          |   |   |
| ) |   |                                                          |   |   |
| . |   |                                                          |   |   |
| P |   |                                                          |   |   |
| r |   |                                                          |   |   |
| e |   |                                                          |   |   |
| s |   |                                                          |   |   |
| c |   |                                                          |   |   |
| r |   |                                                          |   |   |
| i |   |                                                          |   |   |
| p |   |                                                          |   |   |
| t |   |                                                          |   |   |
| i |   |                                                          |   |   |
| o |   |                                                          |   |   |
| n |   |                                                          |   |   |
| d |   |                                                          |   |   |
| r |   |                                                          |   |   |
| u |   |                                                          |   |   |
| g |   |                                                          |   |   |
| b |   |                                                          |   |   |
| e |   |                                                          |   |   |
| n |   |                                                          |   |   |
| e |   |                                                          |   |   |
| f |   |                                                          |   |   |
| i |   |                                                          |   |   |
| t |   |                                                          |   |   |
| s |   |                                                          |   |   |
| * |   |                                                          |   |   |
| * |   |                                                          |   |   |
+---+---+----------------------------------------------------------+---+---+
|   | * | **Here are some important things to keep in mind about   | * |   |
|   | * | these benefits:**                                        | * |   |
|   | I |                                                          | I |   |
|   | * | -   We cover prescribed drugs and medications, as        | * |   |
|   | * |     described in the chart beginning on the next page.   | * |   |
|   |   |                                                          |   |   |
|   | * | -   All benefits are subject to the definitions,         | * |   |
|   | * |     limitations and exclusions in this brochure and are  | * |   |
|   | M |     payable only when we determine they are medically    | M |   |
|   | * |     necessary.                                           | * |   |
|   | * |                                                          | * |   |
|   |   | ```{=html}                                               |   |   |
|   | * | <!-- -->                                                 | * |   |
|   | * | ```                                                      | * |   |
|   | P | -   We have no calendar year deductible.                 | P |   |
|   | * |                                                          | * |   |
|   | * | ```{=html}                                               | * |   |
|   |   | <!-- -->                                                 |   |   |
|   | * | ```                                                      | * |   |
|   | * | -   Certain drugs require your physician to get prior    | * |   |
|   | O |     authorization from us before they can be prescribed  | O |   |
|   | * |     under the Plan. The Plan requires prior              | * |   |
|   | * |     authorization for these drugs to make sure that they | * |   |
|   |   |     are being prescribed and consumed according to       |   |   |
|   | * |     FDA-approved indications and dosing schedules. If    | * |   |
|   | * |     your pharmacist tells you that your prescription     | * |   |
|   | R |     drug requires prior authorization, ask your          | R |   |
|   | * |     pharmacist or physician to call the Pharmacy         | * |   |
|   | * |     Services Department at 1-800-205-3636 for further    | * |   |
|   |   |     instructions.                                        |   |   |
|   | * |                                                          | * |   |
|   | * | ```{=html}                                               | * |   |
|   | T | <!-- -->                                                 | T |   |
|   | * | ```                                                      | * |   |
|   | * | -   Be sure to read Section 4, *Your costs for covered   | * |   |
|   |   |     services,* for valuable information about how cost   |   |   |
|   | * |     sharing works. Also read Section 9 about             | * |   |
|   | * |     coordinating benefits with other coverage, including | * |   |
|   | A |     with Medicare.                                       | A |   |
|   | * |                                                          | * |   |
|   | * |                                                          | * |   |
|   |   |                                                          |   |   |
|   | * |                                                          | * |   |
|   | * |                                                          | * |   |
|   | N |                                                          | N |   |
|   | * |                                                          | * |   |
|   | * |                                                          | * |   |
|   |   |                                                          |   |   |
|   | * |                                                          | * |   |
|   | * |                                                          | * |   |
|   | T |                                                          | T |   |
|   | * |                                                          | * |   |
|   | * |                                                          | * |   |
+---+---+----------------------------------------------------------+---+---+
|   |   | > **There are important features you should be aware     |   |   |
|   |   | > of.** These include:                                   |   |   |
|   |   |                                                          |   |   |
|   |   | -   **Who can write your prescription?** A licensed      |   |   |
|   |   |     physician must write the prescription.               |   |   |
|   |   |                                                          |   |   |
|   |   | ```{=html}                                               |   |   |
|   |   | <!-- -->                                                 |   |   |
|   |   | ```                                                      |   |   |
|   |   | -   **Where you can obtain them.** You may fill the      |   |   |
|   |   |     prescription at a Plan pharmacy. You may fill        |   |   |
|   |   |     prescriptions for maintenance medications either by  |   |   |
|   |   |     mail or at a retail pharmacy. Maintenance            |   |   |
|   |   |     medications are those drugs used on a continual      |   |   |
|   |   |     basis, for six months or longer, for the treatment   |   |   |
|   |   |     of chronic health conditions such as high blood      |   |   |
|   |   |     pressure, asthma, or diabetes. To locate the name of |   |   |
|   |   |     a participating pharmacy near you, refer to your     |   |   |
|   |   |     *Directory of Health Care Professionals*, call our   |   |   |
|   |   |     Member Services Department at 301-360-8080 or\       |   |   |
|   |   |     1-800-251-0956 (TTY: 301-360-8111 or                 |   |   |
|   |   |     1-800-553-7109), or visit our website,               |   |   |
|   |   |     www.mamsi.com/federal.                               |   |   |
|   |   |                                                          |   |   |
|   |   | ```{=html}                                               |   |   |
|   |   | <!-- -->                                                 |   |   |
|   |   | ```                                                      |   |   |
|   |   | -   **We use a formulary.** A formulary is a listing of  |   |   |
|   |   |     prescription drugs that are preferred by the Plan    |   |   |
|   |   |     for use. All generic drugs are on the formulary, as  |   |   |
|   |   |     well as certain name brand drugs. Drugs that are on  |   |   |
|   |   |     the formulary are selected based on safety, efficacy |   |   |
|   |   |     and cost. This listing is periodically reviewed and  |   |   |
|   |   |     updated by a team of physicians and pharmacists.     |   |   |
|   |   |     M.D. IPA uses an open formulary. This means you are  |   |   |
|   |   |     covered for all prescription medications written in  |   |   |
|   |   |     accordance with FDA guidelines for a particular      |   |   |
|   |   |     therapeutic indication whether or not the medication |   |   |
|   |   |     appears on the formulary, except for prescription    |   |   |
|   |   |     drugs or classes of drugs listed under "Not Covered" |   |   |
|   |   |     in this section of the brochure. However drugs not   |   |   |
|   |   |     specifically listed on our formulary are subject to  |   |   |
|   |   |     a non-formulary copayment. Drugs requiring prior     |   |   |
|   |   |     authorization will be covered once reviewed and      |   |   |
|   |   |     approved by the Plan.                                |   |   |
|   |   |                                                          |   |   |
|   |   | > We have an open formulary. If your physician believes  |   |   |
|   |   | > a name brand product is necessary or there is no       |   |   |
|   |   | > generic available, your physician may prescribe a name |   |   |
|   |   | > brand drug from a formulary list. This list of name    |   |   |
|   |   | > brand drugs is a preferred list of drugs that we       |   |   |
|   |   | > selected to meet patient needs at a lower cost. To     |   |   |
|   |   | > order a copy of the formulary, call the Member         |   |   |
|   |   | > Services Department at 301-360-8080 or 1-800-251-0956  |   |   |
|   |   | > (TTY: 301-360-8111 or 1-800-553-7109).                 |   |   |
|   |   |                                                          |   |   |
|   |   | -                                                        |   |   |
|   |   |                                                          |   |   |
|   |   | ```{=html}                                               |   |   |
|   |   | <!-- -->                                                 |   |   |
|   |   | ```                                                      |   |   |
|   |   | -                                                        |   |   |
+---+---+----------------------------------------------------------+---+---+

*Covered medications and supplies \-- continued on next page*

+-----+------------------------------------+--------------------------+---+
|     | -   **These are the dispensing     |                          |   |
|     |     limitations.** You may obtain  |                          |   |
|     |     up to a 34-day supply of       |                          |   |
|     |     non-maintenance prescription   |                          |   |
|     |     drugs at a Plan pharmacy or by |                          |   |
|     |     mail order. Prescriptions for  |                          |   |
|     |     covered maintenance            |                          |   |
|     |     medications may be filled or   |                          |   |
|     |     refilled at a Plan retail      |                          |   |
|     |     pharmacy, or through the mail  |                          |   |
|     |     by Express Scripts, Inc.       |                          |   |
|     |     (ESI). You may obtain up to a  |                          |   |
|     |     consecutive 90-day supply of   |                          |   |
|     |     prescription medications as    |                          |   |
|     |     follows:                       |                          |   |
|     |                                    |                          |   |
|     | ```{=html}                         |                          |   |
|     | <!-- -->                           |                          |   |
|     | ```                                |                          |   |
|     | -   For maintenance medications,   |                          |   |
|     |     you pay one copayment for each |                          |   |
|     |     month's supply after the first |                          |   |
|     |     34 day supply,                 |                          |   |
|     |                                    |                          |   |
|     | ```{=html}                         |                          |   |
|     | <!-- -->                           |                          |   |
|     | ```                                |                          |   |
|     | -   For all contraceptive drugs,   |                          |   |
|     |     you pay one copayment for up   |                          |   |
|     |     to a 90-day supply per         |                          |   |
|     |     prescription or refill.        |                          |   |
|     |                                    |                          |   |
|     | > For more information on mail     |                          |   |
|     | > order benefits, you can reach    |                          |   |
|     | > Express Scripts, Inc. at         |                          |   |
|     | > 1-888-828-2579. A prescription   |                          |   |
|     | > can be refilled when you have    |                          |   |
|     | > used 75 percent of the           |                          |   |
|     | > medication. For example, a       |                          |   |
|     | > prescription that was filled for |                          |   |
|     | > a 34-day supply can be refilled  |                          |   |
|     | > after 26 days. M.D. IPA will     |                          |   |
|     | > give special consideration to    |                          |   |
|     | > filling prescriptions for        |                          |   |
|     | > members covered under the FEHB   |                          |   |
|     | > if:                              |                          |   |
|     |                                    |                          |   |
|     | -   You are called to active duty, |                          |   |
|     |     or                             |                          |   |
|     |                                    |                          |   |
|     | -   You are officially called      |                          |   |
|     |     off-site as a result of a      |                          |   |
|     |     national or other emergency.   |                          |   |
|     |                                    |                          |   |
|     | > In order to fill the             |                          |   |
|     | > prescription, your physician may |                          |   |
|     | > need to request prior            |                          |   |
|     | > authorization from M.D. IPA. If  |                          |   |
|     | > you need to fill a prescription  |                          |   |
|     | > for either of the reasons listed |                          |   |
|     | > above, ask your physician to     |                          |   |
|     | > contact M.D. IPA to request      |                          |   |
|     | > prior authorization, if          |                          |   |
|     | > applicable.                      |                          |   |
|     |                                    |                          |   |
|     | -   **We follow FDA dispensing     |                          |   |
|     |     guidelines.** Generic drugs    |                          |   |
|     |     will be dispensed when         |                          |   |
|     |     substitution is permissible    |                          |   |
|     |     for prescriptions filled at a  |                          |   |
|     |     retail pharmacy or through     |                          |   |
|     |     mail order. If generic         |                          |   |
|     |     substitution is permissible    |                          |   |
|     |     (i.e., a generic drug is       |                          |   |
|     |     available and the prescribing  |                          |   |
|     |     physician does not require the |                          |   |
|     |     use of a brand name drug), but |                          |   |
|     |     you request the brand name     |                          |   |
|     |     drug, you pay the name brand   |                          |   |
|     |     copayment plus the cost        |                          |   |
|     |     difference between the generic |                          |   |
|     |     and the name brand drug. If    |                          |   |
|     |     you fill a prescription for a  |                          |   |
|     |     brand name and there is no     |                          |   |
|     |     generic available, you will be |                          |   |
|     |     responsible for either the     |                          |   |
|     |     formulary or non-formulary     |                          |   |
|     |     brand name copayment.          |                          |   |
|     |                                    |                          |   |
|     | -   **Why use generic drugs?**     |                          |   |
|     |     Generic drugs are lower-priced |                          |   |
|     |     drugs that are the therapeutic |                          |   |
|     |     equivalent to more expensive   |                          |   |
|     |     brand name drugs. They must    |                          |   |
|     |     contain the same active        |                          |   |
|     |     ingredients and must be        |                          |   |
|     |     equivalent in strength and     |                          |   |
|     |     dosage to the original brand   |                          |   |
|     |     name product. Generics cost    |                          |   |
|     |     less than the equivalent brand |                          |   |
|     |     name product. The U.S. Food    |                          |   |
|     |     and Drug Administration sets   |                          |   |
|     |     quality standards for generic  |                          |   |
|     |     drugs to ensure that these     |                          |   |
|     |     drugs meet the same standards  |                          |   |
|     |     of quality and strength as     |                          |   |
|     |     brand name drugs. You can save |                          |   |
|     |     money by using generic drugs.  |                          |   |
|     |     However, you and your          |                          |   |
|     |     physician have the option to   |                          |   |
|     |     request a brand name if a      |                          |   |
|     |     generic option is available.   |                          |   |
|     |                                    |                          |   |
|     | .                                  |                          |   |
|     |                                    |                          |   |
|     | -                                  |                          |   |
|     | -                                  |                          |   |
|     | -                                  |                          |   |
|     | -                                  |                          |   |
+-----+------------------------------------+--------------------------+---+
| >   |                                    | **You pay**              |   |
| **B |                                    |                          |   |
| ene |                                    |                          |   |
| fit |                                    |                          |   |
| > D |                                    |                          |   |
| esc |                                    |                          |   |
| rip |                                    |                          |   |
| tio |                                    |                          |   |
| n** |                                    |                          |   |
+-----+------------------------------------+--------------------------+---+
| >   |                                    |                          |   |
| **C |                                    |                          |   |
| ove |                                    |                          |   |
| red |                                    |                          |   |
| >   |                                    |                          |   |
|  me |                                    |                          |   |
| dic |                                    |                          |   |
| ati |                                    |                          |   |
| ons |                                    |                          |   |
| >   |                                    |                          |   |
| and |                                    |                          |   |
| > s |                                    |                          |   |
| upp |                                    |                          |   |
| lie |                                    |                          |   |
| s** |                                    |                          |   |
+-----+------------------------------------+--------------------------+---+
| >   |                                    | > Generic - \$8          |   |
|  We |                                    | >                        |   |
| >   |                                    | > Formulary brand name - |   |
|  co |                                    | > \$20                   |   |
| ver |                                    | >                        |   |
| >   |                                    | > Non-formulary brand    |   |
| the |                                    | > name - \$35            |   |
| >   |                                    | >                        |   |
| fol |                                    | > Injectable drugs       |   |
| low |                                    | > (except insulin) - 20% |   |
| ing |                                    | > up to \$50             |   |
| >   |                                    | >                        |   |
|  me |                                    | > Note: If there is no   |   |
| dic |                                    | > generic equivalent     |   |
| ati |                                    | > available, you will    |   |
| ons |                                    | > still have to pay the  |   |
| >   |                                    | > brand name copayment.  |   |
| and |                                    |                          |   |
| >   |                                    |                          |   |
|  su |                                    |                          |   |
| ppl |                                    |                          |   |
| ies |                                    |                          |   |
| > p |                                    |                          |   |
| res |                                    |                          |   |
| cri |                                    |                          |   |
| bed |                                    |                          |   |
| >   |                                    |                          |   |
|  by |                                    |                          |   |
| > a |                                    |                          |   |
| > P |                                    |                          |   |
| lan |                                    |                          |   |
| >   |                                    |                          |   |
| phy |                                    |                          |   |
| sic |                                    |                          |   |
| ian |                                    |                          |   |
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| and |                                    |                          |   |
| >   |                                    |                          |   |
|  ob |                                    |                          |   |
| tai |                                    |                          |   |
| ned |                                    |                          |   |
| > f |                                    |                          |   |
| rom |                                    |                          |   |
| > a |                                    |                          |   |
| > P |                                    |                          |   |
| lan |                                    |                          |   |
| >   |                                    |                          |   |
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| arm |                                    |                          |   |
| acy |                                    |                          |   |
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| > t |                                    |                          |   |
| hro |                                    |                          |   |
| ugh |                                    |                          |   |
| >   |                                    |                          |   |
| our |                                    |                          |   |
| > m |                                    |                          |   |
| ail |                                    |                          |   |
| >   |                                    |                          |   |
|  or |                                    |                          |   |
| der |                                    |                          |   |
| >   |                                    |                          |   |
|  pr |                                    |                          |   |
| ogr |                                    |                          |   |
| am: |                                    |                          |   |
|     |                                    |                          |   |
| -   |                                    |                          |   |
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| ugs |                                    |                          |   |
|     |                                    |                          |   |
|     |                                    |                          |   |
| and |                                    |                          |   |
|     |                                    |                          |   |
|     |                                    |                          |   |
| med |                                    |                          |   |
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| nes |                                    |                          |   |
|     |                                    |                          |   |
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|     |                                    |                          |   |
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|     |                                    |                          |   |
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|     |                                    |                          |   |
|     |                                    |                          |   |
| Uni |                                    |                          |   |
| ted |                                    |                          |   |
|     |                                    |                          |   |
|     |                                    |                          |   |
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| tes |                                    |                          |   |
|     |                                    |                          |   |
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| equ |                                    |                          |   |
| ire |                                    |                          |   |
|     |                                    |                          |   |
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|     |                                    |                          |   |
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| ysi |                                    |                          |   |
| cia |                                    |                          |   |
| n's |                                    |                          |   |
|     |                                    |                          |   |
|     |                                    |                          |   |
| pre |                                    |                          |   |
| scr |                                    |                          |   |
| ipt |                                    |                          |   |
| ion |                                    |                          |   |
|     |                                    |                          |   |
|     |                                    |                          |   |
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|     |                                    |                          |   |
|  th |                                    |                          |   |
| eir |                                    |                          |   |
|     |                                    |                          |   |
|     |                                    |                          |   |
| pur |                                    |                          |   |
| cha |                                    |                          |   |
| se, |                                    |                          |   |
|     |                                    |                          |   |
|     |                                    |                          |   |
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| ept |                                    |                          |   |
|     |                                    |                          |   |
|  th |                                    |                          |   |
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|     |                                    |                          |   |
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| lis |                                    |                          |   |
| ted |                                    |                          |   |
|     |                                    |                          |   |
|  as |                                    |                          |   |
|     |                                    |                          |   |
|   * |                                    |                          |   |
| Not |                                    |                          |   |
|     |                                    |                          |   |
|     |                                    |                          |   |
| cov |                                    |                          |   |
| ere |                                    |                          |   |
| d*. |                                    |                          |   |
|     |                                    |                          |   |
| -   |                                    |                          |   |
|  In |                                    |                          |   |
| sul |                                    |                          |   |
| in, |                                    |                          |   |
|     |                                    |                          |   |
|   w |                                    |                          |   |
| ith |                                    |                          |   |
|     |                                    |                          |   |
|   a |                                    |                          |   |
|     |                                    |                          |   |
|     |                                    |                          |   |
| cop |                                    |                          |   |
| aym |                                    |                          |   |
| ent |                                    |                          |   |
|     |                                    |                          |   |
|     |                                    |                          |   |
| cha |                                    |                          |   |
| rge |                                    |                          |   |
|     |                                    |                          |   |
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| ach |                                    |                          |   |
|     |                                    |                          |   |
|  34 |                                    |                          |   |
|     |                                    |                          |   |
|     |                                    |                          |   |
| day |                                    |                          |   |
|     |                                    |                          |   |
|   s |                                    |                          |   |
| upp |                                    |                          |   |
| ly. |                                    |                          |   |
|     |                                    |                          |   |
| -   |                                    |                          |   |
|  Di |                                    |                          |   |
| abe |                                    |                          |   |
| tic |                                    |                          |   |
|     |                                    |                          |   |
|     |                                    |                          |   |
| sup |                                    |                          |   |
| pli |                                    |                          |   |
| es, |                                    |                          |   |
|     |                                    |                          |   |
|     |                                    |                          |   |
| inc |                                    |                          |   |
| lud |                                    |                          |   |
| ing |                                    |                          |   |
|     |                                    |                          |   |
|   i |                                    |                          |   |
| nsu |                                    |                          |   |
| lin |                                    |                          |   |
|     |                                    |                          |   |
|     |                                    |                          |   |
| syr |                                    |                          |   |
| ing |                                    |                          |   |
| es, |                                    |                          |   |
|     |                                    |                          |   |
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| edl |                                    |                          |   |
| es, |                                    |                          |   |
|     |                                    |                          |   |
|   g |                                    |                          |   |
| luc |                                    |                          |   |
| ose |                                    |                          |   |
|     |                                    |                          |   |
|   t |                                    |                          |   |
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|     |                                    |                          |   |
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| ets |                                    |                          |   |
|     |                                    |                          |   |
|     |                                    |                          |   |
| and |                                    |                          |   |
|     |                                    |                          |   |
|   t |                                    |                          |   |
| est |                                    |                          |   |
|     |                                    |                          |   |
|  ta |                                    |                          |   |
| pe, |                                    |                          |   |
|     |                                    |                          |   |
|   B |                                    |                          |   |
| ene |                                    |                          |   |
| dic |                                    |                          |   |
| t's |                                    |                          |   |
|     |                                    |                          |   |
|  so |                                    |                          |   |
| lut |                                    |                          |   |
| ion |                                    |                          |   |
|     |                                    |                          |   |
|  or |                                    |                          |   |
|     |                                    |                          |   |
|  eq |                                    |                          |   |
| uiv |                                    |                          |   |
| ale |                                    |                          |   |
| nt, |                                    |                          |   |
|     |                                    |                          |   |
|     |                                    |                          |   |
| and |                                    |                          |   |
|     |                                    |                          |   |
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| cet |                                    |                          |   |
| one |                                    |                          |   |
|     |                                    |                          |   |
|  te |                                    |                          |   |
| sts |                                    |                          |   |
|     |                                    |                          |   |
|  ta |                                    |                          |   |
| ble |                                    |                          |   |
| ts. |                                    |                          |   |
|     |                                    |                          |   |
| -   |                                    |                          |   |
|   D |                                    |                          |   |
| isp |                                    |                          |   |
| osa |                                    |                          |   |
| ble |                                    |                          |   |
|     |                                    |                          |   |
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| eed |                                    |                          |   |
| les |                                    |                          |   |
|     |                                    |                          |   |
|     |                                    |                          |   |
| and |                                    |                          |   |
|     |                                    |                          |   |
|  sy |                                    |                          |   |
| rin |                                    |                          |   |
| ges |                                    |                          |   |
|     |                                    |                          |   |
|     |                                    |                          |   |
| for |                                    |                          |   |
|     |                                    |                          |   |
|     |                                    |                          |   |
| the |                                    |                          |   |
|     |                                    |                          |   |
|  ad |                                    |                          |   |
| min |                                    |                          |   |
| ist |                                    |                          |   |
| rat |                                    |                          |   |
| ion |                                    |                          |   |
|     |                                    |                          |   |
|  of |                                    |                          |   |
|     |                                    |                          |   |
|  co |                                    |                          |   |
| ver |                                    |                          |   |
| ed, |                                    |                          |   |
|     |                                    |                          |   |
|   p |                                    |                          |   |
| res |                                    |                          |   |
| cri |                                    |                          |   |
| bed |                                    |                          |   |
|     |                                    |                          |   |
|     |                                    |                          |   |
| med |                                    |                          |   |
| ica |                                    |                          |   |
| tio |                                    |                          |   |
| ns. |                                    |                          |   |
|     |                                    |                          |   |
| -   |                                    |                          |   |
|   O |                                    |                          |   |
| ral |                                    |                          |   |
|     |                                    |                          |   |
|     |                                    |                          |   |
| and |                                    |                          |   |
|     |                                    |                          |   |
|   i |                                    |                          |   |
| nje |                                    |                          |   |
| cta |                                    |                          |   |
| ble |                                    |                          |   |
|     |                                    |                          |   |
|   c |                                    |                          |   |
| ont |                                    |                          |   |
| rac |                                    |                          |   |
| ept |                                    |                          |   |
| ive |                                    |                          |   |
|     |                                    |                          |   |
|     |                                    |                          |   |
| dru |                                    |                          |   |
| gs; |                                    |                          |   |
|     |                                    |                          |   |
|   c |                                    |                          |   |
| ont |                                    |                          |   |
| rac |                                    |                          |   |
| ept |                                    |                          |   |
| ive |                                    |                          |   |
|     |                                    |                          |   |
|  de |                                    |                          |   |
| vic |                                    |                          |   |
| es. |                                    |                          |   |
|     |                                    |                          |   |
|  No |                                    |                          |   |
| te: |                                    |                          |   |
|     |                                    |                          |   |
|     |                                    |                          |   |
| All |                                    |                          |   |
|     |                                    |                          |   |
|   c |                                    |                          |   |
| ont |                                    |                          |   |
| rac |                                    |                          |   |
| ept |                                    |                          |   |
| ive |                                    |                          |   |
|     |                                    |                          |   |
|  dr |                                    |                          |   |
| ugs |                                    |                          |   |
|     |                                    |                          |   |
|     |                                    |                          |   |
| are |                                    |                          |   |
|     |                                    |                          |   |
|   s |                                    |                          |   |
| ubj |                                    |                          |   |
| ect |                                    |                          |   |
|     |                                    |                          |   |
|  to |                                    |                          |   |
|     |                                    |                          |   |
|     |                                    |                          |   |
| one |                                    |                          |   |
|     |                                    |                          |   |
|     |                                    |                          |   |
| cop |                                    |                          |   |
| aym |                                    |                          |   |
| ent |                                    |                          |   |
|     |                                    |                          |   |
|     |                                    |                          |   |
| for |                                    |                          |   |
|     |                                    |                          |   |
|  up |                                    |                          |   |
|     |                                    |                          |   |
|  to |                                    |                          |   |
|     |                                    |                          |   |
|   a |                                    |                          |   |
|     |                                    |                          |   |
|     |                                    |                          |   |
| 90- |                                    |                          |   |
| day |                                    |                          |   |
|     |                                    |                          |   |
|     |                                    |                          |   |
| sup |                                    |                          |   |
| ply |                                    |                          |   |
|     |                                    |                          |   |
|     |                                    |                          |   |
| per |                                    |                          |   |
|     |                                    |                          |   |
|     |                                    |                          |   |
| pre |                                    |                          |   |
| scr |                                    |                          |   |
| ipt |                                    |                          |   |
| ion |                                    |                          |   |
|     |                                    |                          |   |
|  or |                                    |                          |   |
|     |                                    |                          |   |
|   r |                                    |                          |   |
| efi |                                    |                          |   |
| ll. |                                    |                          |   |
|     |                                    |                          |   |
| -   |                                    |                          |   |
|     |                                    |                          |   |
| Fer |                                    |                          |   |
| til |                                    |                          |   |
| ity |                                    |                          |   |
|     |                                    |                          |   |
|  dr |                                    |                          |   |
| ugs |                                    |                          |   |
|     |                                    |                          |   |
|  -- |                                    |                          |   |
|     |                                    |                          |   |
|   i |                                    |                          |   |
| nje |                                    |                          |   |
| cta |                                    |                          |   |
| ble |                                    |                          |   |
|     |                                    |                          |   |
|     |                                    |                          |   |
| and |                                    |                          |   |
|     |                                    |                          |   |
|   o |                                    |                          |   |
| ral |                                    |                          |   |
|     |                                    |                          |   |
|     |                                    |                          |   |
| fer |                                    |                          |   |
| til |                                    |                          |   |
| ity |                                    |                          |   |
|     |                                    |                          |   |
|  dr |                                    |                          |   |
| ugs |                                    |                          |   |
|     |                                    |                          |   |
|     |                                    |                          |   |
| for |                                    |                          |   |
|     |                                    |                          |   |
|   a |                                    |                          |   |
| uth |                                    |                          |   |
| ori |                                    |                          |   |
| zed |                                    |                          |   |
|     |                                    |                          |   |
|  in |                                    |                          |   |
| -vi |                                    |                          |   |
| tro |                                    |                          |   |
|     |                                    |                          |   |
|   f |                                    |                          |   |
| ert |                                    |                          |   |
| ili |                                    |                          |   |
| zat |                                    |                          |   |
| ion |                                    |                          |   |
|     |                                    |                          |   |
|  pr |                                    |                          |   |
| oce |                                    |                          |   |
| dur |                                    |                          |   |
| es; |                                    |                          |   |
|     |                                    |                          |   |
|   o |                                    |                          |   |
| nly |                                    |                          |   |
|     |                                    |                          |   |
|     |                                    |                          |   |
| Clo |                                    |                          |   |
| mid |                                    |                          |   |
|     |                                    |                          |   |
|     |                                    |                          |   |
| (cl |                                    |                          |   |
| omi |                                    |                          |   |
| phe |                                    |                          |   |
| ne) |                                    |                          |   |
|     |                                    |                          |   |
|  is |                                    |                          |   |
|     |                                    |                          |   |
|   c |                                    |                          |   |
| ove |                                    |                          |   |
| red |                                    |                          |   |
|     |                                    |                          |   |
|     |                                    |                          |   |
| for |                                    |                          |   |
|     |                                    |                          |   |
|   a |                                    |                          |   |
| rti |                                    |                          |   |
| fic |                                    |                          |   |
| ial |                                    |                          |   |
|     |                                    |                          |   |
|   i |                                    |                          |   |
| nse |                                    |                          |   |
| min |                                    |                          |   |
| ati |                                    |                          |   |
| on. |                                    |                          |   |
|     |                                    |                          |   |
| > L |                                    |                          |   |
| imi |                                    |                          |   |
| ted |                                    |                          |   |
| >   |                                    |                          |   |
|  Be |                                    |                          |   |
| nef |                                    |                          |   |
| its |                                    |                          |   |
|     |                                    |                          |   |
| -   |                                    |                          |   |
|  Dr |                                    |                          |   |
| ugs |                                    |                          |   |
|     |                                    |                          |   |
|  to |                                    |                          |   |
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|     |                                    |                          |   |
|     |                                    |                          |   |
| sex |                                    |                          |   |
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|     |                                    |                          |   |
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|     |                                    |                          |   |
|     |                                    |                          |   |
| dos |                                    |                          |   |
| age |                                    |                          |   |
|     |                                    |                          |   |
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| imi |                                    |                          |   |
| ts. |                                    |                          |   |
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| -   |                                    |                          |   |
|  Dr |                                    |                          |   |
| ugs |                                    |                          |   |
|     |                                    |                          |   |
|   p |                                    |                          |   |
| res |                                    |                          |   |
| cri |                                    |                          |   |
| bed |                                    |                          |   |
|     |                                    |                          |   |
|     |                                    |                          |   |
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|     |                                    |                          |   |
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|     |                                    |                          |   |
|     |                                    |                          |   |
| ces |                                    |                          |   |
| sat |                                    |                          |   |
| ion |                                    |                          |   |
|     |                                    |                          |   |
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|     |                                    |                          |   |
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| imi |                                    |                          |   |
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|     |                                    |                          |   |
|  to |                                    |                          |   |
|     |                                    |                          |   |
|  90 |                                    |                          |   |
|     |                                    |                          |   |
|     |                                    |                          |   |
| day |                                    |                          |   |
|     |                                    |                          |   |
|     |                                    |                          |   |
| sup |                                    |                          |   |
| ply |                                    |                          |   |
|     |                                    |                          |   |
|     |                                    |                          |   |
| wit |                                    |                          |   |
| hin |                                    |                          |   |
|     |                                    |                          |   |
|   a |                                    |                          |   |
|     |                                    |                          |   |
|     |                                    |                          |   |
| 365 |                                    |                          |   |
|     |                                    |                          |   |
|     |                                    |                          |   |
| day |                                    |                          |   |
|     |                                    |                          |   |
|   p |                                    |                          |   |
| eri |                                    |                          |   |
| od. |                                    |                          |   |
+-----+------------------------------------+--------------------------+---+

> *Covered medications and supplies \-- continued on next page*

+------------------------------------------+---------------------------+
| > *Not covered:*                         | > *All charges*           |
|                                          |                           |
| -   *Drugs and supplies for cosmetic     |                           |
|     purposes, including drugs for weight |                           |
|     loss or control*                     |                           |
|                                          |                           |
| -   *Nonprescription medicines*          |                           |
|                                          |                           |
| -   *Vitamins and nutritional substances |                           |
|     that can be purchased without a      |                           |
|     prescription*                        |                           |
|                                          |                           |
| -   *Medical supplies such as dressings  |                           |
|     and antiseptics*                     |                           |
|                                          |                           |
| -   *Artificial insemination fertility   |                           |
|     drugs except Clomid (clomiphene)*    |                           |
|                                          |                           |
| -   *Drugs to enhance athletic           |                           |
|     performance*                         |                           |
|                                          |                           |
| -   *Drugs obtained at a non-Plan        |                           |
|     pharmacy; except for out-of-area     |                           |
|     emergencies*                         |                           |
|                                          |                           |
| -   *Replacement Prescription Drug       |                           |
|     Products resulting from loss, theft, |                           |
|     spoilage, or breakage of original    |                           |
|     product*                             |                           |
|                                          |                           |
| -   *Drugs available over-the-counter    |                           |
|     that do not require a prescription   |                           |
|     order by federal or state law before |                           |
|     being dispensed, and any drug that   |                           |
|     is therapeutically equivalent to an  |                           |
|     over-the-counter drug*               |                           |
+------------------------------------------+---------------------------+

+----------------------+-----------------------------------------------+
| **Section 5 (g).     |                                               |
| Special features**   |                                               |
+----------------------+-----------------------------------------------+
| Feature              | Description                                   |
+----------------------+-----------------------------------------------+
| **Flexible benefits  | Under the flexible benefits option, we        |
| option**             | determine the most effective way to provide   |
|                      | services.                                     |
|                      |                                               |
|                      | -   We may identify medically appropriate     |
|                      |     alternatives to traditional care and      |
|                      |     coordinate other benefits as a less       |
|                      |     costly alternative benefit.               |
|                      |                                               |
|                      | -   Alternative benefits are subject to our   |
|                      |     ongoing review.                           |
|                      |                                               |
|                      | -   By approving an alternative benefit, we   |
|                      |     cannot guarantee you will get it in the   |
|                      |     future.                                   |
|                      |                                               |
|                      | -   The decision to offer an alternative      |
|                      |     benefit is solely ours, and we may        |
|                      |     withdraw it at any time and resume        |
|                      |     regular contract benefits.                |
|                      |                                               |
|                      | -   Our decision to offer or withdraw         |
|                      |     alternative benefits is not subject to    |
|                      |     OPM review under the disputed claims      |
|                      |     process.                                  |
+----------------------+-----------------------------------------------+
| **Centers for        | We use specific institutions called Centers   |
| Cardiac Surgery,     | for Cardiac Surgery, Transplants and Joint    |
| Transplants and      | Replacement. These Centers do a large volume  |
| Joint Replacement**  | of these procedures each year and have a      |
|                      | comprehensive program of care. A list of      |
|                      | these facilities can be found in the          |
|                      | *Directory of Health Care*, or you can call   |
|                      | the Member Services Department at             |
|                      | 301-360-8080 or 1-800-251-0956 for an         |
|                      | up-to-date listing.                           |
+----------------------+-----------------------------------------------+
| **WeeCall Program**  | Our maternity programs offer women support    |
|                      | and education throughout pregnancy. We will   |
|                      | mail you educational materials, and           |
|                      | obstetrical nurses are available to talk to   |
|                      | you on the telephone at no cost. Call the     |
|                      | Member Services Department at 301-360-8080 or |
|                      | 1-800-251-0956 for more information about our |
|                      | maternity programs.                           |
+----------------------+-----------------------------------------------+
| **Plan               | There are several publications available to   |
| Publications**       | you at no cost. They include:                 |
|                      |                                               |
|                      | -   *HealthLine* (immunization and preventive |
|                      |     health check-up schedule)                 |
|                      |                                               |
|                      | -   HealthSense Member Newsletter             |
|                      |                                               |
|                      | -   *Directory of Health Care Professionals*  |
|                      |                                               |
|                      | -   *WeeCall* Pregnancy Education             |
|                      |                                               |
|                      | -   Vaccination Facts                         |
|                      |                                               |
|                      | Call the Member Services Department at        |
|                      | 301-360-8080 or 1-800-251-0956 to request a   |
|                      | copy of any of these publications.            |
+----------------------+-----------------------------------------------+
| **Health Education   | -   Healthwise Knowledgebase -- online       |
| and Disease          |     source for members to research health     |
| Management           |     questions                                 |
| Programs**           |                                               |
|                      | -   Preventive Health, including Women's      |
|                      |     Health and Men's Health                   |
|                      |                                               |
|                      | -   Cardiovascular Disease Prevention         |
|                      |                                               |
|                      | -   Diabetes Mellitus Management              |
|                      |                                               |
|                      | -   Behavioral Health Care/Depression         |
|                      |     Management                                |
|                      |                                               |
|                      | -   Asthma Management                         |
|                      |                                               |
|                      | -   Secondary Prevention of Vascular Disease  |
+----------------------+-----------------------------------------------+

+---+---+----------------------------------------------+-------+---+---+------+
| * |   |                                              |       |   |   |      |
| * |   |                                              |       |   |   |      |
| S |   |                                              |       |   |   |      |
| e |   |                                              |       |   |   |      |
| c |   |                                              |       |   |   |      |
| t |   |                                              |       |   |   |      |
| i |   |                                              |       |   |   |      |
| o |   |                                              |       |   |   |      |
| n |   |                                              |       |   |   |      |
| 5 |   |                                              |       |   |   |      |
| ( |   |                                              |       |   |   |      |
| h |   |                                              |       |   |   |      |
| ) |   |                                              |       |   |   |      |
| . |   |                                              |       |   |   |      |
| D |   |                                              |       |   |   |      |
| e |   |                                              |       |   |   |      |
| n |   |                                              |       |   |   |      |
| t |   |                                              |       |   |   |      |
| a |   |                                              |       |   |   |      |
| l |   |                                              |       |   |   |      |
| b |   |                                              |       |   |   |      |
| e |   |                                              |       |   |   |      |
| n |   |                                              |       |   |   |      |
| e |   |                                              |       |   |   |      |
| f |   |                                              |       |   |   |      |
| i |   |                                              |       |   |   |      |
| t |   |                                              |       |   |   |      |
| s |   |                                              |       |   |   |      |
| * |   |                                              |       |   |   |      |
| * |   |                                              |       |   |   |      |
+---+---+----------------------------------------------+-------+---+---+------+
|   | * | **Here are some important things to keep in  |       | * |   |      |
|   | * | mind about these benefits**:                 |       | * |   |      |
|   | I |                                              |       | I |   |      |
|   | * | -   Please remember that all benefits are    |       | * |   |      |
|   | * |     subject to the definitions, limitations, |       | * |   |      |
|   |   |     and exclusions                           |       |   |   |      |
|   | * |                                              |       | * |   |      |
|   | * | > in this brochure and are payable only when |       | * |   |      |
|   | M | > we determine they are medically necessary. |       | M |   |      |
|   | * |                                              |       | * |   |      |
|   | * | -   This Plan is a discount program. Plan    |       | * |   |      |
|   |   |     dentists must provide or arrange your    |       |   |   |      |
|   | * |     care.                                    |       | * |   |      |
|   | * |                                              |       | * |   |      |
|   | P | -   We have no calendar year deductible.     |       | P |   |      |
|   | * |                                              |       | * |   |      |
|   | * | -   We cover hospitalization for dental      |       | * |   |      |
|   |   |     procedures only when a nondental         |       |   |   |      |
|   | * |     physical impairment exists which makes   |       | * |   |      |
|   | * |     hospitalization necessary to safeguard   |       | * |   |      |
|   | O |     the health of the patient. See Section   |       | O |   |      |
|   | * |     5 (c) for inpatient hospital benefits.   |       | * |   |      |
|   | * |                                              |       | * |   |      |
|   |   | -   Be sure to read Section 4, *Your costs   |       |   |   |      |
|   | * |     for covered services,* for valuable      |       | * |   |      |
|   | * |     information about how cost sharing       |       | * |   |      |
|   | R |     works. Also read Section 9 about         |       | R |   |      |
|   | * |     coordinating benefits with other         |       | * |   |      |
|   | * |     coverage, including with Medicare.       |       | * |   |      |
|   |   |                                              |       |   |   |      |
|   | * |                                              |       | * |   |      |
|   | * |                                              |       | * |   |      |
|   | T |                                              |       | T |   |      |
|   | * |                                              |       | * |   |      |
|   | * |                                              |       | * |   |      |
|   |   |                                              |       |   |   |      |
|   | * |                                              |       | * |   |      |
|   | * |                                              |       | * |   |      |
|   | A |                                              |       | A |   |      |
|   | * |                                              |       | * |   |      |
|   | * |                                              |       | * |   |      |
|   |   |                                              |       |   |   |      |
|   | * |                                              |       | * |   |      |
|   | * |                                              |       | * |   |      |
|   | N |                                              |       | N |   |      |
|   | * |                                              |       | * |   |      |
|   | * |                                              |       | * |   |      |
|   |   |                                              |       |   |   |      |
|   | * |                                              |       | * |   |      |
|   | * |                                              |       | * |   |      |
|   | T |                                              |       | T |   |      |
|   | * |                                              |       | * |   |      |
|   | * |                                              |       | * |   |      |
+---+---+----------------------------------------------+-------+---+---+------+
| > |   |                                              | > You |   |   |      |
|   |   |                                              | > pay |   |   |      |
| A |   |                                              |       |   |   |      |
| c |   |                                              |       |   |   |      |
| c |   |                                              |       |   |   |      |
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|   |   |                                              |       |   |   |      |
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| n |   |                                              |       |   |   |      |
| j |   |                                              |       |   |   |      |
| u |   |                                              |       |   |   |      |
| r |   |                                              |       |   |   |      |
| y |   |                                              |       |   |   |      |
| > |   |                                              |       |   |   |      |
|   |   |                                              |       |   |   |      |
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| f |   |                                              |       |   |   |      |
| i |   |                                              |       |   |   |      |
| t |   |                                              |       |   |   |      |
+---+---+----------------------------------------------+-------+---+---+------+
| > |   |                                              | \$20  |   |   |      |
|   |   |                                              | per   |   |   |      |
| W |   |                                              | visit |   |   |      |
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+---+---+----------------------------------------------+-------+---+---+------+

+-----------------------------------------------------------------------+
| > Dental Discount benefits                                            |
+-----------------------------------------------------------------------+
| The following list summarizes the fees for dental services provided   |
| by a participating PLAN GENERAL DENTIST ONLY. Services rendered by a  |
| plan general dentist that are not on the fee schedule, are provided   |
| at a 25 percent reduction of usual and customary (UCR) costs.         |
| Services (whether on the fee schedule or not) rendered by a Plan      |
| dental specialist are also provided at a 25 percent reduction of      |
| costs. The fees listed on this page, and the following page, do not   |
| reflect the payment to a Plan dental specialist. Cosmetic and         |
| implant-related services (implants, abutments, posts, screws and      |
| implant-supported prosthetics) are provided at a 10 percent discount  |
| by both plan general and specialist dentists. You do not have to      |
| obtain a referral from your Primary Care Physician to obtain the      |
| following dental care services. For additional information, contact   |
| us at 301-360-8080 or 1-800-251-0956; for a complete list of fees, or |
| a list of participating dentists, please refer to the M.D. IPA *2004  |
| Federal Plan Dental Guide*. The list is also on our website,          |
| [www.mamsi.com/federal](http://www.mamsi.com/federal).                |
|                                                                       |
| +-----+---------------------------------------------+------------+    |
| |     | > **Service**                               | > **You    |    |
| |     |                                             | > pay**    |    |
| +-----+---------------------------------------------+------------+    |
| | > T | > Diagnostic and Preventive Services        |            |    |
| | ype |                                             |            |    |
| | > I |                                             |            |    |
| +-----+---------------------------------------------+------------+    |
| | >   | > Topical Application of Fluoride           | > N/C      |    |
| |  D1 | > (Prophylaxis not Included) -- Child       |            |    |
| | 203 |                                             |            |    |
| +-----+---------------------------------------------+------------+    |
| | >   | > Periodic Oral Examination                 | > \$20.00  |    |
| |  D0 |                                             |            |    |
| | 120 |                                             |            |    |
| +-----+---------------------------------------------+------------+    |
| | >   | > Comprehensive Oral Evaluation             | > \$34.00  |    |
| |  D0 |                                             |            |    |
| | 150 |                                             |            |    |
| +-----+---------------------------------------------+------------+    |
| | >   | > Prophylaxis -- Adult                      | > \$35.00  |    |
| |  D1 |                                             |            |    |
| | 110 |                                             |            |    |
| +-----+---------------------------------------------+------------+    |
| | >   | > Prophylaxis -- Child                      | > \$27.00  |    |
| |  D1 |                                             |            |    |
| | 120 |                                             |            |    |
| +-----+---------------------------------------------+------------+    |
| | >   | ####### Sealant, per tooth                  | > \$22.00  |    |
| |  D1 |                                             |            |    |
| | 351 |                                             |            |    |
| +-----+---------------------------------------------+------------+    |
| |     | > Radiological Services                     |            |    |
| +-----+---------------------------------------------+------------+    |
| | >   | > Intraoral -- Complete Series (including   | > \$55.00  |    |
| |  D0 | > bitewings)                                |            |    |
| | 210 |                                             |            |    |
| +-----+---------------------------------------------+------------+    |
| | >   | > Intraoral -- Periapical -- First Film     | > \$11.00  |    |
| |  D0 |                                             |            |    |
| | 220 |                                             |            |    |
| +-----+---------------------------------------------+------------+    |
| | >   | > Bitewings -- 2 Films                      | > \$19.00  |    |
| |  D0 |                                             |            |    |
| | 272 |                                             |            |    |
| +-----+---------------------------------------------+------------+    |
| | >   | > Panoramic Film                            | > \$53.00  |    |
| |  D0 |                                             |            |    |
| | 330 |                                             |            |    |
| +-----+---------------------------------------------+------------+    |
| | > T | > Basic Dental Services, Silver             |            |    |
| | ype | > Restorations and All Other Services       |            |    |
| | >   |                                             |            |    |
| |  II |                                             |            |    |
| +-----+---------------------------------------------+------------+    |
| |     | > Amalgam Restorations -- Adult or child    |            |    |
| +-----+---------------------------------------------+------------+    |
| | >   | > Amalgam -- 2 Surfaces                     | > \$67.00  |    |
| |  D2 |                                             |            |    |
| | 150 |                                             |            |    |
| +-----+---------------------------------------------+------------+    |
| |     | > Composite Restorations (White Filling)    |            |    |
| +-----+---------------------------------------------+------------+    |
| | >   | > Resin -- 2 Surfaces, Anterior             | > \$74.00  |    |
| |  D2 |                                             |            |    |
| | 331 |                                             |            |    |
| +-----+---------------------------------------------+------------+    |
| | >   | > Resin -- 2 Surfaces, Posterior -- Primary | > \$89.00  |    |
| |  D2 |                                             |            |    |
| | 392 |                                             |            |    |
| +-----+---------------------------------------------+------------+    |
| | T   | > Major Dental Services                     |            |    |
| | ype |                                             |            |    |
| | III |                                             |            |    |
| +-----+---------------------------------------------+------------+    |
| |     | > Crown and Inlay Services                  |            |    |
| +-----+---------------------------------------------+------------+    |
| | >   | > Recement Crown                            | > \$44.00  |    |
| |  D2 |                                             |            |    |
| | 920 |                                             |            |    |
| +-----+---------------------------------------------+------------+    |
| | >   | > Prefabricated Stainless Steel             | > \$119.00 |    |
| |  D2 | > Crown\--Primary Tooth                     |            |    |
| | 930 |                                             |            |    |
| +-----+---------------------------------------------+------------+    |
| | >   | > Core Buildup, Including Any Pins          | > \$70.00  |    |
| |  D2 |                                             |            |    |
| | 950 |                                             |            |    |
| +-----+---------------------------------------------+------------+    |
| | >   | > Cast Post and Core In Addition to Crown   | > \$174.00 |    |
| |  D2 |                                             |            |    |
| | 952 |                                             |            |    |
| +-----+---------------------------------------------+------------+    |
| | >   | > Prefabricated Post and Core In Addition   | > \$144.00 |    |
| |  D2 | > to Crown                                  |            |    |
| | 954 |                                             |            |    |
| +-----+---------------------------------------------+------------+    |
| |     | > Bridge Services                           |            |    |
| +-----+---------------------------------------------+------------+    |
| | >   | > Recement Bridge                           | > \$60.00  |    |
| |  D6 |                                             |            |    |
| | 930 |                                             |            |    |
| +-----+---------------------------------------------+------------+    |
| | >   | > Cast Post and Core in Addition to Bridge  | > \$151.00 |    |
| |  D6 |                                             |            |    |
| | 970 |                                             |            |    |
| +-----+---------------------------------------------+------------+    |
| |     | > Endodontic Services                       |            |    |
| +-----+---------------------------------------------+------------+    |
| | >   | > Pulp Cap -- Direct (Excluding Final       | > \$34.00  |    |
| |  D3 | > Restoration)                              |            |    |
| | 110 |                                             |            |    |
| +-----+---------------------------------------------+------------+    |
| | >   | > Anterior (Excluding Final Restoration)    | > \$337.00 |    |
| |  D3 |                                             |            |    |
| | 310 |                                             |            |    |
| +-----+---------------------------------------------+------------+    |
| | >   | > Molar (Excluding Final Restoration)       | > \$551.00 |    |
| |  D3 |                                             |            |    |
| | 330 |                                             |            |    |
| +-----+---------------------------------------------+------------+    |
| |     | > Periodontic Services                      |            |    |
| +-----+---------------------------------------------+------------+    |
| | >   | > Periodontal Scaling and Root Planing --   | > \$90.00  |    |
| |  D4 | > Per Quadrant                              |            |    |
| | 341 |                                             |            |    |
| +-----+---------------------------------------------+------------+    |
| | >   | > Periodontal Maintenance Procedures        | > \$65.00  |    |
| |  D4 | > (Following Active Therapy)                |            |    |
| | 910 |                                             |            |    |
| +-----+---------------------------------------------+------------+    |
| |     | > Prosthodontics -- Removable               |            |    |
| +-----+---------------------------------------------+------------+    |
| | >   | > Complete Denture -- Maxillary             | > \$599.00 |    |
| |  D5 |                                             |            |    |
| | 110 |                                             |            |    |
| +-----+---------------------------------------------+------------+    |
| | >   | > Maxillary Partial Denture -- Cast Metal   | > \$662.00 |    |
| |  D5 | > Framework with Resin Denture Bases        |            |    |
| | 213 | >                                           |            |    |
| |     | > (Including any Conventional Clasps, Rest  |            |    |
| |     | > and Teeth)                                |            |    |
| +-----+---------------------------------------------+------------+    |
| | >   | > Reline Complete Maxillary Denture         | > \$137.00 |    |
| |  D5 | > (Chairside)                               |            |    |
| | 730 |                                             |            |    |
| +-----+---------------------------------------------+------------+    |
| | >   | > Reline Partial Maxillary Denture          | > \$126.00 |    |
| |  D5 | > (Chairside)                               |            |    |
| | 740 |                                             |            |    |
| +-----+---------------------------------------------+------------+    |
| |     | > Oral Surgery Services                     |            |    |
| +-----+---------------------------------------------+------------+    |
| | >   | > Single Tooth                              | > \$66.00  |    |
| |  D7 |                                             |            |    |
| | 140 |                                             |            |    |
| +-----+---------------------------------------------+------------+    |
| | >   | > Surgical Removal of Erupted Tooth         | > \$95.00  |    |
| |  D7 | > Requiring Evaluation of Mucoperiosteal    |            |    |
| | 210 | > Flap                                      |            |    |
| |     | >                                           |            |    |
| |     | > And Removal of Bone and/or Section of     |            |    |
| |     | > Tooth                                     |            |    |
| +-----+---------------------------------------------+------------+    |
| | >   | > Removal of Impacted Tooth -- Partially    | > \$190.00 |    |
| |  D7 | > Bony                                      |            |    |
| | 230 |                                             |            |    |
| +-----+---------------------------------------------+------------+    |
| | >   | > Removal of Impacted Tooth -- Completely   | > \$230.00 |    |
| |  D7 | > Bony                                      |            |    |
| | 240 |                                             |            |    |
| +-----+---------------------------------------------+------------+    |
| | >   |                                             |            |    |
| | For |                                             |            |    |
| | >   |                                             |            |    |
| | all |                                             |            |    |
| | >   |                                             |            |    |
| |  se |                                             |            |    |
| | rvi |                                             |            |    |
| | ces |                                             |            |    |
| | >   |                                             |            |    |
| | per |                                             |            |    |
| | for |                                             |            |    |
| | med |                                             |            |    |
| | >   |                                             |            |    |
| |  by |                                             |            |    |
| | > a |                                             |            |    |
| | >   |                                             |            |    |
| | Den |                                             |            |    |
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| | > a |                                             |            |    |
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| | fee |                                             |            |    |
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| |  75 |                                             |            |    |
| | > p |                                             |            |    |
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| | >   |                                             |            |    |
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| | >   |                                             |            |    |
| | Den |                                             |            |    |
| | tis |                                             |            |    |
| | t's |                                             |            |    |
| | >   |                                             |            |    |
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| | tom |                                             |            |    |
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| | >   |                                             |            |    |
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| | tic |                                             |            |    |
| | >   |                                             |            |    |
| | and |                                             |            |    |
| | >   |                                             |            |    |
| | imp |                                             |            |    |
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| | are |                                             |            |    |
| | > o |                                             |            |    |
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| | red |                                             |            |    |
| | >   |                                             |            |    |
| |  by |                                             |            |    |
| | > b |                                             |            |    |
| | oth |                                             |            |    |
| | > G |                                             |            |    |
| | ene |                                             |            |    |
| | ral |                                             |            |    |
| | >   |                                             |            |    |
| | and |                                             |            |    |
| | > S |                                             |            |    |
| | pec |                                             |            |    |
| | ial |                                             |            |    |
| | ist |                                             |            |    |
| | >   |                                             |            |    |
| | den |                                             |            |    |
| | tis |                                             |            |    |
| | ts, |                                             |            |    |
| | >   |                                             |            |    |
| | for |                                             |            |    |
| | >   |                                             |            |    |
| |  wh |                                             |            |    |
| | ich |                                             |            |    |
| | >   |                                             |            |    |
| | you |                                             |            |    |
| | >   |                                             |            |    |
| | pay |                                             |            |    |
| | >   |                                             |            |    |
| |  90 |                                             |            |    |
| | > p |                                             |            |    |
| | erc |                                             |            |    |
| | ent |                                             |            |    |
| | >   |                                             |            |    |
| |  of |                                             |            |    |
| | >   |                                             |            |    |
| | the |                                             |            |    |
| | > D |                                             |            |    |
| | ent |                                             |            |    |
| | ist |                                             |            |    |
| | \'s |                                             |            |    |
| | >   |                                             |            |    |
| |  Us |                                             |            |    |
| | ual |                                             |            |    |
| | >   |                                             |            |    |
| | and |                                             |            |    |
| | >   |                                             |            |    |
| | Cus |                                             |            |    |
| | tom |                                             |            |    |
| | ary |                                             |            |    |
| | > f |                                             |            |    |
| | ee. |                                             |            |    |
| +-----+---------------------------------------------+------------+    |
+-----------------------------------------------------------------------+

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

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

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

**[PPO Dental Plan]{.smallcaps}**

In addition to the Dental Discount benefit described in Section 5 (h) of
this brochure, M.D. IPA provides a PPO dental Plan to all 2004 Federal
members. There is no additional premium for this benefit and enrollment
is automatic when you enroll in M.D. IPA's FEHB health Plan (JP) for
2004.

Members may go to the dentist of their choice; however, the benefit is
usually better when you visit a dentist who participates in the PPO. The
benefit provides reimbursement of up to \$1,000 per contract year for
covered dental procedures. The PPO dental Plan covers diagnostic (e.g.,
X-rays), preventive (e.g., exams, cleanings), basic (e.g., fillings),
and major procedures (e.g. root canals, surgical extractions).

Members will receive a separate identification card for this benefit in
their enrollment kit. It is issued by MAMSI Life and Health Insurance
Company (MLH), which provides and administers this benefit.

Look for important details about this Plan, its usage, as well as a
listing of participating dentists, in the 2004 Dental Benefits Guide.
This Guide is in the enrollment packet, or can be obtained by calling
Member Services at 1-800-251-0956, or 301-360-8080. You can also find
information about the dental Program on our website,
www.mamsi.com/federal.

**[TLC Laser Vision Correction Discount]{.smallcaps}**

TLC Laser Eye Centers offer M.D. IPA members a preferred savings for
laser vision correction. For more information on this benefit, please
contact TLC toll-free at 1-877-PLAN TLC.

**O[ptical Services]{.smallcaps}**

Discounts are available on eyewear and related services at participating
optical centers listed in the Plan's *Directory of Health Care
Professionals*. Members simply show their health Plan identification
card at a participating center to receive a discount on eyeglasses,
including single, multifocal or designer and other optical services.

Contact lenses may also be available at a discount. Please contact the
Member Services Department for the names of participating health care
practitioners.

**[National Fitness Network Discount]{.smallcaps}**

The National Fitness Network offers discounts at area health and fitness
clubs of up to 30 percent to M.D. IPA members. For more information or
for questions regarding registration, call National Fitness Network at
1-800-811-5454, or visit their Website,
[www.nationalfitnessnetwork.com](http://www.nationalfitnessnetwork.com/).

**MAMSI Complete Benefits**

New for 2004, M.D. IPA is introducing MAMSI Complete benefits for an
additional premium to allow members to select voluntary, short-term
disability income and upgraded dental coverage for their families.
Please see the brochure in your enrollment kit for specific benefit
information and enrollment forms. Information on these products is also
available on our website,
[www.mamsi.com/federal](http://www.mamsi.com/federal). MAMSI Complete
includes:

-   PPO*plus* Dental Plan-Replace your PPO benefit with an upgraded
    benefit at a low premium. Receive a higher benefit level for many
    basic procedures, while adding coverage for major procedures such as
    crowns, bridgework, dentures and orthodontia for children.

-   Sickness and Accident Disability Income Coverage-Helps replace lost
    pay resulting from sickness or off-the-job injury through monthly,
    tax-free benefits, for an additional premium.

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

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

The exclusions in this section apply to all benefits. **Although we may
list a specific service as a benefit, we will not cover it unless your
Plan physician determines it is medically necessary to prevent,
diagnose, or treat your illness disease, injury or condition** **and we
agree, as discussed under *What Services Require Our Prior Approval* on
page** **13.**

We do not cover the following:

-   Care by non-Plan physicians or health care practitioners 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 physician, health
    care practitioner or facility barred from the FEHB Program; or

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

+---------------------------+------------------------------------------+
| **Section 7. Filing a     |                                          |
| claim for covered         |                                          |
| services**                |                                          |
+---------------------------+------------------------------------------+
| When you see Plan         |                                          |
| physicians, receive       |                                          |
| services at Plan          |                                          |
| hospitals and facilities, |                                          |
| or obtain your            |                                          |
| prescription drugs at     |                                          |
| Plan pharmacies, you will |                                          |
| not have to file claims.  |                                          |
| Just present your health  |                                          |
| Plan identification card  |                                          |
| and pay your copayment or |                                          |
| coinsurance.              |                                          |
|                           |                                          |
| You will only need to     |                                          |
| file a claim when you     |                                          |
| receive emergency         |                                          |
| services from non-Plan    |                                          |
| physicians or health care |                                          |
| practitioners. Sometimes  |                                          |
| these physicians or       |                                          |
| health care practitioners |                                          |
| bill us directly. Check   |                                          |
| with the physician or     |                                          |
| health care practitioner. |                                          |
| If you need to file the   |                                          |
| claim, here is the        |                                          |
| process:                  |                                          |
+---------------------------+------------------------------------------+
| **Medical and Hospital    | In most cases, physicians or health care |
| benefits**                | practitioners and facilities file claims |
|                           | for you. Physicians must file on the     |
|                           | form HCFA-1500, Health Insurance Claim   |
|                           | Form. Facilities will file on the UB-92  |
|                           | form. For claims questions and           |
|                           | assistance, call us at 301-360-8080 or   |
|                           | at 1-800-251-0956 (TTY: 301-360-8111 or  |
|                           | 1-800-553-7109).                         |
|                           |                                          |
|                           | When you must file a claim -- such as    |
|                           | for services you receive outside of the  |
|                           | Plan's service area -- submit it on the  |
|                           | HCFA-1500 or a claim form that includes  |
|                           | the information shown below. Bills and   |
|                           | receipts should be itemized and show:    |
|                           |                                          |
|                           | -   Covered member's name and ID number; |
|                           |                                          |
|                           | -   Name and address of the physician or |
|                           |     facility that provided the service   |
|                           |     or supply;                           |
|                           |                                          |
|                           | -   Dates you received the services or   |
|                           |     supplies;                            |
|                           |                                          |
|                           | -   Diagnosis;                           |
|                           |                                          |
|                           | -   Type of each service or supply;      |
|                           |                                          |
|                           | -   The charge for each service or       |
|                           |     supply;                              |
|                           |                                          |
|                           | -   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: P.O. Box 948,   |
|                           | Frederick, MD 21705**                    |
+---------------------------+------------------------------------------+
| **Prescription drugs**    | Usually, there are no claim forms to     |
|                           | fill out when you fill a prescription at |
|                           | a Plan pharmacy. In some cases, however, |
|                           | you may pay out-of-pocket, such as when  |
|                           | you are outside the service area in a    |
|                           | medical emergency. If this happens, send |
|                           | the following information to P.O. Box    |
|                           | 948, Frederick, MD 21705:                |
|                           |                                          |
|                           | -   your receipt                         |
|                           |                                          |
|                           | -   the drug NDC number                  |
|                           |                                          |
|                           | -   the pharmacy's NABP number, and      |
|                           |                                          |
|                           | -   the prescribing physician's or       |
|                           |     dentist's DEA number                 |
+---------------------------+------------------------------------------+
| **Deadline for filing     | Send us all of the documents for your    |
| your claim**              | claim as soon as possible. You must      |
|                           | submit the claim by December 31 of the   |
|                           | year after the year you received the     |
|                           | service, unless timely filing was        |
|                           | prevented by administrative operations   |
|                           | of Government or legal incapacity,       |
|                           | provided the claim was submitted as soon |
|                           | as reasonably possible.                  |
+---------------------------+------------------------------------------+
| **When we need more       | Please reply promptly when we ask for    |
| information**             | additional information. We may delay     |
|                           | processing or deny your claim if you do  |
|                           | not respond.                             |
+---------------------------+------------------------------------------+

+----+-----------------------------------------------------------------+
| *  |                                                                 |
| *S |                                                                 |
| ec |                                                                 |
| ti |                                                                 |
| on |                                                                 |
| 8. |                                                                 |
| T  |                                                                 |
| he |                                                                 |
| di |                                                                 |
| sp |                                                                 |
| ut |                                                                 |
| ed |                                                                 |
| cl |                                                                 |
| ai |                                                                 |
| ms |                                                                 |
| p  |                                                                 |
| ro |                                                                 |
| ce |                                                                 |
| ss |                                                                 |
| ** |                                                                 |
+----+-----------------------------------------------------------------+
| Fo |                                                                 |
| ll |                                                                 |
| ow |                                                                 |
| th |                                                                 |
| is |                                                                 |
| F  |                                                                 |
| ed |                                                                 |
| er |                                                                 |
| al |                                                                 |
| E  |                                                                 |
| mp |                                                                 |
| lo |                                                                 |
| ye |                                                                 |
| es |                                                                 |
| He |                                                                 |
| al |                                                                 |
| th |                                                                 |
| Be |                                                                 |
| ne |                                                                 |
| fi |                                                                 |
| ts |                                                                 |
| P  |                                                                 |
| ro |                                                                 |
| gr |                                                                 |
| am |                                                                 |
| di |                                                                 |
| sp |                                                                 |
| ut |                                                                 |
| ed |                                                                 |
| cl |                                                                 |
| ai |                                                                 |
| ms |                                                                 |
| p  |                                                                 |
| ro |                                                                 |
| ce |                                                                 |
| ss |                                                                 |
| if |                                                                 |
| y  |                                                                 |
| ou |                                                                 |
| di |                                                                 |
| sa |                                                                 |
| gr |                                                                 |
| ee |                                                                 |
| wi |                                                                 |
| th |                                                                 |
| o  |                                                                 |
| ur |                                                                 |
| de |                                                                 |
| ci |                                                                 |
| si |                                                                 |
| on |                                                                 |
| on |                                                                 |
| yo |                                                                 |
| ur |                                                                 |
| c  |                                                                 |
| la |                                                                 |
| im |                                                                 |
| or |                                                                 |
| r  |                                                                 |
| eq |                                                                 |
| ue |                                                                 |
| st |                                                                 |
| f  |                                                                 |
| or |                                                                 |
| s  |                                                                 |
| er |                                                                 |
| vi |                                                                 |
| ce |                                                                 |
| s, |                                                                 |
| dr |                                                                 |
| ug |                                                                 |
| s, |                                                                 |
| or |                                                                 |
| su |                                                                 |
| pp |                                                                 |
| li |                                                                 |
| es |                                                                 |
| -- |                                                                 |
| i  |                                                                 |
| nc |                                                                 |
| lu |                                                                 |
| di |                                                                 |
| ng |                                                                 |
| a  |                                                                 |
| r  |                                                                 |
| eq |                                                                 |
| ue |                                                                 |
| st |                                                                 |
| f  |                                                                 |
| or |                                                                 |
| p  |                                                                 |
| re |                                                                 |
| au |                                                                 |
| th |                                                                 |
| or |                                                                 |
| iz |                                                                 |
| at |                                                                 |
| io |                                                                 |
| n: |                                                                 |
+----+-----------------------------------------------------------------+
| ** | **Description**                                                 |
| St |                                                                 |
| ep |                                                                 |
| ** |                                                                 |
+----+-----------------------------------------------------------------+
| *  | Ask us in writing to reconsider our initial decision. You must: |
| *1 |                                                                 |
| ** | (a) Write to us within six months from the date of our          |
|    |     decision; and                                               |
|    |                                                                 |
|    | (b) Send your request to us at: Customer Support, P.O. Box 933, |
|    |     Frederick, MD 21705                                         |
|    |                                                                 |
|    | (c) Include a statement about why you believe our initial       |
|    |     decision was wrong, based on specific benefit provisions in |
|    |     this brochure; and                                          |
|    |                                                                 |
|    | (d) Include copies of documents that support your claim, such   |
|    |     as physicians' letters, operative reports, bills, medical   |
|    |     records, and explanation of benefits (EOB) forms.           |
+----+-----------------------------------------------------------------+
| *  | We have 30 days from the date we receive your request to:       |
| *2 |                                                                 |
| ** | (a) Pay the claim (or, if applicable, arrange for the physician |
|    |     or health care practitioners to give you the care); or      |
|    |                                                                 |
|    | (b) Write to you and maintain our denial -- go to step 4; or    |
|    |                                                                 |
|    | (c) Ask you or your physician or health care practitioner for   |
|    |     more information. If we ask your physician or health care   |
|    |     practitioner, we will send you a copy of our request -- go  |
|    |     to step 3.                                                  |
+----+-----------------------------------------------------------------+
| *  | You or your physician or health care practitioner must send the |
| *3 | information so that we receive it within 60 days of your        |
| ** | 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.                         |
+----+-----------------------------------------------------------------+
| *  | If you do not agree with our decision, you may ask OPM to       |
| *4 | 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, DC 20415-3630.                          |
|    |                                                                 |
|    | Send OPM the following information:                             |
|    |                                                                 |
|    | -   A statement about why you believe our decision was wrong,   |
|    |     based on specific benefit provisions in this brochure;      |
|    |                                                                 |
|    | -   Copies of documents that support your claim, such as        |
|    |     physicians' letters, operative reports, bills, medical      |
|    |     records, and explanation of benefits (EOB) forms;           |
|    |                                                                 |
|    | -   Copies of all letters you sent to us about the claim;       |
|    |                                                                 |
|    | -   Copies of all letters we sent you about the claim; and      |
|    |                                                                 |
|    | -   Your daytime phone number and the best time to call.        |
|    |                                                                 |
|    | Note: If you want OPM to review more than one claim, you must   |
|    | clearly identify which documents apply to which claim.          |
|    |                                                                 |
|    | Note: You are the only person who has a right to file a         |
|    | disputed claim with OPM. Parties acting as your representative, |
|    | such as a physician or a health care practitioner, must include |
|    | a copy of your specific written consent with the review         |
|    | request.                                                        |
|    |                                                                 |
|    | Note: The above deadlines may be extended if you show that you  |
|    | were unable to meet the deadline because of reasons beyond your |
|    | control.                                                        |
+----+-----------------------------------------------------------------+
| *  | OPM will review your disputed claim request and will use the    |
| *5 | information it collects from you and us to decide whether our   |
| ** | decision is correct. OPM will send you a final decision within  |
|    | 60 days. There are no other administrative appeals.             |
+----+-----------------------------------------------------------------+
|    | If you do not agree with OPM's decision, your only recourse is  |
|    | to sue. If you decide to sue, you must file the suit against    |
|    | OPM in Federal court by December 31 of the third year after the |
|    | year in which you received the disputed services, drugs or      |
|    | supplies, or from the year in which you were denied             |
|    | precertification or prior approval. This is the only deadline   |
|    | that may not be extended.                                       |
|    |                                                                 |
|    | OPM may disclose the information it collects during the review  |
|    | process to support their disputed claim decision. This          |
|    | information will become part of the court record.               |
|    |                                                                 |
|    | You may not sue until you have completed the disputed claims    |
|    | process. Further, Federal law governs your lawsuit, benefits,   |
|    | and payment of benefits. The Federal court will base its review |
|    | on the record that was before OPM when OPM decided to uphold or |
|    | overturn our decision. You may recover only the amount of       |
|    | benefits in dispute.                                            |
+----+-----------------------------------------------------------------+
| *  |                                                                 |
| *N |                                                                 |
| OT |                                                                 |
| E: |                                                                 |
| If |                                                                 |
| y  |                                                                 |
| ou |                                                                 |
| ha |                                                                 |
| ve |                                                                 |
| a  |                                                                 |
| s  |                                                                 |
| er |                                                                 |
| io |                                                                 |
| us |                                                                 |
| or |                                                                 |
| li |                                                                 |
| fe |                                                                 |
| t  |                                                                 |
| hr |                                                                 |
| ea |                                                                 |
| te |                                                                 |
| ni |                                                                 |
| ng |                                                                 |
| c  |                                                                 |
| on |                                                                 |
| di |                                                                 |
| ti |                                                                 |
| on |                                                                 |
| ** |                                                                 |
| (o |                                                                 |
| ne |                                                                 |
| th |                                                                 |
| at |                                                                 |
| m  |                                                                 |
| ay |                                                                 |
| c  |                                                                 |
| au |                                                                 |
| se |                                                                 |
| p  |                                                                 |
| er |                                                                 |
| ma |                                                                 |
| ne |                                                                 |
| nt |                                                                 |
| lo |                                                                 |
| ss |                                                                 |
| of |                                                                 |
| bo |                                                                 |
| di |                                                                 |
| ly |                                                                 |
| f  |                                                                 |
| un |                                                                 |
| ct |                                                                 |
| io |                                                                 |
| ns |                                                                 |
| or |                                                                 |
| d  |                                                                 |
| ea |                                                                 |
| th |                                                                 |
| if |                                                                 |
| n  |                                                                 |
| ot |                                                                 |
| t  |                                                                 |
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| e. |                                                                 |
+----+-----------------------------------------------------------------+

+--------------------------+-------------------------------------------+
| **Section 9.             |                                           |
| Coordinating benefits    |                                           |
| with other coverage**    |                                           |
+--------------------------+-------------------------------------------+
| **When you have other    | You must tell us if you or a covered      |
| health coverage**        | family member have coverage under another |
|                          | group health Plan or have automobile      |
|                          | insurance that pays health care expenses  |
|                          | without regard to fault. This is called   |
|                          | "double coverage."                        |
|                          |                                           |
|                          | When you have double coverage, one Plan   |
|                          | normally pays its benefits in full as the |
|                          | primary payer and the other Plan pays a   |
|                          | reduced benefit as the secondary payer.   |
|                          | We, like other insurers, determine which  |
|                          | coverage is primary according to the      |
|                          | National Association of Insurance         |
|                          | Commissioners' guidelines.                |
|                          |                                           |
|                          | When we are the primary payer, we will    |
|                          | pay the benefits described in this        |
|                          | brochure.                                 |
|                          |                                           |
|                          | When we are the secondary payer, we will  |
|                          | determine our allowance. After the        |
|                          | primary Plan pays, we will pay what is    |
|                          | left of our allowance, up to our regular  |
|                          | benefit. We will not pay more than our    |
|                          | allowance.                                |
+--------------------------+-------------------------------------------+
| > **What is Medicare?**  | Medicare is a Health Insurance Program    |
|                          | for:                                      |
| -   **Should I enroll in |                                           |
|     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.                                |
|                          |                                           |
|                          | The decision to enroll in Medicare is     |
|                          | yours. We encourage you to apply for      |
|                          | Medicare benefits 3 months before you     |
|                          | turn age 65. It's easy. Just call the     |
|                          | Social Security Administration toll-free  |
|                          | number 1-800-772-1213 to set up an        |
|                          | appointment to apply. If you do not apply |
|                          | for one or both Parts of Medicare, you    |
|                          | can still be covered under the FEHB       |
|                          | Program.                                  |
|                          |                                           |
|                          | If you can get premium-free Part A        |
|                          | coverage, we advise you to enroll in it.  |
|                          | Most Federal employees and annuitants are |
|                          | entitled to Medicare Part A at age 65     |
|                          | **without cost**. When you don't have to  |
|                          | pay premiums for Medicare Part A, it      |
|                          | makes good sense to obtain the coverage.  |
|                          | It can reduce your out-of-pocket expenses |
|                          | as well as costs to the FEHB, which can   |
|                          | help keep FEHB premiums down.             |
|                          |                                           |
|                          | Everyone is charged a premium for         |
|                          | Medicare Part B coverage. The Social      |
|                          | Security Administration can provide you   |
|                          | with premium and benefit information.     |
|                          | Review the information and decide if it   |
|                          | makes sense for you to buy the Medicare   |
|                          | Part B coverage.                          |
|                          |                                           |
|                          | If you are eligible for Medicare, yo If   |
|                          | you are eligible for Medicare, you may    |
|                          | have choices in how you get your health   |
|                          | care. Medicare + Choice is the term used  |
|                          | to describe the various health plan       |
|                          | choices available to Medicare             |
|                          | beneficiaries. The information in the     |
|                          | next few pages shows how we coordinate    |
|                          | benefits with Medicare, depending on the  |
|                          | type of Medicare managed care plan you    |
|                          | have.                                     |
+--------------------------+-------------------------------------------+
| -   **The Original       | The Original Medicare Plan (Original      |
|     Medicare Plan**      | Medicare) is available everywhere in the  |
|                          | United States. It is the way everyone     |
| > **(Part A or Part B)** | used to get Medicare benefits and is the  |
|                          | way most people get their Medicare Part A |
|                          | and Part B benefits now. You may go to    |
|                          | any doctor, specialist, or hospital that  |
|                          | accepts Medicare. The Original Medicare   |
|                          | Plan pays its share and you pay your      |
|                          | share. Some things are not covered under  |
|                          | Original Medicare, like prescription      |
|                          | drugs.                                    |
|                          |                                           |
|                          | When you are enrolled in Original         |
|                          | Medicare along with this Plan, you still  |
|                          | need to follow the rules in this brochure |
|                          | for us to cover your care. Your care must |
|                          | continue to be authorized by your Plan    |
|                          | PCP, or precertified as required.         |
+--------------------------+-------------------------------------------+
|                          | **Claims process when you have the        |
|                          | Original Medicare Plan** -- You probably  |
|                          | will never have to file a claim form when |
|                          | you have both our plan and the Original   |
|                          | Medicare Plan.                            |
|                          |                                           |
|                          | -   When we are the primary payer, we     |
|                          |     process the claim first.              |
|                          |                                           |
|                          | ```{=html}                                |
|                          | <!-- -->                                  |
|                          | ```                                       |
|                          | -   When Original Medicare is the primary |
|                          |     payer, Medicare processes your claim  |
|                          |     first. In most cases, your claim will |
|                          |     be coordinated automatically and we   |
|                          |     will then provide secondary benefits  |
|                          |     for covered charges. You will not     |
|                          |     need to do anything. To find out if   |
|                          |     you need to do something to file your |
|                          |     claim, call us at 301-360-8080 or     |
|                          |     1-800-251-0956, or visit our website, |
|                          |     www.mamsi.com/federal.                |
|                          |                                           |
|                          | **We waive some costs if the Original     |
|                          | Medicare Plan is your primary payer.** We |
|                          | will waive some out-of-pocket costs as    |
|                          | follows:                                  |
|                          |                                           |
|                          | -   All copayment and coinsurance amounts |
|                          |     will be applied until you meet your   |
|                          |     Medicare Part B deductible. Once the  |
|                          |     Medicare Part B deductible has been   |
|                          |     met, all copayments and coinsurance   |
|                          |     are waived.                           |
|                          |                                           |
|                          | -   We will pay all amounts identified as |
|                          |     "patient responsibility" on the       |
|                          |     Medicare Explanation of Benefits as   |
|                          |     long as the service rendered is a     |
|                          |     covered benefit.                      |
|                          |                                           |
|                          | We will pay the Inpatient Medicare        |
|                          | deductible.                               |
+--------------------------+-------------------------------------------+

Medicare always makes the final determination as to whether they are the
primary payer. The following chart illustrates whether Original 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...**     | primary   |         |
|                                               | payer for |         |
|                                               | the       |         |
|                                               | i         |         |
|                                               | ndividual |         |
|                                               | with      |         |
|                                               | Medicare  |         |
|                                               | is\...**  |         |
+-----------------------------------------------+-----------+---------+
|                                               | **M       | **This  |
|                                               | edicare** | Plan**  |
+-----------------------------------------------+-----------+---------+
| 1)  Are an active employee with the Federal   |           |        |
|     government and...                         |           |         |
|                                               |           |         |
| -   You have FEHB coverage on your own or     |           |         |
|     through your spouse who is also an active |           |         |
|     employee                                  |           |         |
+-----------------------------------------------+-----------+---------+
| -   You have FEHB coverage through your       |          |         |
|     spouse who is an annuitant                |           |         |
+-----------------------------------------------+-----------+---------+
| 2)  Are an annuitant and...                   |          |         |
|                                               |           |         |
| -   You have FEHB coverage on your own or     |           |         |
|     through your spouse who is also an        |           |         |
|     annuitant                                 |           |         |
+-----------------------------------------------+-----------+---------+
| -   You have FEHB coverage through your       |           |        |
|     spouse who is an active employee          |           |         |
+-----------------------------------------------+-----------+---------+
| 3)  Are a reemployed annuitant with the       | \*       |         |
|     Federal government and your position is   |           |         |
|     excluded from the FEHB (your employing    |           |         |
|     office will know if this is the case)     |           |         |
+-----------------------------------------------+-----------+---------+
| 4)  Are a reemployed annuitant with the       |           |        |
|     Federal Government and your position is   |           |         |
|     not excluded from the FEHB (your          |           |         |
|     employing office will know if this is the |           |         |
|     case) and...                              |           |         |
|                                               |           |         |
| -   You have FEHB coverage on your own or     |           |         |
|     through your spouse who is also an active |           |         |
|     employee                                  |           |         |
+-----------------------------------------------+-----------+---------+
| -   You have FEHB coverage through your       |          |         |
|     spouse who is an annuitant                |           |         |
+-----------------------------------------------+-----------+---------+
| 5)  Are a Federal judge who retired under     | \*       |         |
|     title 28, U.S.C., or a Tax Court judge    |           |         |
|     who retired under Section 7447 of title   |           |         |
|     26, U.S.C. (or if your covered spouse is  |           |         |
|     this type of judge)                       |           |         |
+-----------------------------------------------+-----------+---------+
| 6)  Are enrolled in Part B only, regardless   |          |        |
|     of your employment status                 |           |         |
|                                               | for Part  | for     |
|                                               | B         | other   |
|                                               | services  | s       |
|                                               |           | ervices |
+-----------------------------------------------+-----------+---------+
| 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)                             |           |         |
+-----------------------------------------------+-----------+---------+
| -   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  |           |  for   |
|     while already a Medicare beneficiary      |           | 3       |
|     and...                                    |           | 0-month |
|                                               |           | coord   |
| -   This Plan was the primary payer before    |           | ination |
|     the eligibility due to ESRD               |           | period  |
+-----------------------------------------------+-----------+---------+
| -   Medicare was the primary payer before     |          |         |
|     eligibility due to ESRD                   |           |         |
+-----------------------------------------------+-----------+---------+
| **C. When either you or your spouse are       |           |         |
| eligible for Medicare solely due to           |           |         |
| disability and you...**                       |           |         |
+-----------------------------------------------+-----------+---------+
| 1)  Are an active employee with the Federal   |           |        |
|     Government and...                         |           |         |
|                                               |           |         |
| -   You have FEHB coverage on your own or     |           |         |
|     through your spouse who is also an active |           |         |
|     employee                                  |           |         |
+-----------------------------------------------+-----------+---------+
| -   You have FEHB coverage through your       | >        |         |
|     spouse who is an annuitant                |           |         |
+-----------------------------------------------+-----------+---------+
| 2)  Are an annuitant and...                   |          |         |
|                                               |           |         |
|     -   You have FEHB coverage on your own or |           |         |
|         through your spouse who is also an    |           |         |
|         annuitant                             |           |         |
+-----------------------------------------------+-----------+---------+
| -   You have FEHB coverage through your       |           |        |
|     spouse who is an active employee          |           |         |
+-----------------------------------------------+-----------+---------+
| ######## D. Are covered under FE              | > ****   |         |
| HB Spouse Equity provision as a former spouse |           |         |
+-----------------------------------------------+-----------+---------+

\*Unless you have FEHB coverage through your spouse who is an active
employee

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

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

+---------------------------+------------------------------------------+
| **When other Government   | We do not cover services and supplies    |
| agencies are responsible  | when a local, State, or Federal          |
| for your care**           | Government agency directly or indirectly |
|                           | pays for them.                           |
+---------------------------+------------------------------------------+
| **When others are         | When you receive money to compensate you |
| responsible for           | for medical or hospital care for         |
| injuries**                | injuries or illness caused by another    |
|                           | person, you must reimburse us for any    |
|                           | expenses we paid. However, we will cover |
|                           | the cost of treatment that exceeds the   |
|                           | amount you received in the settlement.   |
|                           |                                          |
|                           | If you do not seek damages you must      |
|                           | agree to let us try. This is called      |
|                           | subrogation. If you need other           |
|                           | 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 14.                       |
+---------------------------+------------------------------------------+
| **Copayment**             | A copayment is a fixed amount of money   |
|                           | you pay when you receive covered         |
|                           | services. See page 14.                   |
+---------------------------+------------------------------------------+
| **Covered services**      | Care we provide benefits for, as         |
|                           | described in this brochure.              |
+---------------------------+------------------------------------------+
| **Custodial care**        | Medical or non-medical services:         |
|                           |                                          |
|                           | -   Which are furnished mainly to assist |
|                           |     you in the activities of daily       |
|                           |     living;                              |
|                           |                                          |
|                           | -   For which professional skills or     |
|                           |     training is not required; and        |
|                           |                                          |
|                           | -   Which are not likely to result in    |
|                           |     the improvement of your condition or |
|                           |     in your recovery                     |
|                           |                                          |
|                           | -   Custodial care that lasts 90 days or |
|                           |     more is sometimes known as long term |
|                           |     care                                 |
+---------------------------+------------------------------------------+
| **Experimental or         | A drug, device, treatment or procedure   |
| investigational           | is considered experimental if:           |
| services**                |                                          |
|                           | -   It is not recognized, in accordance  |
|                           |     with generally accepted medical      |
|                           |     standards, as being safe and         |
|                           |     effective for your condition;        |
|                           |                                          |
|                           | -   It requires approval by a            |
|                           |     governmental authority (including    |
|                           |     the U.S. Food and Drug               |
|                           |     Administration) before you can use   |
|                           |     it, but they have not granted that   |
|                           |     approval; or                         |
|                           |                                          |
|                           | -   It is the subject of a written       |
|                           |     protocol used by the treating        |
|                           |     facility for research, clinical      |
|                           |     trials, or other tests or studies to |
|                           |     evaluate its safety, effectiveness,  |
|                           |     toxicity, or maximum tolerated dose. |
|                           |                                          |
|                           | We evaluate investigational/experimental |
|                           | treatments on a case-by-case basis as    |
|                           | well as on a continual basis as new and  |
|                           | emerging treatments become available. We |
|                           | use a variety of resources to assist the |
|                           | Medical Director in deciding if a        |
|                           | service is experimental or               |
|                           | investigational including specific       |
|                           | database searches of the National        |
|                           | Institutes of Health (NIH) and the       |
|                           | Health Care Financing Administration     |
|                           | (HCFA), review by independent medical    |
|                           | experts and an independent technology    |
|                           | assessment firm.                         |
+---------------------------+------------------------------------------+
| **Infertility**           | The inability to achieve pregnancy after |
|                           | one year of unprotected intercourse.     |
+---------------------------+------------------------------------------+
| **Medical necessity**     | Services which are reasonably necessary  |
|                           | in the exercise of good medical practice |
|                           | in accordance with professional          |
|                           | standards accepted in the United States  |
|                           | for the treatment of an active illness   |
|                           | or injury. We determine medical          |
|                           | necessity.                               |
+---------------------------+------------------------------------------+
| **Plan allowance**        | Plan allowance is the amount we use to   |
|                           | determine our payment and your           |
|                           | coinsurance for covered services. Plans  |
|                           | determine their allowances in different  |
|                           | ways. M.D. IPA\'s Plan allowance is      |
|                           | based on an internally-developed fee     |
|                           | schedule. Each CPT, HCPC or ADA          |
|                           | procedure code is assigned a regional    |
|                           | rate, based on your physician's or       |
|                           | health care practitioner's office        |
|                           | address. This rate includes your         |
|                           | copayment or coinsurance amount.         |
|                           | Participating physicians or health care  |
|                           | practitioners accept this rate,          |
|                           | including your copayment or coinsurance  |
|                           | amount, as payment in full.              |
+---------------------------+------------------------------------------+
| **Us/We**                 | Us and we refer to M.D. IPA.             |
+---------------------------+------------------------------------------+
| **You**                   | You refers to the enrollee and each      |
|                           | covered member.                          |
+---------------------------+------------------------------------------+

+---------------------------+------------------------------------------+
| **Section 11. FEHB        |                                          |
| facts**                   |                                          |
+---------------------------+------------------------------------------+
| **Coverage information**  |                                          |
+---------------------------+------------------------------------------+
| **No pre-existing         | We will not refuse to cover the          |
| condition limitation**    | treatment of a condition that you had    |
|                           | before you enrolled in this Plan solely  |
|                           | because you had the condition before you |
|                           | enrolled.                                |
+---------------------------+------------------------------------------+
| **Where you can get       | See                                      |
| information about         | [www.opm                                 |
| enrolling in the FEHB     | .gov/insure](http://www.opm.gov/insure). |
| Program**                 | Also, your employing or retirement       |
|                           | office can 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      |
|                           | tells you:                               |
|                           |                                          |
|                           | -   When you may change your enrollment; |
|                           |                                          |
|                           | -   How you can cover your family        |
|                           |     members;                             |
|                           |                                          |
|                           | -   What happens when you transfer to    |
|                           |     another Federal agency, go on leave  |
|                           |     without pay, enter military service, |
|                           |     or retire;                           |
|                           |                                          |
|                           | -   When your enrollment ends; and       |
|                           |                                          |
|                           | -   When the next open season for        |
|                           |     enrollment begins.                   |
|                           |                                          |
|                           | We don't determine who is eligible for   |
|                           | coverage and, in most cases, cannot      |
|                           | change your enrollment status without    |
|                           | information from your employing or       |
|                           | retirement office.                       |
+---------------------------+------------------------------------------+
| **Types of coverage       | Self Only coverage is for you alone.     |
| available for you and     | Self and Family coverage is for you,     |
| your family**             | your spouse, and your unmarried          |
|                           | dependent children under age 22,         |
|                           | including any foster children or         |
|                           | stepchildren your employing or           |
|                           | retirement office authorizes coverage    |
|                           | for. Under certain circumstances, you    |
|                           | may also continue coverage for a         |
|                           | disabled child 22 years of age or older  |
|                           | who is incapable of self-support.        |
|                           |                                          |
|                           | If you have a Self-Only enrollment, you  |
|                           | may change to a Self and Family          |
|                           | enrollment if you marry, give birth, or  |
|                           | add a child to your family. You may      |
|                           | change your enrollment 31 days before to |
|                           | 60 days after that event. The Self and   |
|                           | Family enrollment begins on the first    |
|                           | day of the pay period in which the child |
|                           | is born or becomes an eligible family    |
|                           | member. When you change to Self and      |
|                           | Family because you marry, the change is  |
|                           | effective on the first day of the pay    |
|                           | period that begins after your employing  |
|                           | office receives your enrollment form;    |
|                           | benefits will not be available to your   |
|                           | spouse until you marry.                  |
|                           |                                          |
|                           | Your employing or retirement office will |
|                           | **not** notify you when a family member  |
|                           | is no longer eligible to receive health  |
|                           | benefits, nor will we. Please tell us    |
|                           | immediately when you add or remove       |
|                           | family members from your coverage for    |
|                           | any reason, including divorce, or when   |
|                           | your child under age 22 marries or turns |
|                           | 22.                                      |
|                           |                                          |
|                           | If you or one of your family members is  |
|                           | enrolled in one FEHB Plan, that person   |
|                           | may not be enrolled in or covered as a   |
|                           | family member by another FEHB Plan.      |
+---------------------------+------------------------------------------+
| **Children's Equity Act** | OPM has implemented the Federal          |
| OPM has implemented the   | Employees Health Benefits Children\'s    |
| Federal Employees Health  | Equity Act of 2000. This law mandates    |
| Benefits Children\'s      | that you be enrolled for self and family |
| Equity Act of             | coverage in the Federal Employees Health |
|                           | Benefits (FEHB) Program, if you are an   |
|                           | employee subject to a court or           |
|                           | administrative order requiring you to    |
|                           | 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 Blue Cross and Blue    |
|                           |     Shield Service Benefit Plan's Basic  |
|                           |     Option.                              |
|                           |                                          |
|                           | As long as the court/administrative      |
|                           | order is in effect, and you have at      |
|                           | least one child identified in the order  |
|                           | who is still eligible under the FEHB     |
|                           | Program, you cannot cancel your          |
|                           | enrollment, change to Self only, or      |
|                           | change to a Plan that doesn\'t serve the |
|                           | area in which your children live, unless |
|                           | you provide documentation that you have  |
|                           | other coverage for the children. If the  |
|                           | court/administrative order is still in   |
|                           | effect when you retire, and you have at  |
|                           | least one child still eligible for FEHB  |
|                           | coverage, you must continue your FEHB    |
|                           | coverage into retirement (if eligible)   |
|                           | and cannot cancel your coverage, change  |
|                           | to Self Only, or change to a plan that   |
|                           | doesn't serve the area in which your     |
|                           | children live as long as the             |
|                           | court/administrative order is in effect. |
|                           | Contact your employing office for        |
|                           | further information                      |
+---------------------------+------------------------------------------+
| **When benefits and       | The benefits in this brochure are        |
| premiums start**          | effective on 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 during   |
|                           | Open Season and you receive care between |
|                           | January 1 and the effective date of      |
|                           | coverage under your new plan option,     |
|                           | your claims will be paid according to    |
|                           | the 2004 benefits of your old plan or    |
|                           | option. However, if your old plan left   |
|                           | the FEHB Program at the end of the year, |
|                           | you are covered under that plan's 2003   |
|                           | benefits until the effective date of     |
|                           | your coverage with your new plan.        |
|                           | Annuitants' coverage and premiums begin  |
|                           | on January 1. If you joined at any other |
|                           | time during the year, your employing     |
|                           | office will tell you the effective date  |
|                           | of coverage.                             |
+---------------------------+------------------------------------------+
| **When you retire**       | When you retire, you can usually stay in |
|                           | the FEHB Program. Generally, you must    |
|                           | have been enrolled in the FEHB Program   |
|                           | for the last five years of your Federal  |
|                           | service. If you do not meet this         |
|                           | requirement, you may be eligible for     |
|                           | other forms of coverage, such as         |
|                           | temporary continuation of coverage       |
|                           | (TCC).                                   |
+---------------------------+------------------------------------------+
| **When you lose           |                                          |
| benefits**                |                                          |
+---------------------------+------------------------------------------+
| -   **When FEHB coverage  | You will receive an additional 31 days   |
|     ends**                | of coverage, for no additional premium,  |
|                           | when:                                    |
|                           |                                          |
|                           | -   Your enrollment ends, unless you     |
|                           |     cancel your enrollment, or           |
|                           |                                          |
|                           | -   You are a family member no longer    |
|                           |     eligible for coverage.               |
|                           |                                          |
|                           | You may be eligible for spouse equity    |
|                           | coverage or Temporary Continuation of    |
|                           | Coverage (TCC) or a conversion policy (a |
|                           | non-FEHB individual policy).             |
+---------------------------+------------------------------------------+

+---------------------------+------------------------------------------+
| -   **Spouse equity       | If you are divorced from a Federal       |
|     coverage**            | employee or annuitant, you may not       |
|                           | continue to get benefits under your      |
|                           | former spouse's enrollment. This is the  |
|                           | case even when the court has ordered     |
|                           | your former spouse to supply health      |
|                           | coverage to you. But, you may be         |
|                           | eligible for your own FEHB coverage      |
|                           | under the spouse equity law or Temporary |
|                           | Continuation of Coverage (TCC). If you   |
|                           | are recently divorced or are             |
|                           | anticipating a divorce, contact your     |
|                           | ex-spouse's employing or retirement      |
|                           | office to get RI70-5, the *Guide to      |
|                           | Federal Employees Health Benefits Plans  |
|                           | for Temporary Continuation of Coverage   |
|                           | and Former Spouse Enrollees*, or other   |
|                           | information about your coverage choices. |
|                           | You can also download the guide from     |
|                           | OPM's website, www.opm.gov/insure.       |
+---------------------------+------------------------------------------+
| -   **Temporary           | If you leave Federal service, or if you  |
|     Continuation Coverage | lose coverage because you no longer      |
|     (TCC)**               | qualify as a family member, you may be   |
|                           | eligible for Temporary Continuation of   |
|                           | Coverage (TCC). For example, you can     |
|                           | receive TCC if you are not able to       |
|                           | continue your FEHB enrollment after you  |
|                           | retire, if you lose your job, if you are |
|                           | a covered dependent child and you turn   |
|                           | 22 or marry, etc.                        |
|                           |                                          |
|                           | You may not elect TCC if you are fired   |
|                           | from your Federal job due to gross       |
|                           | misconduct.                              |
|                           |                                          |
|                           | **Enrolling in TCC:** Get the RI-79-27,  |
|                           | which describes TCC, and the RI 70-5,    |
|                           | the *Guide to Federal Employees Health   |
|                           | Benefits Plans for Temporary             |
|                           | Continuation of Coverage and former      |
|                           | Spouse Enrollees*, from your employing   |
|                           | or retirement office or from             |
|                           | [www.opm                                 |
|                           | .gov/insure](http://www.opm.gov/insure). |
|                           | It explains what you have to do to       |
|                           | enroll.                                  |
+---------------------------+------------------------------------------+
| -   **Converting to       | You may convert to a non-FEHB individual |
|     individual coverage** | policy if:                               |
|                           |                                          |
|                           | -   Your coverage under TCC or the       |
|                           |     spouse equity law ends (If you       |
|                           |     canceled your coverage or did not    |
|                           |     pay your premium, you cannot         |
|                           |     convert);                            |
|                           |                                          |
|                           | -   You decided not to receive coverage  |
|                           |     under TCC or the spouse equity law;  |
|                           |     or                                   |
|                           |                                          |
|                           | -   You are not eligible for coverage    |
|                           |     under TCC or the spouse equity law.  |
|                           |                                          |
|                           | If you leave Federal service, your       |
|                           | employing office will notify you of your |
|                           | right to convert. You must apply in      |
|                           | writing to us within 31 days after you   |
|                           | receive this notice. However, if you are |
|                           | a family member who is losing coverage,  |
|                           | the employing or retirement office will  |
|                           | **not** notify you. You must apply in    |
|                           | writing to us within 31 days after you   |
|                           | are no longer eligible for coverage.     |
|                           |                                          |
|                           | Your benefits and rates will differ from |
|                           | those under the FEHB Program; however,   |
|                           | you will not have to answer questions    |
|                           | about your health, and we will not       |
|                           | impose a waiting period or limit your    |
|                           | coverage due to pre-existing conditions. |
+---------------------------+------------------------------------------+

+---------------------------+------------------------------------------+
| -   **Getting a           | The Health Insurance Portability and     |
|     Certificate of Group  | Accountability Act of 1996 (HIPAA) is a  |
|     Health Plan           | Federal law that offers limited Federal  |
|     Coverage**            | protections for health coverage          |
|                           | availability and continuity to people    |
|                           | who lose employer group coverage. If you |
|                           | leave the FEHB Program, we will give you |
|                           | a Certificate of Group Health Plan       |
|                           | Coverage that indicates how long you     |
|                           | have been enrolled with us. You can use  |
|                           | this certificate when getting health     |
|                           | insurance or other health care coverage. |
|                           | Your new Plan must reduce or eliminate   |
|                           | waiting periods, limitations, or         |
|                           | exclusions for health related conditions |
|                           | based on the information in the          |
|                           | certificate, as long as you enroll       |
|                           | within 63 days of losing coverage under  |
|                           | this Plan. If you have been enrolled     |
|                           | with us for less than 12 months, but     |
|                           | were previously enrolled in other FEHB   |
|                           | Plans, you may also request a            |
|                           | certificate from those Plans.            |
|                           |                                          |
|                           | For more information, get OPM pamphlet   |
|                           | RI 79-27, Temporary Continuation of      |
|                           | Coverage (TCC) under the FEHB Program.   |
|                           | See also the FEHB website                |
|                           | ([www.opm.gov/insure/hea                 |
|                           | lth](http://www.opm.gov/insure/health)); |
|                           | refer to the "TCC and HIPAA" frequently  |
|                           | asked questions. These highlight HIPAA   |
|                           | rules, such as the requirement that      |
|                           | federal employees must exhaust any TCC   |
|                           | eligibility as one condition for         |
|                           | guaranteed access to individual health   |
|                           | coverage under HIPAA, and have           |
|                           | information about Federal and State      |
|                           | agencies you can contact for more        |
|                           | information.                             |
+---------------------------+------------------------------------------+

  -----------------------------------------------------------------------
  Two new Federal Programs complement FEHB benefits

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

**Who is eligible to enroll?** If you are a Federal employee eligible
for FEHB -- even if you're not enrolled in FEHB--

> you can choose to participate in either, or both, of the flexible
> spending accounts. If you
>
> are not eligible for FEHB, you are not eligible to enroll for a Health
> Care FSA. However, almost all Federal employees are eligible to enroll
> for the Dependent Care FSA. The only exception is intermittent (also
> called when actually employed \[WAE\]) employees expected to work less
> than 180 days during the year.
>
> *Note:* FSAFEDS is the FSA Program established for all Executive
> Branch employees and Legislative Branch employees whose employers
> signed on. Under IRS law, FSAs are not available to annuitants. In
> addition, the U.S. Postal Service and the Judicial Branch, among
> others, are Federal agencies that have their own plans with slightly
> different rules, but the advantages of having an FSA are the same no
> matter what agency you work for.

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

**contribute to my FSA?** benefits of an FSA, the IRS places strict
guidelines on them. You need to estimate how

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

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

> you and the Plan share costs, and medical services and supplies that
> are not covered by the Plan and for which you must pay. These
> out-of-pocket costs are summarized on page 14 and detailed throughout
> this brochure. Your HCFSA will reimburse you for such costs when they
> are for tax deductible medical care for you and your dependents that
> is NOT covered by this FEHB Plan or any other coverage that you have.
>
> Under this Plan, typical out-of-pocket expenses include:

-   *Copayments for Infertility services, durable medical equipment, and
    orthopedic and prosthetic devices, or*

-   *Care by non-Plan physicians or health care practitioners except for
    authorized referrals or emergences, eyeglasses or contact lenses,
    and experimental or investigational procedures, treatments, drugs or
    devices, are expenses not covered by the Plan.*

> The IRS governs expenses reimbursable by a HCFSA. See Publication 502
> for a comprehensive list of tax-deductible medical expenses.  **Note:
> While you will see insurance premiums listed in Publication 502, they
> are NOT a reimbursable expense for FSA purposes**.  Publication 502
> can be found on the IRS Web site at
> <http://www.irs.gov/pub/irs-pdf/p502.pdf>.  If you do not see your
> service or expense listed in Publication 502, please call a FSAFEDS
> Benefit Counselor at 1-877-FSAFEDS (372-3337), who will be able to
> answer your specific questions.

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

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

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

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

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

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

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

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

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

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

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

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

**deductions** reimbursement for them from your HCFSA or DCFSA. Below
are some guidelines that

> may help you decide whether to participate in FSAFEDS.

**Health care expenses** The HCFSA is tax-free from the first dollar. In
addition, you may be reimbursed from

> the HCFSA at any time during the year for expenses up to the annual
> amount you\'ve
>
> elected to contribute.
>
> Only health care expenses exceeding 7.5% of your adjusted gross income
> are eligible to be deducted on your Federal income tax return. Using
> the example listed in the above chart, only health care expenses
> exceeding \$3,750 (7.5% of \$50,000) would be eligible to be deducted
> on your Federal income tax return. In addition, money set aside
> through a HCFSA is also exempt from FICA taxes. This exception is not
> available on your Federal income tax return.

**Dependent care expenses** The DCFSA generally allows many families to
save more than they would with the

> Federal tax credit for dependent care expenses. Note that you may only
> be reimbursed from the DCFSA up to your current account balance. If
> you file a claim for more than your current balance, it will be held
> until additional payroll allotments have been added to your account.
>
> Visit [www.fsafeds.com](http://www.fsafeds.com/) and download the
> Dependent Care Tax Credit Worksheet from the Quick Links box to help
> you determine what is best for your situation. You may also wish to
> consult a tax professional for more details.

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

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

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

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

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

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

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

**The Federal Long Term Care Insurance Program**

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

Program:

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

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

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

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

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

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

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

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

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

+-----------------------+----------------------+----------------------+
| **A**ccidental injury | **F**amily planning  | Out-of-pocket        |
| 40                    | 19                   | expenses 14          |
+-----------------------+----------------------+----------------------+
| Allergy care 20       | Fecal occult blood   | Outpatient facility  |
|                       | test 17              | care 30              |
+-----------------------+----------------------+----------------------+
| Alternative treatment | Fraud 4              | Oxygen 24            |
| 24                    |                      |                      |
+-----------------------+----------------------+----------------------+
| Allogenic (donor)     | **G**eneral          | **P**ap test 16      |
| bone marrow           | Exclusions 44        |                      |
| transplant 28         |                      |                      |
+-----------------------+----------------------+----------------------+
| Ambulance 31          | **H**earing services | Physical examination |
|                       | 21                   | 17                   |
+-----------------------+----------------------+----------------------+
| Anesthesia 28         | Home health services | Physical therapy 20  |
|                       | 24                   |                      |
+-----------------------+----------------------+----------------------+
| Autologous bone       | Hospice care 31      | Pre-surgical testing |
| marrow 28             |                      | 30                   |
+-----------------------+----------------------+----------------------+
| **B**iopsies 26       | Home nursing care 24 | Precertification 13  |
+-----------------------+----------------------+----------------------+
| Blood and blood       | Hospital 29          | Preventive care,     |
| plasma 29             |                      | adult 17             |
+-----------------------+----------------------+----------------------+
| **C**asts 29          | **I**mmunizations 17 | Preventive care,     |
|                       |                      | children 18          |
+-----------------------+----------------------+----------------------+
| Catastrophic          | Infertility 19       | Prescription drugs   |
| out-of-pocket maximum |                      | 36                   |
| 14                    |                      |                      |
+-----------------------+----------------------+----------------------+
| Changes for 2004 9    | Inpatient Hospital   | Prior approval 13    |
|                       | Benefits 29          |                      |
+-----------------------+----------------------+----------------------+
| Chemotherapy 20       | Insulin 37           | Prostate specific    |
|                       |                      | antigen test 17      |
+-----------------------+----------------------+----------------------+
| Childbirth education  | **L**aboratory and   | **R**adiation        |
| classes 25            | pathological         | therapy 20           |
|                       | services 16          |                      |
+-----------------------+----------------------+----------------------+
| Chiropractic 24       | **M**agnetic         | Room and board 29    |
|                       | Resonance Imaging    |                      |
|                       | (MRIs) 16            |                      |
+-----------------------+----------------------+----------------------+
| Cholesterol screening | Mail Order           | **S**econd surgical  |
| 17                    | Prescription Drugs   | opinion 16           |
|                       | 36                   |                      |
+-----------------------+----------------------+----------------------+
| Circumcision 18       | Mammograms 17        | Skilled nursing      |
|                       |                      | facility care 30     |
+-----------------------+----------------------+----------------------+
| Claims 45             | Maternity Care 18    | Speech therapy 20    |
+-----------------------+----------------------+----------------------+
| Coinsurance 53        | Medicaid 52          | Splints 29           |
+-----------------------+----------------------+----------------------+
| Colorectal cancer     | Medically necessary  | Sterilization,       |
| screening 17          | 53                   | voluntary 19         |
+-----------------------+----------------------+----------------------+
| Congenital anomalies  | Medicare 48          | Subrogation 52       |
| 27                    |                      |                      |
+-----------------------+----------------------+----------------------+
| Contraceptive devices | Mental               | Substance abuse 34   |
| and Drugs 37          | Health/Substance     |                      |
|                       | Abuse Benefits 34    |                      |
+-----------------------+----------------------+----------------------+
| Coordination of       | **N**ewborn 18       | Surgery              |
| benefits 48           |                      |                      |
+-----------------------+----------------------+----------------------+
| Crutches 23           | Non-FEHB Benefits 43 | • Anesthesia 28      |
+-----------------------+----------------------+----------------------+
| **D**eductible 14     | Nurse                | > • Oral 27          |
+-----------------------+----------------------+----------------------+
| Definitions 53        | > • Licensed         | > • Outpatient 30    |
|                       | > Practical Nurse 24 |                      |
+-----------------------+----------------------+----------------------+
| Dental care 40        | > • Licensed         | > • Reconstructive   |
|                       | > Vocational Nurse   | > 27                 |
|                       | > 24                 |                      |
+-----------------------+----------------------+----------------------+
| Diagnostic services   | > • Nurse            | Syringes 37          |
| 16                    | > Anesthetist 29     |                      |
+-----------------------+----------------------+----------------------+
| Dialysis 20           | > • Obstetrical      | **T**emporary        |
|                       | > Nurse 18           | continuation of      |
|                       |                      | coverage 56          |
+-----------------------+----------------------+----------------------+
| Disputed claims       | > • Registered Nurse | Transplants 28       |
| process 46            | > 24                 |                      |
+-----------------------+----------------------+----------------------+
| Donor expenses        | Nursery charges 18   | Treatment therapies  |
| (transplants) 28      |                      | 20                   |
+-----------------------+----------------------+----------------------+
| Dressings 29          | **O**bstetrical care | **V**ision services  |
|                       | 18                   | 21                   |
+-----------------------+----------------------+----------------------+
| Durable medical       | Occupational therapy | **W**ell-child care  |
| equipment (DME) 23    | 20                   | 18                   |
+-----------------------+----------------------+----------------------+
| **E**ducational       | Ocular injury 21     | Wheelchairs 23       |
| classes and Programs  |                      |                      |
| 25                    |                      |                      |
+-----------------------+----------------------+----------------------+
| Effective date of     | Office visits 16     | Worker's             |
| enrollment 56         |                      | compensation 50      |
+-----------------------+----------------------+----------------------+
| Emergency 32          | Oral and             | **X**-Rays 16        |
|                       | maxillofacial        |                      |
|                       | surgery 27           |                      |
+-----------------------+----------------------+----------------------+
| Experimental or       | Orthopedic devices   |                      |
| Investigational 53    | 22                   |                      |
+-----------------------+----------------------+----------------------+
| Eyeglasses 21         | Ostomy supplies 22   |                      |
+-----------------------+----------------------+----------------------+

  -----------------------------------------------------------------------
  **Summary of benefits for the M.D. IPA Health Plan -- 2004**

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

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

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

```{=html}
<!-- -->
```
-   We only cover services provided or arranged by Plan physicians,
    except in emergencies.

+------------------------------------------+---------------------+-----+
| **Benefits**                             | **You Pay**         | #   |
|                                          |                     | ### |
|                                          |                     | # P |
|                                          |                     | age |
+------------------------------------------+---------------------+-----+
| Medical services provided by physicians: | > Office visit      | >   |
|                                          | > copayment: \$10   |  16 |
| -   Diagnostic and treatment services    | > primary care;     |     |
|     provided in the office               | > \$20 specialist   |     |
+------------------------------------------+---------------------+-----+
| Services provided by a hospital:         | > \$100 per         | >   |
|                                          | > admission         |  29 |
| -   Inpatient                            | >                   | >   |
|                                          | > \$50 copayment    | >   |
| -   Outpatient                           |                     |  30 |
+------------------------------------------+---------------------+-----+
| Emergency benefits:                      | > \$25 per urgent   | >   |
|                                          | > care center visit |  33 |
| -   In or out-of-area                    | >                   | >   |
|                                          | > \$50 per          | >   |
|                                          | > emergency room    |  33 |
|                                          | > visit             |     |
+------------------------------------------+---------------------+-----+
| Mental health and substance abuse        | > Regular cost      | >   |
| treatment                                | > sharing           |  34 |
+------------------------------------------+---------------------+-----+
| Prescription drugs                       | > \$8 per generic   | >   |
|                                          | > drug              |  37 |
|                                          | >                   |     |
|                                          | > \$20 per brand    |     |
|                                          | > name drug in the  |     |
|                                          | > Plan's formulary  |     |
|                                          | >                   |     |
|                                          | > \$35 per brand    |     |
|                                          | > name drug not in  |     |
|                                          | > the Plan's        |     |
|                                          | > formulary         |     |
|                                          | >                   |     |
|                                          | > 20% up to \$50    |     |
|                                          | > for injectable    |     |
|                                          | > drugs, except for |     |
|                                          | > insulin           |     |
|                                          | >                   |     |
|                                          | > All contraceptive |     |
|                                          | > drugs-one         |     |
|                                          | > copayment up to a |     |
|                                          | > 90-day supply per |     |
|                                          | > prescription or   |     |
|                                          | > refill            |     |
+------------------------------------------+---------------------+-----+
| Dental Care                              | > Discount fee      | >   |
|                                          | > schedule          |  41 |
+------------------------------------------+---------------------+-----+
| Vision Care                              | > \$25 copayment    | >   |
|                                          | > for eye           |  21 |
|                                          | > refraction exam   |     |
+------------------------------------------+---------------------+-----+
| Special features: Centers for Cardiac    |                     | >   |
| Surgery, Transplants, and Joint          |                     |  39 |
| Replacement, WeeCall, Plan Publications, |                     |     |
| Health Education and Disease Management  |                     |     |
| Programs                                 |                     |     |
+------------------------------------------+---------------------+-----+
| Protection against catastrophic costs    | Nothing after       | 14  |
|                                          | \$1,800/Self Only   |     |
| (your catastrophic protection            | or \$4,800/Family   |     |
| out-of-pocket maximum)                   | enrollment per year |     |
|                                          |                     |     |
|                                          | Some costs do not   |     |
|                                          | count toward this   |     |
|                                          | protection          |     |
+------------------------------------------+---------------------+-----+

**2004 Rate Information for**

**M.D. IPA**

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

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

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

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

Washington, D.C. area, all of Maryland and N.Va/Central
Va/Richmond/Tidewater/Roanoke

+--------------+-----+-------+-------+-------+-------+-------+-------+
| **Self       | #   | **    | *     | **    | *     | **    | *     |
| Only**       | ### | \$110 | *\$36 | \$238 | *\$79 | \$312 | *\$16 |
|              | #   | .11** | .70** | .57** | .52** | .73** | .52** |
|              | JP1 |       |       |       |       |       |       |
+--------------+-----+-------+-------+-------+-------+-------+-------+
| **Self and   | *   | **    | *     | **    | **    | **    | *     |
| Family**     | *JP | \$264 | *\$88 | \$572 | \$190 | \$130 | *\$39 |
|              | 2** | .28** | .09** | .60** | .87** | .29** | .64** |
+--------------+-----+-------+-------+-------+-------+-------+-------+