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Dear Federal Employees Health Benefits Program Participant:

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

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

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

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

> Sincerely,
>
> ![](media/image7.png)
>
> Kay Coles James
>
> Director

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

**Privacy Practices**

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

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

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

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

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

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

-   Where required by law.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

-   Get a separate paper copy of this notice.

For more information on exercising your rights set out in this notice,
look at [www.opm.gov/insure](http://www.opm.gov/insure) on the Web. You
may also call 202-606-0745 and ask for OPM's FEHB Program privacy
official for this purpose.

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

Privacy Complaints

Unites States Office of Personnel Management

P.O. Box 707

Washington, DC 20004-0707

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

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

Table of Contents

Introduction [3](#introduction)

Plain Language [3](#plain-language)

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

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

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

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

Your Rights [7](#your-rights)

Service Area [8](#service-area)

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

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

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

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

Identification cards [10](#identification-cards)

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

Plan providers [10](#plan-providers)

Plan facilities [10](#plan-facilities)

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

Primary care [10](#primary-care)

Specialty care [11](#specialty-care)

Hospital care [12](#hospital-care)

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

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

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

Copayments [13](#copayments)

Deductible [13](#deductible)

Coinsurance [13](#coinsurance)

Fees when you fail to make your payment
[13](#fees-when-you-fail-to-make-your-payment)

Fees when you miss a medical appointment
[13](#fees-when-you-miss-a-medical-appointment)

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

Section 5. Benefits -- OVERVIEW *(See page 9 for how our benefits
changed this year and pages 77 and 78 for a benefits summary.)*
[14](#section-5.-benefits-overview-see-page-9-for-how-our-benefits-changed-this-year-and-pages-77-and-78-for-a-benefits-summary.)

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

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

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

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

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

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

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

-   
-   
-   
-   
-   
-   
-   
-   
-   

Flexible benefits option [48](#flexible-benefits-option)24 hour nurse
line [48](#hour-nurse-line)Services for deaf and hearing impaired
[48](#services-for-deaf-and-hearing-impaired)Language interpretation
[48](#language-interpretation)High risk pregnancies
[48](#high-risk-pregnancies)Centers of Excellence
[49](#centers-of-excellence)Travel benefit [49](#travel-benefit)Services
from other Kaiser Permanente Plans
[50](#services-from-other-kaiser-permanente-plans)Student coverage
outside the service area
[50](#student-coverage-outside-the-service-area)Section 5(h) Dental
benefits [51](#section-5h-dental-benefits)

Section 5(i) Non-FEHBP benefits available to Plan members
[56](#section-5i-non-fehbp-benefits-available-to-plan-members)

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

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

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

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

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

What is Medicare? [61](#what-is-medicare)

Should I enroll in Medicare? [61](#should-i-enroll-in-medicare)

If you enroll in Medicare Part B [62](#if-you-enroll-in-medicare-part-b)

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

Medicare Advantage [64](#medicare-advantage)

TRICARE and CHAMPVA [65](#tricare-and-champva)

Workers' Compensation [65](#workers-compensation)

Medicaid [65](#medicaid)

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

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

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

Section 11. FEHB Facts [69](#section-11.-fehb-facts)

Coverage information [69](#coverage-information)

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

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

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

Children's Equity Act [70](#childrens-equity-act)

When benefits and premiums start [70](#when-benefits-and-premiums-start)

When you retire [70](#when-you-retire)

When you lose benefits [70](#when-you-lose-benefits)

When FEHB coverage ends [70](#when-fehb-coverage-ends)

Spouse equity coverage [71](#spouse-equity-coverage)

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

Converting to individual coverage
[71](#converting-to-individual-coverage)

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

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

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

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

Index [76](#index)

Summary of benefits for Kaiser Foundation Health Plan of the Northwest
[77](#summary-of-benefits-for-kaiser-foundation-health-plan-of-the-northwest)

2005 Rate Information for Kaiser Foundation Health Plan of the Northwest
[79](#rate-information-for-kaiser-foundation-health-plan-of-the-northwest)

# Introduction

This brochure describes the benefits of Kaiser Foundation Health Plan of
the Northwest under our contract (CS 1047) with the United States Office
of Personnel Management, as authorized by the Federal Employees Health
Benefits law. The address for Kaiser Foundation Health Plan of the
Northwest\'s administrative office is:

Kaiser Foundation Health Plan of the Northwest

500 N.E. Multnomah Street, Suite 100

Portland, Oregon 97232-2099

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

If you are enrolled in this Plan, you are entitled to the benefits
described in this brochure. If you are enrolled in self and family
coverage, each eligible family member is also entitled to these
benefits. You do not have a right to benefits that were available before
January 1, 2005, unless those benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefit
changes are effective January 1, 2005, and changes are summarized on
page 9. Rates are shown 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
    Kaiser Foundation Health Plan of the Northwest*.*

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

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

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

# Stop Health Care Fraud!

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

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

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

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

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

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

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

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

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

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

    If the provider does not resolve the matter, call us from Portland
    at 503/813-2000, or from other areas call 800/813-2000, or our TTY
    number at 800/735-2900 and explain the situation.

    If we do not resolve the issue:

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

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

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

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

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

# Preventing medical mistakes

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

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

-   Ask questions and make sure you understand the answers.

-   Choose a doctor with whom you feel comfortable talking.

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

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

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

-   Tell them about any drug allergies you have.

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

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

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

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

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

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

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

-   Call your doctor and ask for your results.

-   Ask what the results mean for your care.

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

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

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

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

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

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

-   Ask your surgeon:

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

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

Want more information on patient safety?

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

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

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

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

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

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

# Section 1. Facts about this HMO plan

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

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

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

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

### How we pay providers

The Northwest Permanente Medical Group provides patient care services
through a group capitation arrangement with Kaiser Foundation Health
Plan of the Northwest. Northwest Permanente physicians provide
approximately 98% of primary care services and more than 80% of
specialty services to members. The Medical Group receives a lump sum
incentive payment within a narrow range at the end of the year based on
financial performance of the Health Plan and the Medical Group against
budget. Compensation for physicians is designed to be competitive in
order to recruit and retain quality physicians. Physicians in the
Medical Group do not receive financial incentives linked to individual
utilization patterns. Instead, approximately ninety percent or more of
compensation received by individual physicians is salary; and the
remaining amount of variable compensation is based on clinical quality,
patient satisfaction and financial performance of the Medical Group and
the Health Plan.

### Your Rights

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

Kaiser Foundation Health Plan of the Northwest is a non-profit
corporation. Kaiser Permanente began offering medical services to
workers and their families at Grand Coulee Dam in northeastern
Washington and later the Kaiser shipyards in Portland, Oregon and
Vancouver, Washington during World War II. When the shipyards were
closed in 1945, enrollment was opened to the community. This Plan is
part of the Kaiser Permanente Medical Care Program, a group of
non-profit organizations and contracting medical groups that serve over
8 million members nationwide. Our Medical Group, Northwest Permanente (a
for-profit Oregon-based professional corporation), delivers care in Plan
medical facilities throughout Kaiser Foundation Health Plan of the
Northwest service area.

In 1995, Kaiser Permanente became the first HMO in Oregon and southwest
Washington to receive a three-year, full accreditation from the National
Committee for Quality Assurance (NCQA). We were again awarded
three-year, full accreditation in 1998. In 2001 and again in 2004, we
were awarded the highest level of accreditation, known as \"Excellent
Accreditation.\" Excellent Accreditation status is awarded to plans
whose service and clinical quality meet or exceed NCQA's rigorous
requirements for consumer protection and quality improvement, and whose
HEDIS (Health Plan Employer Data and Information Set) results are in the
highest range of national performance.

All Kaiser Permanente and affiliated hospitals are accredited by the
Joint Commission on Accreditation of Healthcare Organizations (JCAHO).

All applicants for employment with Northwest Permanente P.C., or
Permanente Dental Associates must meet rigorous Kaiser Permanente
credentialing standards. Once hired, they undergo periodic review by
peers and hospital boards to assure their credentials are up to date and
in order.

If you want more information about us, from Portland, call 503/813-2000,
or from other areas call 800/813-2000 or our TTY number at 800/735-2900,
or write to Kaiser Foundation Health Plan of the Northwest, 500 N.E.
Multnomah, Suite 100, Portland, OR 97232. You may also visit our website
at
[my.kaiserpermanente.org/federalemployees](http://my.kaiserpermanente.org/federalemployees/).

Interpreters are available to assist members who do not speak English.
Please see the listing in your Medical Directory.

For free language interpretation services, or information about
providers who speak languages other than English, call 800/324-8010 or
our TTY number at 800/735-2900.

### Service Area

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

These Oregon counties: Columbia, Multnomah, Polk, Yamhill

And these Oregon ZIP codes:

Benton County: 97330, 97331, 97333, 97339, 97370

Clackamas County: 97004, 97009, 97011, 97013, 97015, 97017, 97022-23,
97027, 97034-36, 97038, 97042, 97045, 97055, 97067-68, 97070, 97222,
97267-68

Linn County: 97321, 97322, 97335, 97355, 97358, 97360, 97374, 97389

Marion County: 97002, 97020, 97026, 97032, 97071, 97137, 97301-3,
97305-14, 97325, 97352, 97359, 97362, 97375, 97381, 97383-85, 97392

Washington County: 97005-8, 97062, 97075-78, 97106, 97109, 97113,
97116-17, 97119, 97123-25, 97133, 97140, 97144, 97223-25, 97229, 97281,
97291

These Washington counties: Clark County

And these Washington ZIP codes:

Cowlitz County: 98581, 98603, 98609, 98611, 98616, 98625-26, 98632,
98645, 98649, 98674

Lewis County: 98591, 98593, 98596

Wahkiakum County: 98612, 98647

Ordinarily, you must receive your care from physicians, hospitals, and
other providers who contract with us. However, we are part of the Kaiser
Permanente Medical Care Program, and if you are visiting another Kaiser
Permanente service area, you can receive virtually all of the benefits
of this Plan at any other Kaiser Permanente facility, including our mail
order prescription program. You must pay the charges or copayments
imposed by the Kaiser Permanente Plan you are visiting, with the
exception of mail order prescriptions which are administered by your
home Plan. See Section 5(g), Special Features, for more details. We also
pay for certain follow-up services or continuing care services while you
are traveling outside the service area, as described on page 49; and for
emergency care obtained from any non-Plan provider, as described on page
39. We will not pay for any other health care services.

If you or a covered family member move outside of our service area, you
can enroll in another plan. If your dependents live out of the area (for
example, if your child goes to college in another state), you should
consider enrolling in a fee-for-service plan or an HMO that has
agreements with affiliates in other areas. If your dependent goes to
college outside any Kaiser Permanente service area, they may qualify for
the student out-of-area coverage. See page 50. If you or a family member
move, you do not have to wait until Open Season to change plans. Contact
your employing or retirement office.

# Section 2. How we change for 2005

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

### Program-wide changes

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

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

### Changes to this Plan

**Both Standard and High Options:**

-   Your share of the non-Postal premium will decrease by 12.1% for Self
    Only or 13.8% for Self and Family under the High Option and will
    increase by 6.1% for Self Only or 5.6% for Self and Family under the
    Standard Option.

-   We increased the out-of-pocket maximum to \$750 per person and to
    \$1,500 per family.

-   We added an inpatient hospital copayment of \$100 per admission.
    This copayment applies to inpatient and residential admissions for
    mental health and substance abuse, and inpatient multidisciplinary
    rehabilitation at a hospital or skilled nursing facility.

-   We increased the mail order prescription drug copayment for
    maintenance drugs to two copayments for up to a 90-day supply of
    generic or brand maintenance drugs.

**High Option:**

-   We increased the copayment for primary and specialty care office
    visits and for urgent care to \$15.

-   We increased the copayment for self-referred chiropractic to \$20
    for up to 20 visits.

-   We increased the copayment for mental health and substance abuse
    outpatient individual visits to \$15 and for group therapy to \$7.

-   We increased the prescription drug copayment to \$15 for generic
    drugs or devices and to \$30 for brand name drugs or devices.

-   We increased the dental office visit copayment to \$15 per office
    visit.

**Standard Option:**

-   We increased the vision allowance to \$150.

# Section 3. How you get care

+--------------------+-------------------------------------------------+
| ### Id             | We will send you an identification (ID) card    |
| entification cards | when you enroll. You should carry your ID card  |
|                    | with you at all times. You must show it         |
|                    | whenever you receive services from a Plan       |
|                    | provider, or obtain a prescription at a Plan    |
|                    | pharmacy. Until you receive your ID card, use   |
|                    | your copy of the Health Benefits Election Form, |
|                    | SF-2809, your health benefits enrollment        |
|                    | confirmation (for annuitants), or your Employee |
|                    | Express confirmation letter.                    |
+--------------------+-------------------------------------------------+
|                    | If you do not receive your ID card within 30    |
|                    | days after the effective date of your           |
|                    | enrollment, or if you need replacement cards,   |
|                    | call us from Portland at 503/813-2000, or from  |
|                    | other areas call 800/813-2000 or our TTY number |
|                    | at 800/735-2900, or write to us at: Membership  |
|                    | Administration, Kaiser Permanente, P.O. Box     |
|                    | 921008, Fort Worth, Texas 96121-0008. You may   |
|                    | also request replacement cards through our      |
|                    | website at                                      |
|                    | [my.kaiserpermanente.org/federalemployees](ht   |
|                    | tp://my.kaiserpermanente.org/federalemployees). |
+--------------------+-------------------------------------------------+
| ### Where yo       | You get care from \"Plan providers\" and \"Plan |
| u get covered care | facilities.\" You will only pay copayments      |
|                    | and/or coinsurance, and you will not have to    |
|                    | file claims.                                    |
+--------------------+-------------------------------------------------+
| #                  | The Plan contracts with Northwest Permanente,   |
| ### Plan providers | P.C. to provide physician services. They        |
|                    | practice in medical offices located within our  |
|                    | service area. Permanente Dental Associates, an  |
|                    | independent group of dentists, provides or      |
|                    | arranges dental care for members of the High    |
|                    | Option plan.                                    |
|                    |                                                 |
|                    | We list Plan providers in the provider          |
|                    | directory, which we update periodically. The    |
|                    | list is also on our website.                    |
+--------------------+-------------------------------------------------+
| ##                 | Plan facilities are hospitals and other         |
| ## Plan facilities | facilities in our service area that we contract |
|                    | with to provide covered services to our         |
|                    | members. Medical centers, medical offices and   |
|                    | dental offices are conveniently located         |
|                    | throughout Portland and Salem, Oregon and       |
|                    | Vancouver and Longview-Kelso, Washington. We    |
|                    | list these facilities and hospitals in the      |
|                    | provider directory, which we update             |
|                    | periodically. The list is also on our website.  |
|                    |                                                 |
|                    | You must receive your health services at Plan   |
|                    | facilities, except if you have an emergency. If |
|                    | you are visiting another Kaiser Permanente      |
|                    | service area, you may receive health care       |
|                    | services at those Kaiser Permanente facilities. |
|                    | Under the circumstances specified in this       |
|                    | brochure you may receive follow-up or           |
|                    | continuing care while you travel anywhere.      |
+--------------------+-------------------------------------------------+
| ###                | It depends on the type of care you need. First, |
| What you must do t | you and each family member must choose a        |
| o get covered care | primary care physician. This decision is        |
|                    | important since your primary care physician     |
|                    | provides or arranges for most of your health    |
|                    | care. Our website has information about our     |
|                    | providers. Membership Services can help you     |
|                    | too, by telling you who is available and        |
|                    | sharing information about them. To choose or    |
|                    | change a primary care physician, call           |
|                    | Membership Services from Portland at            |
|                    | 503/813-2000, or from other areas call          |
|                    | 800/813-2000 or our TTY number at 800/735-2900. |
+--------------------+-------------------------------------------------+
| #### Primary care  | Your primary care physician can be a physician, |
|                    | nurse practitioner, or physician assistant in   |
|                    | family practice, internal medicine, or          |
|                    | pediatrics. Your primary care physician will    |
|                    | provide most of your health care, or give you a |
|                    | referral to see a specialist.                   |
|                    |                                                 |
|                    | If you want to change primary care physicians   |
|                    | or if your primary care physician leaves the    |
|                    | Plan, call us. We will help you select a new    |
|                    | one.                                            |
+--------------------+-------------------------------------------------+
| #                  | Your primary care physician will refer you to a |
| ### Specialty care | specialist for needed care. When you receive a  |
|                    | referral from your primary care physician, you  |
|                    | must return to the primary care physician after |
|                    | the consultation, unless your primary care      |
|                    | physician authorized a certain number of visits |
|                    | without additional referrals. The primary care  |
|                    | physician must provide or authorize all         |
|                    | follow-up care. Do not go to the specialist for |
|                    | return visits unless your primary care          |
|                    | physician gives you a referral. However, a      |
|                    | woman may see her obstetrician/gynecologist     |
|                    | without having to obtain a referral. You may    |
|                    | also receive outpatient alcohol and drug        |
|                    | treatment, cancer counseling, eye examinations, |
|                    | outpatient mental health, chiropractic,         |
|                    | occupational health, and social work services   |
|                    | without a referral.                             |
|                    |                                                 |
|                    | Here are other things you should know about     |
|                    | specialty care:                                 |
|                    |                                                 |
|                    | -   If you need to see a specialist frequently  |
|                    |     because of a chronic, complex, or serious   |
|                    |     medical condition, your primary care        |
|                    |     physician will develop a treatment plan     |
|                    |     that allows you to see your specialist for  |
|                    |     a certain number of visits without          |
|                    |     additional referrals. Your primary care     |
|                    |     physician will use our criteria when        |
|                    |     creating your treatment plan.               |
|                    |                                                 |
|                    | -   If you are seeing a specialist when you     |
|                    |     enroll in our Plan, talk to your primary    |
|                    |     care physician. Your primary care physician |
|                    |     will decide what treatment you need. If he  |
|                    |     or she decides to refer you to a            |
|                    |     specialist, ask if you can see your current |
|                    |     specialist. If your current specialist does |
|                    |     not participate with us, you must receive   |
|                    |     treatment from a specialist who does.       |
|                    |     Generally, we will not pay for you to see a |
|                    |     specialist who does not participate with    |
|                    |     our Plan.                                   |
|                    |                                                 |
|                    | -   If you are seeing a specialist and your     |
|                    |     specialist leaves the Plan, call your       |
|                    |     primary care physician, who will arrange    |
|                    |     for you to see another specialist. You may  |
|                    |     receive services from your current          |
|                    |     specialist until we can make arrangements   |
|                    |     for you to see someone else.                |
|                    |                                                 |
|                    | -   If you have a chronic or disabling          |
|                    |     condition and lose access to your           |
|                    |     specialist because we:                      |
|                    |                                                 |
|                    | ```{=html}                                      |
|                    | <!-- -->                                        |
|                    | ```                                             |
|                    | -   Terminate our contract with your specialist |
|                    |     for other than cause; or                    |
|                    |                                                 |
|                    | -   Drop out of the Federal Employees Health    |
|                    |     Benefits (FEHB) Program and you enroll in   |
|                    |     another FEHB program Plan; or               |
|                    |                                                 |
|                    | -   Reduce our service area and you enroll in   |
|                    |     another FEHB Plan,                          |
|                    |                                                 |
|                    | you may be able to continue seeing your         |
|                    | specialist for up to 90 days after you receive  |
|                    | notice of the change. Contact us, or if we drop |
|                    | out of the Program, contact your new plan.      |
|                    |                                                 |
|                    | If you are in the second or third trimester of  |
|                    | pregnancy and you lose access to your           |
|                    | specialist based on the above circumstances,    |
|                    | you can continue to see your specialist until   |
|                    | the end of your postpartum care, even if it is  |
|                    | beyond the 90 days.                             |
+--------------------+-------------------------------------------------+
| ####  {#se         | Note: Under certain circumstances and for a     |
| ction .unnumbered} | limited period of time, we may continue to pay  |
|                    | for covered services provided by your Kaiser    |
|                    | Permanente physician or a physician you have    |
|                    | been referred to by your Kaiser Permanente      |
|                    | physician, when the physician\'s contract with  |
|                    | us has been terminated. This extension of care  |
|                    | is available for a period up to 120 days from   |
|                    | the date we notify you of the physician\'s      |
|                    | termination, as long as you are receiving an    |
|                    | active course of medically necessary treatment, |
|                    | and your treating physician agrees that it is   |
|                    | desirable to maintain continuity of care.       |
|                    | Additionally, this extension of coverage is     |
|                    | available if you are in the second trimester of |
|                    | pregnancy, until the later of the following     |
|                    | dates: the 45th day after the baby\'s birth, or |
|                    | as long as you are receiving active treatment,  |
|                    | not to exceed 120 days from the date you        |
|                    | receive notice of the termination. To apply for |
|                    | this continuity of care extension, you must     |
|                    | submit a written request to us.                 |
+--------------------+-------------------------------------------------+
| ####  {#sect       | This continuity of care provision is applicable |
| ion-1 .unnumbered} | only when your Kaiser Permanente physician or   |
|                    | referred physician agrees to adhere to the      |
|                    | reimbursement rate applicable at the time of    |
|                    | contract termination or an equivalent rate, if  |
|                    | the contractual rate was not based on a         |
|                    | fee-for-service basis.                          |
+--------------------+-------------------------------------------------+
| #### Hospital care | Your Plan primary care physician or specialist  |
|                    | will make necessary hospital arrangements and   |
|                    | supervise your care. This includes admission to |
|                    | a skilled nursing or other type of facility.    |
|                    |                                                 |
|                    | If you are in the hospital when your enrollment |
|                    | in our Plan begins, call our Membership         |
|                    | Services department immediately from Portland   |
|                    | at 503/813-2000, or from other areas call       |
|                    | 800/813-2000 or our TTY number at 800/735-2900. |
|                    | If you are new to the FEHB Program, we will     |
|                    | arrange for you to receive care.                |
|                    |                                                 |
|                    | If you changed from another FEHB plan to us,    |
|                    | your former plan will pay for the hospital stay |
|                    | until:                                          |
|                    |                                                 |
|                    | -   You are discharged, not merely moved to an  |
|                    |     alternative care center; or                 |
|                    |                                                 |
|                    | -   The day your benefits from your former plan |
|                    |     run out; or                                 |
|                    |                                                 |
|                    | -   The 92^nd^ day after you become a member of |
|                    |     this Plan, whichever happens first.         |
|                    |                                                 |
|                    | These provisions apply only to the benefits of  |
|                    | the hospitalized person. If your plan           |
|                    | terminates participation in the FEHB Program in |
|                    | whole or in part, or if OPM orders an           |
|                    | enrollment change, this continuation of         |
|                    | coverage provision does not apply. In such      |
|                    | case, the hospitalized family member's benefits |
|                    | under the new plan begin on the effective date  |
|                    | of enrollment.                                  |
+--------------------+-------------------------------------------------+
| ### Circumstances  | Under certain extraordinary circumstances, such |
| beyond our control | as natural disasters, we may have to delay your |
|                    | services or we may be unable to provide them.   |
|                    | In that case, we will make all reasonable       |
|                    | efforts to provide you with the necessary care. |
+--------------------+-------------------------------------------------+
| ### S              | Most care and service is not subject to         |
| ervices requiring  | administrative prior authorization. Prior       |
| our prior approval | authorization is required for select services   |
|                    | such as care at skilled nursing facilities,     |
|                    | home health and hospice services, referrals to  |
|                    | non-Kaiser Permanente physicians, and           |
|                    | transplants. Your primary care physician will   |
|                    | give a referral for these services if they are  |
|                    | medically necessary.                            |
+--------------------+-------------------------------------------------+

# Section 4. Your costs for covered services

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

+------------------+---------------------------------------------------+
| ### Copayments   | A copayment is a fixed amount of money you pay to |
|                  | the provider, facility, pharmacy, etc., when you  |
|                  | receive services.                                 |
|                  |                                                   |
|                  | Example: When you see your primary care           |
|                  | physician, you pay a copayment of \$15 per office |
|                  | visit under either the High Option or the         |
|                  | Standard Option plan. When you go in the          |
|                  | hospital, you pay \$100 per admission under       |
|                  | either Option.                                    |
+------------------+---------------------------------------------------+
| ### Deductible   | We do not have a deductible.                      |
+------------------+---------------------------------------------------+
| ### Coinsurance  | Coinsurance is the percentage of our allowance    |
|                  | that you must pay for certain services you        |
|                  | receive.                                          |
|                  |                                                   |
|                  | Example: In our Plan, you pay 50% of our          |
|                  | allowance for infertility services.               |
+------------------+---------------------------------------------------+
| ### Fees wh      | If you do not pay your copayment or coinsurance   |
| en you fail to m | at the time you receive services, we will bill    |
| ake your payment | you. You will be required to pay a \$10 charge    |
|                  | for each bill sent for unpaid services.           |
+------------------+---------------------------------------------------+
| ### Fees whe     | If you miss a medical appointment, we will charge |
| n you miss a med | you \$10, unless you notify us in advance.        |
| ical appointment |                                                   |
|                  | Note: Affiliated physician offices and other      |
|                  | providers and facilities may bill you an          |
|                  | additional charge along with any unpaid           |
|                  | copayments or coinsurance.                        |
+------------------+---------------------------------------------------+
| ### You          | After your copayments and coinsurance total \$750 |
| r catastrophic p | per person or \$1,500 per family enrollment in    |
| rotection out-of | any calendar year, you do not have to pay any     |
| -pocket maximum  | more for covered services. However, copayments    |
|                  | and coinsurances for the following services do    |
|                  | not count toward your catastrophic protection     |
|                  | out-of-pocket maximum. You must continue to pay   |
|                  | copayments and coinsurance for these services     |
|                  | under both the High Option and Standard Option.   |
|                  |                                                   |
|                  | -   Outpatient prescription drugs                 |
|                  |                                                   |
|                  | -   Contraceptive devices                         |
|                  |                                                   |
|                  | -   Dental services                               |
|                  |                                                   |
|                  | -   Corrective appliances and artificial aids     |
|                  |                                                   |
|                  | -   The \$25 charges paid for follow-up or        |
|                  |     continuing care when you are traveling out of |
|                  |     our service area                              |
|                  |                                                   |
|                  | -   Long-term physical therapy and rehabilitation |
|                  |                                                   |
|                  | -   Eyeglasses and contact lenses                 |
|                  |                                                   |
|                  | -   Health education services                     |
|                  |                                                   |
|                  | -   Self-referred chiropractic care               |
|                  |                                                   |
|                  | 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 pages 77 and 78 for a benefits summary.)*

Note: This benefits section is divided into subsections. Please read the
important things you should keep in mind at the beginning of each
subsection. Also read the General Exclusions in Section 6; they apply to
the benefits in the following subsections. To obtain claim forms, claims
filing advice, or more information about our benefits, contact us from
Portland at 503/813-2000, or from other areas call 800/813-2000 or our
TTY number at 800/735-2900 or at our website at
[my.kaiserpermanente.org/federalemployees](http://my.kaiserpermanente.org/federalemployees)*.*

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

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

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

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

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

Maternity care [19](#maternity-care)

Family planning [20](#family-planning)

Infertility services [20](#infertility-services)

Allergy care [21](#allergy-care)

Treatment therapies [21](#treatment-therapies)

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

Speech therapy [23](#speech-therapy)

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

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

Foot care [26](#foot-care)

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

Durable medical equipment (DME) [28](#durable-medical-equipment-dme)

Home health services [28](#home-health-services)

Chiropractic [29](#chiropractic)

Alternative treatments [29](#alternative-treatments)

Educational classes and programs [29](#educational-classes-and-programs)

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

Surgical procedures [30](#surgical-procedures)

Reconstructive surgery [31](#reconstructive-surgery)

Oral and maxillofacial surgery [32](#oral-and-maxillofacial-surgery)

Organ/tissue transplants [33](#organtissue-transplants)

Anesthesia [34](#anesthesia)

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

Inpatient hospital [35](#inpatient-hospital)

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

Skilled nursing care benefits [37](#skilled-nursing-care-benefits)

Hospice care [38](#hospice-care)

Ambulance [38](#ambulance)

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

Emergency within our service area [40](#__RefHeading___Toc84322599)

Emergency outside our service area [41](#__RefHeading___Toc84322600)

Ambulance [41](#__RefHeading___Toc84322601)

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

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

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

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

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

Flexible benefits option [48](#flexible-benefits-option)

24 hour nurse line [48](#hour-nurse-line)

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

Language interpretation [48](#language-interpretation)

High risk pregnancies [48](#high-risk-pregnancies)

Centers of Excellence [49](#centers-of-excellence)

Travel benefit [49](#travel-benefit)

Services from other Kaiser Permanente Plans
[50](#services-from-other-kaiser-permanente-plans)

Student coverage outside the service area
[50](#student-coverage-outside-the-service-area)

Section 5(h) Dental benefits [51](#section-5h-dental-benefits)

Dental benefits [51](#dental-benefits)

Section 5(i) Non-FEHBP benefits available to Plan members
[56](#section-5i-non-fehbp-benefits-available-to-plan-members)

Summary of benefits for Kaiser Foundation Health Plan of the Northwest
*-* 2005
[77](#summary-of-benefits-for-kaiser-foundation-health-plan-of-the-northwest)

2005 Rate Information for Kaiser Foundation Health Plan of the Northwest
[79](#rate-information-for-kaiser-foundation-health-plan-of-the-northwest)

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

+---+---+------------------------+-------------------+-------------+---+---+
|   | * | **Here are some        |                   |             | * |   |
|   | * | important things you   |                   |             | * |   |
|   | I | should keep in mind    |                   |             | I |   |
|   | * | about these            |                   |             | * |   |
|   | * | benefits:**            |                   |             | * |   |
|   |   |                        |                   |             |   |   |
|   | * | -   Please remember    |                   |             | * |   |
|   | * |     that all benefits  |                   |             | * |   |
|   | M |     are subject to the |                   |             | M |   |
|   | * |     definitions,       |                   |             | * |   |
|   | * |     limitations, and   |                   |             | * |   |
|   |   |     exclusions in this |                   |             |   |   |
|   | * |     brochure and are   |                   |             | * |   |
|   | * |     payable only when  |                   |             | * |   |
|   | P |     we determine they  |                   |             | P |   |
|   | * |     are medically      |                   |             | * |   |
|   | * |     necessary.         |                   |             | * |   |
|   |   |                        |                   |             |   |   |
|   | * | -   Plan physicians    |                   |             | * |   |
|   | * |     must provide or    |                   |             | * |   |
|   | O |     arrange your care. |                   |             | O |   |
|   | * |                        |                   |             | * |   |
|   | * | -   We have no         |                   |             | * |   |
|   |   |     calendar year      |                   |             |   |   |
|   | * |     deductible.        |                   |             | * |   |
|   | * |                        |                   |             | * |   |
|   | R | -   Be sure to read    |                   |             | R |   |
|   | * |     Section 4, *Your   |                   |             | * |   |
|   | * |     costs for covered  |                   |             | * |   |
|   |   |     services*, for     |                   |             |   |   |
|   | * |     valuable           |                   |             | * |   |
|   | * |     information about  |                   |             | * |   |
|   | T |     how cost sharing   |                   |             | T |   |
|   | * |     works. Also read   |                   |             | * |   |
|   | * |     Section 9 about    |                   |             | * |   |
|   |   |     coordinating       |                   |             |   |   |
|   | * |     benefits with      |                   |             | * |   |
|   | * |     other coverage,    |                   |             | * |   |
|   | A |     including with     |                   |             | A |   |
|   | * |     Medicare.          |                   |             | * |   |
|   | * |                        |                   |             | * |   |
|   |   | -   Note: We waive the |                   |             |   |   |
|   | * |     \$15 charge if you |                   |             | * |   |
|   | * |     enroll in our      |                   |             | * |   |
|   | N |     Medicare Advantage |                   |             | N |   |
|   | * |     Plan and assign    |                   |             | * |   |
|   | * |     your Medicare      |                   |             | * |   |
|   |   |     benefits to the    |                   |             |   |   |
|   | * |     Plan.              |                   |             | * |   |
|   | * |                        |                   |             | * |   |
|   | T |                        |                   |             | T |   |
|   | * |                        |                   |             | * |   |
|   | * |                        |                   |             | * |   |
+---+---+------------------------+-------------------+-------------+---+---+
| B |   |                        |                   |             |   |   |
| e |   |                        |                   |             |   |   |
| n |   |                        |                   |             |   |   |
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| f |   |                        |                   |             |   |   |
| i |   |                        |                   |             |   |   |
| t |   |                        |                   |             |   |   |
| D |   |                        |                   |             |   |   |
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| c |   |                        |                   |             |   |   |
| r |   |                        |                   |             |   |   |
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| p |   |                        |                   |             |   |   |
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| i |   |                        |                   |             |   |   |
| o |   |                        |                   |             |   |   |
| n |   |                        |                   |             |   |   |
+---+---+------------------------+-------------------+-------------+---+---+
| # |   |                        | You pay --        | You pay --  |   |   |
| # |   |                        | Standard Option   | High Option |   |   |
| # |   |                        |                   |             |   |   |
| # |   |                        |                   |             |   |   |
| # |   |                        |                   |             |   |   |
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| r |   |                        |                   |             |   |   |
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| t |   |                        |                   |             |   |   |
| m |   |                        |                   |             |   |   |
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| n |   |                        |                   |             |   |   |
| t |   |                        |                   |             |   |   |
|   |   |                        |                   |             |   |   |
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| v |   |                        |                   |             |   |   |
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| e |   |                        |                   |             |   |   |
| s |   |                        |                   |             |   |   |
|   |   |                        |                   |             |   |   |
+---+---+------------------------+-------------------+-------------+---+---+
| P |   |                        | \$15 per office   | \$15 per    |   |   |
| r |   |                        | visit             | office      |   |   |
| o |   |                        |                   | visit       |   |   |
| f |   |                        |                   |             |   |   |
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+---+---+------------------------+-------------------+-------------+---+---+
| P |   |                        | Nothing for       | Nothing for |   |   |
| r |   |                        | inpatient         | inpatient   |   |   |
| o |   |                        | professional      | p           |   |   |
| f |   |                        | services          | rofessional |   |   |
| e |   |                        |                   | services    |   |   |
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| s |   |                        |                   |             |   |   |
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| d |   |                        |                   |             |   |   |
| o |   |                        |                   |             |   |   |
| t |   |                        |                   |             |   |   |
| h |   |                        |                   |             |   |   |
| e |   |                        |                   |             |   |   |
| r |   |                        |                   |             |   |   |
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| e |   |                        |                   |             |   |   |
| a |   |                        |                   |             |   |   |
| l |   |                        |                   |             |   |   |
| t |   |                        |                   |             |   |   |
| h |   |                        |                   |             |   |   |
| c |   |                        |                   |             |   |   |
| a |   |                        |                   |             |   |   |
| r |   |                        |                   |             |   |   |
| e |   |                        |                   |             |   |   |
| p |   |                        |                   |             |   |   |
| r |   |                        |                   |             |   |   |
| o |   |                        |                   |             |   |   |
| f |   |                        |                   |             |   |   |
| e |   |                        |                   |             |   |   |
| s |   |                        |                   |             |   |   |
| s |   |                        |                   |             |   |   |
| i |   |                        |                   |             |   |   |
| o |   |                        |                   |             |   |   |
| n |   |                        |                   |             |   |   |
| a |   |                        |                   |             |   |   |
| l |   |                        |                   |             |   |   |
| s |   |                        |                   |             |   |   |
|   |   |                        |                   |             |   |   |
| - |   |                        |                   |             |   |   |
|   |   |                        |                   |             |   |   |
|   |   |                        |                   |             |   |   |
|   |   |                        |                   |             |   |   |
| D |   |                        |                   |             |   |   |
| u |   |                        |                   |             |   |   |
| r |   |                        |                   |             |   |   |
| i |   |                        |                   |             |   |   |
| n |   |                        |                   |             |   |   |
| g |   |                        |                   |             |   |   |
|   |   |                        |                   |             |   |   |
|   |   |                        |                   |             |   |   |
|   |   |                        |                   |             |   |   |
|   |   |                        |                   |             |   |   |
| a |   |                        |                   |             |   |   |
|   |   |                        |                   |             |   |   |
|   |   |                        |                   |             |   |   |
|   |   |                        |                   |             |   |   |
|   |   |                        |                   |             |   |   |
| h |   |                        |                   |             |   |   |
| o |   |                        |                   |             |   |   |
| s |   |                        |                   |             |   |   |
| p |   |                        |                   |             |   |   |
| i |   |                        |                   |             |   |   |
| t |   |                        |                   |             |   |   |
| a |   |                        |                   |             |   |   |
| l |   |                        |                   |             |   |   |
|   |   |                        |                   |             |   |   |
|   |   |                        |                   |             |   |   |
|   |   |                        |                   |             |   |   |
|   |   |                        |                   |             |   |   |
| s |   |                        |                   |             |   |   |
| t |   |                        |                   |             |   |   |
| a |   |                        |                   |             |   |   |
| y |   |                        |                   |             |   |   |
+---+---+------------------------+-------------------+-------------+---+---+
| A |   |                        | Nothing           | Nothing     |   |   |
| t |   |                        |                   |             |   |   |
| h |   |                        |                   |             |   |   |
| o |   |                        |                   |             |   |   |
| m |   |                        |                   |             |   |   |
| e |   |                        |                   |             |   |   |
+---+---+------------------------+-------------------+-------------+---+---+

+------------------------------+-------------------+-------------------+
| ###### Lab, X-ra             | You pay --        | You pay -- High   |
| y and other diagnostic tests | Standard Option   | Option            |
+------------------------------+-------------------+-------------------+
| Tests, such as:              | Nothing           | Nothing           |
|                              |                   |                   |
| -   Blood tests              |                   |                   |
|                              |                   |                   |
| -   Urinalysis               |                   |                   |
|                              |                   |                   |
| -   Non-routine Pap tests    |                   |                   |
|                              |                   |                   |
| -   Pathology                |                   |                   |
|                              |                   |                   |
| -   X-rays                   |                   |                   |
|                              |                   |                   |
| -   Non-routine mammograms   |                   |                   |
|                              |                   |                   |
| -   CAT scans/MRI            |                   |                   |
|                              |                   |                   |
| -   Ultrasound               |                   |                   |
|                              |                   |                   |
| -   Electrocardiogram and    |                   |                   |
|     EEG                      |                   |                   |
+------------------------------+-------------------+-------------------+
| #                            |                   |                   |
| ##### Preventive care, adult |                   |                   |
+------------------------------+-------------------+-------------------+
| Routine screenings, such as: | \$15 per office   | \$15 per office   |
|                              | visit             | visit             |
| -   Total Blood Cholesterol  |                   |                   |
|                              |                   |                   |
| -   Colorectal Cancer        |                   |                   |
|     Screening, including     |                   |                   |
|                              |                   |                   |
| ```{=html}                   |                   |                   |
| <!-- -->                     |                   |                   |
| ```                          |                   |                   |
| -   Colonoscopy screening -- |                   |                   |
|     every ten years starting |                   |                   |
|     at age 50                |                   |                   |
|                              |                   |                   |
| -   Double contrast barium   |                   |                   |
|     enema every five years   |                   |                   |
|     starting at age 50       |                   |                   |
|                              |                   |                   |
| -   Fecal occult blood test  |                   |                   |
|                              |                   |                   |
| -   Sigmoidoscopy screening  |                   |                   |
|     -- every five years      |                   |                   |
|     starting at age 50       |                   |                   |
|                              |                   |                   |
| ```{=html}                   |                   |                   |
| <!-- -->                     |                   |                   |
| ```                          |                   |                   |
| -   Routine Prostate         |                   |                   |
|     Specific Antigen (PSA)   |                   |                   |
|     test - one annually for  |                   |                   |
|     men age 40 and older     |                   |                   |
|                              |                   |                   |
| -   Routine Pap test         |                   |                   |
|                              |                   |                   |
| Notes:                       |                   |                   |
|                              |                   |                   |
| -   You should consult with  |                   |                   |
|     your physician to        |                   |                   |
|     determine what is        |                   |                   |
|     appropriate and          |                   |                   |
|     medically necessary for  |                   |                   |
|     you.                     |                   |                   |
|                              |                   |                   |
| -   You will pay only one    |                   |                   |
|     copayment if you receive |                   |                   |
|     your routine screening   |                   |                   |
|     on the same day as your  |                   |                   |
|     office visit.            |                   |                   |
+------------------------------+-------------------+-------------------+

*Preventive care, adult---continued on next page*

+------------------------------+-------------------+-------------------+
| Preventive care, adult       | You pay --        | You pay -- High   |
| *(continued)*                | Standard Option   | Option            |
+------------------------------+-------------------+-------------------+
| Routine mammogram -- covered | Nothing           | Nothing           |
| for women age 35 and older,  |                   |                   |
| as follows:                  |                   |                   |
|                              |                   |                   |
| -   From age 35 through 39,  |                   |                   |
|     one during this five     |                   |                   |
|     year period              |                   |                   |
|                              |                   |                   |
| -   From age 40 through 64,  |                   |                   |
|     one every calendar year  |                   |                   |
|                              |                   |                   |
| -   At age 65 and older, one |                   |                   |
|     every two consecutive    |                   |                   |
|     calendar years           |                   |                   |
|                              |                   |                   |
| Note: In addition to routine |                   |                   |
| screening, we cover          |                   |                   |
| mammograms when medically    |                   |                   |
| necessary to diagnose or     |                   |                   |
| treat your illness.          |                   |                   |
+------------------------------+-------------------+-------------------+
| -   Routine immunizations    | Nothing           | Nothing           |
|     and boosters             |                   |                   |
+------------------------------+-------------------+-------------------+
| -   Visits to receive        | \$5 per office    | \$5 per office    |
|     injections               | visit             | visit             |
+------------------------------+-------------------+-------------------+
| -   Injectable travel        | \$15 per office   | \$15 per office   |
|     immunizations            | visit             | visit             |
|                              |                   |                   |
| Note: We cover oral travel   |                   |                   |
| immunizations under the      |                   |                   |
| prescription drug benefit.   |                   |                   |
+------------------------------+-------------------+-------------------+
| *Not covered:*               | *All charges*     | *All charges*     |
|                              |                   |                   |
| *Physical exams required     |                   |                   |
| for*:                        |                   |                   |
|                              |                   |                   |
| -   Obtaining or continuing  |                   |                   |
|     employment               |                   |                   |
|                              |                   |                   |
| -   Insurance                |                   |                   |
|                              |                   |                   |
| -   Attending schools        |                   |                   |
+------------------------------+-------------------+-------------------+
| ####                         |                   |                   |
| ## Preventive care, children |                   |                   |
+------------------------------+-------------------+-------------------+
| -   Childhood immunizations  | Nothing           | Nothing           |
|     recommended by the       |                   |                   |
|     American Academy of      |                   |                   |
|     Pediatrics               |                   |                   |
+------------------------------+-------------------+-------------------+
| -   Examinations, such as:   | \$15 per office   | \$15 per office   |
|                              | visit             | visit             |
| ```{=html}                   |                   |                   |
| <!-- -->                     |                   |                   |
| ```                          |                   |                   |
| -   Eye exams to determine   |                   |                   |
|     the need for vision      |                   |                   |
|     correction               |                   |                   |
|                              |                   |                   |
| -   Ear exams to determine   |                   |                   |
|     the need for hearing     |                   |                   |
|     correction               |                   |                   |
|                              |                   |                   |
| -   Examinations done on the |                   |                   |
|     day of immunizations     |                   |                   |
|                              |                   |                   |
| ```{=html}                   |                   |                   |
| <!-- -->                     |                   |                   |
| ```                          |                   |                   |
| -   Well-child care charges  |                   |                   |
|     for routine              |                   |                   |
|     examinations,            |                   |                   |
|     immunizations, and care  |                   |                   |
+------------------------------+-------------------+-------------------+

*Preventive care, children---continued on next page*

+------------------------------+-------------------+-------------------+
| ###### Preventive            | You pay --        | You pay -- High   |
| care, children *(continued)* | Standard Option   | Option            |
+------------------------------+-------------------+-------------------+
| Injectable travel            | \$15 per office   | \$15 per office   |
| immunizations                | visit             | visit             |
|                              |                   |                   |
| Note: We cover oral travel   |                   |                   |
| immunizations under the      |                   |                   |
| Prescription drug benefit.   |                   |                   |
| See Section 5(f) for         |                   |                   |
| prescription drug benefits.  |                   |                   |
+------------------------------+-------------------+-------------------+
| *Not covered:*               | *All charges*     | *All charges*     |
|                              |                   |                   |
| *Physical exams required     |                   |                   |
| for*:                        |                   |                   |
|                              |                   |                   |
| -   Obtaining or continuing  |                   |                   |
|     employment               |                   |                   |
|                              |                   |                   |
| -   Insurance                |                   |                   |
|                              |                   |                   |
| -   Attending schools or     |                   |                   |
|     camps                    |                   |                   |
+------------------------------+-------------------+-------------------+
| ###### Maternity care        |                   |                   |
+------------------------------+-------------------+-------------------+
| Complete maternity           | \$15 per office   | \$15 per office   |
| (obstetrical) care, such as: | visit             | visit             |
|                              |                   |                   |
| -   Prenatal care            | (See Section 5(c) | (See Section 5(c) |
|                              | for hospital      | for hospital      |
| -   Delivery                 | charges)          | charges)          |
|                              |                   |                   |
| -   Postnatal care           |                   |                   |
|                              |                   |                   |
| Note: Here are some things   |                   |                   |
| to keep in mind:             |                   |                   |
|                              |                   |                   |
| -   You may remain in the    |                   |                   |
|     hospital up to 48 hours  |                   |                   |
|     after a regular delivery |                   |                   |
|     and 96 hours after a     |                   |                   |
|     cesarean delivery. Your  |                   |                   |
|     physician will extend    |                   |                   |
|     your inpatient stay if   |                   |                   |
|     medically necessary.     |                   |                   |
|                              |                   |                   |
| -   We cover routine nursery |                   |                   |
|     care of the newborn      |                   |                   |
|     child during the covered |                   |                   |
|     portion of the mother's  |                   |                   |
|     maternity stay. We will  |                   |                   |
|     cover other care of an   |                   |                   |
|     infant who requires      |                   |                   |
|     non-routine treatment    |                   |                   |
|     only if we cover the     |                   |                   |
|     infant under a Self and  |                   |                   |
|     Family enrollment.       |                   |                   |
|                              |                   |                   |
| -   We pay hospitalization   |                   |                   |
|     and surgeon services     |                   |                   |
|     (delivery) the same as   |                   |                   |
|     for illness and injury.  |                   |                   |
|     See Section 5(c) for     |                   |                   |
|     hospital benefits and    |                   |                   |
|     Section 5(b) for surgery |                   |                   |
|     benefits*.*              |                   |                   |
+------------------------------+-------------------+-------------------+
| *Not covered*                | *All charges*     | *All charges*     |
|                              |                   |                   |
| -   Routine sonograms to     |                   |                   |
|     determine fetal age,     |                   |                   |
|     size or sex              |                   |                   |
+------------------------------+-------------------+-------------------+
| ###### Family planning       | You pay --        | You pay -- High   |
|                              | Standard Option   | Option            |
+------------------------------+-------------------+-------------------+
| -   Family planning services | \$15 per office   | \$15 per office   |
|     including counseling     | visit             | visit             |
|                              |                   |                   |
| -   Voluntary sterilization  |                   |                   |
|     (See Surgical procedures |                   |                   |
|     Section 5(b))            |                   |                   |
|                              |                   |                   |
| -   Surgically implanted     |                   |                   |
|     time-release             |                   |                   |
|     contraceptives and       |                   |                   |
|     intrauterine devices     |                   |                   |
|     (IUDs)                   |                   |                   |
|                              |                   |                   |
| Note: In addition to the     |                   |                   |
| office visit copayment for   |                   |                   |
| surgical procedures related  |                   |                   |
| to internally implanted      |                   |                   |
| time-release contraceptive   |                   |                   |
| drugs and contraceptive      |                   |                   |
| devices, we charge for the   |                   |                   |
| drug or device according to  |                   |                   |
| your Prescription Drug       |                   |                   |
| benefit. Other contraceptive |                   |                   |
| drugs and diaphragms are     |                   |                   |
| also covered under your      |                   |                   |
| Prescription Drug benefit.   |                   |                   |
+------------------------------+-------------------+-------------------+
| *Not covered:*               | *All charges*     | *All charges*     |
|                              |                   |                   |
| -   Reversal of voluntary    |                   |                   |
|     surgical sterilization   |                   |                   |
|                              |                   |                   |
| -   Genetic counseling       |                   |                   |
+------------------------------+-------------------+-------------------+
| ###### Infertility services  |                   |                   |
+------------------------------+-------------------+-------------------+
| Diagnosis and treatment of   | 50% of our        | 50% of our        |
| involuntary infertility      | allowance         | allowance         |
| including artificial         |                   |                   |
| insemination limited to      |                   |                   |
| intrauterine insemination    |                   |                   |
| (IUI)                        |                   |                   |
+------------------------------+-------------------+-------------------+
| *Not covered:*               | *All charges*     | *All charges*     |
|                              |                   |                   |
| *These exclusions apply to   |                   |                   |
| fertile as well as infertile |                   |                   |
| individuals or couples:*     |                   |                   |
|                              |                   |                   |
| -   Intravaginal             |                   |                   |
|     insemination (IVI)       |                   |                   |
|                              |                   |                   |
| -   Intracervical            |                   |                   |
|     insemination (ICI)       |                   |                   |
|                              |                   |                   |
| -   Assisted reproductive    |                   |                   |
|     technology (ART)         |                   |                   |
|     procedures, such as:     |                   |                   |
|                              |                   |                   |
| ```{=html}                   |                   |                   |
| <!-- -->                     |                   |                   |
| ```                          |                   |                   |
| -   *in vitro fertilization* |                   |                   |
|                              |                   |                   |
| -   *embryo transfer, gamete |                   |                   |
|     intra-fallopian transfer |                   |                   |
|     (GIFT) and zygote        |                   |                   |
|     intra-fallopian transfer |                   |                   |
|     (ZIFT)*                  |                   |                   |
|                              |                   |                   |
| ```{=html}                   |                   |                   |
| <!-- -->                     |                   |                   |
| ```                          |                   |                   |
| -   Services and supplies    |                   |                   |
|     related to excluded ART  |                   |                   |
|     procedures               |                   |                   |
|                              |                   |                   |
| -   Cost of donor sperm and  |                   |                   |
|     donor eggs and services  |                   |                   |
|     related to their         |                   |                   |
|     procurement and storage  |                   |                   |
|                              |                   |                   |
| -   Drugs used in the        |                   |                   |
|     diagnosis and treatment  |                   |                   |
|     of infertility           |                   |                   |
+------------------------------+-------------------+-------------------+
| ###### Allergy care          | You pay --        | You pay -- High   |
|                              | Standard Option   | Option            |
+------------------------------+-------------------+-------------------+
| -   Allergy testing          | \$15 per office   | \$15 per office   |
|                              | visit             | visit             |
+------------------------------+-------------------+-------------------+
| -   Allergy injections       | \$5 per office    | \$5 per office    |
|                              | visit             | visit             |
+------------------------------+-------------------+-------------------+
| -   Allergy serum            | Nothing           | Nothing           |
+------------------------------+-------------------+-------------------+
| *Not covered:*               | *All charges*     | *All charges*     |
|                              |                   |                   |
| -   Provocative food testing |                   |                   |
|                              |                   |                   |
| -   Sublingual allergy       |                   |                   |
|     desensitization          |                   |                   |
+------------------------------+-------------------+-------------------+
| ###### Treatment therapies   |                   |                   |
+------------------------------+-------------------+-------------------+
| -   Chemotherapy and         | \$15 per office   | \$15 per office   |
|     radiation therapy        | visit             | visit             |
|                              |                   |                   |
| Note: We limit high dose     |                   |                   |
| chemotherapy in association  |                   |                   |
| with autologous bone marrow  |                   |                   |
| transplants to those         |                   |                   |
| transplants listed under     |                   |                   |
| Organ/Tissue Transplants in  |                   |                   |
| Section 5(b), Surgical and   |                   |                   |
| anesthesia services.         |                   |                   |
|                              |                   |                   |
| -   Respiratory and          |                   |                   |
|     inhalation therapy       |                   |                   |
|                              |                   |                   |
| -   Dialysis -- hemodialysis |                   |                   |
|     and peritoneal dialysis  |                   |                   |
+------------------------------+-------------------+-------------------+
| Note: We cover growth        | Nothing           | Nothing           |
| hormone therapy (GHT) under  |                   |                   |
| the Prescription Drug        |                   |                   |
| benefit. See Section 5(f)    |                   |                   |
| for growth hormone coverage. |                   |                   |
|                              |                   |                   |
| -   Intravenous              |                   |                   |
|     (IV)/Infusion Therapy -- |                   |                   |
|     home IV and antibiotic   |                   |                   |
|     therapy                  |                   |                   |
+------------------------------+-------------------+-------------------+
| *Not covered:*               | *All charges*     | *All charges*     |
|                              |                   |                   |
| -   Long-term rehabilitative |                   |                   |
|     therapy                  |                   |                   |
|                              |                   |                   |
| -   Chemotherapy supported   |                   |                   |
|     by a bone marrow         |                   |                   |
|     transplant or with stem  |                   |                   |
|     cell support, for any    |                   |                   |
|     diagnosis not listed as  |                   |                   |
|     covered                  |                   |                   |
|                              |                   |                   |
| -   Cognitive therapy        |                   |                   |
+------------------------------+-------------------+-------------------+
| ###### Physical              | You pay --        | You pay -- High   |
|  and occupational therapies  | Standard Option   | Option            |
+------------------------------+-------------------+-------------------+
| Benefit is limited to the    | \$15 per          | \$15 per          |
| greater of 20 visits or 2    | outpatient visit  | outpatient visit  |
| months per condition for     |                   |                   |
| each therapy:                | Nothing for       | Nothing for       |
|                              | inpatient         | inpatient         |
| -   Physical therapy by      | professional      | professional      |
|     qualified physical       | services          | services          |
|     therapists to restore    |                   |                   |
|     bodily function when you | (See Section 5(c) | (See Section 5(c) |
|     have a total or partial  | for hospital      | for hospital      |
|     loss of bodily function  | charges)          | charges)          |
|     due to illness or injury |                   |                   |
|                              |                   |                   |
| -   Occupational therapy is  |                   |                   |
|     limited to services that |                   |                   |
|     assist the member to     |                   |                   |
|     achieve and maintain     |                   |                   |
|     self-care and improved   |                   |                   |
|     functioning in other     |                   |                   |
|     activities of daily      |                   |                   |
|     living                   |                   |                   |
|                              |                   |                   |
| Cardiac rehabilitation       |                   |                   |
| following a heart            |                   |                   |
| transplant, bypass surgery,  |                   |                   |
| or a myocardial infarction.  |                   |                   |
+------------------------------+-------------------+-------------------+
| -   Multidisciplinary        | \$15 per day      | \$15 per day      |
|     rehabilitation is        |                   |                   |
|     provided for up to two   | Nothing for       | Nothing for       |
|     months per condition.    | inpatient         | inpatient         |
|     The two-month limit      | professional      | professional      |
|     applies to all           | services          | services          |
|     prescribed inpatient and |                   |                   |
|     outpatient               | (See Section 5(c) | (See Section 5(c) |
|     multidisciplinary        | for hospital      | for hospital      |
|     rehabilitative services  | charges)          | charges)          |
|     you may receive for the  |                   |                   |
|     same condition, provided |                   |                   |
|     in an organized          |                   |                   |
|     comprehensive            |                   |                   |
|     multidisciplinary        |                   |                   |
|     facility or program.     |                   |                   |
|                              |                   |                   |
| ```{=html}                   |                   |                   |
| <!-- -->                     |                   |                   |
| ```                          |                   |                   |
| -   Outpatient               |                   |                   |
|     multidisciplinary        |                   |                   |
|     rehabilitation           |                   |                   |
|                              |                   |                   |
| -   Inpatient                |                   |                   |
|     multidisciplinary        |                   |                   |
|     rehabilitation at        |                   |                   |
|     hospital or SNF facility |                   |                   |
|     when admitted from home  |                   |                   |
+------------------------------+-------------------+-------------------+
| *Not covered:*               | *All charges*     | *All charges*     |
|                              |                   |                   |
| -   Long-term rehabilitative |                   |                   |
|     therapy                  |                   |                   |
|                              |                   |                   |
| -   Exercise programs        |                   |                   |
+------------------------------+-------------------+-------------------+

+------------------------------+-------------------+-------------------+
| ###### Speech therapy        | You pay --        | You pay -- High   |
|                              | Standard Option   | Option            |
+------------------------------+-------------------+-------------------+
| Benefit is limited to the    | \$15 per          | \$15 per          |
| greater of 20 visits or 2    | outpatient visit  | outpatient visit  |
| months per condition for     |                   |                   |
| each therapy:                | Nothing for       | Nothing for       |
|                              | inpatient         | inpatient         |
| -   Speech therapy by speech | professional      | professional      |
|     pathologists when        | services          | services          |
|     medically necessary      |                   |                   |
|                              | (See Section 5(c) | (See Section 5(c) |
|                              | for hospital      | for hospital      |
|                              | charges)          | charges)          |
+------------------------------+-------------------+-------------------+
| *Not covered:*               | *All charges*     | *All charges*     |
|                              |                   |                   |
| *Speech therapy that is not  |                   |                   |
| medically necessary such     |                   |                   |
| as:*                         |                   |                   |
|                              |                   |                   |
| -   Therapy for educational  |                   |                   |
|     placement or other       |                   |                   |
|     educational purposes     |                   |                   |
|                              |                   |                   |
| -   Training or therapy to   |                   |                   |
|     improve articulation in  |                   |                   |
|     the absence of injury,   |                   |                   |
|     illness, or medical      |                   |                   |
|     condition affecting      |                   |                   |
|     articulation             |                   |                   |
|                              |                   |                   |
| -   Therapy for tongue       |                   |                   |
|     thrust in the absence of |                   |                   |
|     swallowing problems      |                   |                   |
+------------------------------+-------------------+-------------------+
| ##                           |                   |                   |
| #### Hearing services (testi |                   |                   |
| ng, treatment, and supplies) |                   |                   |
+------------------------------+-------------------+-------------------+
| -   Ear and hearing          | \$15 per office   | \$15 per office   |
|     examinations to          | visit             | visit             |
|     determine the need for   |                   |                   |
|     hearing correction       |                   |                   |
|                              |                   |                   |
| -   Hearing testing for      |                   |                   |
|     children through age 17  |                   |                   |
|     (see Preventive care,    |                   |                   |
|     children)                |                   |                   |
+------------------------------+-------------------+-------------------+
| *Not covered:*               | *All charges*     | *All charges*     |
|                              |                   |                   |
| -   All other hearing        |                   |                   |
|     testing                  |                   |                   |
|                              |                   |                   |
| -   Hearing aids and         |                   |                   |
|     supplies                 |                   |                   |
+------------------------------+-------------------+-------------------+
| #                            | You pay --        | You pay -- High   |
| ##### Vision services (testi | Standard Option   | Option            |
| ng, treatment, and supplies) |                   |                   |
+------------------------------+-------------------+-------------------+
| -   Diagnosis and treatment  | \$15 per office   | \$15 per office   |
|     of diseases of the eye   | visit             | visit             |
|                              |                   |                   |
| -   Eye refractions          |                   |                   |
+------------------------------+-------------------+-------------------+
| -   Lenses, frames,          | The cost of       | The cost of       |
|     industrial safety        | lenses, frames,   | lenses, frames,   |
|     glasses and/or medically | industrial safety | industrial safety |
|     necessary contact lenses | glasses, and/or   | glasses, and/or   |
|     every 24 months          | medically         | medically         |
|                              | necessary contact | necessary contact |
| -   Medically necessary      | lenses less \$150 | lenses less \$150 |
|     contact lenses for:      |                   |                   |
|                              |                   |                   |
| ```{=html}                   |                   |                   |
| <!-- -->                     |                   |                   |
| ```                          |                   |                   |
| -   Extremely high degrees   |                   |                   |
|     of near or               |                   |                   |
|     farsightedness           |                   |                   |
|                              |                   |                   |
| -   Distorted corneas which  |                   |                   |
|     limit the best visual    |                   |                   |
|     acuity with glasses      |                   |                   |
|                              |                   |                   |
| -   Visual error of the two  |                   |                   |
|     eyes which are greatly   |                   |                   |
|     different in power       |                   |                   |
+------------------------------+-------------------+-------------------+
| -   You may select           | The cost of       | The cost of       |
|     non-medically necessary  | contact lenses    | contact lenses    |
|     contact lenses instead   | less \$150        | less \$150        |
|     of lenses, frames,       |                   |                   |
|     and/or industrial safety |                   |                   |
|     glasses.                 |                   |                   |
+------------------------------+-------------------+-------------------+
| -   Eyeglasses and contact   | Nothing           | Nothing           |
|     lens(es) after cataract  |                   |                   |
|     surgery with intraocular |                   |                   |
|     lens implant:            |                   |                   |
|                              |                   |                   |
| ```{=html}                   |                   |                   |
| <!-- -->                     |                   |                   |
| ```                          |                   |                   |
| -   Medically necessary      |                   |                   |
|     intraocular lenses       |                   |                   |
|                              |                   |                   |
| -   One pair of eyeglasses   |                   |                   |
|     (regular lenses and      |                   |                   |
|     designated frames); or   |                   |                   |
|                              |                   |                   |
| -   One pair of contact      |                   |                   |
|     lenses                   |                   |                   |
+------------------------------+-------------------+-------------------+
| -   Eyeglasses and contact   | Nothing           | Nothing           |
|     lens(es) after cataract  |                   |                   |
|     surgery not involving    |                   |                   |
|     intraocular lens         |                   |                   |
|     implant:                 |                   |                   |
|                              |                   |                   |
| ```{=html}                   |                   |                   |
| <!-- -->                     |                   |                   |
| ```                          |                   |                   |
| -   One pair of contact      |                   |                   |
|     lenses and/or one pair   |                   |                   |
|     of designated frames and |                   |                   |
|     regular lenses if both   |                   |                   |
|     must be worn at the same |                   |                   |
|     time to provide a        |                   |                   |
|     significant improvement  |                   |                   |
|     in visual acuity or      |                   |                   |
|     binocular vision not     |                   |                   |
|     obtainable with regular  |                   |                   |
|     lenses or contact        |                   |                   |
|     lens(es) alone           |                   |                   |
+------------------------------+-------------------+-------------------+
| What you should know:        | \$60 for single   | \$60 for single   |
|                              | vision and        | vision and        |
| Vision care benefits are     | cosmetic contact  | cosmetic contact  |
| provided to members when     | lenses;           | lenses;           |
| prescribed by Plan           |                   |                   |
| physicians or optometrists   | \$90 for          | \$90 for          |
| and provided at Plan         | multifocal lenses | multifocal lenses |
| facilities and optical       |                   |                   |
| departments.                 |                   |                   |
|                              |                   |                   |
| Your vision care benefits    |                   |                   |
| for lenses, frames,          |                   |                   |
| industrial safety glasses    |                   |                   |
| and/or medically necessary   |                   |                   |
| contact lenses renews every  |                   |                   |
| 24 months from the date you  |                   |                   |
| last received them.          |                   |                   |
+------------------------------+-------------------+-------------------+

*Vision services* (testing, treatment, and supplies)---continued on next
page

+------------------------------+-------------------+-------------------+
| ###### Vision s              | You pay --        | You pay -- High   |
| ervices (testing, treatment, | Standard Option   | Option            |
|  and supplies) *(continued)* |                   |                   |
+------------------------------+-------------------+-------------------+
| If a significant change in   |                   |                   |
| correction occurs in one or  |                   |                   |
| both eyes within 12 months   |                   |                   |
| of the initial exam, we      |                   |                   |
| cover lenses, industrial     |                   |                   |
| safety lenses or medically   |                   |                   |
| necessary contact lenses     |                   |                   |
| with the new correction at   |                   |                   |
| these maximum values.        |                   |                   |
| Replacement coverage is for  |                   |                   |
| the original product type    |                   |                   |
| (contacts or eyeglasses)     |                   |                   |
| only.                        |                   |                   |
|                              |                   |                   |
| If you have selected         |                   |                   |
| non-medically necessary      |                   |                   |
| contact lenses in lieu of    |                   |                   |
| lenses and frames, and/or    |                   |                   |
| industrial safety glasses,   |                   |                   |
| and a significant change in  |                   |                   |
| correction occurs in one or  |                   |                   |
| both eyes within 12 months   |                   |                   |
| of the initial exam, we will |                   |                   |
| cover replacement of         |                   |                   |
| non-medically necessary      |                   |                   |
| contact lenses at these      |                   |                   |
| maximum values. Replacement  |                   |                   |
| coverage is for the original |                   |                   |
| product type (contacts or    |                   |                   |
| eyeglasses) only.            |                   |                   |
+------------------------------+-------------------+-------------------+
| *Not covered:*               | *All charges*     | *All charges*     |
|                              |                   |                   |
| -   Repair or replacement of |                   |                   |
|     eyewear and accessories  |                   |                   |
|     due to loss or damage    |                   |                   |
|                              |                   |                   |
| -   Contacts having no       |                   |                   |
|     refractive value         |                   |                   |
|                              |                   |                   |
| -   Fitting and routine      |                   |                   |
|     follow-up services for   |                   |                   |
|     non-medically indicated  |                   |                   |
|     contact lenses           |                   |                   |
|                              |                   |                   |
| -   Refractions for          |                   |                   |
|     non-medically indicated  |                   |                   |
|     contact lenses           |                   |                   |
|                              |                   |                   |
| -   Vision therapy           |                   |                   |
|     (orthoptics or eye       |                   |                   |
|     exercises)               |                   |                   |
|                              |                   |                   |
| -   Radial keratotomy,       |                   |                   |
|     Photorefractive          |                   |                   |
|     Keratectomy and other    |                   |                   |
|     refractive surgery such  |                   |                   |
|     as Lasik surgery and     |                   |                   |
|     evaluations for these    |                   |                   |
|     procedures               |                   |                   |
|                              |                   |                   |
| -   Visual training          |                   |                   |
|                              |                   |                   |
| -   Low vision aids          |                   |                   |
+------------------------------+-------------------+-------------------+

+------------------------------+-------------------+-------------------+
| ###### Foot care             | You pay --        | You pay -- High   |
|                              | Standard Option   | Option            |
+------------------------------+-------------------+-------------------+
| Routine foot care when you   | \$15 per office   | \$15 per office   |
| are under active treatment   | visit             | visit             |
| for a metabolic or           |                   |                   |
| peripheral vascular disease. |                   |                   |
|                              |                   |                   |
| Note: See Orthopedic and     |                   |                   |
| prosthetic devices for       |                   |                   |
| information on podiatric     |                   |                   |
| shoe inserts.                |                   |                   |
+------------------------------+-------------------+-------------------+
| *Not covered:*               | *All charges*     | *All charges*     |
|                              |                   |                   |
| -   Cutting, trimming or     |                   |                   |
|     removal of corns,        |                   |                   |
|     calluses, or the free    |                   |                   |
|     edge of toenails and     |                   |                   |
|     similar routine          |                   |                   |
|     treatment of conditions  |                   |                   |
|     of the foot, unless      |                   |                   |
|     medically necessary for  |                   |                   |
|     conditions referenced in |                   |                   |
|     foot care section        |                   |                   |
|                              |                   |                   |
| -   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 surgical |                   |                   |
|     means)                   |                   |                   |
+------------------------------+-------------------+-------------------+
| ###### Orthop                |                   |                   |
| edic and prosthetic devices  |                   |                   |
+------------------------------+-------------------+-------------------+
| -   Internal prosthetic      | Nothing           | Nothing           |
|     devices, such as         |                   |                   |
|     artificial joints,       |                   |                   |
|     pacemakers, and          |                   |                   |
|     surgically implanted     |                   |                   |
|     breast implant following |                   |                   |
|     mastectomy. Note: See    |                   |                   |
|     Section 5(c) for payment |                   |                   |
|     information and Section  |                   |                   |
|     5(b) for coverage of the |                   |                   |
|     surgery to insert the    |                   |                   |
|     device.                  |                   |                   |
+------------------------------+-------------------+-------------------+
| -   Externally worn breast   | 50% of our        | 50% of our        |
|     prostheses and surgical  | allowance         | allowance         |
|     bras, including          |                   |                   |
|     necessary replacements,  |                   |                   |
|     following a mastectomy   |                   |                   |
|                              |                   |                   |
| -   Corrective orthopedic    |                   |                   |
|     appliances for nondental |                   |                   |
|     treatment of             |                   |                   |
|     temporomandibular joint  |                   |                   |
|     (TMJ) pain dysfunction   |                   |                   |
|     syndrome                 |                   |                   |
+------------------------------+-------------------+-------------------+
| Maxillo-facial prosthetic    | 20% of our        | 20% of our        |
| devices to restore or manage | allowance         | allowance         |
| head and facial structures   |                   |                   |
| that are defective           |                   |                   |
+------------------------------+-------------------+-------------------+
| When prescribed by a Plan    | 50% of our        | 50% of our        |
| physician, we cover          | allowance         | allowance         |
| orthopedic and other         |                   |                   |
| prosthetic devices not       |                   |                   |
| listed above, including      |                   |                   |
| repairs, adjustments or      |                   |                   |
| replacements other than      |                   |                   |
| those necessitated by misuse |                   |                   |
| or loss.                     |                   |                   |
|                              |                   |                   |
| Notes:                       |                   |                   |
|                              |                   |                   |
| -   We cover only those      |                   |                   |
|     standard items that are  |                   |                   |
|     adequate to meet the     |                   |                   |
|     medical needs of the     |                   |                   |
|     member.                  |                   |                   |
|                              |                   |                   |
| -   Orthopedic and other     |                   |                   |
|     prosthetic devices are   |                   |                   |
|     provided in accordance   |                   |                   |
|     with the Plan\'s DME     |                   |                   |
|     formulary and its        |                   |                   |
|     guidelines.              |                   |                   |
+------------------------------+-------------------+-------------------+

*Orthopedic and prosthetic devices---continued on next page*

+------------------------------+-------------------+-------------------+
| ###### Orthopedic and pros   | You pay --        | You pay -- High   |
| thetic devices *(continued)* | Standard Option   | Option            |
+------------------------------+-------------------+-------------------+
| *Not covered:*               | *All charges*     | *All charges*     |
|                              |                   |                   |
| -   Devices used primarily   |                   |                   |
|     for cosmetic purposes    |                   |                   |
|     that are not necessary   |                   |                   |
|     to control or eliminate  |                   |                   |
|     infection, pain, or      |                   |                   |
|     restore functions such   |                   |                   |
|     as speech, swallowing,   |                   |                   |
|     or chewing               |                   |                   |
|                              |                   |                   |
| -   Artificial larynxes      |                   |                   |
|                              |                   |                   |
| -   Voice machines           |                   |                   |
|                              |                   |                   |
| -   Artificial hearts        |                   |                   |
|                              |                   |                   |
| -   Internally implanted     |                   |                   |
|     insulin pumps            |                   |                   |
|                              |                   |                   |
| -   Dentures (except High    |                   |                   |
|     Option)                  |                   |                   |
|                              |                   |                   |
| -   External and internally  |                   |                   |
|     implanted hearing aids   |                   |                   |
|                              |                   |                   |
| -   Devices, equipment,      |                   |                   |
|     supplies, and            |                   |                   |
|     prosthetics related to   |                   |                   |
|     the treatment of sexual  |                   |                   |
|     dysfunction              |                   |                   |
|                              |                   |                   |
| -   Orthotic devices         |                   |                   |
|     including corrective     |                   |                   |
|     shoes                    |                   |                   |
|                              |                   |                   |
| -   Arch supports            |                   |                   |
|                              |                   |                   |
| -   Foot orthotics           |                   |                   |
|                              |                   |                   |
| -   Heel pads and heel cups  |                   |                   |
|                              |                   |                   |
| -   Lumbosacral supports     |                   |                   |
|                              |                   |                   |
| -   Corsets, trusses,        |                   |                   |
|     elastic stockings,       |                   |                   |
|     support hose, and other  |                   |                   |
|     supportive devices       |                   |                   |
+------------------------------+-------------------+-------------------+

+------------------------------+-------------------+-------------------+
| ###### Dur                   | You pay --        | You pay -- High   |
| able medical equipment (DME) | Standard Option   | Option            |
+------------------------------+-------------------+-------------------+
| When prescribed by a Plan    | 50% of our        | 50% of our        |
| physician, we cover or       | allowance         | allowance         |
| purchase, at our option,     |                   |                   |
| durable medical equipment    |                   |                   |
| intended to be used          |                   |                   |
| repeatedly and in the home.  |                   |                   |
|                              |                   |                   |
| Necessary repairs,           |                   |                   |
| adjustments, and             |                   |                   |
| replacements other than      |                   |                   |
| those necessitated by misuse |                   |                   |
| or loss are also covered.    |                   |                   |
+------------------------------+-------------------+-------------------+
| -   When prescribed in       | 20% of our        | 20% of our        |
|     conjunction with Home    | allowance         | allowance         |
|     Health care that is in   |                   |                   |
|     lieu of inpatient        |                   |                   |
|     hospitalization.         |                   |                   |
+------------------------------+-------------------+-------------------+
| Notes on DME benefits:       |                   |                   |
|                              |                   |                   |
| -   We cover only those      |                   |                   |
|     standard items that are  |                   |                   |
|     adequate to meet the     |                   |                   |
|     medical needs of the     |                   |                   |
|     member.                  |                   |                   |
|                              |                   |                   |
| -   DME-related supplies are |                   |                   |
|     provided in accordance   |                   |                   |
|     with the Plan\'s DME     |                   |                   |
|     formulary and its        |                   |                   |
|     guidelines.              |                   |                   |
|                              |                   |                   |
| -   DME-related supplies for |                   |                   |
|     the treatment of         |                   |                   |
|     diabetes are covered     |                   |                   |
|     under your Prescription  |                   |                   |
|     Drug benefit.            |                   |                   |
+------------------------------+-------------------+-------------------+
| ###### Home health services  |                   |                   |
+------------------------------+-------------------+-------------------+
| If you are homebound and     | Nothing           | Nothing           |
| reside in the service area:  |                   |                   |
|                              |                   |                   |
| -   You may receive home     |                   |                   |
|     health services of       |                   |                   |
|     nurses and health aides, |                   |                   |
|     physical or occupational |                   |                   |
|     therapists, and speech   |                   |                   |
|     and language             |                   |                   |
|     pathologists, when       |                   |                   |
|     prescribed by your plan  |                   |                   |
|     physician, who will      |                   |                   |
|     periodically review the  |                   |                   |
|     program for continuing   |                   |                   |
|     appropriateness and need |                   |                   |
|                              |                   |                   |
| -   Services include         |                   |                   |
|     intravenous therapy, and |                   |                   |
|     medications              |                   |                   |
+------------------------------+-------------------+-------------------+
| *Not covered:*               | *All charges*     | *All charges*     |
|                              |                   |                   |
| -   Nursing care requested   |                   |                   |
|     by, or for the           |                   |                   |
|     convenience of, the      |                   |                   |
|     patient or the patient's |                   |                   |
|     family                   |                   |                   |
|                              |                   |                   |
| -   Home care primarily for  |                   |                   |
|     personal assistance that |                   |                   |
|     does not include a       |                   |                   |
|     medical component and is |                   |                   |
|     not diagnostic,          |                   |                   |
|     therapeutic, or          |                   |                   |
|     rehabilitative           |                   |                   |
|                              |                   |                   |
| -   Services outside our     |                   |                   |
|     service area             |                   |                   |
+------------------------------+-------------------+-------------------+
| ###### Chiropractic          | You pay --        | You pay -- High   |
|                              | Standard Option   | Option            |
+------------------------------+-------------------+-------------------+
| Chiropractic services up to  | \$20 per office   | \$20 per office   |
| 20 visits per calendar year  | visit             | visit             |
|                              |                   |                   |
| -   Services include         |                   |                   |
|     evaluation and           |                   |                   |
|     management,              |                   |                   |
|     musculoskeletal          |                   |                   |
|     treatments, physical     |                   |                   |
|     therapy modalities such  |                   |                   |
|     as hot and cold packs,   |                   |                   |
|     and X-rays               |                   |                   |
|                              |                   |                   |
| Note: You must choose the    |                   |                   |
| chiropractor from our list   |                   |                   |
| of Participating             |                   |                   |
| Chiropractors. Contact us to |                   |                   |
| get the list. You may see a  |                   |                   |
| chiropractor without         |                   |                   |
| referral from your Plan      |                   |                   |
| physician.                   |                   |                   |
+------------------------------+-------------------+-------------------+
| *Not covered:*               | *All charges*     | *All charges*     |
|                              |                   |                   |
| -   Non-neuroskeletal        |                   |                   |
|     disorders                |                   |                   |
|                              |                   |                   |
| -   Vocational               |                   |                   |
|     rehabilitation services  |                   |                   |
|                              |                   |                   |
| -   Laboratory services; MRI |                   |                   |
|     or other type of         |                   |                   |
|     advanced diagnostic      |                   |                   |
|     radiology                |                   |                   |
|                              |                   |                   |
| -   Durable medical          |                   |                   |
|     equipment or supplies    |                   |                   |
|     for use in the home      |                   |                   |
+------------------------------+-------------------+-------------------+
| #                            |                   |                   |
| ##### Alternative treatments |                   |                   |
+------------------------------+-------------------+-------------------+
| No benefit                   | *All charges*     | *All charges*     |
|                              |                   |                   |
| Note: No coverage for any    |                   |                   |
| services such as             |                   |                   |
| acupuncture, naturopathic    |                   |                   |
| services, hypnotherapy.      |                   |                   |
+------------------------------+-------------------+-------------------+
| ###### Educ                  |                   |                   |
| ational classes and programs |                   |                   |
+------------------------------+-------------------+-------------------+
| No benefit                   | *All charges*     | *All charges*     |
+------------------------------+-------------------+-------------------+

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

+---+---+-----------------------+-------------------+-------------+---+---+
|   | * | **Here are some       |                   |             | * |   |
|   | * | important things you  |                   |             | * |   |
|   | I | should keep in mind   |                   |             | I |   |
|   | * | about these           |                   |             | * |   |
|   | * | benefits:**           |                   |             | * |   |
|   |   |                       |                   |             |   |   |
|   | * | -   Please remember   |                   |             | * |   |
|   | * |     that all benefits |                   |             | * |   |
|   | M |     are subject to    |                   |             | M |   |
|   | * |     the definitions,  |                   |             | * |   |
|   | * |     limitations, and  |                   |             | * |   |
|   |   |     exclusions in     |                   |             |   |   |
|   | * |     this brochure and |                   |             | * |   |
|   | * |     we cover them     |                   |             | * |   |
|   | P |     only when we      |                   |             | P |   |
|   | * |     determine they    |                   |             | * |   |
|   | * |     are medically     |                   |             | * |   |
|   |   |     necessary         |                   |             |   |   |
|   | * |                       |                   |             | * |   |
|   | * | -   Plan physicians   |                   |             | * |   |
|   | O |     must provide or   |                   |             | O |   |
|   | * |     arrange your      |                   |             | * |   |
|   | * |     care.             |                   |             | * |   |
|   |   |                       |                   |             |   |   |
|   | * | -   We have no        |                   |             | * |   |
|   | * |     calendar year     |                   |             | * |   |
|   | R |     deductible.       |                   |             | R |   |
|   | * |                       |                   |             | * |   |
|   | * | -   Be sure to read   |                   |             | * |   |
|   |   |     Section 4, *Your  |                   |             |   |   |
|   | * |     costs for covered |                   |             | * |   |
|   | * |     services*, for    |                   |             | * |   |
|   | T |     valuable          |                   |             | T |   |
|   | * |     information about |                   |             | * |   |
|   | * |     how cost sharing  |                   |             | * |   |
|   |   |     works. Also read  |                   |             |   |   |
|   | * |     Section 9 about   |                   |             | * |   |
|   | * |     coordinating      |                   |             | * |   |
|   | A |     benefits with     |                   |             | A |   |
|   | * |     other coverage,   |                   |             | * |   |
|   | * |     including with    |                   |             | * |   |
|   |   |     Medicare.         |                   |             |   |   |
|   | * |                       |                   |             | * |   |
|   | * | -   The amounts       |                   |             | * |   |
|   | N |     listed below are  |                   |             | N |   |
|   | * |     for the charges   |                   |             | * |   |
|   | * |     billed by a       |                   |             | * |   |
|   |   |     physician or      |                   |             |   |   |
|   | * |     other health care |                   |             | * |   |
|   | * |     professional for  |                   |             | * |   |
|   | T |     your surgical     |                   |             | T |   |
|   | * |     care. Look in     |                   |             | * |   |
|   | * |     Section 5(c) for  |                   |             | * |   |
|   |   |     charges           |                   |             |   |   |
|   |   |     associated with   |                   |             |   |   |
|   |   |     the facility      |                   |             |   |   |
|   |   |     (i.e. hospital,   |                   |             |   |   |
|   |   |     surgical center,  |                   |             |   |   |
|   |   |     etc.).            |                   |             |   |   |
|   |   |                       |                   |             |   |   |
|   |   | -   YouR PHYSICIAN    |                   |             |   |   |
|   |   |     must get          |                   |             |   |   |
|   |   |     pre-authorization |                   |             |   |   |
|   |   |     for some surgical |                   |             |   |   |
|   |   |     procedures.       |                   |             |   |   |
|   |   |     please refer to   |                   |             |   |   |
|   |   |     the               |                   |             |   |   |
|   |   |     pre-authorization |                   |             |   |   |
|   |   |     shown in Section  |                   |             |   |   |
|   |   |     3 to be sure      |                   |             |   |   |
|   |   |     which services    |                   |             |   |   |
|   |   |     and surgeries     |                   |             |   |   |
|   |   |     require           |                   |             |   |   |
|   |   |                       |                   |             |   |   |
|   |   |    pre-authorization. |                   |             |   |   |
+---+---+-----------------------+-------------------+-------------+---+---+
| B |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| n |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| f |   |                       |                   |             |   |   |
| i |   |                       |                   |             |   |   |
| t |   |                       |                   |             |   |   |
| D |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| s |   |                       |                   |             |   |   |
| c |   |                       |                   |             |   |   |
| r |   |                       |                   |             |   |   |
| i |   |                       |                   |             |   |   |
| p |   |                       |                   |             |   |   |
| t |   |                       |                   |             |   |   |
| i |   |                       |                   |             |   |   |
| o |   |                       |                   |             |   |   |
| n |   |                       |                   |             |   |   |
+---+---+-----------------------+-------------------+-------------+---+---+
| # |   |                       | You pay --        | You pay --  |   |   |
| # |   |                       | Standard Option   | High Option |   |   |
| # |   |                       |                   |             |   |   |
| # |   |                       |                   |             |   |   |
| # |   |                       |                   |             |   |   |
| # |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| S |   |                       |                   |             |   |   |
| u |   |                       |                   |             |   |   |
| r |   |                       |                   |             |   |   |
| g |   |                       |                   |             |   |   |
| i |   |                       |                   |             |   |   |
| c |   |                       |                   |             |   |   |
| a |   |                       |                   |             |   |   |
| l |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| p |   |                       |                   |             |   |   |
| r |   |                       |                   |             |   |   |
| o |   |                       |                   |             |   |   |
| c |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| d |   |                       |                   |             |   |   |
| u |   |                       |                   |             |   |   |
| r |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| s |   |                       |                   |             |   |   |
+---+---+-----------------------+-------------------+-------------+---+---+
| A |   |                       | \$15 per office   | \$15 per    |   |   |
| c |   |                       | visit for         | office      |   |   |
| o |   |                       | outpatient        | visit for   |   |   |
| m |   |                       | services          | outpatient  |   |   |
| p |   |                       |                   | services    |   |   |
| r |   |                       | Nothing for       |             |   |   |
| e |   |                       | inpatient         | Nothing for |   |   |
| h |   |                       | professional      | inpatient   |   |   |
| e |   |                       | services          | p           |   |   |
| n |   |                       |                   | rofessional |   |   |
| s |   |                       | (See Section 5(c) | services    |   |   |
| i |   |                       | for hospital      |             |   |   |
| v |   |                       | charges)          | (See        |   |   |
| e |   |                       |                   | Section     |   |   |
| r |   |                       |                   | 5(c) for    |   |   |
| a |   |                       |                   | hospital    |   |   |
| n |   |                       |                   | charges)    |   |   |
| g |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| o |   |                       |                   |             |   |   |
| f |   |                       |                   |             |   |   |
| s |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| r |   |                       |                   |             |   |   |
| v |   |                       |                   |             |   |   |
| i |   |                       |                   |             |   |   |
| c |   |                       |                   |             |   |   |
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| s |   |                       |                   |             |   |   |
| , |   |                       |                   |             |   |   |
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| s |   |                       |                   |             |   |   |
| : |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| - |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
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| p |   |                       |                   |             |   |   |
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|   |   |                       |                   |             |   |   |
| - |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| T |   |                       |                   |             |   |   |
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|   |   |                       |                   |             |   |   |
| o |   |                       |                   |             |   |   |
| f |   |                       |                   |             |   |   |
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|   |   |                       |                   |             |   |   |
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| c |   |                       |                   |             |   |   |
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| m |   |                       |                   |             |   |   |
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+---+---+-----------------------+-------------------+-------------+---+---+

*Surgical procedures---continued on next page*

+-----------------------------+-------------------+--------------------+
| Surgical procedures         | You pay --        | You pay -- High    |
| *(continued)*               | Standard Option   | Option             |
+-----------------------------+-------------------+--------------------+
| -   Insertion of internal   | \$15 per office   | \$15 per office    |
|     prosthetic devices. See | visit for         | visit for          |
|     Section 5(a) Orthopedic | outpatient        | outpatient         |
|     and prosthetic devices  | services          | services           |
|     for coverage            |                   |                    |
|     information             | Nothing for       | Nothing for        |
|                             | inpatient         | inpatient          |
| -   Voluntary sterilization | professional      | professional       |
|     (e.g., Tubal ligation,  | services          | services           |
|     Vasectomy)              |                   |                    |
|                             | (See Section 5(c) | (See Section 5(c)  |
| -   Surgically implanted    | for hospital      | for hospital       |
|     time-release            | charges)          | charges)           |
|     contraceptives and      |                   |                    |
|     intrauterine devices    |                   |                    |
|     (IUDs)                  |                   |                    |
|                             |                   |                    |
| -   Other implanted         |                   |                    |
|     time-release drugs      |                   |                    |
|                             |                   |                    |
| Note: In addition to the    |                   |                    |
| office visit copayment, we  |                   |                    |
| charge the prescription     |                   |                    |
| drug copayment for the drug |                   |                    |
| or device.                  |                   |                    |
|                             |                   |                    |
| -   Treatment of burns      |                   |                    |
+-----------------------------+-------------------+--------------------+
| *Not covered:*              | *All charges*     | *All charges*      |
|                             |                   |                    |
| -   Reversal of voluntary   |                   |                    |
|     sterilization           |                   |                    |
+-----------------------------+-------------------+--------------------+
| ###                         |                   |                    |
| ### Reconstructive surgery  |                   |                    |
+-----------------------------+-------------------+--------------------+
| -   Surgery to correct a    | \$15 per office   | \$15 per office    |
|     functional defect       | visit for         | visit for          |
|                             | outpatient        | outpatient         |
| -   Surgery to correct a    | services          | services           |
|     condition caused by     |                   |                    |
|     injury or illness if:   | Nothing for       | Nothing for        |
|                             | inpatient         | inpatient          |
| ```{=html}                  | professional      | professional       |
| <!-- -->                    | services          | services           |
| ```                         |                   |                    |
| -   the condition produced  | (See Section 5(c) | (See Section 5(c)  |
|     a major effect on the   | for hospital      | for hospital       |
|     member's appearance;    | charges)          | charges)           |
|     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,           |                   |                    |
|     birthmarks, webbed      |                   |                    |
|     fingers, and webbed     |                   |                    |
|     toes.                   |                   |                    |
+-----------------------------+-------------------+--------------------+

*Reconstructive surgery---continued on next page*

+-----------------------------+-------------------+--------------------+
| ###### Reconstru            | You pay --        | You pay -- High    |
| ctive surgery *(continued)* | Standard Option   | Option             |
+-----------------------------+-------------------+--------------------+
| -   All stages of breast    | Nothing for       | Nothing for        |
|     reconstruction surgery  | inpatient         | inpatient          |
|     following a mastectomy, | professional      | professional       |
|     such as:                | services          | services           |
|                             |                   |                    |
| ```{=html}                  | (See Section 5(c) | (See Section 5(c)  |
| <!-- -->                    | for hospital      | for hospital       |
| ```                         | charges)          | charges)           |
| -   surgery to produce a    |                   |                    |
|     symmetrical appearance  |                   |                    |
|     on the other breast;    |                   |                    |
|                             |                   |                    |
| -   treatment of any        |                   |                    |
|     physical complications, |                   |                    |
|     such as lymphedemas;    |                   |                    |
|     and                     |                   |                    |
|                             |                   |                    |
| -   breast prostheses and   |                   |                    |
|     surgical bras and       |                   |                    |
|     replacements covered at |                   |                    |
|     no charge (see          |                   |                    |
|     Prosthetic devices).    |                   |                    |
|                             |                   |                    |
| Note: If you need a         |                   |                    |
| mastectomy, you may choose  |                   |                    |
| to have the procedure       |                   |                    |
| performed on an inpatient   |                   |                    |
| basis and remain in the     |                   |                    |
| hospital up to 48 hours     |                   |                    |
| after the procedure.        |                   |                    |
+-----------------------------+-------------------+--------------------+
| *Not covered:*              | *All charges*     | *All charges*      |
|                             |                   |                    |
| -   Cosmetic surgery -- any |                   |                    |
|     surgical procedure (or  |                   |                    |
|     any portion of a        |                   |                    |
|     procedure) performed    |                   |                    |
|     primarily to improve    |                   |                    |
|     physical appearance     |                   |                    |
|     through change in       |                   |                    |
|     bodily form             |                   |                    |
|                             |                   |                    |
| -   Surgeries related to    |                   |                    |
|     sex transformation      |                   |                    |
+-----------------------------+-------------------+--------------------+
| ###### Oral                 |                   |                    |
|  and maxillofacial surgery  |                   |                    |
+-----------------------------+-------------------+--------------------+
| Oral surgical procedures,   | \$15 per office   | \$15 per office    |
| limited to:                 | visit for         | visit for          |
|                             | outpatient        | outpatient         |
| -   Reduction of fractures  | services          | services           |
|     of the jaws or facial   |                   |                    |
|     bones                   | Nothing for       | Nothing for        |
|                             | inpatient         | inpatient          |
| -   Surgical correction of  | professional      | professional       |
|     cleft lip, cleft        | services          | services           |
|     palate, or severe       |                   |                    |
|     functional malocclusion | (See Section 5(c) | (See Section 5(c)  |
|                             | for hospital      | for hospital       |
| -   Removal of stones from  | charges)          | charges)           |
|     salivary ducts          |                   |                    |
|                             |                   |                    |
| -   Excision of leukoplakia |                   |                    |
|     or malignancies         |                   |                    |
|                             |                   |                    |
| -   Excision of cysts and   |                   |                    |
|     incision of abscesses   |                   |                    |
|     when done as            |                   |                    |
|     independent procedures  |                   |                    |
|                             |                   |                    |
| -   Medical and surgical    |                   |                    |
|     treatment of TMJ        |                   |                    |
|     (non-dental in origin)  |                   |                    |
|                             |                   |                    |
| -   Other surgical          |                   |                    |
|     procedures that do not  |                   |                    |
|     involve the teeth or    |                   |                    |
|     their supporting        |                   |                    |
|     structures              |                   |                    |
+-----------------------------+-------------------+--------------------+
| *Not covered:*              | *All charges*     | *All charges*      |
|                             |                   |                    |
| -   Oral implants and       |                   |                    |
|     transplants             |                   |                    |
|                             |                   |                    |
| -   Procedures that involve |                   |                    |
|     the teeth or their      |                   |                    |
|     supporting structures   |                   |                    |
|     (such as the            |                   |                    |
|     periodontal membrane,   |                   |                    |
|     gingiva, and alveolar   |                   |                    |
|     bone)                   |                   |                    |
+-----------------------------+-------------------+--------------------+
| ####                        | You pay --        | You pay -- High    |
| ## Organ/tissue transplants | Standard Option   | Option             |
+-----------------------------+-------------------+--------------------+
| Limited to:                 | \$15 per office   | \$15 per office    |
|                             | visit for         | visit for          |
| -   Cornea                  | outpatient        | outpatient         |
|                             | services          | services           |
| -   Heart                   |                   |                    |
|                             | Nothing for       | Nothing for        |
| -   Heart/Lung              | inpatient         | inpatient          |
|                             | professional      | professional       |
| -   Kidney                  | services          | services           |
|                             |                   |                    |
| -   Kidney/Pancreas         | (See Section 5(c) | (See Section 5(c)  |
|                             | for hospital      | for hospital       |
| -   Liver                   | charges)          | charges)           |
|                             |                   |                    |
| -   Lung: Single -- Double  |                   |                    |
|                             |                   |                    |
| -   Pancreas                |                   |                    |
|                             |                   |                    |
| -   Stem cell               |                   |                    |
|                             |                   |                    |
| -   Autologous tandem       |                   |                    |
|                             |                   |                    |
| -   Allogeneic (donor) bone |                   |                    |
|     marrow transplants      |                   |                    |
|                             |                   |                    |
| -   Autologous bone marrow  |                   |                    |
|     transplants (autologous |                   |                    |
|     stem cell and           |                   |                    |
|     peripheral stem cell    |                   |                    |
|     support) for the        |                   |                    |
|     following conditions:   |                   |                    |
|     acute lymphocytic or    |                   |                    |
|     non-lymphocytic         |                   |                    |
|     leukemia; advanced      |                   |                    |
|     Hodgkin\'s lymphoma;    |                   |                    |
|     advanced non-Hodgkin\'s |                   |                    |
|     lymphoma; advanced      |                   |                    |
|     neuroblastoma; breast   |                   |                    |
|     cancer; multiple        |                   |                    |
|     myeloma; epithelial     |                   |                    |
|     ovarian cancer; and     |                   |                    |
|     testicular,             |                   |                    |
|     mediastinal,            |                   |                    |
|     retroperitoneal and     |                   |                    |
|     ovarian germ cell       |                   |                    |
|     tumors                  |                   |                    |
|                             |                   |                    |
| -   Intestinal transplants  |                   |                    |
|     (small intestine) and   |                   |                    |
|     the small intestine     |                   |                    |
|     with the liver or small |                   |                    |
|     intestine with multiple |                   |                    |
|     organs such as the      |                   |                    |
|     liver, stomach, and     |                   |                    |
|     pancreas                |                   |                    |
|                             |                   |                    |
| Note: We cover related      |                   |                    |
| medical and hospital        |                   |                    |
| expenses of the donor when  |                   |                    |
| we cover your transplant.   |                   |                    |
+-----------------------------+-------------------+--------------------+
| *Not covered:*              | *All charges*     | *All charges*      |
|                             |                   |                    |
| -   Donor screening tests   |                   |                    |
|     and donor search        |                   |                    |
|     expenses, except those  |                   |                    |
|     performed for the       |                   |                    |
|     actual donor            |                   |                    |
|                             |                   |                    |
| -   Implants of non-human   |                   |                    |
|     or artificial organs    |                   |                    |
|                             |                   |                    |
| -   Transplants not listed  |                   |                    |
|     as covered              |                   |                    |
+-----------------------------+-------------------+--------------------+
| ###### Anesthesia           | You pay --        | You pay -- High    |
|                             | Standard Option   | Option             |
+-----------------------------+-------------------+--------------------+
| Professional services       | Nothing for       | Nothing for        |
| provided in --              | inpatient         | inpatient          |
|                             | professional      | professional       |
| -   Hospital (inpatient)    | services          | services           |
|                             |                   |                    |
| -   Hospital outpatient     | (See Section 5(c) | (See Section 5(c)  |
|     department              | for hospital      | for hospital       |
|                             | charges)          | charges)           |
| -   Ambulatory surgical     |                   |                    |
|     center                  |                   |                    |
|                             |                   |                    |
| -   Office                  |                   |                    |
+-----------------------------+-------------------+--------------------+

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

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

Inpatient hospital---continued on next page

+--------------------------------+------------------+------------------+
| Inpatient hospital             | You pay --       | You pay -- High  |
| *(continued)*                  | Standard Option  | Option           |
+--------------------------------+------------------+------------------+
| Other hospital services and    | \$100 per        | \$100 per        |
| supplies, such as:             | admission        | admission        |
|                                |                  |                  |
| -   Operating, recovery,       |                  |                  |
|     maternity, and other       |                  |                  |
|     treatment rooms            |                  |                  |
|                                |                  |                  |
| -   Prescribed drugs and       |                  |                  |
|     medicines                  |                  |                  |
|                                |                  |                  |
| -   Diagnostic laboratory      |                  |                  |
|     tests and X-rays           |                  |                  |
|                                |                  |                  |
| -   Administration of blood    |                  |                  |
|     and blood products         |                  |                  |
|                                |                  |                  |
| -   Blood or blood plasma      |                  |                  |
|                                |                  |                  |
| -   Pre-surgical testing       |                  |                  |
|                                |                  |                  |
| -   Costs associated with      |                  |                  |
|     blood donated by you for a |                  |                  |
|     scheduled covered surgery  |                  |                  |
|                                |                  |                  |
| -   Dressings, splints, casts, |                  |                  |
|     and sterile tray services  |                  |                  |
|                                |                  |                  |
| -   Medical supplies and       |                  |                  |
|     equipment, including       |                  |                  |
|     oxygen                     |                  |                  |
|                                |                  |                  |
| -   Anesthetics, including     |                  |                  |
|     nurse anesthetist services |                  |                  |
|                                |                  |                  |
| -   Take-home items            |                  |                  |
|                                |                  |                  |
| Note: You may receive covered  |                  |                  |
| hospital services for certain  |                  |                  |
| dental procedures if a Plan    |                  |                  |
| physician determines you need  |                  |                  |
| to be hospitalized for reasons |                  |                  |
| unrelated to the dental        |                  |                  |
| procedure. The conditions for  |                  |                  |
| which we will provide          |                  |                  |
| hospitalization include        |                  |                  |
| hemophilia and heart disease.  |                  |                  |
| The need for anesthesia, by    |                  |                  |
| itself, is not such a          |                  |                  |
| condition.                     |                  |                  |
+--------------------------------+------------------+------------------+
| *Not covered:*                 | *All charges*    | *All charges*    |
|                                |                  |                  |
| -   Custodial care             |                  |                  |
|                                |                  |                  |
| -   Non-covered facilities     |                  |                  |
|                                |                  |                  |
| -   Personal comfort items,    |                  |                  |
|     such as telephone,         |                  |                  |
|     television, barber         |                  |                  |
|     services, guest meals and  |                  |                  |
|     beds                       |                  |                  |
|                                |                  |                  |
| -   Private nursing care       |                  |                  |
|                                |                  |                  |
| -   Cord blood procurement and |                  |                  |
|     storage for possible       |                  |                  |
|     future need or for a       |                  |                  |
|     yet-to-be determined       |                  |                  |
|     member recipient           |                  |                  |
|                                |                  |                  |
| -   Any inpatient dental       |                  |                  |
|     procedures                 |                  |                  |
+--------------------------------+------------------+------------------+
| ###### Outpatient hospital     | You pay --       | You pay -- High  |
|  or ambulatory surgical center | Standard Option  | Option           |
+--------------------------------+------------------+------------------+
| -   Operating, recovery, and   | Nothing          | Nothing          |
|     other treatment rooms      |                  |                  |
|                                |                  |                  |
| -   Prescribed drugs and       |                  |                  |
|     medicines                  |                  |                  |
|                                |                  |                  |
| -   Diagnostic laboratory      |                  |                  |
|     tests, X-rays, and         |                  |                  |
|     pathology services         |                  |                  |
|                                |                  |                  |
| -   Administration of blood    |                  |                  |
|     and blood products         |                  |                  |
|                                |                  |                  |
| -   Blood and blood plasma     |                  |                  |
|                                |                  |                  |
| -   Costs associated with      |                  |                  |
|     blood donated by you for a |                  |                  |
|     scheduled covered surgery  |                  |                  |
|                                |                  |                  |
| -   Dressings, casts, and      |                  |                  |
|     sterile tray services      |                  |                  |
|                                |                  |                  |
| -   Medical supplies           |                  |                  |
|                                |                  |                  |
| -   Anesthetics and anesthesia |                  |                  |
|     service                    |                  |                  |
|                                |                  |                  |
| Note: Your regular             |                  |                  |
| prescription drug copayment    |                  |                  |
| will apply for prescriptions   |                  |                  |
| purchased at Plan pharmacies.  |                  |                  |
+--------------------------------+------------------+------------------+
| *Not covered:*                 | *All charges*    | *All charges*    |
|                                |                  |                  |
| -   Collection, processing,    |                  |                  |
|     and storage of blood       |                  |                  |
|     donated by donors          |                  |                  |
|     designated by you or a     |                  |                  |
|     family member              |                  |                  |
|                                |                  |                  |
| -   Cord blood procurement and |                  |                  |
|     storage for possible       |                  |                  |
|     future need of for a       |                  |                  |
|     yet-to-be determined       |                  |                  |
|     member recipient           |                  |                  |
+--------------------------------+------------------+------------------+
| ######                         |                  |                  |
|  Skilled nursing care benefits |                  |                  |
+--------------------------------+------------------+------------------+
| Up to 100 days per calendar    | Nothing          | Nothing          |
| year when full-time skilled    |                  |                  |
| nursing care is necessary and  |                  |                  |
| confinement in a skilled       |                  |                  |
| nursing facility is medically  |                  |                  |
| appropriate. We cover the      |                  |                  |
| following:                     |                  |                  |
|                                |                  |                  |
| -   Room, board, and general   |                  |                  |
|     nursing care               |                  |                  |
|                                |                  |                  |
| -   Prescribed drugs and their |                  |                  |
|     administration,            |                  |                  |
|     biologicals, supplies, and |                  |                  |
|     equipment ordinarily       |                  |                  |
|     provided or arranged by    |                  |                  |
|     the skilled nursing        |                  |                  |
|     facility                   |                  |                  |
+--------------------------------+------------------+------------------+
| *Not covered:*                 | *All charges*    | *All charges*    |
|                                |                  |                  |
| -   Custodial care             |                  |                  |
|                                |                  |                  |
| -   Care in an intermediate    |                  |                  |
|     care facility              |                  |                  |
|                                |                  |                  |
| -   Personal comfort items     |                  |                  |
|     such as telephone or       |                  |                  |
|     television                 |                  |                  |
+--------------------------------+------------------+------------------+

+--------------------------------+------------------+------------------+
| ###### Hospice care            | You pay --       | You pay -- High  |
|                                | Standard Option  | Option           |
+--------------------------------+------------------+------------------+
| Supportive and palliative care | Nothing          | Nothing          |
| for a terminally ill member:   |                  |                  |
|                                |                  |                  |
| -   You must reside in the     |                  |                  |
|     service area               |                  |                  |
|                                |                  |                  |
| -   Services are provided in   |                  |                  |
|     the home                   |                  |                  |
|                                |                  |                  |
| -   Services are provided in a |                  |                  |
|     Plan approved hospice      |                  |                  |
|     facility                   |                  |                  |
|                                |                  |                  |
| Services include inpatient     |                  |                  |
| care, outpatient care, and     |                  |                  |
| family counseling. A Plan      |                  |                  |
| physician must certify that    |                  |                  |
| you have a terminal illness,   |                  |                  |
| with a life expectancy of      |                  |                  |
| approximately six months or    |                  |                  |
| less.                          |                  |                  |
|                                |                  |                  |
| Note: Hospice is a program for |                  |                  |
| caring for the terminally ill  |                  |                  |
| that emphasizes supportive     |                  |                  |
| services, such as home care    |                  |                  |
| and pain control, rather than  |                  |                  |
| curative care of the terminal  |                  |                  |
| illness. A person who is       |                  |                  |
| terminally ill may elect to    |                  |                  |
| receive hospice benefits.      |                  |                  |
| These palliative and           |                  |                  |
| supportive services include    |                  |                  |
| nursing care, medical social   |                  |                  |
| services, physician services,  |                  |                  |
| and short-term inpatient care  |                  |                  |
| for pain control and acute and |                  |                  |
| chronic symptom management. We |                  |                  |
| also provide counseling and    |                  |                  |
| bereavement services for the   |                  |                  |
| individual and family members, |                  |                  |
| and therapy for purposes of    |                  |                  |
| symptom control to enable the  |                  |                  |
| person to continue life with   |                  |                  |
| as little disruption as        |                  |                  |
| possible. If you make a        |                  |                  |
| hospice election, you are not  |                  |                  |
| entitled to receive other      |                  |                  |
| health care services that are  |                  |                  |
| related to the terminal        |                  |                  |
| illness. If you have made a    |                  |                  |
| hospice election, you may      |                  |                  |
| revoke that election at any    |                  |                  |
| time, and your standard health |                  |                  |
| benefits will be covered.      |                  |                  |
+--------------------------------+------------------+------------------+
| *Not covered:*                 | *All charges*    | *All charges*    |
|                                |                  |                  |
| -   Private duty nursing       |                  |                  |
|     (independent nursing)      |                  |                  |
|                                |                  |                  |
| -   Homemaker services         |                  |                  |
+--------------------------------+------------------+------------------+
| ###### Ambulance               |                  |                  |
+--------------------------------+------------------+------------------+
| -   Local professional         | \$75 per         | \$75 per         |
|     ambulance service when     | transport        | transport        |
|     medically appropriate      |                  |                  |
+--------------------------------+------------------+------------------+
| *Not covered:*                 | *All charges*    | *All charges*    |
|                                |                  |                  |
| -   Transports that we         |                  |                  |
|     determine are not          |                  |                  |
|     medically necessary        |                  |                  |
+--------------------------------+------------------+------------------+

## Section 5(d) Emergency services/accidents

+---+---+----------------------------+-----------------+------------+---+---+---+
| # | * | **Here are some important  |                 |            | * |   |   |
| # | * | things you should keep in  |                 |            | * |   |   |
| # | I | mind about these           |                 |            | I |   |   |
| # | * | benefits:**                |                 |            | * |   |   |
| # | * |                            |                 |            | * |   |   |
|   |   | -   Please remember that   |                 |            |   |   |   |
|   | * |     all benefits are       |                 |            | * |   |   |
|   | * |     subject to the         |                 |            | * |   |   |
|   | M |     definitions,           |                 |            | M |   |   |
|   | * |     limitations, and       |                 |            | * |   |   |
|   | * |     exclusions in this     |                 |            | * |   |   |
|   |   |     brochure and we cover  |                 |            |   |   |   |
|   | * |     them only when we      |                 |            | * |   |   |
|   | * |     determine they are     |                 |            | * |   |   |
|   | P |     medically necessary.   |                 |            | P |   |   |
|   | * |                            |                 |            | * |   |   |
|   | * | -   We have no calendar    |                 |            | * |   |   |
|   |   |     year deductible.       |                 |            |   |   |   |
|   | * |                            |                 |            | * |   |   |
|   | * | -   Be sure to read        |                 |            | * |   |   |
|   | O |     Section 4, *Your costs |                 |            | O |   |   |
|   | * |     for covered services,* |                 |            | * |   |   |
|   | * |     for valuable           |                 |            | * |   |   |
|   |   |     information about how  |                 |            |   |   |   |
|   | * |     cost sharing works.    |                 |            | * |   |   |
|   | * |     Also read Section 9    |                 |            | * |   |   |
|   | R |     about coordinating     |                 |            | R |   |   |
|   | * |     benefits with other    |                 |            | * |   |   |
|   | * |     coverage, including    |                 |            | * |   |   |
|   |   |     with Medicare.         |                 |            |   |   |   |
|   | * |                            |                 |            | * |   |   |
|   | * | #####                      |                 |            | * |   |   |
|   | T |                            |                 |            | T |   |   |
|   | * |                            |                 |            | * |   |   |
|   | * |                            |                 |            | * |   |   |
|   |   |                            |                 |            |   |   |   |
|   | * |                            |                 |            | * |   |   |
|   | * |                            |                 |            | * |   |   |
|   | A |                            |                 |            | A |   |   |
|   | * |                            |                 |            | * |   |   |
|   | * |                            |                 |            | * |   |   |
|   |   |                            |                 |            |   |   |   |
|   | * |                            |                 |            | * |   |   |
|   | * |                            |                 |            | * |   |   |
|   | N |                            |                 |            | N |   |   |
|   | * |                            |                 |            | * |   |   |
|   | * |                            |                 |            | * |   |   |
|   |   |                            |                 |            |   |   |   |
|   | * |                            |                 |            | * |   |   |
|   | * |                            |                 |            | * |   |   |
|   | T |                            |                 |            | T |   |   |
|   | * |                            |                 |            | * |   |   |
|   | * |                            |                 |            | * |   |   |
+---+---+----------------------------+-----------------+------------+---+---+---+
| * |   |                            |                 |            |   |   |   |
| * |   |                            |                 |            |   |   |   |
| W |   |                            |                 |            |   |   |   |
| h |   |                            |                 |            |   |   |   |
| a |   |                            |                 |            |   |   |   |
| t |   |                            |                 |            |   |   |   |
| i |   |                            |                 |            |   |   |   |
| s |   |                            |                 |            |   |   |   |
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| m |   |                            |                 |            |   |   |   |
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| c |   |                            |                 |            |   |   |   |
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| ? |   |                            |                 |            |   |   |   |
| * |   |                            |                 |            |   |   |   |
| * |   |                            |                 |            |   |   |   |
|   |   |                            |                 |            |   |   |   |
| A |   |                            |                 |            |   |   |   |
| m |   |                            |                 |            |   |   |   |
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| d |   |                            |                 |            |   |   |   |
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| t |   |                            |                 |            |   |   |   |
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| n |   |                            |                 |            |   |   |   |
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| p |   |                            |                 |            |   |   |   |
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+---+---+----------------------------+-----------------+------------+---+---+---+
| B |   |                            |                 |            |   |   |   |
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+---+---+----------------------------+-----------------+------------+---+---+---+
| E |   |                            | You pay --      | You Pay -- |   |   |   |
| m |   |                            | Standard Option | High       |   |   |   |
| e |   |                            |                 | Option     |   |   |   |
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+---+---+----------------------------+-----------------+------------+---+---+---+
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| \ |   |                            |                 |            |   |   |   |
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+---+---+----------------------------+-----------------+------------+---+---+---+
| - |   |                            | \$15 per office | \$15 per   |   |   |   |
|   |   |                            | visit           | office     |   |   |   |
|   |   |                            |                 | visit      |   |   |   |
|   |   |                            |                 |            |   |   |   |
| A |   |                            |                 |            |   |   |   |
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| p |   |                            |                 |            |   |   |   |
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|   |   |                            |                 |            |   |   |   |
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|   |   |                            |                 |            |   |   |   |
|   |   |                            |                 |            |   |   |   |
| o |   |                            |                 |            |   |   |   |
| f |   |                            |                 |            |   |   |   |
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| e |   |                            |                 |            |   |   |   |
+---+---+----------------------------+-----------------+------------+---+---+---+
| - |   |                            | \$15 per office | \$15 per   |   |   |   |
|   |   |                            | visit           | office     |   |   |   |
|   |   |                            |                 | visit      |   |   |   |
|   |   |                            |                 |            |   |   |   |
| A |   |                            |                 |            |   |   |   |
| t |   |                            |                 |            |   |   |   |
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| . |   |                            |                 |            |   |   |   |
+---+---+----------------------------+-----------------+------------+---+---+---+
| E |   |                            | \$75 per office | \$75 per   |   |   |   |
| m |   |                            | visit           | office     |   |   |   |
| e |   |                            |                 | visit      |   |   |   |
| r |   |                            |                 |            |   |   |   |
| g |   |                            |                 |            |   |   |   |
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| n |   |                            |                 |            |   |   |   |
| a |   |                            |                 |            |   |   |   |
| n |   |                            |                 |            |   |   |   |
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| n |   |                            |                 |            |   |   |   |
| - |   |                            |                 |            |   |   |   |
| P |   |                            |                 |            |   |   |   |
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| a |   |                            |                 |            |   |   |   |
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| h |   |                            |                 |            |   |   |   |
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| s |   |                            |                 |            |   |   |   |
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| a |   |                            |                 |            |   |   |   |
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| e |   |                            |                 |            |   |   |   |
| r |   |                            |                 |            |   |   |   |
| g |   |                            |                 |            |   |   |   |
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| n |   |                            |                 |            |   |   |   |
| c |   |                            |                 |            |   |   |   |
| y |   |                            |                 |            |   |   |   |
| d |   |                            |                 |            |   |   |   |
| e |   |                            |                 |            |   |   |   |
| p |   |                            |                 |            |   |   |   |
| a |   |                            |                 |            |   |   |   |
| r |   |                            |                 |            |   |   |   |
| t |   |                            |                 |            |   |   |   |
| m |   |                            |                 |            |   |   |   |
| e |   |                            |                 |            |   |   |   |
| n |   |                            |                 |            |   |   |   |
| t |   |                            |                 |            |   |   |   |
| o |   |                            |                 |            |   |   |   |
| r |   |                            |                 |            |   |   |   |
| u |   |                            |                 |            |   |   |   |
| r |   |                            |                 |            |   |   |   |
| g |   |                            |                 |            |   |   |   |
| e |   |                            |                 |            |   |   |   |
| n |   |                            |                 |            |   |   |   |
| t |   |                            |                 |            |   |   |   |
| c |   |                            |                 |            |   |   |   |
| a |   |                            |                 |            |   |   |   |
| r |   |                            |                 |            |   |   |   |
| e |   |                            |                 |            |   |   |   |
| c |   |                            |                 |            |   |   |   |
| e |   |                            |                 |            |   |   |   |
| n |   |                            |                 |            |   |   |   |
| t |   |                            |                 |            |   |   |   |
| e |   |                            |                 |            |   |   |   |
| r |   |                            |                 |            |   |   |   |
+---+---+----------------------------+-----------------+------------+---+---+---+
| * |   |                            | *All charges*   | *All       |   |   |   |
| N |   |                            |                 | charges*   |   |   |   |
| o |   |                            |                 |            |   |   |   |
| t |   |                            |                 |            |   |   |   |
| c |   |                            |                 |            |   |   |   |
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| d |   |                            |                 |            |   |   |   |
| : |   |                            |                 |            |   |   |   |
| * |   |                            |                 |            |   |   |   |
|   |   |                            |                 |            |   |   |   |
| - |   |                            |                 |            |   |   |   |
|   |   |                            |                 |            |   |   |   |
|   |   |                            |                 |            |   |   |   |
|   |   |                            |                 |            |   |   |   |
| E |   |                            |                 |            |   |   |   |
| l |   |                            |                 |            |   |   |   |
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| i |   |                            |                 |            |   |   |   |
| v |   |                            |                 |            |   |   |   |
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|   |   |                            |                 |            |   |   |   |
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|   |   |                            |                 |            |   |   |   |
|   |   |                            |                 |            |   |   |   |
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| a |   |                            |                 |            |   |   |   |
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|   |   |                            |                 |            |   |   |   |
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|   |   |                            |                 |            |   |   |   |
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|   |   |                            |                 |            |   |   |   |
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| r |   |                            |                 |            |   |   |   |
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| n |   |                            |                 |            |   |   |   |
| c |   |                            |                 |            |   |   |   |
| y |   |                            |                 |            |   |   |   |
|   |   |                            |                 |            |   |   |   |
|   |   |                            |                 |            |   |   |   |
|   |   |                            |                 |            |   |   |   |
|   |   |                            |                 |            |   |   |   |
| c |   |                            |                 |            |   |   |   |
| a |   |                            |                 |            |   |   |   |
| r |   |                            |                 |            |   |   |   |
| e |   |                            |                 |            |   |   |   |
+---+---+----------------------------+-----------------+------------+---+---+---+

+---------------------------------+-----------------+-----------------+
| Emergency outside our service   | You pay --      | You pay -- High |
| are                             | Standard Option | Option          |
| a[]{#__RefHeading___Toc84322600 |                 |                 |
| .anchor}                        |                 |                 |
+---------------------------------+-----------------+-----------------+
| Emergency care as an outpatient |                 |                 |
| or inpatient at a hospital,     |                 |                 |
| including physicians' services  |                 |                 |
+---------------------------------+-----------------+-----------------+
| -   At a physician's office     | \$15 per office | \$15 per office |
|                                 | visit           | visit           |
+---------------------------------+-----------------+-----------------+
| -   At an urgent care center    | \$15 per office | \$15 per office |
|                                 | visit           | visit           |
+---------------------------------+-----------------+-----------------+
| -   In a hospital emergency     | \$75 per office | \$75 per office |
|     department                  | visit           | visit           |
+---------------------------------+-----------------+-----------------+
| -   In a Kaiser Foundation      | The amount you  | The amount you  |
|     hospital in another Kaiser  | would be        | would be        |
|     Foundation Health Plan      | charged if you  | charged if you  |
|     service area                | were a member   | were a member   |
|                                 | in that service | in that service |
|                                 | area            | area            |
+---------------------------------+-----------------+-----------------+
| Notes:                          |                 |                 |
|                                 |                 |                 |
| -   If you are transferred from |                 |                 |
|     a licensed emergency        |                 |                 |
|     department to an            |                 |                 |
|     observation bed, there is   |                 |                 |
|     no additional copayment.    |                 |                 |
|                                 |                 |                 |
| -   If you are directly         |                 |                 |
|     admitted as an inpatient    |                 |                 |
|     after being seen in an      |                 |                 |
|     emergency department or     |                 |                 |
|     from an observation bed,    |                 |                 |
|     your emergency department   |                 |                 |
|     copayment will be waived    |                 |                 |
|     and your inpatient copay    |                 |                 |
|     will apply.                 |                 |                 |
|                                 |                 |                 |
| -   See the Travel Benefit for  |                 |                 |
|     coverage of continuing or   |                 |                 |
|     follow-up care.             |                 |                 |
+---------------------------------+-----------------+-----------------+
| *Not covered:*                  | *All charges*   | *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                        |                 |                 |
+---------------------------------+-----------------+-----------------+
| Ambulanc                        |                 |                 |
| e[]{#__RefHeading___Toc84322601 |                 |                 |
| .anchor}                        |                 |                 |
+---------------------------------+-----------------+-----------------+
| Professional ambulance service, | \$75 per        | \$75 per        |
| including air ambulance, when   | transport       | transport       |
| medically appropriate. See      |                 |                 |
| Section 5(c) for non-emergency  |                 |                 |
| service.                        |                 |                 |
+---------------------------------+-----------------+-----------------+
| *Not covered:*                  | *All charges*   | *All charges*   |
|                                 |                 |                 |
| -   Transports we determine are |                 |                 |
|     not medically necessary     |                 |                 |
+---------------------------------+-----------------+-----------------+

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

+---+---+-----------------------+-------------------+-------------+---+---+
|   | * | When you get our      |                   |             | * |   |
|   | * | approval for services |                   |             | * |   |
|   | I | and follow a          |                   |             | I |   |
|   | * | treatment plan we     |                   |             | * |   |
|   | * | approve, cost-sharing |                   |             | * |   |
|   |   | and limitations for   |                   |             |   |   |
|   | * | Plan mental health    |                   |             | * |   |
|   | * | and substance abuse   |                   |             | * |   |
|   | M | benefits will be no   |                   |             | M |   |
|   | * | greater than for      |                   |             | * |   |
|   | * | similar benefits for  |                   |             | * |   |
|   |   | other illnesses and   |                   |             |   |   |
|   | * | conditions.           |                   |             | * |   |
|   | * |                       |                   |             | * |   |
|   | P | **Here are some       |                   |             | P |   |
|   | * | important things you  |                   |             | * |   |
|   | * | should keep in mind   |                   |             | * |   |
|   |   | about these           |                   |             |   |   |
|   | * | benefits:**           |                   |             | * |   |
|   | * |                       |                   |             | * |   |
|   | O | -   Please remember   |                   |             | O |   |
|   | * |     that all benefits |                   |             | * |   |
|   | * |     are subject to    |                   |             | * |   |
|   |   |     the definitions,  |                   |             |   |   |
|   | * |     limitations, and  |                   |             | * |   |
|   | * |     exclusions in     |                   |             | * |   |
|   | R |     this brochure and |                   |             | R |   |
|   | * |     we cover them     |                   |             | * |   |
|   | * |     only when we      |                   |             | * |   |
|   |   |     determine they    |                   |             |   |   |
|   | * |     are clinically    |                   |             | * |   |
|   | * |     appropriate to    |                   |             | * |   |
|   | T |     treat your        |                   |             | T |   |
|   | * |     condition.        |                   |             | * |   |
|   | * |                       |                   |             | * |   |
|   |   | -   Plan physicians   |                   |             |   |   |
|   | * |     must provide or   |                   |             | * |   |
|   | * |     arrange your      |                   |             | * |   |
|   | A |     care.             |                   |             | A |   |
|   | * |                       |                   |             | * |   |
|   | * | -   We have no        |                   |             | * |   |
|   |   |     calendar year     |                   |             |   |   |
|   | * |     deductible.       |                   |             | * |   |
|   | * |                       |                   |             | * |   |
|   | N | -   Be sure to read   |                   |             | N |   |
|   | * |     Section 4, *Your  |                   |             | * |   |
|   | * |     costs for covered |                   |             | * |   |
|   |   |     services,* for    |                   |             |   |   |
|   | * |     valuable          |                   |             | * |   |
|   | * |     information about |                   |             | * |   |
|   | T |     how cost sharing  |                   |             | T |   |
|   | * |     works. Also read  |                   |             | * |   |
|   | * |     Section 9 about   |                   |             | * |   |
|   |   |     coordinating      |                   |             |   |   |
|   |   |     benefits with     |                   |             |   |   |
|   |   |     other coverage,   |                   |             |   |   |
|   |   |     including with    |                   |             |   |   |
|   |   |     Medicare.         |                   |             |   |   |
+---+---+-----------------------+-------------------+-------------+---+---+
| B |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| n |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| f |   |                       |                   |             |   |   |
| i |   |                       |                   |             |   |   |
| t |   |                       |                   |             |   |   |
| D |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| s |   |                       |                   |             |   |   |
| c |   |                       |                   |             |   |   |
| r |   |                       |                   |             |   |   |
| i |   |                       |                   |             |   |   |
| p |   |                       |                   |             |   |   |
| t |   |                       |                   |             |   |   |
| i |   |                       |                   |             |   |   |
| o |   |                       |                   |             |   |   |
| n |   |                       |                   |             |   |   |
+---+---+-----------------------+-------------------+-------------+---+---+
| # |   |                       | You pay --        | You pay --  |   |   |
| # |   |                       | Standard Option   | High Option |   |   |
| # |   |                       |                   |             |   |   |
| # |   |                       |                   |             |   |   |
| # |   |                       |                   |             |   |   |
| # |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| M |   |                       |                   |             |   |   |
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|   |   |                       |                   |             |   |   |
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|   |   |                       |                   |             |   |   |
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| d |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| s |   |                       |                   |             |   |   |
| u |   |                       |                   |             |   |   |
| b |   |                       |                   |             |   |   |
| s |   |                       |                   |             |   |   |
| t |   |                       |                   |             |   |   |
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|   |   |                       |                   |             |   |   |
| a |   |                       |                   |             |   |   |
| b |   |                       |                   |             |   |   |
| u |   |                       |                   |             |   |   |
| s |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| b |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| n |   |                       |                   |             |   |   |
| e |   |                       |                   |             |   |   |
| f |   |                       |                   |             |   |   |
| i |   |                       |                   |             |   |   |
| t |   |                       |                   |             |   |   |
| s |   |                       |                   |             |   |   |
+---+---+-----------------------+-------------------+-------------+---+---+
| W |   |                       | Your cost sharing | Your cost   |   |   |
| e |   |                       | responsibilities  | sharing     |   |   |
| c |   |                       | are no greater    | respo       |   |   |
| o |   |                       | than for other    | nsibilities |   |   |
| v |   |                       | illnesses or      | are no      |   |   |
| e |   |                       | conditions        | greater     |   |   |
| r |   |                       |                   | than for    |   |   |
| a |   |                       |                   | other       |   |   |
| l |   |                       |                   | illnesses   |   |   |
| l |   |                       |                   | or          |   |   |
| d |   |                       |                   | conditions  |   |   |
| i |   |                       |                   |             |   |   |
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| g |   |                       |                   |             |   |   |
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| a |   |                       |                   |             |   |   |
| v |   |                       |                   |             |   |   |
| o |   |                       |                   |             |   |   |
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| f |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
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|   |   |                       |                   |             |   |   |
|   |   |                       |                   |             |   |   |
| a |   |                       |                   |             |   |   |
| n |   |                       |                   |             |   |   |
| o |   |                       |                   |             |   |   |
| t |   |                       |                   |             |   |   |
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| . |   |                       |                   |             |   |   |
+---+---+-----------------------+-------------------+-------------+---+---+

*Mental health and substance abuse benefits---continued on next page*

+------------------------------+-------------------+-------------------+
| Mental health and substance  | You pay --        | You pay -- High   |
| abuse benefits *(continued)* | Standard Option   | Option            |
+------------------------------+-------------------+-------------------+
| Diagnosis and treatment of   | \$15 per          | \$15 per          |
| psychiatric disorders,       | individual        | individual        |
| mental illness or disorders  | therapy office    | therapy office    |
| of children, adolescents,    | visit             | visit             |
| and adults. Services         |                   |                   |
| include:                     | \$7 per group     | \$7 per group     |
|                              | therapy office    | therapy office    |
| -   Diagnostic evaluation    | visit             | visit             |
|                              |                   |                   |
| -   Treatment services       |                   |                   |
|     (including individual    |                   |                   |
|     and group therapy        |                   |                   |
|     visits)                  |                   |                   |
|                              |                   |                   |
| -   Crisis intervention and  |                   |                   |
|     stabilization for acute  |                   |                   |
|     episodes                 |                   |                   |
|                              |                   |                   |
| -   Psychological testing    |                   |                   |
|     necessary to determine   |                   |                   |
|     the appropriate          |                   |                   |
|     psychiatric treatment    |                   |                   |
|                              |                   |                   |
| -   Medication evaluation    |                   |                   |
|     and management           |                   |                   |
|                              |                   |                   |
| Diagnosis and treatment of   |                   |                   |
| chemical dependency.         |                   |                   |
| Services include:            |                   |                   |
|                              |                   |                   |
| -   Detoxification (medical  |                   |                   |
|     management of withdrawal |                   |                   |
|     from the substance)      |                   |                   |
|                              |                   |                   |
| -   Treatment and counseling |                   |                   |
|     (including individual    |                   |                   |
|     and group therapy        |                   |                   |
|     visits)                  |                   |                   |
|                              |                   |                   |
| Notes:                       |                   |                   |
|                              |                   |                   |
| -   Your mental health or    |                   |                   |
|     substance abuse provider |                   |                   |
|     will develop a treatment |                   |                   |
|     plan to assist you in    |                   |                   |
|     improving or maintaining |                   |                   |
|     your condition and       |                   |                   |
|     functional level, or to  |                   |                   |
|     prevent relapse.         |                   |                   |
|                              |                   |                   |
| -   You may see a Plan       |                   |                   |
|     outpatient mental health |                   |                   |
|     or chemical dependency   |                   |                   |
|     provider without a       |                   |                   |
|     referral from your       |                   |                   |
|     primary care physician.  |                   |                   |
+------------------------------+-------------------+-------------------+
| -   Inpatient psychiatric    | \$100 per         | \$100 per         |
|     care                     | admission         | admission         |
|                              |                   |                   |
| -   Inpatient care           |                   |                   |
|                              |                   |                   |
| -   Residential treatment    |                   |                   |
|                              |                   |                   |
| Note: All inpatient          |                   |                   |
| admissions and hospital      |                   |                   |
| alternative services         |                   |                   |
| treatment programs require   |                   |                   |
| pre-approval by a Plan       |                   |                   |
| physician.                   |                   |                   |
+------------------------------+-------------------+-------------------+
| -   Intensive outpatient     | \$50 per day up   | \$50 per day up   |
|     psychiatric treatment    | to a maximum of   | to a maximum of   |
|     programs                 | \$250 per episode | \$250 per episode |
|                              | or course of      | or course of      |
| Note: These services must be | treatment         | treatment         |
| pre-approved by a Plan       |                   |                   |
| physician.                   |                   |                   |
+------------------------------+-------------------+-------------------+

Mental health and substance abuse benefits---continued on next page

+------------------------------+-------------------+-------------------+
| Mental health and substance  | You pay --        | You pay -- High   |
| abuse benefits *(continued)* | Standard Option   | Option            |
+------------------------------+-------------------+-------------------+
| *Not covered:*               | *All charges*     | *All charges*     |
|                              |                   |                   |
| -   Care that is not         |                   |                   |
|     clinically appropriate   |                   |                   |
|     for the treatment of     |                   |                   |
|     your condition           |                   |                   |
|                              |                   |                   |
| -   Services we have not     |                   |                   |
|     approved                 |                   |                   |
|                              |                   |                   |
| -   Intelligence, IQ,        |                   |                   |
|     aptitude ability, or     |                   |                   |
|     interest testing not     |                   |                   |
|     necessary to determine   |                   |                   |
|     the appropriate          |                   |                   |
|     treatment of a           |                   |                   |
|     psychiatric condition    |                   |                   |
|                              |                   |                   |
| -   Evaluation or therapy on |                   |                   |
|     court order or as a      |                   |                   |
|     condition of parole or   |                   |                   |
|     probation, or otherwise  |                   |                   |
|     required by the criminal |                   |                   |
|     justice system, unless   |                   |                   |
|     determined by a Plan     |                   |                   |
|     physician to be          |                   |                   |
|     medically necessary and  |                   |                   |
|     appropriate              |                   |                   |
|                              |                   |                   |
| -   Services that are        |                   |                   |
|     custodial in nature      |                   |                   |
|                              |                   |                   |
| -   Marital, family, or      |                   |                   |
|     educational services     |                   |                   |
|                              |                   |                   |
| -   Services rendered or     |                   |                   |
|     billed by a school or a  |                   |                   |
|     member of its staff      |                   |                   |
|                              |                   |                   |
| -   Services provided under  |                   |                   |
|     a federal, state, or     |                   |                   |
|     local government program |                   |                   |
|                              |                   |                   |
| -   Psychoanalysis or        |                   |                   |
|     psychotherapy credited   |                   |                   |
|     toward earning a degree  |                   |                   |
|     or furtherance of        |                   |                   |
|     education or training    |                   |                   |
|     regardless of diagnosis  |                   |                   |
|     or symptoms that may be  |                   |                   |
|     present                  |                   |                   |
+------------------------------+-------------------+-------------------+
| **Limitation** We may limit  |                   |                   |
| your benefits if you do not  |                   |                   |
| obtain a treatment plan.     |                   |                   |
+------------------------------+-------------------+-------------------+

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

+---+---+--------------------------------------------------------+---+---+
|   | * | **Here are some important things you should keep in    | * |   |
|   | * | mind about these benefits:**                           | * |   |
|   | I |                                                        | I |   |
|   | * | -   We cover prescribed drugs and medications, as      | * |   |
|   | * |     described in the chart beginning on the next page. | * |   |
|   |   |                                                        |   |   |
|   | * | -   Please remember that all benefits are subject to   | * |   |
|   | * |     the definitions, limitations, and exclusions in    | * |   |
|   | M |     this brochure and we cover them only when we       | M |   |
|   | * |     determine they are medically necessary.            | * |   |
|   | * |                                                        | * |   |
|   |   | -   We have no calendar year deductible.               |   |   |
|   | * |                                                        | * |   |
|   | * | -   Be sure to read Section 4, *Your costs for covered | * |   |
|   | P |     services,* for valuable information about how cost | P |   |
|   | * |     sharing works. Also read Section 9 about           | * |   |
|   | * |     coordinating benefits with other coverage,         | * |   |
|   |   |     including with Medicare.                           |   |   |
|   | * |                                                        | * |   |
|   | * |                                                        | * |   |
|   | O |                                                        | O |   |
|   | * |                                                        | * |   |
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+---+---+--------------------------------------------------------+---+---+
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+---+---+--------------------------------------------------------+---+---+

Covered medications and supplies---begin on the next page

+--------------------------------+------------------+------------------+
| **Benefit Description**        |                  |                  |
+--------------------------------+------------------+------------------+
| ###### Co                      | You pay --       | You pay -- High  |
| vered medications and supplies | Standard Option  | Option           |
+--------------------------------+------------------+------------------+
| We cover the following         | \$15 per         | \$15 per         |
| medications and supplies       | prescription or  | prescription or  |
| prescribed by a Plan physician | refill for       | refill for       |
| and obtained from a Plan       | generic drugs or | generic drugs or |
| pharmacy or through our mail   | devices          | devices          |
| order program:                 |                  |                  |
|                                | \$30 per         | \$30 per         |
| -   Drugs for which a          | prescription or  | prescription or  |
|     prescription is required   | refill for       | refill for       |
|     by law                     | brand-name drugs | brand-name drugs |
|                                | or devices       | or devices       |
| -   Insulin                    |                  |                  |
|                                |                  |                  |
| -   Glucose test strips        |                  |                  |
|                                |                  |                  |
| -   Disposable needles and     |                  |                  |
|     syringes for               |                  |                  |
|     administration of covered  |                  |                  |
|     prescribed medications     |                  |                  |
|                                |                  |                  |
| Note: The cost of any needles  |                  |                  |
| and syringes (not for insulin) |                  |                  |
| may be less than your          |                  |                  |
| copayment. If this is the      |                  |                  |
| case, you are required to pay  |                  |                  |
| the cost of the needles and    |                  |                  |
| syringes.                      |                  |                  |
|                                |                  |                  |
| -   Smoking cessation drugs    |                  |                  |
|     and medication, including  |                  |                  |
|     prescribed nicotine gum    |                  |                  |
|     and patches, when used in  |                  |                  |
|     conjunction with smoking   |                  |                  |
|     cessation programs         |                  |                  |
|                                |                  |                  |
| -   Chemotherapy               |                  |                  |
|                                |                  |                  |
| -   Drugs for foreign travel   |                  |                  |
|                                |                  |                  |
| -   Certain over-the-counter   |                  |                  |
|     medications prescribed by  |                  |                  |
|     a Plan physician and       |                  |                  |
|     listed on the Plan\'s      |                  |                  |
|     formulary as the most      |                  |                  |
|     appropriate treatment for  |                  |                  |
|     a particular condition     |                  |                  |
|                                |                  |                  |
| -   Contraceptive drugs and    |                  |                  |
|     devices:                   |                  |                  |
|                                |                  |                  |
| ```{=html}                     |                  |                  |
| <!-- -->                       |                  |                  |
| ```                            |                  |                  |
| -   Diaphragms and cervical    |                  |                  |
|     caps                       |                  |                  |
|                                |                  |                  |
| -   Intrauterine devices       |                  |                  |
|     (IUDs)                     |                  |                  |
|                                |                  |                  |
| -   Injectable contraceptive   |                  |                  |
|     drugs                      |                  |                  |
|                                |                  |                  |
| -   Implanted time-release     |                  |                  |
|     contraceptive drug         |                  |                  |
|                                |                  |                  |
| -   Oral contraceptive drugs   |                  |                  |
|                                |                  |                  |
| ```{=html}                     |                  |                  |
| <!-- -->                       |                  |                  |
| ```                            |                  |                  |
| -   Other implanted            |                  |                  |
|     time-release drugs         |                  |                  |
+--------------------------------+------------------+------------------+

Covered medications and supplies---continued on next page

+--------------------------------+------------------+------------------+
| ###### Covered medicati        | You pay --       | You pay -- High  |
| ons and supplies *(continued)* | Standard Option  | Option           |
+--------------------------------+------------------+------------------+
| -   Drugs to treat sexual      | 50% of our       | 50% of our       |
|     dysfunction                | allowance        | allowance        |
|                                |                  |                  |
| Note: These drugs have         |                  |                  |
| dispensing limitations.        |                  |                  |
| Contact the Plan for details.  |                  |                  |
+--------------------------------+------------------+------------------+
| -   Diabetic supplies such as  | 20% of our       | 20% of our       |
|     external insulin pumps,    | allowance        | allowance        |
|     infusion devices, lancets, |                  |                  |
|     glucose monitors, and      |                  |                  |
|     diabetic foot care         |                  |                  |
|     appliances                 |                  |                  |
+--------------------------------+------------------+------------------+
| -   Amino acid modified        | Nothing          | Nothing          |
|     products used in the       |                  |                  |
|     treatment of inborn errors |                  |                  |
|     of amino acid metabolism   |                  |                  |
|     (PKU)                      |                  |                  |
|                                |                  |                  |
| -   Immunosuppressive drugs    |                  |                  |
|     required after a           |                  |                  |
|     transplant                 |                  |                  |
|                                |                  |                  |
| -   Intravenous fluids and     |                  |                  |
|     medication for home        |                  |                  |
+--------------------------------+------------------+------------------+
| *Not covered:*                 | *All charges*    | *All charges*    |
|                                |                  |                  |
| -   Drugs available without a  |                  |                  |
|     prescription or for which  |                  |                  |
|     there is a nonprescription |                  |                  |
|     equivalent available,      |                  |                  |
|     except those listed on the |                  |                  |
|     Plan's formulary and       |                  |                  |
|     prescribed by a Plan       |                  |                  |
|     physician                  |                  |                  |
|                                |                  |                  |
| -   Drugs obtained at a        |                  |                  |
|     non-Plan pharmacy except   |                  |                  |
|     for out-of-area            |                  |                  |
|     emergencies                |                  |                  |
|                                |                  |                  |
| -   Vitamins and nutritional   |                  |                  |
|     supplements that can be    |                  |                  |
|     purchased without a        |                  |                  |
|     prescription               |                  |                  |
|                                |                  |                  |
| -   Medical supplies such as   |                  |                  |
|     dressings and antiseptics  |                  |                  |
|                                |                  |                  |
| -   Drugs for cosmetic         |                  |                  |
|     purposes                   |                  |                  |
|                                |                  |                  |
| -   Drugs to enhance athletic  |                  |                  |
|     performance                |                  |                  |
|                                |                  |                  |
| -   Drugs used in the          |                  |                  |
|     diagnosis and treatment of |                  |                  |
|     infertility                |                  |                  |
|                                |                  |                  |
| -   Drugs related to           |                  |                  |
|     non-covered services       |                  |                  |
|                                |                  |                  |
| -   Drugs used for weight      |                  |                  |
|     management                 |                  |                  |
|                                |                  |                  |
| -   Any packaging other than   |                  |                  |
|     the dispensing pharmacy's  |                  |                  |
|     standard packaging         |                  |                  |
|                                |                  |                  |
| -   Replacement of lost,       |                  |                  |
|     stolen, or damaged drugs   |                  |                  |
|     and accessories            |                  |                  |
+--------------------------------+------------------+------------------+

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

+----------------------+-----------------------------------------------+
| Feature              | Description                                   |
+----------------------+-----------------------------------------------+
| ##### Flex           | Under the flexible benefits option, we        |
| ible benefits option | determine the most effective way to provide   |
|                      | services.                                     |
|                      |                                               |
|                      | -   We may identify medically appropriate     |
|                      |     alternatives to traditional care and      |
|                      |     coordinate other treatments as a less     |
|                      |     costly alternative benefit.               |
|                      |                                               |
|                      | -   Alternative treatments are subject to our |
|                      |     ongoing review.                           |
|                      |                                               |
|                      | -   By approving an alternative treatment, we |
|                      |     cannot guarantee you will get it in the   |
|                      |     future.                                   |
|                      |                                               |
|                      | -   The decision to offer an alternative      |
|                      |     treatment is solely ours, and we may      |
|                      |     withdraw it at any time and resume        |
|                      |     regular contract benefits.                |
|                      |                                               |
|                      | -   Our decision to offer or withdraw         |
|                      |     alternative treatments is not subject to  |
|                      |     OPM review under the disputed claims      |
|                      |     process.                                  |
+----------------------+-----------------------------------------------+
| ####                 | For any of your health concerns, 24 hours a   |
| # 24 hour nurse line | day, 7 days a week, you may call from         |
|                      | Portland at 503/813-2000, or from other areas |
|                      | call 800/813-2000 or our TTY number at        |
|                      | 800/735-2900, and talk with a registered      |
|                      | nurse who will discuss treatment options and  |
|                      | answer your health questions.                 |
+----------------------+-----------------------------------------------+
| ####                 | We provide TTY/text telephone number at       |
| # Services for deaf  | 800/735-2900. Sign language services are also |
| and hearing impaired | available.                                    |
+----------------------+-----------------------------------------------+
| ##### Lan            | Interpreters are available to assist          |
| guage interpretation | non-English speaking members. Please see the  |
|                      | listing in your Medical Directory.            |
+----------------------+-----------------------------------------------+
| ##### H              | Starring Healthy Babies was born August 1995  |
| igh risk pregnancies | in response to the need for a comprehensive   |
|                      | program to prevent pre-term birth. Our        |
|                      | program works with you to:                    |
|                      |                                               |
|                      | -   Increase the gestational age of newborns  |
|                      |     and decrease our premature birth rate     |
|                      |     though prevention and education.          |
|                      |                                               |
|                      | -   Decrease the length of stay our infants   |
|                      |     require in the Neonatal Intensive Care    |
|                      |     Unit due to premature birth.              |
|                      |                                               |
|                      | -   Decrease the amount of time our high-risk |
|                      |     mothers need to spend in the hospital     |
|                      |     during their pregnancies by helping with  |
|                      |     their care at home.                       |
|                      |                                               |
|                      | All pregnant Kaiser Permanente members are    |
|                      | screened at their prenatal appointments or at |
|                      | an urgent hospital visit. We enroll those     |
|                      | identified as being high risk for pre-term    |
|                      | labor and assign them to their own case       |
|                      | manager.                                      |
+----------------------+-----------------------------------------------+

+----------------------+-----------------------------------------------+
| ##### Ce             | The Centers of Excellence program began in    |
| nters of Excellence  | Fall 1987. As new technologies proliferate    |
|                      | and become the standard of care, Kaiser       |
|                      | Permanente refers members to contracted       |
|                      | \"centers of excellence\" for certain         |
|                      | specialized medical procedures.               |
|                      |                                               |
|                      | We have developed a network of Centers of     |
|                      | Excellence for organ transplantation, which   |
|                      | consists of medical facilities that have met  |
|                      | stringent criteria for quality care in        |
|                      | specific procedures. A national clinical and  |
|                      | administrative team has developed guidelines  |
|                      | for site selection, site visit protocol,      |
|                      | volume and survival criteria for evaluation   |
|                      | and selection of facilities. The institutions |
|                      | have a record of positive outcomes and        |
|                      | exceptional standards of quality.             |
+----------------------+-----------------------------------------------+
| ##### Travel benefit | Kaiser Permanente's travel benefits for       |
|                      | Federal employees provides you with           |
|                      | outpatient follow-up or continuing medical    |
|                      | care when you are temporarily outside your    |
|                      | home service area by more than 100 miles and  |
|                      | outside of any other Kaiser Permanente        |
|                      | service area. This benefit is in addition to  |
|                      | your emergency, urgent care and student       |
|                      | coverage outside the service area benefits    |
|                      | and include:                                  |
|                      |                                               |
|                      | -   Outpatient follow-up care necessary to    |
|                      |     complete a course of treatment after a    |
|                      |     covered emergency. Services include       |
|                      |     removal of stitches, a catheter, or a     |
|                      |     cast.                                     |
|                      |                                               |
|                      | -   Outpatient continuing care for conditions |
|                      |     diagnosed and treated within the previous |
|                      |     90 days by a Kaiser Permanente health     |
|                      |     care provider or affiliated Plan          |
|                      |     provider. Services include dialysis and   |
|                      |     prescription drug monitoring.             |
|                      |                                               |
|                      | -   You pay \$25 for each follow-up or        |
|                      |     continuing care office visit. This amount |
|                      |     will be deducted from the payment we make |
|                      |     to you.                                   |
|                      |                                               |
|                      | -   Your benefit is limited to \$1,200 each   |
|                      |     calendar year**.**                        |
|                      |                                               |
|                      | -   For more information about this benefit   |
|                      |     call 800/813-2000.                        |
|                      |                                               |
|                      | -   File claims as shown in Section 7.        |
|                      |                                               |
|                      |     The following are a few examples of       |
|                      |     services not included in your travel      |
|                      |     benefits coverage:                        |
|                      |                                               |
|                      | ```{=html}                                    |
|                      | <!-- -->                                      |
|                      | ```                                           |
|                      | -   Non-emergency hospitalization             |
|                      |                                               |
|                      | -   Infertility treatments                    |
|                      |                                               |
|                      | -   Medical and hospital costs resulting from |
|                      |     a normal full-term delivery of a baby     |
|                      |     outside the service area                  |
|                      |                                               |
|                      | -   Transplants                               |
|                      |                                               |
|                      | -   DME                                       |
|                      |                                               |
|                      | -   Prescription drugs                        |
|                      |                                               |
|                      | -   Home health services                      |
+----------------------+-----------------------------------------------+

+----------------------+-----------------------------------------------+
| ##### Ser            | When you visit the service area of another    |
| vices from other Kai | Kaiser Permanente plan, you are entitled to   |
| ser Permanente Plans | receive virtually all the services described  |
|                      | in this brochure (including our mail order    |
|                      | prescription program) at any Kaiser           |
|                      | Permanente medical office or medical center.  |
|                      | You will have to pay the copayments or other  |
|                      | charges imposed by the plan you are visiting, |
|                      | with the exception of mail order              |
|                      | prescriptions which are administered by your  |
|                      | home Plan. If the plan you are visiting has a |
|                      | service that differs from the services of     |
|                      | this Plan, you are not entitled to receive    |
|                      | that service.                                 |
|                      |                                               |
|                      | Some services covered by this Plan, such as   |
|                      | artificial reproductive services and the      |
|                      | services of specialized rehabilitation        |
|                      | facilities, will not be available in other    |
|                      | Kaiser Permanente service areas. If a service |
|                      | is limited to a specific number of visits or  |
|                      | days, you are entitled to receive only the    |
|                      | number of visits or days covered by this      |
|                      | Plan.                                         |
|                      |                                               |
|                      | If you are seeking routine, non-emergent, or  |
|                      | non-urgent services, you should call the      |
|                      | Kaiser Permanente Membership Services         |
|                      | department in that service area and request   |
|                      | an appointment. You may obtain routine        |
|                      | follow-up or continuing care from these       |
|                      | plans, even when you have obtained the        |
|                      | original services in the service area. If you |
|                      | require emergency services as the result of   |
|                      | unexpected or unforeseen illness that         |
|                      | requires immediate attention, you should go   |
|                      | directly to the nearest Kaiser Permanente     |
|                      | facility to receive care.                     |
|                      |                                               |
|                      | At the time you register for services, you    |
|                      | will be asked to pay the charges required by  |
|                      | the local plan.                               |
|                      |                                               |
|                      | If you plan to travel to an area with another |
|                      | Kaiser Permanente plan, and wish to obtain    |
|                      | more information about the services available |
|                      | to you from the Kaiser Permanente plan,       |
|                      | please call Membership Services at            |
|                      | 503/813-2000 or 800/813-2000.                 |
+----------------------+-----------------------------------------------+
| ##### S              | We provide a limited benefit to dependents of |
| tudent coverage outs | eligible subscribers who are full time        |
| ide the service area | registered college students (at least 12      |
|                      | credit hours per semester) attending a        |
|                      | recognized accredited institution outside     |
|                      | Kaiser Permanente's service areas and within  |
|                      | the United States. These benefits are in      |
|                      | addition to your emergency and travel         |
|                      | benefits.                                     |
|                      |                                               |
|                      | -   You are covered for routine, continuing   |
|                      |     and follow-up medical care                |
|                      |                                               |
|                      | -   You pay 20% of the usual and customary    |
|                      |     charges.                                  |
|                      |                                               |
|                      | -   Your benefit is limited to \$1,200 each   |
|                      |     calendar year.                            |
|                      |                                               |
|                      | -   You must certify your dependent\'s        |
|                      |     student status annually.                  |
|                      |                                               |
|                      | -   For more information about this benefit,  |
|                      |     call 800/813-2000.                        |
|                      |                                               |
|                      | -   File claims as shown in Section 7.        |
|                      |                                               |
|                      | *The following are not included in your       |
|                      | out-of-area student coverage benefit:*        |
|                      |                                               |
|                      | -   Transplants                               |
|                      |                                               |
|                      | -   Dental (High Option)                      |
+----------------------+-----------------------------------------------+

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

+---+---+------------------------+------------------+-------------+---+---+
|   | * | **Here are some        |                  |             | * |   |
|   | * | important things you   |                  |             | * |   |
|   | I | should keep in mind    |                  |             | I |   |
|   | * | about these            |                  |             | * |   |
|   | * | benefits:**            |                  |             | * |   |
|   |   |                        |                  |             |   |   |
|   | * | -   Please remember    |                  |             | * |   |
|   | * |     that all benefits  |                  |             | * |   |
|   | M |     are subject to the |                  |             | M |   |
|   | * |     definitions,       |                  |             | * |   |
|   | * |     limitations, and   |                  |             | * |   |
|   |   |     exclusions in this |                  |             |   |   |
|   | * |     brochure and we    |                  |             | * |   |
|   | * |     cover them only    |                  |             | * |   |
|   | P |     when we determine  |                  |             | P |   |
|   | * |     they are medically |                  |             | * |   |
|   | * |     necessary.         |                  |             | * |   |
|   |   |                        |                  |             |   |   |
|   | * | -   Plan dentists must |                  |             | * |   |
|   | * |     provide or arrange |                  |             | * |   |
|   | O |     your care.         |                  |             | O |   |
|   | * |                        |                  |             | * |   |
|   | * | -   We cover           |                  |             | * |   |
|   |   |     hospitalization    |                  |             |   |   |
|   | * |     for dental         |                  |             | * |   |
|   | * |     procedures at a    |                  |             | * |   |
|   | R |     Plan hospital we   |                  |             | R |   |
|   | * |     designate subject  |                  |             | * |   |
|   | * |     to                 |                  |             | * |   |
|   |   |     pre-authorization  |                  |             |   |   |
|   | * |     only when a        |                  |             | * |   |
|   | * |     non-dental         |                  |             | * |   |
|   | T |     physical           |                  |             | T |   |
|   | * |     impairment exists  |                  |             | * |   |
|   | * |     which makes        |                  |             | * |   |
|   |   |     hospitalization    |                  |             |   |   |
|   | * |     necessary to       |                  |             | * |   |
|   | * |     safeguard the      |                  |             | * |   |
|   | A |     health of the      |                  |             | A |   |
|   | * |     patient. See       |                  |             | * |   |
|   | * |     Section 5(c) for   |                  |             | * |   |
|   |   |     inpatient hospital |                  |             |   |   |
|   | * |     benefits. We do    |                  |             | * |   |
|   | * |     not cover the      |                  |             | * |   |
|   | N |     dental procedure   |                  |             | N |   |
|   | * |     except as          |                  |             | * |   |
|   | * |     described below.   |                  |             | * |   |
|   |   |                        |                  |             |   |   |
|   | * | -   We have no         |                  |             | * |   |
|   | * |     calendar year      |                  |             | * |   |
|   | T |     deductible.        |                  |             | 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 with     |                  |             |   |   |
|   |   |     Medicare.          |                  |             |   |   |
|   |   |                        |                  |             |   |   |
|   |   | Note: You will have to |                  |             |   |   |
|   |   | pay \$10 for each      |                  |             |   |   |
|   |   | missed appointment,    |                  |             |   |   |
|   |   | unless you notify the  |                  |             |   |   |
|   |   | dental office in       |                  |             |   |   |
|   |   | advance.               |                  |             |   |   |
+===+===+========================+==================+=============+===+===+
| # |   |                        |                  |             |   |   |
| # |   |                        |                  |             |   |   |
| # |   |                        |                  |             |   |   |
| # |   |                        |                  |             |   |   |
| # |   |                        |                  |             |   |   |
| # |   |                        |                  |             |   |   |
|   |   |                        |                  |             |   |   |
| D |   |                        |                  |             |   |   |
| e |   |                        |                  |             |   |   |
| n |   |                        |                  |             |   |   |
| t |   |                        |                  |             |   |   |
| a |   |                        |                  |             |   |   |
| l |   |                        |                  |             |   |   |
|   |   |                        |                  |             |   |   |
| b |   |                        |                  |             |   |   |
| e |   |                        |                  |             |   |   |
| n |   |                        |                  |             |   |   |
| e |   |                        |                  |             |   |   |
| f |   |                        |                  |             |   |   |
| i |   |                        |                  |             |   |   |
| t |   |                        |                  |             |   |   |
| s |   |                        |                  |             |   |   |
+---+---+------------------------+------------------+-------------+---+---+
| S |   |                        | ####             | #########   |   |   |
| e |   |                        | ##### You pay -- | You pay --  |   |   |
| r |   |                        |  Standard Option | High Option |   |   |
| v |   |                        |                  |             |   |   |
| i |   |                        |                  |             |   |   |
| c |   |                        |                  |             |   |   |
| e |   |                        |                  |             |   |   |
+---+---+------------------------+------------------+-------------+---+---+
| M |   |                        | No benefit       | See below   |   |   |
| e |   |                        |                  |             |   |   |
| m |   |                        |                  |             |   |   |
| b |   |                        |                  |             |   |   |
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| D |   |                        | *All charges*    | \$15 per    |   |   |
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|   |   |                        |                  |             |   |   |
| p |   |                        |                  |             |   |   |
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| o |   |                        |                  |             |   |   |
| d |   |                        |                  |             |   |   |
|   |   |                        |                  |             |   |   |
| - |   |                        |                  |             |   |   |
|   |   |                        |                  |             |   |   |
|   |   |                        |                  |             |   |   |
|   |   |                        |                  |             |   |   |
| P |   |                        |                  |             |   |   |
| r |   |                        |                  |             |   |   |
| e |   |                        |                  |             |   |   |
| s |   |                        |                  |             |   |   |
| c |   |                        |                  |             |   |   |
| r |   |                        |                  |             |   |   |
| i |   |                        |                  |             |   |   |
| b |   |                        |                  |             |   |   |
| e |   |                        |                  |             |   |   |
| d |   |                        |                  |             |   |   |
|   |   |                        |                  |             |   |   |
|   |   |                        |                  |             |   |   |
|   |   |                        |                  |             |   |   |
|   |   |                        |                  |             |   |   |
| s |   |                        |                  |             |   |   |
| p |   |                        |                  |             |   |   |
| a |   |                        |                  |             |   |   |
| c |   |                        |                  |             |   |   |
| e |   |                        |                  |             |   |   |
|   |   |                        |                  |             |   |   |
|   |   |                        |                  |             |   |   |
|   |   |                        |                  |             |   |   |
|   |   |                        |                  |             |   |   |
| m |   |                        |                  |             |   |   |
| a |   |                        |                  |             |   |   |
| i |   |                        |                  |             |   |   |
| n |   |                        |                  |             |   |   |
| t |   |                        |                  |             |   |   |
| a |   |                        |                  |             |   |   |
| i |   |                        |                  |             |   |   |
| n |   |                        |                  |             |   |   |
| e |   |                        |                  |             |   |   |
| r |   |                        |                  |             |   |   |
| s |   |                        |                  |             |   |   |
|   |   |                        |                  |             |   |   |
|   |   |                        |                  |             |   |   |
|   |   |                        |                  |             |   |   |
|   |   |                        |                  |             |   |   |
| a |   |                        |                  |             |   |   |
| n |   |                        |                  |             |   |   |
| d |   |                        |                  |             |   |   |
|   |   |                        |                  |             |   |   |
|   |   |                        |                  |             |   |   |
|   |   |                        |                  |             |   |   |
|   |   |                        |                  |             |   |   |
| h |   |                        |                  |             |   |   |
| a |   |                        |                  |             |   |   |
| b |   |                        |                  |             |   |   |
| i |   |                        |                  |             |   |   |
| t |   |                        |                  |             |   |   |
|   |   |                        |                  |             |   |   |
|   |   |                        |                  |             |   |   |
|   |   |                        |                  |             |   |   |
|   |   |                        |                  |             |   |   |
| a |   |                        |                  |             |   |   |
| p |   |                        |                  |             |   |   |
| p |   |                        |                  |             |   |   |
| l |   |                        |                  |             |   |   |
| i |   |                        |                  |             |   |   |
| a |   |                        |                  |             |   |   |
| n |   |                        |                  |             |   |   |
| c |   |                        |                  |             |   |   |
| e |   |                        |                  |             |   |   |
| s |   |                        |                  |             |   |   |
+---+---+------------------------+------------------+-------------+---+---+

+------------------------------+------------------+--------------------+
| **Dental Benefits**          |                  |                    |
| *(continued)*                |                  |                    |
+------------------------------+------------------+--------------------+
| Service                      | ##               | ######### You      |
|                              | ####### You pay  |  pay - High Option |
|                              | -Standard Option |                    |
+------------------------------+------------------+--------------------+
| Basic Restorative Services   | *All charges*    | \$15 per office    |
| including basic restorative  |                  | visit plus 50% of  |
| services resulting from      |                  | our allowance      |
| accidental injury as         |                  |                    |
| follows:                     |                  |                    |
|                              |                  |                    |
| -   Amalgam (silver)         |                  |                    |
|     restorations in          |                  |                    |
|     posterior teeth and      |                  |                    |
|     anterior teeth           |                  |                    |
|                              |                  |                    |
| -   Synthetic (plastic,      |                  |                    |
|     resin and glass ionomer) |                  |                    |
|     restorations in all      |                  |                    |
|     primary teeth, anterior  |                  |                    |
|     teeth and one-surface    |                  |                    |
|     restorations of          |                  |                    |
|     posterior permanent      |                  |                    |
|     teeth                    |                  |                    |
|                              |                  |                    |
| -   Stainless steel or       |                  |                    |
|     plastic crowns when      |                  |                    |
|     amalgam or synthetic     |                  |                    |
|     restorative materials    |                  |                    |
|     are not professionally   |                  |                    |
|     appropriate              |                  |                    |
|                              |                  |                    |
| -   If a member requests a   |                  |                    |
|     procedure or material in |                  |                    |
|     excess of that           |                  |                    |
|     recommended by a Plan    |                  |                    |
|     dentist, the desired     |                  |                    |
|     procedure or material    |                  |                    |
|     may be provided upon     |                  |                    |
|     payment of charges that  |                  |                    |
|     reflect the additional   |                  |                    |
|     value of providing the   |                  |                    |
|     procedure or material,   |                  |                    |
|     only if a Plan dentist   |                  |                    |
|     agrees to perform the    |                  |                    |
|     service                  |                  |                    |
|                              |                  |                    |
| Major Restorative Services   |                  |                    |
| as follows:                  |                  |                    |
|                              |                  |                    |
| -   Placement of crowns,     |                  |                    |
|     inlays, bridge pontics,  |                  |                    |
|     or other cast metal      |                  |                    |
|     restoration when         |                  |                    |
|     prescribed by a Plan     |                  |                    |
|     dentist                  |                  |                    |
|                              |                  |                    |
| -   If a member requests a   |                  |                    |
|     procedure or material in |                  |                    |
|     excess of that           |                  |                    |
|     recommended by a Plan    |                  |                    |
|     dentist, the desired     |                  |                    |
|     procedure or material    |                  |                    |
|     may be provided upon     |                  |                    |
|     payment of charges that  |                  |                    |
|     reflect the additional   |                  |                    |
|     value of providing the   |                  |                    |
|     procedure or material,   |                  |                    |
|     only if a Plan dentist   |                  |                    |
|     agrees to perform the    |                  |                    |
|     service                  |                  |                    |
|                              |                  |                    |
| Note: We do not cover repair |                  |                    |
| or replacement of existing   |                  |                    |
| cast crowns, inlays, bridge  |                  |                    |
| pontics, or other cast metal |                  |                    |
| restorations less than five  |                  |                    |
| years after the date of the  |                  |                    |
| most recent placement or     |                  |                    |
| replacement.                 |                  |                    |
+------------------------------+------------------+--------------------+

Dental benefits---continued on next page

+------------------------------+------------------+--------------------+
| **Dental Benefits**          |                  |                    |
| *(continued)*                |                  |                    |
+------------------------------+------------------+--------------------+
| Service                      | ###              | ######### You      |
|                              | ###### You pay - |  pay - High Option |
|                              |  Standard Option |                    |
+------------------------------+------------------+--------------------+
| Oral Surgery Services as     | *All charges*    | \$15 per office    |
| follows:                     |                  | visit plus 50% of  |
|                              |                  | our allowance      |
| -   Diagnosis, evaluation,   |                  |                    |
|     consultation, and        |                  |                    |
|     treatment for removal of |                  |                    |
|     teeth (including local   |                  |                    |
|     anesthesia)              |                  |                    |
|                              |                  |                    |
| -   Minor surgical           |                  |                    |
|     preparation of mouth for |                  |                    |
|     insertion of dentures    |                  |                    |
|                              |                  |                    |
| -   Surgical treatment       |                  |                    |
|     normally performed by a  |                  |                    |
|     dentist for minor        |                  |                    |
|     pathological conditions  |                  |                    |
+------------------------------+------------------+--------------------+
| Periodontal Services as      | *All charges*    | \$15 per office    |
| follows:                     |                  | visit plus 50% of  |
|                              |                  | our allowance      |
| -   Diagnosis, evaluation,   |                  |                    |
|     consultation, and        |                  |                    |
|     treatment for diseases   |                  |                    |
|     of tissues supporting    |                  |                    |
|     the teeth including all  |                  |                    |
|     follow-up cleaning       |                  |                    |
|     visits                   |                  |                    |
+------------------------------+------------------+--------------------+
| Endodontic Services as       |                  |                    |
| follows:                     |                  |                    |
|                              |                  |                    |
| -   Diagnosis, evaluation,   |                  |                    |
|     consultation, and        |                  |                    |
|     treatment for root canal |                  |                    |
|     therapy                  |                  |                    |
+------------------------------+------------------+--------------------+
| Removable Prosthetic         |                  |                    |
| Appliances and Services as   |                  |                    |
| follows:                     |                  |                    |
|                              |                  |                    |
| -   Diagnosis, evaluation,   |                  |                    |
|     consultation, and        |                  |                    |
|     treatment for removable  |                  |                    |
|     prosthetic appliances,   |                  |                    |
|     including full or        |                  |                    |
|     partial dentures,        |                  |                    |
|     relines, and rebases     |                  |                    |
|                              |                  |                    |
| Note: If the removable       |                  |                    |
| appliance cannot be          |                  |                    |
| satisfactorily repaired or   |                  |                    |
| adjusted, then we cover a    |                  |                    |
| new prosthetic appliance as  |                  |                    |
| long as the existing         |                  |                    |
| appliance is more than 5     |                  |                    |
| years old.                   |                  |                    |
+------------------------------+------------------+--------------------+
| Emergency or Urgent Care     | *All charges*    | \*\$25 per office  |
|                              |                  | visit              |
| \*Notes:                     |                  |                    |
|                              |                  |                    |
| -   This copayment applies   |                  |                    |
|     only to emergency or     |                  |                    |
|     urgent dental care       |                  |                    |
|     received from a Plan     |                  |                    |
|     dentist at Plan dental   |                  |                    |
|     offices.                 |                  |                    |
|                              |                  |                    |
| -   All other applicable     |                  |                    |
|     copayments and           |                  |                    |
|     coinsurance apply.       |                  |                    |
+------------------------------+------------------+--------------------+

Dental benefits---continued on next page

+------------------------------+------------------+--------------------+
| **Dental Benefits            |                  |                    |
| *(continued)***              |                  |                    |
+------------------------------+------------------+--------------------+
| Service                      | ##               | ######### You      |
|                              | ####### You pay  |  pay - High Option |
|                              | -Standard Option |                    |
+------------------------------+------------------+--------------------+
| Out-of-Area Emergency Care   | *All charges*    | All charges        |
|                              |                  | exceeding \$100    |
| Note: The Plan pays up to    |                  |                    |
| \$100 for emergency care for |                  |                    |
| relief of pain, acute        |                  |                    |
| infection, or hemorrhage, or |                  |                    |
| necessary treatment          |                  |                    |
| (including local anesthesia  |                  |                    |
| and pre-medication) due to   |                  |                    |
| injury.                      |                  |                    |
+------------------------------+------------------+--------------------+
| Prescription Drugs           |                  |                    |
|                              |                  |                    |
| Covered under Prescription   |                  |                    |
| Drug benefits                |                  |                    |
+------------------------------+------------------+--------------------+
| Nitrous Oxide                | *All charges*    | \$15 per           |
|                              |                  | occurrence         |
| -   Adults and children over | *All charges*    |                    |
|     12 years of age          |                  | Nothing            |
|                              |                  |                    |
| -   Children 12 years of age |                  |                    |
|     and under                |                  |                    |
+------------------------------+------------------+--------------------+
| Nightguards                  | *All charges*    | 10% of our         |
|                              |                  | allowance          |
+------------------------------+------------------+--------------------+
| *Not covered:*               | *All charges*    | *All charges*      |
|                              |                  |                    |
| -   Orthodontics             |                  |                    |
|                              |                  |                    |
| -   Dental treatment for     |                  |                    |
|     problems of the jaw      |                  |                    |
|     joint, including         |                  |                    |
|     temporomandibular joint  |                  |                    |
|     syndrome/                |                  |                    |
|     craniomandibular         |                  |                    |
|     disorders; or other      |                  |                    |
|     conditions of the joint  |                  |                    |
|     linking the jaw bone and |                  |                    |
|     skull, and of the        |                  |                    |
|     complex of muscles,      |                  |                    |
|     nerves, and other        |                  |                    |
|     tissues related to that  |                  |                    |
|     joint                    |                  |                    |
|                              |                  |                    |
| -   Dental implants,         |                  |                    |
|     including bone           |                  |                    |
|     augmentation and the     |                  |                    |
|     fixed or removable       |                  |                    |
|     prosthetic devices       |                  |                    |
|     attached to or covering  |                  |                    |
|     the implants; and all    |                  |                    |
|     services and materials   |                  |                    |
|     relating to the          |                  |                    |
|     placement or removal of  |                  |                    |
|     implants including, but  |                  |                    |
|     not limited to,          |                  |                    |
|     diagnostic               |                  |                    |
|     consultations,           |                  |                    |
|     impressions, oral        |                  |                    |
|     surgery, and removal of  |                  |                    |
|     implants for cleaning;   |                  |                    |
|     and dental services      |                  |                    |
|     related to               |                  |                    |
|     post-operative           |                  |                    |
|     conditions or            |                  |                    |
|     complications arising    |                  |                    |
|     from implants            |                  |                    |
|                              |                  |                    |
| -   Restorative or           |                  |                    |
|     reconstructive services  |                  |                    |
|     for congenital or        |                  |                    |
|     developmental            |                  |                    |
|     malformations            |                  |                    |
|                              |                  |                    |
| -   Full mouth               |                  |                    |
|     reconstructions. This    |                  |                    |
|     includes appliances,     |                  |                    |
|     restoration, and         |                  |                    |
|     procedures needed to     |                  |                    |
|     alter vertical dimension |                  |                    |
|     or occlusion, or in      |                  |                    |
|     conjunction with         |                  |                    |
|     alteration of vertical   |                  |                    |
|     dimension or occlusion   |                  |                    |
|     or for the purpose of    |                  |                    |
|     splinting teeth or       |                  |                    |
|     correcting attrition or  |                  |                    |
|     abrasion.                |                  |                    |
+------------------------------+------------------+--------------------+

Dental benefits---continued on next page

+------------------------------+------------------+--------------------+
| **Dental Benefits            |                  |                    |
| *(continued)***              |                  |                    |
+------------------------------+------------------+--------------------+
| Service                      | ##               | ######### You      |
|                              | ####### You pay  |  pay - High Option |
|                              | -Standard Option |                    |
+------------------------------+------------------+--------------------+
| -   Cosmetic dental          | *All charges*    | *All charges*      |
|     services, including      |                  |                    |
|     replacement of cosmetic  |                  |                    |
|     dental restoration       |                  |                    |
|                              |                  |                    |
| -   Restoration replacement. |                  |                    |
|     Clinically acceptable    |                  |                    |
|     restorations or material |                  |                    |
|     will not be removed or   |                  |                    |
|     replaced with            |                  |                    |
|     alternative materials    |                  |                    |
|     unless a pathological    |                  |                    |
|     condition of the teeth   |                  |                    |
|     exists                   |                  |                    |
|                              |                  |                    |
| -   IV sedation              |                  |                    |
|                              |                  |                    |
| -   Genetic testing          |                  |                    |
|                              |                  |                    |
| -   Replacement of           |                  |                    |
|     pre-fabricated, non-cast |                  |                    |
|     crowns, including        |                  |                    |
|     non-cast stainless steel |                  |                    |
|     crowns, which have not   |                  |                    |
|     been placed by a Kaiser  |                  |                    |
|     Permanente dentist       |                  |                    |
|                              |                  |                    |
| -   Replacement of any       |                  |                    |
|     permanent removable      |                  |                    |
|     appliances with new      |                  |                    |
|     permanent removable or   |                  |                    |
|     fixed prosthetic         |                  |                    |
|     appliances within 5      |                  |                    |
|     years of the date the    |                  |                    |
|     member receives the      |                  |                    |
|     appliance regardless of  |                  |                    |
|     where the appliance was  |                  |                    |
|     obtained                 |                  |                    |
|                              |                  |                    |
| -   Replacement of any       |                  |                    |
|     nightguards within 5     |                  |                    |
|     years of the date the    |                  |                    |
|     member receives the      |                  |                    |
|     appliance even if        |                  |                    |
|     prescribed by a dentist  |                  |                    |
|     outside the Plan         |                  |                    |
+------------------------------+------------------+--------------------+

## **Section** 5(i) Non-FEHBP 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.

Kaiser Permanente offers a wide range of services to help you achieve
and maintain good health. Here are some ways we can support you in
making healthier choices.

**Talk with a health consultant**

If you're a member who is thinking about losing weight, quitting
tobacco, or in some other way improving your health, a brief chat with a
consultant in our Health Education Services department can help. From
Portland, call 503/286-6816 and choose option 2. From all other areas,
call 866/301-3866 and choose option 2.

**Complementary care discounts**

All Kaiser Permanente members are now eligible for special discounts on
health club memberships and certain kinds of complementary care. These
include acupuncture, chiropractic care, massage therapy, and
naturopathic care. Before you schedule an appointment or join a health
club, be sure to ask about the provider's or club's specific discount
(discounts vary). If you want chiropractic care, use your FEHB
chiropractic benefit first.

Visit [kp.org/specialdiscounts/nw](http://kp.org/specialdiscounts/nw)
for a list of participating clubs and Complementary Healthcare Plans
providers. Or call Membership Services to learn more. From Portland,
call 503/813-2000. From all other areas, call 800/813-2000.

**Classes**

Through our health education classes, you can learn tools and skills to
help you have a safer pregnancy, kick the tobacco habit, improve
personal and family relationships, better manage weight or chronic
conditions such as diabetes---and much more. For more information, pick
up a *Health Education Services* catalog at any Kaiser Permanente
facility. Or call 503/286-6816 from Portland and choose option 1. From
all other areas, call 866/301-3866 and choose option 1.

**Self-care options**

We also offer services to help you take care of yourself and your loved
ones.

-   [kaiserpermanente.org](http://kaiserpermanente.org/)\
    Kaiser Permanente's website provides information and services 24
    hours a day. For example, you can search the health and drug
    encyclopedias. If you register on the site, you can email an advice
    nurse or pharmacist, refill prescriptions, and more.

-   **Healthphone: Call 800/332-7563 (for TTY call 800/777-9059)**\
    This free and confidential 24-hour service provides prerecorded
    health information in English and Spanish. Call and listen to
    messages on more than 200 topics.

-   **Kaiser Permanente Healthwise Handbook**\
    This self-care guide has information on more than 180 health topics.
    It is free at any Membership Services desk or Health Resource
    Center.

# 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.**

We do not cover the following:

-   Care by non-Plan providers except for authorized referrals or
    emergencies (see Section 5(d)), services under the Travel Benefit
    (see Section 5(g)), and services received from other Kaiser
    Permanente plans (see Section 5(g));

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

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

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

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

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

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

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

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

-   Services required for (a) obtaining or maintaining employment or
    participation in employee programs or (b) insurance or governmental
    licensing; or

-   Services provided or arranged by criminal justice institutions for
    members confined therein.

# Section 7. Filing a claim for covered services

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

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

+------------------+---------------------------------------------------+
| Medical and      | In most cases, providers and facilities file      |
| hospital         | claims for you. Physicians must file on the form  |
| benefits         | CMS-1500, Health Insurance Claim Form. Facilities |
|                  | will file on the UB-92 form. For claims questions |
|                  | and assistance, call us from Portland at          |
|                  | 503/813-2000, or from other areas call            |
|                  | 800/813-2000 or our TTY number at 800/735-2900.   |
|                  |                                                   |
|                  | When you must file a claim -- such as for         |
|                  | services you receive outside of the Plan\'s       |
|                  | service area -- please complete the Emergency     |
|                  | Care Information (ECI) form and submit it with    |
|                  | the CMS-1500 or a claim form that includes the    |
|                  | information shown below. ECI forms may be         |
|                  | obtained by calling us from Portland at           |
|                  | 503/813-2000, or from other areas call            |
|                  | 800/813-2000 or our TTY number at 800/735-2900.   |
|                  | 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;        |
|                  |                                                   |
|                  | -   Follow up services rendered out-of-area;      |
|                  |                                                   |
|                  | -   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:**                        |
|                  |                                                   |
|                  | Claims Administration                             |
|                  |                                                   |
|                  | Kaiser Foundation Health Plan of the Northwest    |
|                  |                                                   |
|                  | 500 N.E. Multnomah, Suite 100                     |
|                  |                                                   |
|                  | Portland, Oregon 97232-2099                       |
+------------------+---------------------------------------------------+
| Deadline for     | Send us all of the documents for your claim as    |
| filing your      | soon as possible. You must submit the claim by    |
| claim            | December 31 of the year after the year you        |
|                  | received the service, unless timely filing was    |
|                  | prevented by administrative operations of         |
|                  | Government or legal incapacity, provided the      |
|                  | claim was submitted as soon as reasonably         |
|                  | possible.                                         |
+------------------+---------------------------------------------------+
| When we need     | Please reply promptly when we ask for additional  |
| more information | information. We may delay processing or deny your |
|                  | claim if you do not respond.                      |
+------------------+---------------------------------------------------+

# Section 8. The disputed claims process

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

+----+-----------------------------------------------------------------+
| St | Description                                                     |
| ep |                                                                 |
+----+-----------------------------------------------------------------+
| 1  | Ask us in writing to reconsider our initial decision. You must: |
|    |                                                                 |
|    | a)  Write to us within 6 months from the date of our decision;  |
|    |     and                                                         |
|    |                                                                 |
|    | b)  Send your request to us at: Kaiser Foundation Health Plan   |
|    |     of the Northwest, 500 N.E. Multnomah, Suite 100, Portland,  |
|    |     Oregon 97232-2099; and                                      |
|    |                                                                 |
|    | c)  Include a statement about why you believe our initial       |
|    |     decision was wrong, based on specific benefit provisions in |
|    |     this brochure; and                                          |
|    |                                                                 |
|    | d)  Include copies of documents that support your claim, such   |
|    |     as physicians\' letters, operative reports, bills, medical  |
|    |     records, and explanation of benefits (EOB) forms.           |
+----+-----------------------------------------------------------------+
| 2  | We have 30 days from the date we receive your request to:       |
|    |                                                                 |
|    | a)  Pay the claim (or, if applicable, arrange for the health    |
|    |     care provider to give you the care); or                     |
|    |                                                                 |
|    | b)  Write to you and maintain our denial go to step 4; or       |
|    |                                                                 |
|    | c)  Ask you or your provider for more information. If we ask    |
|    |     your provider, we will send you a copy of our request---go  |
|    |     to step 3.                                                  |
+----+-----------------------------------------------------------------+
| 3  | You or your provider must send the information so that we       |
|    | receive it within 60 days of our request. We will then decide   |
|    | within 30 more days.                                            |
|    |                                                                 |
|    | If we do not receive the information within 60 days, we will    |
|    | decide within 30 days of the date the information was due. We   |
|    | will base our decision on the information we already have.      |
|    |                                                                 |
|    | We will write to you with our decision.                         |
+----+-----------------------------------------------------------------+
| 4  | If you do not agree with our decision, you may ask OPM to       |
|    | review it.                                                      |
+----+-----------------------------------------------------------------+
|    | You must write to OPM within:                                   |
|    |                                                                 |
|    | -   90 days after the date of our letter upholding our initial  |
|    |     decision; or                                                |
|    |                                                                 |
|    | -   120 days after you first wrote to us if we did not answer   |
|    |     that request in some way within 30 days; or                 |
|    |                                                                 |
|    | -   120 days after we asked for additional information.         |
+----+-----------------------------------------------------------------+
|    | Write to OPM at: United States Office of Personnel Management,  |
|    | Insurance Services Programs, Health Insurance Group 3, 1900 E   |
|    | Street, NW, Washington, DC 20415-2630.                          |
+----+-----------------------------------------------------------------+
| T  |                                                                 |
| he |                                                                 |
| di |                                                                 |
| sp |                                                                 |
| ut |                                                                 |
| ed |                                                                 |
| cl |                                                                 |
| ai |                                                                 |
| ms |                                                                 |
| p  |                                                                 |
| ro |                                                                 |
| ce |                                                                 |
| ss |                                                                 |
| *  |                                                                 |
| (c |                                                                 |
| on |                                                                 |
| ti |                                                                 |
| nu |                                                                 |
| ed |                                                                 |
| )* |                                                                 |
+----+-----------------------------------------------------------------+
|    | Send OPM the following information:                             |
|    |                                                                 |
|    | -   A statement about why you believe our decision was wrong,   |
|    |     based on specific benefit provisions in this brochure;      |
|    |                                                                 |
|    | -   Copies of documents that support your claim, such as        |
|    |     physicians\' letters, operative reports, bills, medical     |
|    |     records, and explanation of benefits (EOB) forms;           |
|    |                                                                 |
|    | -   Copies of all letters you sent to us about the claim;       |
|    |                                                                 |
|    | -   Copies of all letters we sent to you about the claim; and   |
|    |                                                                 |
|    | -   Your daytime phone number and the best time to call.        |
|    |                                                                 |
|    | Note: If you want OPM to review more than one claim, you must   |
|    | clearly identify which documents apply to which claim.          |
+----+-----------------------------------------------------------------+
|    | Note: You are the only person who has a right to file a         |
|    | disputed claim with OPM. Parties acting as your representative, |
|    | such as medical providers, must include a copy of your specific |
|    | written consent with the review request.                        |
|    |                                                                 |
|    | Note: The above deadlines may be extended if you show that you  |
|    | were unable to meet the deadline because of reasons beyond your |
|    | control.                                                        |
+----+-----------------------------------------------------------------+
| *  | OPM will review your disputed claim request and will use the    |
| *5 | information it collects from you and us to decide whether our   |
| ** | decision is correct. OPM will send you a final decision within  |
|    | 60 days. There are no other administrative appeals.             |
+----+-----------------------------------------------------------------+
|    | If you do not agree with OPM's decision, your only recourse is  |
|    | to sue. If you decide to sue, you must file the suit against    |
|    | OPM in Federal court by December 31 of the third year after the |
|    | year in which you received the disputed services, drugs, or     |
|    | supplies or from the year in which you were denied              |
|    | precertification or prior approval. This is the only deadline   |
|    | that may not be extended.                                       |
|    |                                                                 |
|    | OPM may disclose the information it collects during the review  |
|    | process to support their disputed claim decision. This          |
|    | information will become part of the court record.               |
+----+-----------------------------------------------------------------+
|    | You may not sue until you have completed the disputed claims    |
|    | process. Further, Federal law governs your lawsuit, benefits,   |
|    | and payment of benefits. The Federal court will base its review |
|    | on the record that was before OPM when OPM decided to uphold or |
|    | overturn our decision. You may recover only the amount of       |
|    | benefits in dispute.                                            |
+----+-----------------------------------------------------------------+

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

a)  We haven't responded yet to your initial request for care or
    preauthorization/prior approval, then call us from Portland at
    503/813-2000, or from other areas call 800/813-2000 or out TTY
    number at 800/735-2900 and we will expedite our review; or

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

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

-   You may call OPM's Health Insurance Group 3 at 202/606-0755 between
    8 a.m. and 5 p.m. eastern time.

# Section 9. Coordinating benefits with other coverage

+------------------+---------------------------------------------------+
| ### Whe          | You must tell us if you or a covered family       |
| n you have other | member have coverage under another group health   |
|  health coverage | plan or have automobile insurance that pays       |
|                  | health care expenses without regard to fault.     |
|                  | This is called \"double coverage.\"               |
|                  |                                                   |
|                  | When you have double coverage, one plan normally  |
|                  | pays its benefits in full as the primary payer    |
|                  | and the other plan pays a reduced benefit as the  |
|                  | secondary payer. We, like other insurers,         |
|                  | determine which coverage is primary according to  |
|                  | the National Association of Insurance             |
|                  | Commissioners\' Guidelines.                       |
|                  |                                                   |
|                  | When we are the primary payer, we will pay the    |
|                  | benefits described in this brochure.              |
|                  |                                                   |
|                  | When we are the secondary payer, we will          |
|                  | determine our allowance. After the primary payer  |
|                  | plan pays, we will pay what is left of our        |
|                  | allowance, up to our regular benefit. We will not |
|                  | pay more than our allowance. If we are the        |
|                  | secondary payer, and you received your services   |
|                  | from Plan providers, we may bill the primary      |
|                  | carrier.                                          |
+------------------+---------------------------------------------------+
| ### W            | Medicare is a Health Insurance Program for:       |
| hat is Medicare? |                                                   |
|                  | -   People 65 years of age and older.             |
|                  |                                                   |
|                  | -   Some people with disabilities, under 65 years |
|                  |     of age.                                       |
|                  |                                                   |
|                  | -   People with End-Stage Renal Disease           |
|                  |     (permanent kidney failure requiring dialysis  |
|                  |     or a transplant).                             |
|                  |                                                   |
|                  | Medicare has two parts:                           |
|                  |                                                   |
|                  | -   Part A (Hospital Insurance). Most people do   |
|                  |     not have to pay for Part A. If you or your    |
|                  |     spouse worked for at least 10 years in        |
|                  |     Medicare-covered employment, you should be    |
|                  |     able to qualify for premium-free Part A       |
|                  |     insurance. (Someone who was a Federal         |
|                  |     employee on January 1, 1983 or since          |
|                  |     automatically qualifies.) Otherwise, if you   |
|                  |     are age 65 or older, you may be able to buy   |
|                  |     it. Contact 1-800-MEDICARE for more           |
|                  |     information.                                  |
|                  |                                                   |
|                  | -   Part B (Medical Insurance). Most people pay   |
|                  |     monthly for Part B. Generally, Part B         |
|                  |     premiums are withheld from your monthly       |
|                  |     Social Security check or your retirement      |
|                  |     check.                                        |
|                  |                                                   |
|                  | If you are eligible for Medicare, you may have    |
|                  | choices in how you get your health care. Medicare |
|                  | Advantage is the term used to describe the        |
|                  | various private health plan choices available to  |
|                  | Medicare beneficiaries. The information in the    |
|                  | next few pages shows how we coordinate benefits   |
|                  | with Medicare, depending on whether you are in    |
|                  | the Original Medicare Plan or a private Medicare  |
|                  | Advantage plan.                                   |
+------------------+---------------------------------------------------+
| #                | The decision to enroll in Medicare is yours. We   |
| ### Should I enr | encourage you to apply for Medicare benefits 3    |
| oll in Medicare? | months before you turn age 65. It's easy. Just    |
|                  | call the Social Security Administration toll-free |
|                  | number 1-800-772-1213 to set up an appointment to |
|                  | apply. If you do not apply for one or both Parts  |
|                  | of Medicare, you can still be covered under the   |
|                  | FEHB Program.                                     |
|                  |                                                   |
|                  | If you can get premium-free Part A coverage, we   |
|                  | advise you to enroll in it. Most Federal          |
|                  | employees and annuitants are entitled to Medicare |
|                  | Part A at age 65 **without cost**. When you don't |
|                  | have to pay premiums for Medicare Part A, it      |
|                  | makes good sense to obtain the coverage. It can   |
|                  | reduce your out-of-pocket expenses as well as     |
|                  | costs to the FEHB, which can help keep FEHB       |
|                  | premiums down.                                    |
|                  |                                                   |
|                  | Everyone is charged a premium for Medicare Part B |
|                  | coverage. The Social Security Administration can  |
|                  | provide you with premium and benefit information. |
|                  | Review the information and decide if it makes     |
|                  | sense for you to buy the Medicare Part B          |
|                  | coverage.                                         |
+------------------+---------------------------------------------------+
| ####             | If you enroll in Medicare Part B, we require you  |
| If you enroll in | to assign your Medicare Part B benefits to the    |
|  Medicare Part B | Plan for its services.                            |
+------------------+---------------------------------------------------+
| ##               | The Original Medicare Plan (Original Medicare) is |
| ## The Original  | available everywhere in the United States. It is  |
| Medicare Plan (P | the way everyone used to get Medicare benefits    |
| art A or Part B) | and is the way most people get their Medicare     |
|                  | Part A and Part B benefits now. You may go to any |
|                  | doctor, specialist, or hospital that accepts      |
|                  | Medicare. The Original Medicare Plan pays its     |
|                  | share and you pay your share. Some things are not |
|                  | covered under Original Medicare, such as most     |
|                  | prescription drugs (but coverage through private  |
|                  | prescription drug plans will be available         |
|                  | starting in 2006).                                |
|                  |                                                   |
|                  | When you are enrolled in Original Medicare along  |
|                  | with this Plan, you still need to follow the      |
|                  | rules in this brochure for us to cover your care. |
|                  | We will not waive any of our copayments.          |
+------------------+---------------------------------------------------+
|                  | **Claims process when you have the Original       |
|                  | Medicare Plan \--** You probably will never have  |
|                  | to file a claim form when you have both our Plan  |
|                  | and the Original Medicare Plan.                   |
|                  |                                                   |
|                  | -   When we are the primary payer, we process the |
|                  |     claim first.                                  |
|                  |                                                   |
|                  | -   When Original Medicare is the primary payer,  |
|                  |     Medicare processes your claim first. In most  |
|                  |     cases, your claim will be coordinated         |
|                  |     automatically and we will then provide        |
|                  |     secondary benefits for covered charges. You   |
|                  |     will not need to do anything. To find out if  |
|                  |     you need to do something to file your claim,  |
|                  |     call us from Portland at 503/813-2000 or from |
|                  |     other areas at 800/813-2000 or our TTY number |
|                  |     at 800/735-2900. You may also see our website |
|                  |     at                                            |
|                  |     [my.kaiserpermanente.org/federalemployees](   |
|                  | http://my.kaiserpermanente.org/federalemployees). |
|                  |                                                   |
|                  | **(Primary payer chart -- begins on next page.)** |
+------------------+---------------------------------------------------+

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

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

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

+--------------------+-------------------------------------------------+
| ####               | If you are eligible for Medicare, you may       |
| Medicare Advantage | choose to enroll in and get your Medicare       |
|                    | benefits from a Medicare Advantage plan. These  |
|                    | are private health care choices (like HMOs) in  |
|                    | some areas of the country. In most Medicare     |
|                    | Advantage plans, you can only go to doctors,    |
|                    | specialists, or hospitals that are part of the  |
|                    | plan. Medicare Advantage plans provide all the  |
|                    | benefits that Original Medicare covers. Some    |
|                    | cover extras, like prescription drugs. To learn |
|                    | more about enrolling in a Medicare Advantage    |
|                    | plan, contact Medicare at 1-800-MEDICARE        |
|                    | (1-800-633-4227) or at                          |
|                    | [www.medicare.gov](http://www.medicare.gov/).   |
|                    |                                                 |
|                    | If you enroll in a Medicare Advantage plan, the |
|                    | following options are available to you:         |
|                    |                                                 |
|                    | **This Plan and our Medicare Advantage plan:**  |
|                    | You may enroll in our Medicare Advantage plan,  |
|                    | Kaiser Permanente Senior Advantage, and also    |
|                    | remain enrolled in our FEHB Plan. There is no   |
|                    | additional premium to enroll in Senior          |
|                    | Advantage. In this case, we waive or lower some |
|                    | of our copayments and coinsurance for your FEHB |
|                    | and Medicare coverage. If you would like        |
|                    | information about our Medicare Advantage plan,  |
|                    | please call from Portland 503/813-2000 or from  |
|                    | other areas 800/813-2000 or our TTY number at   |
|                    | 800/735-2900. Your Kaiser Permanente Senior     |
|                    | Advantage-FEHBP benefits that we lowered or     |
|                    | waived include:                                 |
|                    |                                                 |
|                    | -   Primary and Specialty care visits such as   |
|                    |     physical exams, allergy testing and         |
|                    |     injections, respiratory therapy, radiation  |
|                    |     therapy, same-day outpatient surgery,       |
|                    |     gynecological visits, hearing and vision    |
|                    |     exams, and manual manipulation of the       |
|                    |     spine: \$0                                  |
|                    |                                                 |
|                    | -   Dialysis: \$0                               |
|                    |                                                 |
|                    | -   Hospital care: \$0                          |
|                    |                                                 |
|                    | -   Durable medical equipment, prosthetics,     |
|                    |     orthotics, supplies (including diabetic     |
|                    |     supplies) and certain drugs per Medicare    |
|                    |     criteria: \$0                               |
|                    |                                                 |
|                    | -   Family planning: \$0                        |
|                    |                                                 |
|                    | -   Home health care: \$0                       |
|                    |                                                 |
|                    | -   Hospice care: \$0                           |
|                    |                                                 |
|                    | -   House calls: \$0                            |
|                    |                                                 |
|                    | -   Medical social services: \$0                |
|                    |                                                 |
|                    | -   Mental health and substance abuse:          |
|                    |     inpatient and outpatient services           |
|                    |     (residential/day treatment does have a      |
|                    |     copayment): \$0                             |
|                    |                                                 |
|                    | -   Physical, occupational and speech therapy,  |
|                    |     and multidisciplinary rehabilitation        |
|                    |     services: \$0                               |
|                    |                                                 |
|                    | -   Reconstructive therapy: \$0                 |
|                    |                                                 |
|                    | -   Skilled Nursing Facility care: up to 100    |
|                    |     days per benefit period: \$0                |
|                    |                                                 |
|                    | -   Transplants: \$0                            |
|                    |                                                 |
|                    | -   Vision exams: \$0                           |
|                    |                                                 |
|                    | -   X-ray, lab tests, and other special         |
|                    |     procedures: \$0                             |
|                    |                                                 |
|                    | **This Plan and another plan's Medicare         |
|                    | Advantage plan:** You may enroll in another     |
|                    | plan's Medicare Advantage plan and also remain  |
|                    | enrolled in our FEHB plan. We will still        |
|                    | provide benefits when your Medicare Advantage   |
|                    | plan is primary if you use our Plan providers,  |
|                    | but we will not lower or waive any of our       |
|                    | copayments or coinsurance. If you enroll in a   |
|                    | Medicare Advantage plan, tell us. We will need  |
|                    | to know whether you are in the Original         |
|                    | Medicare Plan or in a Medicare Advantage plan   |
|                    | so we can correctly coordinate benefits with    |
|                    | Medicare.                                       |
|                    |                                                 |
|                    | **Suspended FEHB coverage to enroll in a        |
|                    | Medicare Advantage plan:** If you are an        |
|                    | annuitant or former spouse, you can suspend     |
|                    | your FEHB coverage to enroll in a Medicare      |
|                    | Advantage plan, eliminating your FEHB premium.  |
|                    | (OPM does not contribute to your Medicare       |
|                    | Advantage plan premium.) For information on     |
|                    | suspending your FEHB enrollment, contact your   |
|                    | retirement office. If you later want to         |
|                    | re-enroll in the FEHB Program, generally you    |
|                    | may do so only at the next open season unless   |
|                    | you involuntarily lose coverage or move out of  |
|                    | the Medicare Advantage service area.            |
+--------------------+-------------------------------------------------+
| ### T              | TRICARE is the health care program for eligible |
| RICARE and CHAMPVA | dependents of military persons and retirees of  |
|                    | the military. TRICARE includes the CHAMPUS      |
|                    | program. CHAMPVA provides health coverage to    |
|                    | disabled Veterans and their eligible            |
|                    | dependents. If TRICARE or CHAMPVA and this Plan |
|                    | cover you, we pay first. See your TRICARE or    |
|                    | CHAMPVA Health Benefits Advisor if you have     |
|                    | questions about these programs.                 |
|                    |                                                 |
|                    | **Suspended FEHB coverage to enroll in TRICARE  |
|                    | or CHAMPVA:** If you are an annuitant or former |
|                    | spouse, you can suspend your FEHB coverage to   |
|                    | enroll in one of these programs, eliminating    |
|                    | your FEHB premium. (OPM does not contribute to  |
|                    | any applicable plan premiums.) For information  |
|                    | on suspending your FEHB enrollment, contact     |
|                    | your retirement office. If you later want to    |
|                    | re-enroll in the FEHB Program, generally you    |
|                    | may do so only at the next Open Season unless   |
|                    | you involuntarily lose coverage under the       |
|                    | program.                                        |
+--------------------+-------------------------------------------------+
| ### Wor            | We do not cover services that:                  |
| kers' Compensation |                                                 |
|                    | -   you need because of a workplace-related     |
|                    |     illness or injury that the Office of        |
|                    |     Workers' Compensation Programs (OWCP) or a  |
|                    |     similar Federal or State agency determines  |
|                    |     they must provide; or                       |
|                    |                                                 |
|                    | -   OWCP or a similar agency pays for through a |
|                    |     third party injury settlement or other      |
|                    |     similar proceeding that is based on a claim |
|                    |     you filed under OWCP or similar laws        |
|                    |                                                 |
|                    | Once OWCP or similar agency pays its maximum    |
|                    | benefits for your treatment, we will cover your |
|                    | care. You must use our providers.               |
+--------------------+-------------------------------------------------+
| ### Medicaid       | When you have this Plan and Medicaid, we pay    |
|                    | first.                                          |
|                    |                                                 |
|                    | **Suspended FEHB coverage to enroll in Medicaid |
|                    | or a similar State-sponsored program of medical |
|                    | assistance:** If you are an annuitant or former |
|                    | spouse, you can suspend your FEHB coverage to   |
|                    | enroll in one of these State programs,          |
|                    | eliminating your FEHB premium. For information  |
|                    | on suspending your FEHB enrollment, contact     |
|                    | your retirement office. If you later want to    |
|                    | re-enroll in the FEHB Program, generally you    |
|                    | may do so only at the next Open Season unless   |
|                    | you involuntarily lose coverage under the State |
|                    | program.                                        |
+--------------------+-------------------------------------------------+

+--------------------+-------------------------------------------------+
| ### When o         | We do not cover services and supplies when a    |
| ther Government ag | local, State, or Federal Government agency      |
| encies are respons | directly or indirectly pays for them.           |
| ible for your care |                                                 |
+--------------------+-------------------------------------------------+
| ### When           | When you receive money to compensate you for    |
|  others are respon | medical or hospital care for injuries or        |
| sible for injuries | illness caused by another person, you must      |
|                    | reimburse us for any expenses we paid. However, |
|                    | we will cover the cost of treatment that        |
|                    | exceeds the amount you received in the          |
|                    | settlement.                                     |
|                    |                                                 |
|                    | If you do not seek damages, you must agree to   |
|                    | let us try. This is called subrogation. If you  |
|                    | need more information, contact us for our       |
|                    | subrogation procedures.                         |
+--------------------+-------------------------------------------------+

# 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.

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

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

  Custodial care      \(1\) Assistance with activities of daily living,
                      for example, walking, getting in and out of bed,
                      dressing, feeding, toileting, and taking medicine.
                      (2) Care that can be performed safely and
                      effectively by people who, in order to provide the
                      care, do not require medical licenses or
                      certificates or the presence of a supervising
                      licensed nurse. Custodial care that lasts 90 days
                      or more is sometimes known as Long term care.

  Deductible          A deductible is a fixed amount of covered expenses
                      you must incur for certain covered services and
                      supplies before we start paying benefits for those
                      services.

  Durable medical     Durable medical equipment (DME) is equipment that
  equipment           is intended for repeated use, medically necessary,
                      primarily and customarily used to serve a medical
                      purpose, generally not useful to a person who is
                      not ill or injured, designed for prolonged use,
                      appropriate for use in the home, and serves a
                      specific therapeutic purpose in the treatment of an
                      illness or injury.

  Experimental or     We carefully evaluate whether a particular therapy
  investigational     is safe and effective or offers a reasonable degree
  services            of promise with respect to improving health
                      outcomes. The primary source of evidence about
                      health outcomes of any intervention is
                      peer-reviewed medical or dental literature. When
                      the service or supply, including a drug: (1) has
                      not been approved by the FDA; or (2) is the subject
                      of a new drug or new device application on file
                      with the FDA; or (3) is part of a Phase I or Phase
                      II clinical trial, as the experimental or research
                      arm of a Phase III clinical trial; or is intended
                      to evaluate the safety, toxicity, or efficacy of
                      the service; or (4) is available as the result of a
                      written protocol that evaluates the service's
                      safety, toxicity, or efficacy; or (5) is subject to
                      the approval or review of an Institutional Review
                      Board; or (6) requires an informed consent that
                      describes the service as experimental or
                      investigational; then this Plan considers that
                      service, supply, or drug to be experimental, and
                      not covered by the Plan.

  Group health        Health care benefits that are available as a result
  coverage            of your employment, or the employment of your
                      spouse, and that are offered by an employer or
                      through membership in an employee organization.
                      Health care coverage may be insured or indemnity
                      coverage, self-insured or self-funded coverage, or
                      coverage through health maintenance organizations
                      or other managed care plans. Health care coverage
                      purchased through membership in an organization is
                      also "group health coverage."

  Medically necessary All benefits need to be medically necessary in
                      order for them to be covered benefits. Generally,
                      if your Plan physician provides the service in
                      accord with the terms of this brochure, it will be
                      considered medically necessary. However, some
                      services are reviewed in advance of your receiving
                      them to determine if they are medically necessary.
                      When we review a service to determine if it is
                      medically necessary, a Plan physician will evaluate
                      what would happen to you if you do not receive the
                      service. If not receiving the service would
                      adversely affect your health, it will be considered
                      medically necessary. The services must be a
                      medically appropriate course of treatment for your
                      condition. If they are not medically necessary, we
                      will not cover the services. In case of emergency
                      services, the services that you received will be
                      evaluated to determine if they were medically
                      necessary.
  ------------------- ---------------------------------------------------

  ------------------- ---------------------------------------------------
  Our allowance       The amount we use to determine your coinsurance.
                      When you receive services or supplies from Plan
                      providers, it is the amount that we set for the
                      services or supplies if we were to charge for them.
                      When you receive services from non-Plan providers,
                      it is either the amount that we have negotiated
                      with the non-Plan Provider, or if we do not have a
                      negotiated amount, the amount that we believe is
                      usual and customary for the service or supply,
                      compared to the billed charges. Our allowance is
                      based upon the reasonableness of the billed
                      charges. If the billed charges exceed what we
                      believe is reasonable, you may be responsible for
                      the excess over our allowance in addition to your
                      coinsurance.

  Us/We               Us and we refer to Kaiser Foundation Health Plan of
                      the Northwest.

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

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

# Section 11. FEHB Facts

### Coverage information

+------------------+---------------------------------------------------+
| #### No p        | We will not refuse to cover the treatment of a    |
| re-existing cond | condition that you had before you enrolled in     |
| ition limitation | this Plan solely because you had the condition    |
|                  | before you enrolled.                              |
+------------------+---------------------------------------------------+
| #### W           | See <http://www.opm.gov/insure>. Also, your       |
| here you can get | employing or retirement office can answer your    |
|  information abo | questions, and give you a *Guide to Federal       |
| ut enrolling in  | Employees Health Benefits Plans,* brochures for   |
| the FEHB Program | other plans, and other materials you need to make |
|                  | an informed decision about your FEHB coverage.    |
|                  | These materials tell you:                         |
|                  |                                                   |
|                  | -   When you may change your enrollment;          |
|                  |                                                   |
|                  | -   How you can cover your family members;        |
|                  |                                                   |
|                  | -   What happens when you transfer to another     |
|                  |     Federal agency, go on leave without pay,      |
|                  |     enter military service, or retire;            |
|                  |                                                   |
|                  | -   When your enrollment ends; and                |
|                  |                                                   |
|                  | -   When the next open season for enrollment      |
|                  |     begins.                                       |
|                  |                                                   |
|                  | We don't determine who is eligible for coverage   |
|                  | and, in most cases, cannot change your enrollment |
|                  | status without information from your employing or |
|                  | retirement office.                                |
+------------------+---------------------------------------------------+
| #### Typ         | Self Only coverage is for you alone. Self and     |
| es of coverage a | Family coverage is for you, your spouse, and your |
| vailable for you | unmarried dependent children under age 22,        |
|  and your family | including any foster children or stepchildren     |
|                  | your employing or retirement office authorizes    |
|                  | coverage for. Under certain circumstances, you    |
|                  | may also continue coverage for a disabled child   |
|                  | 22 years of age or older who is incapable of      |
|                  | self-support.                                     |
|                  |                                                   |
|                  | If you have a Self Only enrollment, you may       |
|                  | change to a Self and Family 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.                                             |
+------------------+---------------------------------------------------+
| #### Child       | OPM has implemented the Federal Employees Health  |
| ren's Equity Act | Benefits Children's Equity Act of 2000. This law  |
|                  | mandates that you be enrolled for Self and Family |
|                  | coverage in the Federal Employees Health Benefits |
|                  | (FEHB) Program, if you are an employee subject to |
|                  | a court or administrative order requiring you to  |
|                  | provide health benefits for your child(ren).      |
|                  |                                                   |
|                  | If this law applies to you, you must enroll for   |
|                  | Self and Family coverage in a health plan that    |
|                  | provides full benefits in the area where your     |
|                  | children live or provide documentation to your    |
|                  | employing office that you have obtained other     |
|                  | health benefits coverage for your children. If    |
|                  | you do not do so, your employing office will      |
|                  | enroll you involuntarily as follows:              |
|                  |                                                   |
|                  | -   If you have no FEHB coverage, your employing  |
|                  |     office will enroll you for Self and Family    |
|                  |     coverage in the Blue Cross and Blue Shield    |
|                  |     Service Benefit Plan's Basic Option,          |
|                  |                                                   |
|                  | -   If you have a Self Only enrollment in a       |
|                  |     fee-for-service plan or in an HMO that serves |
|                  |     the area where your children live, your       |
|                  |     employing office will change your enrollment  |
|                  |     to Self and Family in the same option of the  |
|                  |     same plan; or                                 |
|                  |                                                   |
|                  | -   If you are enrolled in an HMO that does not   |
|                  |     serve the area where the children live, your  |
|                  |     employing office will change your enrollment  |
|                  |     to Self and Family in the Blue Cross and Blue |
|                  |     Shield Service Benefit Plan's Basic Option.   |
|                  |                                                   |
|                  | As long as the court/administrative order is in   |
|                  | effect, and you have at least one child           |
|                  | identified in the order who is still eligible     |
|                  | under the FEHB Program, you cannot cancel your    |
|                  | enrollment, change to Self Only, or change to a   |
|                  | plan that doesn't serve the area in which your    |
|                  | children live, unless you provide documentation   |
|                  | that you have other coverage for the children. If |
|                  | the court/administrative order is still in effect |
|                  | when you retire, and you have at least one child  |
|                  | still eligible for FEHB coverage, you must        |
|                  | continue your FEHB coverage into retirement (if   |
|                  | eligible) and cannot cancel your coverage, change |
|                  | to Self Only, or change to a plan that doesn't    |
|                  | serve the area in which your children live as     |
|                  | long as the court/administrative order is in      |
|                  | effect. Contact your employing office for further |
|                  | information.                                      |
+------------------+---------------------------------------------------+
| ####             | The benefits in this brochure are effective on    |
| When benefits an | January 1. If you joined this Plan during Open    |
| d premiums start | Season, your coverage begins on the first day of  |
|                  | your first pay period that starts on or after     |
|                  | January 1. If you changed plans or plan options   |
|                  | during Open Season and you receive care between   |
|                  | January 1 and the effective date of coverage      |
|                  | under your new plan or option, your claims will   |
|                  | be paid according to the 2005 benefits of your    |
|                  | old plan or option. However, if your old plan     |
|                  | left the FEHB Program at the end of the year, you |
|                  | are covered under that plan's 2004 benefits until |
|                  | the effective date of your coverage with your new |
|                  | plan. Annuitants' coverage and premiums begin on  |
|                  | January 1. If you joined at any other time during |
|                  | the year, your employing office will tell you the |
|                  | effective date of coverage.                       |
+------------------+---------------------------------------------------+
| ####             | When you retire, you can usually stay in the FEHB |
|  When you retire | Program. Generally, you must have been enrolled   |
|                  | in the FEHB Program for the last five years of    |
|                  | your Federal service. If you do not meet this     |
|                  | requirement, you may be eligible for other forms  |
|                  | of coverage, such as temporary continuation of    |
|                  | coverage (TCC).                                   |
+------------------+---------------------------------------------------+

### When you lose benefits

+------------------+---------------------------------------------------+
| #### When FE     | You will receive an additional 31 days of         |
| HB coverage ends | coverage, for no additional premium, when:        |
|                  |                                                   |
|                  | -   Your enrollment ends, unless you cancel your  |
|                  |     enrollment, or                                |
|                  |                                                   |
|                  | -   You are a family member no longer eligible    |
|                  |     for coverage.                                 |
|                  |                                                   |
|                  | You may be eligible for spouse equity coverage or |
|                  | Temporary Continuation of Coverage (TCC), or a    |
|                  | conversion policy (a non-FEHB individual policy). |
+------------------+---------------------------------------------------+
| #### Spouse      | If you are divorced from a Federal employee or    |
|  equity coverage | annuitant, you may not continue to get benefits   |
|                  | under your former spouse's enrollment. This is    |
|                  | the case even when the court has ordered your     |
|                  | former spouse to supply health coverage to you.   |
|                  | But, you may be eligible for your own FEHB        |
|                  | coverage under the spouse equity law or Temporary |
|                  | Continuation of Coverage (TCC). If you are        |
|                  | recently divorced or are anticipating a divorce,  |
|                  | contact your ex-spouse's employing or retirement  |
|                  | office to get RI 70-5, the *Guide to Federal      |
|                  | Employees Health Benefits Plans for Temporary     |
|                  | Continuation of Coverage and Former Spouse        |
|                  | Enrollees*, or other information about your       |
|                  | coverage choices. You can also download the guide |
|                  | from OPM's website, <http://www.opm.gov/insure>.  |
+------------------+---------------------------------------------------+
| #### Temporar    | If you leave Federal service, or if you lose      |
| y Continuation o | coverage because you no longer qualify as a       |
| f Coverage (TCC) | family member, you may be eligible for Temporary  |
|                  | Continuation of Coverage (TCC). For example, you  |
|                  | can receive TCC if you are not able to continue   |
|                  | your FEHB enrollment after you retire, if you     |
|                  | lose your 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                         |
|                  | <http://www.opm.gov/insure>. It explains what you |
|                  | have to do to enroll.                             |
+------------------+---------------------------------------------------+
| #### C           | You may convert to a non-FEHB individual policy   |
| onverting to ind | if:                                               |
| ividual coverage |                                                   |
|                  | -   Your coverage under TCC or the spouse equity  |
|                  |     law ends (if you canceled your coverage or    |
|                  |     did not pay your premium, you cannot          |
|                  |     convert);                                     |
|                  |                                                   |
|                  | -   You decided not to receive coverage under TCC |
|                  |     or the spouse equity law; or                  |
|                  |                                                   |
|                  | -   You are not eligible for coverage under TCC   |
|                  |     or the spouse equity law.                     |
|                  |                                                   |
|                  | If you leave Federal service, your employing      |
|                  | office will notify you of your right to convert.  |
|                  | You must apply in writing to us within 31 days    |
|                  | after you receive this notice. However, if you    |
|                  | are a family member who is losing coverage, the   |
|                  | employing or retirement office will **not**       |
|                  | notify you. You must apply in writing to us       |
|                  | within 31 days after you are no longer eligible   |
|                  | for coverage. Conversion to an individual dental  |
|                  | plan is not available.                            |
|                  |                                                   |
|                  | Your benefits and rates will differ from those    |
|                  | under the FEHB Program; however, you will not     |
|                  | have to answer questions about your health, and   |
|                  | we will not impose a waiting period or limit your |
|                  | coverage due to pre-existing conditions.          |
+------------------+---------------------------------------------------+
| #### Get         | The Health Insurance Portability and              |
| ting a Certifica | Accountability Act of 1996 (HIPAA) is a Federal   |
| te of Group Heal | law that offers limited Federal protections for   |
| th Plan Coverage | health coverage availability and continuity to    |
|                  | people who lose employer group coverage. If you   |
|                  | leave the FEHB Program, we will give you a        |
|                  | Certificate of Group Health Plan Coverage that    |
|                  | indicates how long you have been enrolled with    |
|                  | us. You can use this certificate when getting     |
|                  | health insurance or other health care coverage.   |
|                  | Your new plan must reduce or eliminate waiting    |
|                  | periods, limitations, or exclusions for health    |
|                  | related conditions based on the information in    |
|                  | the certificate, as long as you enroll within 63  |
|                  | days of losing coverage under this Plan. If you   |
|                  | have been enrolled with us for less than 12       |
|                  | months, but were previously enrolled in other     |
|                  | FEHB plans, you may also request a certificate    |
|                  | from those plans. For more information, get OPM   |
|                  | pamphlet RI 79-27, Temporary Continuation of      |
|                  | Coverage (TCC) under the FEHB Program. See also   |
|                  | the FEHB website                                  |
|                  | (<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.                                      |
+------------------+---------------------------------------------------+

# Section 12. Two Federal Programs complement FEHB benefits

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

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

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

+------------------+---------------------------------------------------+
| -   What is an   | It is a tax-favored benefit that allows you to    |
|     FSA?         | set aside pre-tax money from your paychecks to    |
|                  | pay for a variety of eligible expenses. *By using |
|                  | an FSA, you can reduce your taxes while paying    |
|                  | for services you would have to pay for anyway,    |
|                  | producing a discount that can be over 40%.*       |
|                  |                                                   |
|                  | There are two types of FSAs offered by FSAFEDS:   |
+------------------+---------------------------------------------------+
| Health Care      | -   Covers eligible health care expenses not      |
| Flexible         |     reimbursed by this Plan, or any other         |
| Spending Account |     medical, dental, or vision care plan you or   |
| (HCFSA)          |     your dependents may have.                     |
|                  |                                                   |
|                  | -   Eligible dependents for this account include  |
|                  |     anyone you claim on your Federal Income Tax   |
|                  |     return as a qualified dependent under the     |
|                  |     U.S. Internal Revenue Service (IRS)           |
|                  |     definition and/or with whom you jointly file  |
|                  |     your Federal Income Tax return, even if you   |
|                  |     don't have self and family health benefits    |
|                  |     coverage. *Note:* The IRS has a broader       |
|                  |     definition of a "family member" than is used  |
|                  |     under the FEHB Program to provide benefits by |
|                  |     your FEHB Plan.                               |
|                  |                                                   |
|                  | -   The maximum annual amount that can be         |
|                  |     allotted for the HCFSA is \$4,000. *Note:*    |
|                  |     The Federal workforce includes a number of    |
|                  |     employees married to each other. If each      |
|                  |     spouse/employee is eligible for FEHB          |
|                  |     coverage, both may enroll for a HCFSA up to   |
|                  |     the maximum of \$4,000 each (\$8,000 total).  |
|                  |     Both are covered under each other's HCFSA.    |
|                  |     The minimum annual amount is \$250.           |
+------------------+---------------------------------------------------+
| Dependent Care   | -   Covers eligible dependent care expenses       |
| Flexible         |     incurred so you and your spouse, if married,  |
| Spending Account |     can work, look for work, or attend school     |
| (DCFSA)          |     full-time.                                    |
|                  |                                                   |
|                  | -   Qualifying dependents for this account        |
|                  |     include your dependent children under age 13, |
|                  |     or any person of any age whom you claim as a  |
|                  |     dependent on your Federal Income Tax return   |
|                  |     (and who is mentally or physically incapable  |
|                  |     of self care).                                |
|                  |                                                   |
|                  | -   The maximum annual amount that can be         |
|                  |     allotted for the DCFSA is \$5,000. The        |
|                  |     minimum annual amount is \$250. *Note:* The   |
|                  |     IRS limits contributions to a DCFSA. For      |
|                  |     single taxpayers and taxpayers filing a joint |
|                  |     return, the maximum is \$5,000 per year. For  |
|                  |     taxpayers who file their taxes separately     |
|                  |     with a spouse, the maximum is \$2,500 per     |
|                  |     year. The limit includes any child care       |
|                  |     subsidy you may receive.                      |
+------------------+---------------------------------------------------+
| -   Enroll       | You **must make an election** to enroll in an FSA |
|     during Open  | during the 2005 FEHB Open Season. Even if you     |
|     Season       | enrolled during 2004, you must make a new         |
|                  | election to continue participating in 2005.       |
|                  | Enrollment is easy!                               |
|                  |                                                   |
|                  | -   **Online: visit                               |
|                  |     [www.FSAFEDS.com](http://www.FSAFEDS.com/)    |
|                  |     and click on [Enroll]{.underline}.**          |
|                  |                                                   |
|                  | -   Telephone: call an FSAFEDS Benefits Counselor |
|                  |     toll-free at 1-877-FSAFEDS (372-3337), Monday |
|                  |     through Friday, from 9 a.m. until 9 p.m.,     |
|                  |     Eastern Time. TTY: 1-800-952-0450.            |
+------------------+---------------------------------------------------+

+------------------+--------------------------------+--------+--------+
| What is SHPS?    | SHPS is a third-party          |        |        |
|                  | administrator hired by OPM to  |        |        |
|                  | manage the FSAFEDS Program.    |        |        |
|                  | SHPS is the largest FSA        |        |        |
|                  | administrator in the nation    |        |        |
|                  | and is responsible for         |        |        |
|                  | enrollment, claims processing, |        |        |
|                  | customer service, and          |        |        |
|                  | day-to-day operations of       |        |        |
|                  | FSAFEDS.                       |        |        |
+------------------+--------------------------------+--------+--------+
| Who is eligible  | If you are a Federal employee  |        |        |
| to enroll?       | eligible for FEHB -- even if   |        |        |
|                  | you're not enrolled in FEHB -- |        |        |
|                  | you can choose to participate  |        |        |
|                  | in either, or both, of the     |        |        |
|                  | FSAs. *However, if you enroll  |        |        |
|                  | in a High Deductible Health    |        |        |
|                  | Plan (HDHP) with a Health      |        |        |
|                  | Savings Account (HSA), you are |        |        |
|                  | not eligible to participate in |        |        |
|                  | an HCFSA*.                     |        |        |
|                  |                                |        |        |
|                  | Almost all Federal employees   |        |        |
|                  | are eligible to enroll for a   |        |        |
|                  | DCFSA. The only exception is   |        |        |
|                  | intermittent (also called      |        |        |
|                  | "when actually employed"       |        |        |
|                  | \[WAE\]) employees expected to |        |        |
|                  | work fewer than 180 days       |        |        |
|                  | during the year.               |        |        |
|                  |                                |        |        |
|                  | *Note:* FSAFEDS is the FSA     |        |        |
|                  | Program established for all    |        |        |
|                  | Executive Branch employees and |        |        |
|                  | Legislative Branch employees   |        |        |
|                  | whose employers have signed on |        |        |
|                  | to participate. Under IRS law, |        |        |
|                  | FSAs are not available to      |        |        |
|                  | annuitants. Also, the U.S.     |        |        |
|                  | Postal Service and the         |        |        |
|                  | Judicial Branch, among others, |        |        |
|                  | have their own plans with      |        |        |
|                  | slightly different rules.      |        |        |
|                  | However, the advantages of     |        |        |
|                  | having an FSA are the same     |        |        |
|                  | regardless of the agency for   |        |        |
|                  | which you work.                |        |        |
+------------------+--------------------------------+--------+--------+
| -   How much     | Plan carefully when deciding   |        |        |
|     should I     | how much to contribute to an   |        |        |
|     contribute   | FSA. Because of the tax        |        |        |
|     to my FSA?   | benefits an FSA provides, the  |        |        |
|                  | IRS places strict guidelines   |        |        |
|                  | on how the money can be used.  |        |        |
|                  | Under current IRS tax rules,   |        |        |
|                  | you are required to forfeit    |        |        |
|                  | any money for which you did    |        |        |
|                  | not incur an eligible expense  |        |        |
|                  | under your FSA account(s)      |        |        |
|                  | during the Plan Year. This is  |        |        |
|                  | known as the                   |        |        |
|                  | "use-it-or-lose-it" rule. You  |        |        |
|                  | will have until April 30,      |        |        |
|                  | following the end of the Plan  |        |        |
|                  | Year to submit claims for your |        |        |
|                  | eligible expenses incurred     |        |        |
|                  | from January 1through December |        |        |
|                  | 31. For example if you enroll  |        |        |
|                  | in FSAFEDS for the 2005 Plan   |        |        |
|                  | Year, you will have until      |        |        |
|                  | April 30, 2006 to submit       |        |        |
|                  | claims for eligible expenses.  |        |        |
|                  |                                |        |        |
|                  | The [FSAFEDS                   |        |        |
|                  | Calculator]{.underline} at     |        |        |
|                  | [www.FSAFEDS                   |        |        |
|                  | .com](http://www.fsafeds.com/) |        |        |
|                  | will help you plan your FSA    |        |        |
|                  | allocations and provide an     |        |        |
|                  | estimate of your tax savings   |        |        |
|                  | based on your individual       |        |        |
|                  | situation.                     |        |        |
+------------------+--------------------------------+--------+--------+
| -   What can my  | Every FEHB plan includes cost  |        |        |
|     HCFSA pay    | sharing features, such as      |        |        |
|     for?         | deductibles you must meet      |        |        |
|                  | before the Plan provides       |        |        |
|                  | benefits, coinsurance or       |        |        |
|                  | copayments that you pay when   |        |        |
|                  | you and the Plan share costs,  |        |        |
|                  | and medical services and       |        |        |
|                  | supplies that are not covered  |        |        |
|                  | by the Plan and for which you  |        |        |
|                  | must pay. These out-of-pocket  |        |        |
|                  | costs are summarized on page   |        |        |
|                  | 13 and detailed throughout     |        |        |
|                  | this brochure. Your HCFSA will |        |        |
|                  | reimburse you when those costs |        |        |
|                  | are for qualified medical care |        |        |
|                  | that you, your spouse and/or   |        |        |
|                  | your dependents receive that   |        |        |
|                  | is NOT covered or reimbursed   |        |        |
|                  | by this FEHB Plan or any other |        |        |
|                  | coverage that you have.        |        |        |
|                  |                                |        |        |
|                  | Under the High Option of this  |        |        |
|                  | Plan, typical out-of-pocket    |        |        |
|                  | expenses include: office visit |        |        |
|                  | copayments, pharmacy           |        |        |
|                  | copayments and durable medical |        |        |
|                  | goods coinsurance.             |        |        |
|                  |                                |        |        |
|                  | Under the Standard Option of   |        |        |
|                  | this Plan, typical             |        |        |
|                  | out-of-pocket expenses         |        |        |
|                  | include: office visit          |        |        |
|                  | copayments, pharmacy           |        |        |
|                  | copayments and durable medical |        |        |
|                  | goods coinsurance.             |        |        |
|                  |                                |        |        |
|                  | 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 website at          |        |        |
|                  | <http://www.                   |        |        |
|                  | irs.gov/pub/irs-pdf/p502.pdf>. |        |        |
|                  | The FSAFEDS website also has a |        |        |
|                  | comprehensive list of eligible |        |        |
|                  | expenses at                    |        |        |
|                  | [www.FSAFEDS.com/fsafeds/eli   |        |        |
|                  | gibleexpenses.asp](http://www. |        |        |
|                  | irs.gov/pub/irs-pdf/p502.pdf). |        |        |
|                  | If you do not see your service |        |        |
|                  | or expense listed please call  |        |        |
|                  | an FSAFEDS Benefits Counselor  |        |        |
|                  | at 1-877-FSAFEDS (372-3337),   |        |        |
|                  | who will be able to answer     |        |        |
|                  | your specific questions.       |        |        |
+------------------+--------------------------------+--------+--------+
| -   Tax savings  | An FSA lets you allot money    |        |        |
|     with an FSA  | for eligible expenses          |        |        |
|                  | ***before*** your agency       |        |        |
|                  | deducts taxes from your        |        |        |
|                  | paycheck. This means the       |        |        |
|                  | amount of income that your     |        |        |
|                  | taxes are based on will be     |        |        |
|                  | lower, so your tax liability   |        |        |
|                  | will be less. Without an FSA,  |        |        |
|                  | you would still pay for these  |        |        |
|                  | expenses, but you would do so  |        |        |
|                  | using money remaining in your  |        |        |
|                  | paycheck after Federal (and    |        |        |
|                  | often state and local) taxes   |        |        |
|                  | are deducted. The following    |        |        |
|                  | chart illustrates a typical    |        |        |
|                  | tax savings example:           |        |        |
+------------------+--------------------------------+--------+--------+
|                  | **Annual Tax Savings Example** | **With | **Wi   |
|                  |                                | FSA**  | thout\ |
|                  |                                |        | FSA**  |
+------------------+--------------------------------+--------+--------+
|                  | If your taxable income is:     | \$     | \$     |
|                  |                                | 50,000 | 50,000 |
+------------------+--------------------------------+--------+--------+
|                  | And you deposit this amount    | \      | -\$0-  |
|                  | into an FSA:                   | $2,000 |        |
+------------------+--------------------------------+--------+--------+
|                  | Your taxable income is now:    | \$     | \$     |
|                  |                                | 48,000 | 50,000 |
+------------------+--------------------------------+--------+--------+
|                  | Subtract Federal & Social      | \$     | \$     |
|                  | Security taxes:                | 13,807 | 14,383 |
+------------------+--------------------------------+--------+--------+
|                  | If you spend after-tax dollars | -\$0-  | \      |
|                  | for expenses:                  |        | $2,000 |
+------------------+--------------------------------+--------+--------+
|                  | Your real spendable income is: | \$     | \$     |
|                  |                                | 34,193 | 33,617 |
+------------------+--------------------------------+--------+--------+
|                  | **Your tax savings:**          | **\    | **-    |
|                  |                                | $576** | \$0-** |
+------------------+--------------------------------+--------+--------+
|                  | **Note:** This example is      |        |        |
|                  | intended to demonstrate a      |        |        |
|                  | typical tax savings based on   |        |        |
|                  | 27% Federal and 7.65% FICA     |        |        |
|                  | taxes. Actual savings will     |        |        |
|                  | vary based upon the retirement |        |        |
|                  | system in which you are        |        |        |
|                  | enrolled (CSRS or FERS), your  |        |        |
|                  | state of residence, and your   |        |        |
|                  | individual tax situation. In   |        |        |
|                  | this example, the individual   |        |        |
|                  | received \$2,000 in services   |        |        |
|                  | for \$1,424 - a discount of    |        |        |
|                  | almost 36%! You may also wish  |        |        |
|                  | to consult a tax professional  |        |        |
|                  | for more information on the    |        |        |
|                  | tax implications of an FSA.    |        |        |
+------------------+--------------------------------+--------+--------+
| -   Tax credits  | You *cannot* claim expenses on |        |        |
|     and          | your Federal Income Tax return |        |        |
|     deductions   | if you receive reimbursement   |        |        |
|                  | for them from your HCFSA or    |        |        |
|                  | DCFSA. Below are some          |        |        |
|                  | guidelines that may help you   |        |        |
|                  | decide whether to participate  |        |        |
|                  | in FSAFEDS.                    |        |        |
+------------------+--------------------------------+--------+--------+
| Health care      | The HCFSA is Federal Income    |        |        |
| expenses         | Tax-free from the first        |        |        |
|                  | dollar. In addition, you may   |        |        |
|                  | be reimbursed from your HCFSA  |        |        |
|                  | at any time during the year    |        |        |
|                  | for expenses up to the annual  |        |        |
|                  | amount you've elected to       |        |        |
|                  | contribute.                    |        |        |
|                  |                                |        |        |
|                  | Only health care expenses      |        |        |
|                  | exceeding 7.5% of your         |        |        |
|                  | adjusted gross income are      |        |        |
|                  | eligible to be deducted on     |        |        |
|                  | your Federal Income Tax        |        |        |
|                  | return. Using the example      |        |        |
|                  | shown above, only health care  |        |        |
|                  | expenses exceeding \$3,750     |        |        |
|                  | (7.5% of \$50,000) would be    |        |        |
|                  | eligible to be deducted on     |        |        |
|                  | your Federal Income Tax        |        |        |
|                  | return. In addition, money set |        |        |
|                  | aside through an HCFSA is also |        |        |
|                  | exempt from FICA taxes. This   |        |        |
|                  | exemption is not available on  |        |        |
|                  | your Federal Income Tax        |        |        |
|                  | return.                        |        |        |
+------------------+--------------------------------+--------+--------+
| Dependent care   | The DCFSA generally allows     |        |        |
| expenses         | many families to save more     |        |        |
|                  | than they would with the       |        |        |
|                  | Federal tax credit for         |        |        |
|                  | dependent care expenses. Note  |        |        |
|                  | that you may only be           |        |        |
|                  | reimbursed from the DCFSA up   |        |        |
|                  | to your current account        |        |        |
|                  | balance. If you file a claim   |        |        |
|                  | for more than your current     |        |        |
|                  | balance, it will be held until |        |        |
|                  | additional payroll allotments  |        |        |
|                  | have been added to your        |        |        |
|                  | account.                       |        |        |
|                  |                                |        |        |
|                  | Visit                          |        |        |
|                  | [www.FSAFEDS                   |        |        |
|                  | .com](http://www.FSAFEDS.com/) |        |        |
|                  | and download the [Dependent    |        |        |
|                  | Care Tax Credit                |        |        |
|                  | Worksheet]{.underline} from    |        |        |
|                  | the Forms and Literature page  |        |        |
|                  | to help you determine what is  |        |        |
|                  | best for your situation. You   |        |        |
|                  | may also wish to consult a tax |        |        |
|                  | professional for more details. |        |        |
+------------------+--------------------------------+--------+--------+
| -   Does it cost | Section 1127 of the National   |        |        |
|     me anything  | Defense Authorization Act      |        |        |
|     to           | (Public Law 108-136) requires  |        |        |
|     participate  | agencies that offer FSAFEDS to |        |        |
|     in FSAFEDS?  | employees to cover the         |        |        |
|                  | administrative fee(s) on       |        |        |
|                  | behalf of their employees.     |        |        |
|                  | However, remember that         |        |        |
|                  | participating in FSAFEDS can   |        |        |
|                  | cost you money if you don't    |        |        |
|                  | spend your entire account      |        |        |
|                  | balance by the end of the Plan |        |        |
|                  | Year, resulting in the         |        |        |
|                  | forfeiture of funds remaining  |        |        |
|                  | in your account (the IRS       |        |        |
|                  | "use-it-or-lose-it" rule).     |        |        |
+------------------+--------------------------------+--------+--------+
| -   Contact us   | To learn more or to enroll,    |        |        |
|                  | please visit the **FSAFEDS     |        |        |
|                  | website** at                   |        |        |
|                  | [www.FSAFEDS.                  |        |        |
|                  | com](http://www.fsafeds.com/), |        |        |
|                  | or contact SHPS directly via   |        |        |
|                  | email or by phone. FSAFEDS     |        |        |
|                  | Benefits Counselors are        |        |        |
|                  | available Monday through       |        |        |
|                  | Friday, from 9:00 a.m. until   |        |        |
|                  | 9:00 p.m. Eastern Time.        |        |        |
|                  |                                |        |        |
|                  | -   E-mail: <FSAFEDS@shps.net> |        |        |
|                  |                                |        |        |
|                  | -   Telephone: 1-877-FSAFEDS   |        |        |
|                  |     (1-877-372-3337)           |        |        |
|                  |                                |        |        |
|                  | -   TTY: 1-800-952-0450        |        |        |
+------------------+--------------------------------+--------+--------+

### The Federal Long Term Care Insurance Program

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

# Index

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

24 hour nurse line 48

Accidental injury to teeth 52

Allergy care 21

Alternative treatments 29

Ambulance 35, 38, 41

Anesthesia 5, 30, 34

Autologous bone marrow transplants 21, 33

Biopsy 30

Blood and blood plasma 36

Breast cancer screening 18

Casts 36, 37

Catastrophic protection out-of-pocket maximum 13, 77, 78

Centers of Excellence 49

Changes for 2005 9

Chemotherapy 21

Chiropractic 29

Cholesterol tests 17

Claims 59, 63, 73

Coinsurance 13, 67, 73

Colorectal cancer screening 17

Congenital anomalies 30, 31, 32

Contraceptive drugs and devices 20, 31, 46

Coordination of benefits 61

Covered providers 10

Deaf and hearing impaired services 48

Deductible 13, 67, 73

Definitions 16, 67, 77, 78

Dental care 51, 52, 53, 54, 55, 77, 78

Diabetes 28, 47, 64

Diagnostic services 16, 77, 78

Disputed claims review 59

Donor expenses (transplants) 33

Dressings 36

Drugs, prescription 45, 46, 47

Durable medical equipment (DME) 28, 67

Educational classes and programs 56

Effective date of enrollment 70

Emergency 39, 40, 41, 77, 78

Exclusions, general 57

Experimental or investigational 67

Eyeglasses 24, 25

Family planning 20

Fecal occult blood test 17

Flexible benefits option 48

Fraud 3

General exclusions 57

Hearing services 23

Home health services 28

Hospice care 38

Hospital 4, 5, 6, 35, 77, 78

Immunizations 18

Infertility 20

Inpatient hospital benefits 35

Insulin 46

Laboratory and pathological services 17, 29

Language interpretation 8, 48

Magnetic resonance imagings (MRIs) 17, 29

Mail order prescription drugs 45

Mammogram 18

Maternity benefits 19

Medicaid 65

Medically necessary 16, 67

Medicare 42, 61, 63

Medicare Advantage 64

Original 62, 64

Members

Associate 79

Family 69

Plan 56

Mental conditions/substance abuse benefits 42

Newborn care 16, 19

Non-FEHBP benefits 56

Nursery charges 19

Obstetrical care 19

Occupational therapy 22

Oral and maxillofacial surgery 32

Orthopedic devices 26

Out-of-pocket expenses 13

Outside the service area student coverage 50

Oxygen 36

Pap test 17

Physical examinations 18

Physical therapy 22

Precertification 60

Prescription drugs 45, 47, 77, 78

Preventive care, adult 17

Preventive care, children 18, 19

Preventive services 17

Prior approval 12, 59, 60

Prostate cancer screening 17

Prosthetic devices 26

Psychotherapy 44

Radiation therapy 21

Renal dialysis 21

Room and board 35

Second surgical opinion 16

Services from other Kaiser Permanente Plans 50

Skilled nursing care benefits 37

Smoking cessation 56

Speech therapy 23

Splints 36

Sterilization procedures 31

Student coverage outside the service area 50

Subrogation 66

Substance abuse 42, 77, 78

Surgery 5, 30

Anesthesia 34

Oral 32

Outpatient 37

Reconstructive 31, 32

Syringes 46

Temporary continuation of coverage 71

Transplants 33

Travel benefit 49

Treatment therapies 21

TTY... 8, 48

Vision services 24, 25, 77, 78

Well child care 18

Workers' compensation 65

X-rays 17

#  Summary of benefits for Kaiser Foundation Health Plan of the Northwest

**Standard Option -- 2005**

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

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

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

+----------------------------------------+-----------------------+----+
| **Benefits**                           | **You pay**           | ** |
|                                        |                       | Pa |
|                                        |                       | ge |
|                                        |                       | ** |
+----------------------------------------+-----------------------+----+
| Medical services provided by           | \$15 per office visit | 16 |
| physicians:                            |                       |    |
|                                        |                       |    |
| -   Diagnostic and treatment services  |                       |    |
|     provided in the office             |                       |    |
+----------------------------------------+-----------------------+----+
| Services provided by a hospital:       | \$100 per admission   | 35 |
|                                        |                       |    |
| -   Inpatient                          | Various copayments    | 37 |
|                                        | based on procedure    |    |
| -   Outpatient                         | rendered              |    |
+----------------------------------------+-----------------------+----+
| Emergency benefits                     | \$75 per visit        | 40 |
|                                        |                       |    |
| -   In-area                            | \$75 per visit        | 41 |
|                                        |                       |    |
| -   Out-of-area                        |                       |    |
+----------------------------------------+-----------------------+----+
| Mental health and substance abuse      | Regular cost sharing  | 42 |
| treatment                              |                       |    |
+----------------------------------------+-----------------------+----+
| Prescription drugs                     | \$15 per prescription | 45 |
|                                        | or refill for generic |    |
|                                        | drugs (30 day supply) |    |
|                                        |                       |    |
|                                        | \$30 per prescription |    |
|                                        | or refill for         |    |
|                                        | brand-name drugs (30  |    |
|                                        | day supply)           |    |
+----------------------------------------+-----------------------+----+
| Dental care .                          | No current benefit    | NA |
+----------------------------------------+-----------------------+----+
| Vision care .                          | Refractions; \$15 per | 24 |
|                                        | office visit          |    |
+----------------------------------------+-----------------------+----+
| Special features: Flexible benefits    |                       | 48 |
| option; 24 hour nurse line; Services   |                       |    |
| for deaf and hearing impaired;         |                       |    |
| Language interpretation; High risk     |                       |    |
| pregnancies; Centers of Excellence;    |                       |    |
| Travel benefit; Services from other    |                       |    |
| Kaiser Permanente Plans; Student       |                       |    |
| coverage outside the service area      |                       |    |
+----------------------------------------+-----------------------+----+
| Protection against catastrophic costs  | Nothing after         | 13 |
|                                        | \$750/Self Only or    |    |
| (your catastrophic protection          | \$1500/Family         |    |
| out-of-pocket maximum)                 | enrollment per year   |    |
|                                        |                       |    |
|                                        | Some costs do not     |    |
|                                        | count toward this     |    |
|                                        | protection            |    |
+----------------------------------------+-----------------------+----+

**Summary of benefits for Kaiser Foundation Health Plan of the
Northwest**

**High Option -- 2005**

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

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

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

+----------------------------------------+-----------------------+----+
| **Benefits**                           | **You pay**           | ** |
|                                        |                       | Pa |
|                                        |                       | ge |
|                                        |                       | ** |
+----------------------------------------+-----------------------+----+
| Medical services provided by           | \$15 per office visit | 16 |
| physicians:                            |                       |    |
|                                        |                       |    |
| -   Diagnostic and treatment services  |                       |    |
|     provided in the office             |                       |    |
+----------------------------------------+-----------------------+----+
| Services provided by a hospital:       | \$100 per admission   | 35 |
|                                        |                       |    |
| -   Inpatient                          | Various copayments    | 37 |
|                                        | based on procedure    |    |
| -   Outpatient                         | rendered              |    |
+----------------------------------------+-----------------------+----+
| Emergency benefits                     | \$75 per visit        | 40 |
|                                        |                       |    |
| -   In-area                            | \$75 per visit        | 41 |
|                                        |                       |    |
| -   Out-of-area                        |                       |    |
+----------------------------------------+-----------------------+----+
| Mental health and substance abuse      | Regular cost sharing  | 42 |
| treatment                              |                       |    |
+----------------------------------------+-----------------------+----+
| Prescription drugs                     | \$15 per prescription | 45 |
|                                        | or refill for generic |    |
|                                        | drugs (30 day supply) |    |
|                                        |                       |    |
|                                        | \$30 per prescription |    |
|                                        | or refill for         |    |
|                                        | brand-name drugs (30  |    |
|                                        | day supply)           |    |
+----------------------------------------+-----------------------+----+
| Dental care .                          | Various copayments    | 51 |
|                                        | based on procedure    |    |
|                                        | rendered              |    |
+----------------------------------------+-----------------------+----+
| Vision care .                          | Refractions; \$15 per | 24 |
|                                        | office visit          |    |
+----------------------------------------+-----------------------+----+
| Special features: Flexible benefits    |                       | 48 |
| option; 24 hour nurse line; Services   |                       |    |
| for deaf and hearing impaired;         |                       |    |
| Language interpretation; High risk     |                       |    |
| pregnancies; Centers of Excellence;    |                       |    |
| Travel benefit; Services from other    |                       |    |
| Kaiser Permanente Plans; Student       |                       |    |
| coverage outside the service area      |                       |    |
+----------------------------------------+-----------------------+----+
| Protection against catastrophic costs  | Nothing after         | 13 |
|                                        | \$750/Self Only or    |    |
| (your catastrophic protection          | \$1,500/Family        |    |
| out-of-pocket maximum)                 | enrollment per year   |    |
|                                        |                       |    |
|                                        | Some costs do not     |    |
|                                        | count toward this     |    |
|                                        | protection            |    |
+----------------------------------------+-----------------------+----+

# 2005 Rate Information for Kaiser Foundation Health Plan of the Northwest

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

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

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

+--------------+-----+-------+-------+-------+-------+-------+-------+
|              |     | **    |       |       |       | **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** |
+--------------+-----+-------+-------+-------+-------+-------+-------+

+--------------+-----+-------+-------+-------+-------+-------+-------+
| **High       | *   | **    | *     | **    | *     | **    | *     |
| Option**     | *57 | \$129 | *\$43 | \$281 | *\$93 | \$153 | *\$19 |
|              | 1** | .74** | .25** | .11** | .70** | .53** | .46** |
| **Self       |     |       |       |       |       |       |       |
| Only**       |     |       |       |       |       |       |       |
+--------------+-----+-------+-------+-------+-------+-------+-------+
| **High       | *   | **    | *     | **    | **    | **    | *     |
| Option**     | *57 | \$296 | *\$98 | \$641 | \$213 | \$350 | *\$44 |
|              | 2** | .08** | .69** | .51** | .83** | .36** | .41** |
| **Self and   |     |       |       |       |       |       |       |
| Family**     |     |       |       |       |       |       |       |
+--------------+-----+-------+-------+-------+-------+-------+-------+
| **Standard   | *   | **    | *     | **    | *     | **    | *     |
| Option**     | *57 | \$119 | *\$39 | \$258 | *\$86 | \$141 | *\$17 |
|              | 4** | .17** | .72** | .20** | .06** | .01** | .88** |
| **Self       |     |       |       |       |       |       |       |
| Only**       |     |       |       |       |       |       |       |
+--------------+-----+-------+-------+-------+-------+-------+-------+
| **Standard   | *   | **    | *     | **    | **    | **    | *     |
| Option**     | *57 | \$271 | *\$90 | \$589 | \$196 | \$321 | *\$40 |
|              | 5** | .94** | .64** | .19** | .40** | .79** | .79** |
| **Self and   |     |       |       |       |       |       |       |
| Family**     |     |       |       |       |       |       |       |
+--------------+-----+-------+-------+-------+-------+-------+-------+