![](media/image1.png)

**Health Net of California**

**www.healthnet.com**

**Formerly Health Net**

**2004**

**A Health Maintenance Organization**

![](media/image2.png){width="1.5194444444444444in"
height="1.5263888888888888in"}

**Serving:** **Most of California**

**Enrollment in this Plan is limited. You must live or work in our
Geographic service area to enroll. See page 9 for requirements.**

![](media/image3.wmf){width="0.80625in" height="0.8069444444444445in"}

*This plan has Excellent accreditation from the NCQA. See\
the 2004 Guide for more information on accreditation.*

**Enrollment codes for this Plan:**

########  LB1 Self Only 

**LB2 Self and Family**

![](media/image4.png){width="1.1888888888888889in"
height="0.8888888888888888in"}

![](media/image5.png){width="2.8097222222222222in"
height="1.1236111111111111in"} **RI 73-159**

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

Dear Federal Employees Health Benefits Program Participant:

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

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

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

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

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

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

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

# Notice of the Office of Personnel Management's

# Privacy Practices

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

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

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

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

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

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

-   Where required by law.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

-   Get a separate paper copy of this notice.

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

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

Privacy Complaints

United States Office of Personnel Management

P.O. Box 707

Washington, DC 20004-0707

Filing a complaint will not affect your benefits under the FEHB Program.
You also may file a complaint with the Secretary of the 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
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Introduction............................................................................
5

Plain
Language........................................................................
5

Stop Health Care Fraud! 5

Preventing medical mistakes 6

Section 1. Facts about this HMO plan 8

How we pay providers 8

Who provides my health care? 8

Your Rights 8

Service Area 9

Section 2. How we change for
2004............................................... 11

Program-wide changes 11

Changes to this Plan 11

Section 3. How you get care ............\... 12

Identification cards 12

Where you get covered care 12

• Plan providers 12

• Plan facilities 12

What you must do to get covered care 12

• Primary care 12

• Specialty care 13

• Hospital care 14

Circumstances beyond our control 14

Services requiring our prior approval 14

Section 4. Your costs for covered services 15

• Copayments 15

• Deductible 15

• Coinsurance 15

Your catastrophic protection out-of-pocket maximum 15

Section 5.
Benefits..................................................................
16

Overview 16

(a) Medical services and supplies provided by physicians and other
    health care professionals 17

(b) Surgical and anesthesia services provided by physicians and other
    health care professionals 27

(c) Services provided by a hospital or other facility, and ambulance
    services 31

(d) Emergency services/accidents 34

(e) Mental health and substance abuse benefits 36

(f) Prescription drug benefits 38

(g) Special features 41

-   Flexible benefits option

-   Services for the Deaf and Hearing Impaired

-   Early Prenatal Program

-   Centers of Excellence

(h) Dental benefits 42

(i) Non-FEHB benefits available to Plan members 43

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

Section 7. Filing a claim for covered services 45

Section 8. The disputed claims process 46

Section 9. Coordinating benefits with other coverage 48

When you have other health coverage 48 •Other health coverage 46

• What is Medicare? 48

• Should I enroll in Medicare? 48

• Medicare + Choice 52

-   TRICARE and CHAMPVA 52

-   Workers' Compensation 53

-   Medicaid 53

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-   Other Government agencies 53

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-   When others are responsible for injuries 53

Section 10. Definitions of terms we use in this brochure 54

Section 11. FEHB facts 55

Coverage information.... .........55

• No pre-existing condition limitation 55

• Where you can get information about enrolling in the FEHB Program 55

• Types of coverage available for you and your family 55

• Children's Equity Act 55

• When benefits and premiums start 56

• When you retire 56

When you lose benefits 56

• When FEHB coverage ends 56

• Spouse equity coverage 56

• Temporary Continuation of Coverage (TCC) 57

• Converting to individual coverage 57

• Getting a Certificate of Group Health Plan Coverage 57

Two new Federal Programs to complement FEHB benefits 58

The Federal Flexible Spending Account Program - *FSAFEDS* 58

The Federal Long Term Care Insurance Program 61

Index
........................................................................................................................................................62

Summary of benefits 63

Rates..............................................................................................................................................Back
cover

  -----------------------------------------------------------------------
  Introduction

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

This brochure describes the benefits of Health Net of California under
our contract (CS 2002) with the Office of Personnel Management (OPM), as
authorized by the Federal Employees Health Benefits law. The address for
Health Net of California's administrative offices is:

Health Net of California

P.O. Box 9103

Van Nuys, CA 91409-9103

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

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

OPM negotiates benefits and rates with each plan annually. Benefit
changes are effective January 1, 2004, and changes are summarized on
page 11. Rates are shown at the end of this brochure.

  -----------------------------------------------------------------------
  Plain Language

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

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

-   Except for necessary technical terms, we use common words. For
    instance, "you" means the enrollee or family member; \"we\" means
    Health Net of California.

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

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

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

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  Stop Health Care Fraud!

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

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

premium.

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

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

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

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

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

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

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

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

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

-   If the provider does not resolve the matter, call us at 800-522-0088
    and explain the situation.

-   If we do not resolve the issue:

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

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

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

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

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

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

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

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

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

-   Ask questions and make sure you understand the answers.

-   Choose a doctor with whom you feel comfortable talking.

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

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

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

-   Tell them about any drug allergies you have.

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

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

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

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

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

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

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

-   Call your doctor and ask for your results.

-   Ask what the results mean for your care.

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

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

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

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

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

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

-   Ask your surgeon:

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

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

Want more information on patient safety?

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

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

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

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

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

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

  -----------------------------------------------------------------------
  **Section 1. Facts about this HMO plan**

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

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

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

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

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

How we pay providers

We contract with Participating Physician Groups (PPGs), rather than
directly with physicians, on a capitated basis for HMO plans. We will
also contract directly with an individual physician in rural areas where
PPGs do not exist.

In contractual agreements with PPGs that are capitated, we prepay PPGs a
monthly fixed dollar amount based on a Per Member Per Month (PMPM) rate
schedule. The amount and the method for utilizing the capitation payment
vary among the PPGs. Influencing the capitation payment is the division
of financial responsibility agreed to between Health Net of California
and the PPG, as well as Member demographics and level of benefits.

In dual risk arrangements, the PPG will receive a capitation that covers
some hospital or institutional services as well as professional
services. In shared risk arrangements, the PPG will receive a capitation
that covers only professional services.

While we contract with PPGs on a capitated basis, the PPGs contract with
and reimburse both primary and specialty care physicians. These
reimbursement methods include subcapitation, salary, and discounted fee
schedules. In those instances where we contract directly with
physicians, the physician reimbursement is based on RBRVS (Resource
Based Relative Value System), an industry accepted fee schedule that the
Health Care Financing Administration (HCFA) established.

Who provides my health care

We are a Mixed Model HMO with an extensive network of over 600
participating physician groups and 415 hospitals conveniently located in
the communities where you work or live. Over 36,000 primary care and
referral specialist physicians are affiliated with us through our
participating physician groups.

You must select a participating physician group within a 30-mile radius
of your home or work-site. Although each of your family members may
select their own primary care physician, we encourage family members to
choose their primary care physicians within the same participating
physicians group. This helps strengthen your family's doctor/patient
relationships.

**Your Rights**

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

Health Net of California is a for profit, Mixed Model (MMP) HMO that
received certification as a Federally Qualified HMO in 1979 and was
licensed by the California Department of Corporations in 1991.

If you want more information about us, call 1-800-522-0088, visit our
website, [www.healthnet.com]{.underline}, or write to:

Health Net of California

P.O. Box 9103

Van Nuys, CA 91409-9103.

**Service Area**

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

> **Full counties:** Alameda, Contra Costa, Kings, Los Angeles, Madera,
> Marin, Merced, Napa, Orange, Sacramento, San Diego, San Francisco, San
> Joaquin, San Mateo, Santa Barbara, Santa Clara, Santa Cruz, Solano,
> Sonoma, Stanislaus, Tulare, Ventura, and Yolo counties, California.
>
> **Partial counties:** El Dorado, Fresno, Kern, Nevada, Placer,
> Riverside, and San Bernardino, counties, California. The following ZIP
> codes are those included in these partial counties:

# EL DORADO 

> 95613-14
>
> 95619
>
> 95623
>
> 95633-36
>
> 95643
>
> 95651
>
> 95664
>
> 95667
>
> 95672
>
> 95682
>
> 95684
>
> 95709
>
> 95726-27
>
> 95762

# FRESNO 

> 93210
>
> 93234
>
> 93242
>
> 93602
>
> 93605-09
>
> 93611-13
>
> 93616
>
> 93621-22
>
> 93624-31
>
> 93634
>
> 93640-42
>
> 93646
>
> 93648-52
>
> 93654
>
> 93656-57
>
> 93660
>
> 93662
>
> 93664
>
> 93667-68
>
> 93675
>
> 93700-99

# KERN 

> 93203
>
> 93205-06
>
> 93215-17
>
> 93220
>
> 93222
>
> 93224-26
>
> 93238
>
> 93240-41
>
> 93243
>
> 93249-52
>
> 93255
>
> 93263
>
> 93268
>
> 93276
>
> 93280
>
> 93283
>
> 93285
>
> 93287-88
>
> 93300-91
>
> 93399
>
> 93501-05
>
> 93516
>
> 93518-19
>
> 93523-24
>
> 93531
>
> 93560-61
>
> 93581-82
>
> 93596

# NEVADA 

> 95712
>
> 95924
>
> 95945-46
>
> 95949
>
> 95959-60
>
> 95975

# PLACER 

> 95602-04
>
> 95631
>
> 95648
>
> 95650
>
> 95658
>
> 95661
>
> 95663
>
> 95677-78
>
> 95681
>
> 95701
>
> 95703-04
>
> 95713-14
>
> 95717
>
> 95722
>
> 95736
>
> 95746-47
>
> 95765

[RIVERSIDE]{.underline}

## 91718-20

91752

91760

92201-03

92210-11

92220

92223

92230

92234-36

92240-41

92253-55

92258

92260-64

92270

92274-76

92282

92302-03

92306

92313

92320

92330-31

92343-44

92348-49

92353

92355

92360-62

92367

92370

92380-81

92383

92387-88

92390

92395-96

92500-23

92530-32

92536

92539

92543-46

92548-57

92561-64

92567

92570-72

92581-93

92595-96

92860

92877-83

## SAN BERNARDINO 

## 91701 

91708-10

91729-30

91737

91739

91743

91758-59

91761-64

91784-86

91798

92252

92256

92268

92277-78

92284-86

92301

92305

92307-18

92314-18

92321-22

92324-27

92329

92333-37

92339-42

92345-47

92350

92352

92354

92356-59

92365

92368-69

92371-78

92382

92385-86

92391-94

92397-99

92400-27

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

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

  -----------------------------------------------------------------------
  **Section 2. How we change for 2004**

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

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

**Program-wide changes**

-   We added information regarding two new Federal Programs that
    complement FEHB benefits, the Federal Flexible Spending Account
    Program -- *FSAFEDS* and the Federal Long Term Care Insurance
    Program. See page 58.

-   We added information regarding Preventing medical mistakes. See page
    6.

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

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

**Changes to this Plan** []{.mark}

-   Your share of the non-Postal premium will increase by 13.6% for Self
    Only or 13.6% for Self and Family.

-   We will no longer be offered in the following county: San Luis
    Obispo

  -----------------------------------------------------------------------
  Section 3. How you get care
  -----------------------------------------------------------------------

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

**Identification cards** We will send you an identification (ID) card
when you enroll. You should carry your ID card with you at all times.
You must show it whenever you receive services from a Plan provider, or
fill a prescription at a Plan pharmacy. Until you receive your ID card,
use your copy of the Health Benefits Election Form, SF-2809, your health
benefits enrollment confirmation (for annuitants), or your Employee
Express confirmation letter.

If you do not receive your ID card within 30 days after the effective
date of your enrollment, or if you need replacement cards, call us at
1-800-522-0088. You may also request replacement cards through our
website at www.healthnet.com.

**Where you get covered care** You get care from "Plan providers" and
"Plan facilities." You will only pay copayments, or coinsurance, and you
will not have to file claims.

**• Plan providers** Plan providers are participating physician groups,
physicians and other health care professionals in our service area that
we contract with to provide covered services to our members. We maintain
stringent credentialing and recredentialing criteria for our Plan
Providers.

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

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

It depends on the type of care you need. First, you and each family
member must choose a primary care physician from our network of
participating physician groups. This decision is important since your
primary care physician provides or arranges for most of your health
care.

> You must select a Participating Physicians Group (PPG) within a 30
> mile radius of your home or work-site. Each family member may choose
> their own PPG and primary care physician.

[]{.mark}

You may transfer to another PPG by calling us at 1-800-522-0088. You may
change PPG's once a month or upon our approval. All transfers will
become effective on the first day of the month following our receipt of
the transfer, provided the request is received by the 14^th^ of the
month. The request will be denied if you are more than three months
pregnant, confined to a hospital, in a surgery follow-up period (not yet
released by the surgeon) or receiving treatment for an illness that is
not yet complete.

**•Primary care** Your primary care physician can be a family
practitioner, internist or pediatrician. Your primary care physician
will provide most of your health care, or give you a referral to see a
specialist.

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

**• Specialty care** Your primary care physician will refer you to a
specialist for needed care. When you receive a referral from your
primary care physician, you must return to the primary care physician
after the consultation, unless your primary care physician authorized a
certain number of visits without additional referrals. The primary care
physician must provide or authorize all follow-up care. Do not go to the
specialist for return visits unless your primary care physician gives
you a referral. However, you may see a participating chiropractor (as
described on page 24) and a woman may see her participating gynecologist
at anytime 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:

> \- terminate our contract with your specialist for other than cause;
> or
>
> \- drop out of the Federal Employees Health Benefits (FEHB) Program
> and you enroll in another FEHB Plan; or
>
> \- reduce our service area and you enroll in another FEHB Plan,

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

If you are in the second or third trimester of pregnancy and you lose
access to your specialist based on the above circumstances, you can
continue to see your specialist until the end of your postpartum care,
even if it is beyond the 90 days.

> You also have the right to request a second opinion when:

-   Your primary care physician or a referral physician gives a
    diagnosis or recommends a treatment plan that you are not satisfied
    with; or

```{=html}
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```
-   You are not satisfied with the result of treatment you have
    received; or

-   You are diagnosed with, or a treatment plan is recommended for a
    condition that threatens loss of life, limb or bodily function, or a
    substantial impairment, including but not limited to a serious
    chronic condition; or

-   Your primary care physician or a referral physician is unable to
    diagnose your condition, or test results are conflicting.

To request an authorization for a second opinion, contact your Primary
Care Physician or Health Net of California Member Services at (800)
522-0088. Physicians at your Physician Group or Health Net of California
will review your request in accordance with Health Net of California's
second opinion policy. You may obtain a copy of this policy from Health
Net of California's Member Service Department. All second opinions must
be provided by a participating network physician who specializes in the
illness, disease or condition associated with the request. If there is
no appropriately qualified physician in the network, your primary care
physician will arrange for an out-of--network second opinion.

**• Hospital care** Your Plan primary care physician or specialist will
make necessary hospital arrangements and supervise your care. This
includes admission to a skilled nursing or other type of facility.

If you are in the hospital when your enrollment in our Plan begins, call
our customer service department immediately at 1-800-522-0088. If you
are new to the FEHB Program, we will arrange for you to receive care.

If you changed from another FEHB plan to us, your former plan will pay
for the hospital stay until:

-   You are discharged, not merely moved to an alternative care center;
    or

-   The day your benefits from your former plan run out; or

-   The 92^nd^ day after you become a member of this Plan, whichever
    happens first.

These provisions apply only to the benefits of the hospitalized person.

**Circumstances beyond our control** Under certain extraordinary
circumstances, such as natural disasters, we may have to delay your
services or we may be unable to provide them. In that case, we will make
all reasonable efforts to provide you with the necessary care.

**Services requiring our**

**prior approval** Your primary care physician has authority to refer
you for most services. For certain services, however, your physician
must obtain approval from us. Before giving approval, we consider if the
service is covered, medically necessary, and follows generally accepted
medical practice.

Services that are not authorized by your primary care physician or
Health Net of California will not be covered.

In addition, authorization by the Plan may be required for some
formulary and non-formulary prescription drugs.

  -----------------------------------------------------------------------
  Section 4. Your costs for covered services
  -----------------------------------------------------------------------

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

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

**• Copayments** A copayment is a fixed amount of money you pay to the
provider, facility, pharmacy, etc., when you receive services.

Example: When you see your primary care physician you pay a copayment of
\$10 per office visit and when you go in the hospital, you pay \$100 per
admission.

**•Deductible** We do not have a deductible*.*

**•Coinsurance** Coinsurance is the percentage of our negotiated fee
that you must pay for your care.

Example: In our Plan, you pay 50% of our allowance for infertility
services.

**Your catastrophic protection**

**out-of-pocket maximum**

**for coinsurance and copayments** After your copayments and coinsurance
total \$1,500 per person or \$4,500 per family enrollment in any
calendar year, you do not have to pay any more for covered services.
However, copayments for the following services do not count toward your
catastrophic protection out-of-pocket maximum and you must continue to
pay copayments for these services:

-   Prescription Drugs

-   Chiropractic Care

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

+-----------------------------------------------------------------------+
| **Section 5. Benefits -- OVERVIEW**                                   |
|                                                                       |
| ***(See page 11 for how our benefits changed this year and page 63    |
| 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 claims forms,
claims filing advice, or more information about our benefits, contact us
at 1-800-522-0088 or at our website at [www.healthnet.com]()*.*

(a) Medical services and supplies provided by physicians and other
    health care professionals 17-26

+---------------------------------+------------------------------------+
| •Diagnostic and treatment       | •Speech therapy                    |
| services                        |                                    |
|                                 | •Hearing services (testing,        |
| •Lab, X-ray, and other          | treatment, and supplies)           |
| diagnostic tests                |                                    |
|                                 | •Vision services (testing,         |
| •Preventive care, adult         | treatment, and supplies)           |
|                                 |                                    |
| •Preventive care, children      | •Foot care                         |
|                                 |                                    |
| •Maternity care                 | •Orthopedic and prosthetic devices |
|                                 |                                    |
| •Family planning                | •Durable medical equipment (DME)   |
|                                 |                                    |
| •Infertility services           | •Home health services              |
|                                 |                                    |
| •Allergy care                   | •Chiropractic                      |
|                                 |                                    |
| •Treatment therapies            | •Alternative treatments            |
|                                 |                                    |
| •Physical and occupational      | •Educational classes and programs  |
| therapies                       |                                    |
|                                 | •Clinical Trials                   |
+---------------------------------+------------------------------------+

(b) Surgical and anesthesia services provided by physicians and other
    health care professionals 27-30

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

(c) Services provided by a hospital or other facility, and ambulance
    services 31-33

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

(d) Emergency services/accidents 34-35

> •Medical emergency •Ambulance

(e) Mental health and substance abuse benefits 36-37

(f) Prescription drug benefits 38-40

(g) Special features 41

+---------------------------------+------------------------------------+
| •Flexible benefits option       | •Early Prenatal Program            |
|                                 |                                    |
| •Services for the Deaf and      | •Centers of Excellence             |
| Hearing Impaired                |                                    |
+---------------------------------+------------------------------------+

(h) Dental benefits 42

(i) Non-FEHB benefits available to Plan members 43

Summary of benefits 63

+---+---+----------------------------------+-------------------+---+----+
| > |   |                                  |                   |   |    |
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| * |   |                                  |                   |   |    |
+---+---+----------------------------------+-------------------+---+----+
|   | * | **Here are some important things |                   | * |    |
|   | * | to keep in mind about these      |                   | * |    |
|   | I | benefits:**                      |                   | I |    |
|   | * |                                  |                   | * |    |
|   | * | -   Please remember that all     |                   | * |    |
|   |   |     benefits are subject to the  |                   |   |    |
|   | * |     definitions, limitations,    |                   | * |    |
|   | * |     and exclusions in this       |                   | * |    |
|   | M |     brochure and are payable     |                   | M |    |
|   | * |     only when we determine they  |                   | * |    |
|   | * |     are medically necessary.     |                   | * |    |
|   |   |                                  |                   |   |    |
|   | * | -   Plan physicians must provide |                   | * |    |
|   | * |     or arrange your care.        |                   | * |    |
|   | P |                                  |                   | P |    |
|   | * | -   We have no calendar year     |                   | * |    |
|   | * |     deductible.                  |                   | * |    |
|   |   |                                  |                   |   |    |
|   | * | ```{=html}                       |                   | * |    |
|   | * | <!-- -->                         |                   | * |    |
|   | O | ```                              |                   | O |    |
|   | * | -   Be sure to read Section 4,   |                   | * |    |
|   | * |     *Your costs for covered      |                   | * |    |
|   |   |     services,* for valuable      |                   |   |    |
|   | * |     information about how cost   |                   | * |    |
|   | * |     sharing works. Also read     |                   | * |    |
|   | R |     Section 9 about coordinating |                   | R |    |
|   | * |     benefits with other          |                   | * |    |
|   | * |     coverage, including with     |                   | * |    |
|   |   |     Medicare.                    |                   |   |    |
|   | * |                                  |                   | * |    |
|   | * |                                  |                   | * |    |
|   | T |                                  |                   | T |    |
|   | * |                                  |                   | * |    |
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|   | * |                                  |                   | * |    |
|   | T |                                  |                   | T |    |
|   | * |                                  |                   | * |    |
|   | * |                                  |                   | * |    |
+---+---+----------------------------------+-------------------+---+----+
| > |   |                                  | **You pay**       |   |    |
|   |   |                                  |                   |   |    |
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+---+---+----------------------------------+-------------------+---+----+
| # |   |                                  |                   |   |    |
| # |   |                                  |                   |   |    |
| # |   |                                  |                   |   |    |
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| * |   |                                  |                   |   |    |
| * |   |                                  |                   |   |    |
+---+---+----------------------------------+-------------------+---+----+
| > |   |                                  | > \$10 per office |   |    |
|   |   |                                  | > visit           |   |    |
| P |   |                                  |                   |   |    |
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|   |   |                                  |                   |   |    |
| - |   |                                  |                   |   |    |
|   |   |                                  |                   |   |    |
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+---+---+----------------------------------+-------------------+---+----+
| > |   |                                  | > Nothing         |   |    |
|   |   |                                  |                   |   |    |
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| e |   |                                  |                   |   |    |
| w |   |                                  |                   |   |    |
| b |   |                                  |                   |   |    |
| o |   |                                  |                   |   |    |
| r |   |                                  |                   |   |    |
| n |   |                                  |                   |   |    |
|   |   |                                  |                   |   |    |
|   |   |                                  |                   |   |    |
|   |   |                                  |                   |   |    |
|   |   |                                  |                   |   |    |
| t |   |                                  |                   |   |    |
| h |   |                                  |                   |   |    |
| r |   |                                  |                   |   |    |
| o |   |                                  |                   |   |    |
| u |   |                                  |                   |   |    |
| g |   |                                  |                   |   |    |
| h |   |                                  |                   |   |    |
|   |   |                                  |                   |   |    |
|   |   |                                  |                   |   |    |
|   |   |                                  |                   |   |    |
|   |   |                                  |                   |   |    |
| t |   |                                  |                   |   |    |
| h |   |                                  |                   |   |    |
| e |   |                                  |                   |   |    |
|   |   |                                  |                   |   |    |
|   |   |                                  |                   |   |    |
|   |   |                                  |                   |   |    |
|   |   |                                  |                   |   |    |
| f |   |                                  |                   |   |    |
| i |   |                                  |                   |   |    |
| r |   |                                  |                   |   |    |
| s |   |                                  |                   |   |    |
| t |   |                                  |                   |   |    |
|   |   |                                  |                   |   |    |
|   |   |                                  |                   |   |    |
|   |   |                                  |                   |   |    |
|   |   |                                  |                   |   |    |
| 3 |   |                                  |                   |   |    |
| 0 |   |                                  |                   |   |    |
|   |   |                                  |                   |   |    |
|   |   |                                  |                   |   |    |
|   |   |                                  |                   |   |    |
|   |   |                                  |                   |   |    |
| d |   |                                  |                   |   |    |
| a |   |                                  |                   |   |    |
| y |   |                                  |                   |   |    |
| s |   |                                  |                   |   |    |
|   |   |                                  |                   |   |    |
|   |   |                                  |                   |   |    |
|   |   |                                  |                   |   |    |
|   |   |                                  |                   |   |    |
| o |   |                                  |                   |   |    |
| f |   |                                  |                   |   |    |
|   |   |                                  |                   |   |    |
|   |   |                                  |                   |   |    |
|   |   |                                  |                   |   |    |
|   |   |                                  |                   |   |    |
| l |   |                                  |                   |   |    |
| i |   |                                  |                   |   |    |
| f |   |                                  |                   |   |    |
| e |   |                                  |                   |   |    |
+---+---+----------------------------------+-------------------+---+----+
| - |   |                                  | > \$35 per visit  |   |    |
|   |   |                                  |                   |   |    |
|   |   |                                  |                   |   |    |
|   |   |                                  |                   |   |    |
| I |   |                                  |                   |   |    |
| n |   |                                  |                   |   |    |
|   |   |                                  |                   |   |    |
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|   |   |                                  |                   |   |    |
|   |   |                                  |                   |   |    |
| a |   |                                  |                   |   |    |
| n |   |                                  |                   |   |    |
|   |   |                                  |                   |   |    |
|   |   |                                  |                   |   |    |
|   |   |                                  |                   |   |    |
|   |   |                                  |                   |   |    |
| u |   |                                  |                   |   |    |
| r |   |                                  |                   |   |    |
| g |   |                                  |                   |   |    |
| e |   |                                  |                   |   |    |
| n |   |                                  |                   |   |    |
| t |   |                                  |                   |   |    |
|   |   |                                  |                   |   |    |
|   |   |                                  |                   |   |    |
|   |   |                                  |                   |   |    |
|   |   |                                  |                   |   |    |
| c |   |                                  |                   |   |    |
| a |   |                                  |                   |   |    |
| r |   |                                  |                   |   |    |
| e |   |                                  |                   |   |    |
|   |   |                                  |                   |   |    |
|   |   |                                  |                   |   |    |
|   |   |                                  |                   |   |    |
|   |   |                                  |                   |   |    |
| c |   |                                  |                   |   |    |
| e |   |                                  |                   |   |    |
| n |   |                                  |                   |   |    |
| t |   |                                  |                   |   |    |
| e |   |                                  |                   |   |    |
| r |   |                                  |                   |   |    |
+---+---+----------------------------------+-------------------+---+----+
| > |   |                                  | > \$20 per visit  |   |    |
|   |   |                                  |                   |   |    |
| A |   |                                  |                   |   |    |
| t |   |                                  |                   |   |    |
| > |   |                                  |                   |   |    |
|   |   |                                  |                   |   |    |
| h |   |                                  |                   |   |    |
| o |   |                                  |                   |   |    |
| m |   |                                  |                   |   |    |
| e |   |                                  |                   |   |    |
+---+---+----------------------------------+-------------------+---+----+
| > |   |                                  | > *All charges*   |   |    |
|   |   |                                  |                   |   |    |
| N |   |                                  |                   |   |    |
| o |   |                                  |                   |   |    |
| t |   |                                  |                   |   |    |
| > |   |                                  |                   |   |    |
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| c |   |                                  |                   |   |    |
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| v |   |                                  |                   |   |    |
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| r |   |                                  |                   |   |    |
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| d |   |                                  |                   |   |    |
| : |   |                                  |                   |   |    |
|   |   |                                  |                   |   |    |
| - |   |                                  |                   |   |    |
|   |   |                                  |                   |   |    |
|   |   |                                  |                   |   |    |
|   |   |                                  |                   |   |    |
| * |   |                                  |                   |   |    |
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| a |   |                                  |                   |   |    |
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| e |   |                                  |                   |   |    |
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| r |   |                                  |                   |   |    |
| y |   |                                  |                   |   |    |
| * |   |                                  |                   |   |    |
+---+---+----------------------------------+-------------------+---+----+

+-------------------------------------------+--------------------------+
| ###                                       | **You pay**              |
| **Lab, X-ray and other diagnostic tests** |                          |
+-------------------------------------------+--------------------------+
| > Tests, such as:                         | > 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:            | > Nothing                |
|                                           |                          |
| -   Total Blood Cholesterol -- once every |                          |
|     three years                           |                          |
|                                           |                          |
| -   Colorectal Cancer Screening,          |                          |
|     including                             |                          |
|                                           |                          |
| > \- Fecal occult blood test              |                          |
| >                                         |                          |
| > \- Sigmoidoscopy, screening -- every    |                          |
| > five years starting at age 50           |                          |
+-------------------------------------------+--------------------------+
| > Routine Prostate Specific Antigen (PSA) | > Nothing                |
| > test                                    |                          |
|                                           |                          |
| -   One annually for men age 40 and older |                          |
+-------------------------------------------+--------------------------+
| > Routine pap test                        | > Nothing                |
| >                                         |                          |
| > Routine Mammogram covered for women age |                          |
| > 35 and older, as                        |                          |
| >                                         |                          |
| > follows:                                |                          |
|                                           |                          |
| -   From age 35 through 39, one during    |                          |
|     this 5 year period                    |                          |
|                                           |                          |
| -   From age 40 through 64, one every     |                          |
|     calendar year                         |                          |
|                                           |                          |
| -   At age 65, one every two consecutive  |                          |
|     calendar years                        |                          |
+-------------------------------------------+--------------------------+
| > *Not covered: Physical exams required   | > *All charges*          |
| > for obtaining or continuing employment  |                          |
| > or insurance, attending schools or      |                          |
| > camp, or travel.*                       |                          |
+-------------------------------------------+--------------------------+
| > Routine immunizations, limited to:      | > Nothing                |
|                                           |                          |
| -   Tetanus-diphtheria (Td) booster --    |                          |
|     once every 10 years, ages 19 and over |                          |
|     (except as provided for under         |                          |
|     Childhood immunizations)              |                          |
|                                           |                          |
| -   Influenza vaccine, annually           |                          |
|                                           |                          |
| -   Pneumococcal vaccine, age 65 and over |                          |
+-------------------------------------------+--------------------------+
| > Immunizations for occupational and      | > 20% of charges         |
| > foreign travel:                         |                          |
+-------------------------------------------+--------------------------+

+------------------------------------------+---------------------------+
| ##### Preventive care, children          | **You pay**               |
+------------------------------------------+---------------------------+
| -   Childhood immunizations recommended  | > Nothing                 |
|     by the American Academy of           |                           |
|     Pediatrics                           |                           |
+------------------------------------------+---------------------------+
| -   Well-child care charges for routine  | > \$10 per office visit   |
|     examinations, and care (through age  |                           |
|     22)                                  |                           |
|                                          |                           |
| > Examinations, such as:                 |                           |
| >                                        |                           |
| > \- 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                          |                           |
+------------------------------------------+---------------------------+
| > *Not covered: Physical exams required  | > *All charges*           |
| > for obtaining or continuing employment |                           |
| > or insurance, attending schools or     |                           |
| > camp, or travel.*                      |                           |
+------------------------------------------+---------------------------+
| ######## Maternity care                  |                           |
+------------------------------------------+---------------------------+
| > Complete maternity (obstetrical) care, | > \$10 per office visit   |
| > such as:                               |                           |
|                                          |                           |
| -   Prenatal care                        |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   Postnatal care                       |                           |
+------------------------------------------+---------------------------+
| -   Delivery                             | Nothing                   |
|                                          |                           |
| > Note: Here are some things to keep in  |                           |
| > mind:                                  |                           |
|                                          |                           |
| -   You do not need to pre-certify your  |                           |
|     normal delivery; see page 12 for     |                           |
|     other circumstances, such as         |                           |
|     extended stays for you or your baby. |                           |
|                                          |                           |
| -   You may remain in the hospital up to |                           |
|     48 hours after a regular delivery    |                           |
|     and 96 hours after a cesarean        |                           |
|     delivery. We will extend your        |                           |
|     inpatient stay if medically          |                           |
|     necessary.                           |                           |
|                                          |                           |
| -   We cover routine nursery care of the |                           |
|     newborn child during the covered     |                           |
|     portion of the mother's maternity    |                           |
|     stay. We will cover other care of an |                           |
|     infant who requires non-routine      |                           |
|     treatment only if we cover the       |                           |
|     infant under a Self and Family       |                           |
|     enrollment.                          |                           |
|                                          |                           |
| > We pay hospitalization and surgeon     |                           |
| > services (delivery) the same as for    |                           |
| > illness and injury. See Hospital       |                           |
| > benefits (Section 5c) and Surgery      |                           |
| > benefits (Section 5b)*.*               |                           |
+------------------------------------------+---------------------------+

+-------------------------------------------+--------------------------+
| ######## Family planning                  | **You pay**              |
+-------------------------------------------+--------------------------+
| A broad range of voluntary family         | > Nothing                |
| planning services, limited to:            |                          |
|                                           |                          |
| -   Surgically implanted contraceptives   |                          |
|                                           |                          |
| -   Injectable contraceptive drugs (such  |                          |
|     as Depo provera)                      |                          |
|                                           |                          |
| -   Intrauterine devices (IUDs)           |                          |
|                                           |                          |
| -   Diaphragms                            |                          |
|                                           |                          |
| > NOTE: We cover oral contraceptives,     |                          |
| > cervical caps and diaphragms under the  |                          |
| > prescription drug benefit.              |                          |
+-------------------------------------------+--------------------------+
| -   Voluntary sterilization (females)     | > \$150                  |
|     (e.g., Tubal ligation)                |                          |
+-------------------------------------------+--------------------------+
| -   Voluntary sterilization (males)       | > \$50                   |
|     (e.g., Vasectomy)                     |                          |
+-------------------------------------------+--------------------------+
| > *Not covered: reversal of voluntary     | > *All charges*          |
| > surgical sterilization, genetic         |                          |
| > counseling,*                            |                          |
+-------------------------------------------+--------------------------+
| ######## Infertility services             |                          |
+-------------------------------------------+--------------------------+
| > Diagnosis and treatment of infertility, | > 50% of charges         |
| > such as:                                |                          |
|                                           |                          |
| -   Artificial insemination:              |                          |
|                                           |                          |
| > \- intravaginal insemination (IVI)      |                          |
| >                                         |                          |
| > \- intra­cervical insemination (ICI)     |                          |
| >                                         |                          |
| > \- intrauterine insemina­tion (IUI)      |                          |
|                                           |                          |
| -   Fertility drugs                       |                          |
|                                           |                          |
| Note: We cover injectable fertility drugs |                          |
| under medical benefits and oral fertility |                          |
| drugs under the prescription drug         |                          |
| benefit.                                  |                          |
+-------------------------------------------+--------------------------+
| > *Not covered:*                          | > *All charges*          |
|                                           |                          |
| -   *Assisted reproductive technology     |                          |
|     (ART) procedures, such as:*           |                          |
|                                           |                          |
| > \- *in vitro fertilization*             |                          |
|                                           |                          |
| -   *embryo transfer, gamete GIFT and     |                          |
|     zygote ZIFT*                          |                          |
|                                           |                          |
| -   *Zygote transfer*                     |                          |
|                                           |                          |
| ```{=html}                                |                          |
| <!-- -->                                  |                          |
| ```                                       |                          |
| -   *Services and supplies related to     |                          |
|     excluded ART procedures*              |                          |
|                                           |                          |
| -   *Cost of donor sperm, ova, or their   |                          |
|     collection or storage*                |                          |
|                                           |                          |
| -   *Injectable medications for           |                          |
|     infertility treatments not covered by |                          |
|     the plan*                             |                          |
+-------------------------------------------+--------------------------+

+-------------------------------------------+--------------------------+
| > **Allergy care**                        | **You pay**              |
+-------------------------------------------+--------------------------+
| > Testing and treatment                   | > Nothing                |
+-------------------------------------------+--------------------------+
| > Allergy injection                       | > Nothing                |
| >                                         |                          |
| > Allergy serum                           |                          |
+-------------------------------------------+--------------------------+
| > *Not covered: provocative food testing  | > *All charges*          |
| > and sublingual allergy desensitization* |                          |
+-------------------------------------------+--------------------------+
| ######## Treatment therapies              |                          |
+-------------------------------------------+--------------------------+
| -   Chemotherapy and radiation therapy    | > Nothing                |
|                                           |                          |
| > Note: High dose chemotherapy in         |                          |
| > association with autologous bone marrow |                          |
| > transplants is limited to those         |                          |
| > transplants listed under Organ/Tissue   |                          |
| > Transplants on page 30.                 |                          |
|                                           |                          |
| -   Respiratory and inhalation therapy    |                          |
|                                           |                          |
| ```{=html}                                |                          |
| <!-- -->                                  |                          |
| ```                                       |                          |
| -   Dialysis -- hemodialysis and          |                          |
|     peritoneal dialysis                   |                          |
|                                           |                          |
| -   Intravenous (IV)/Infusion Therapy --  |                          |
|     Home IV and antibiotic therapy        |                          |
|                                           |                          |
| ```{=html}                                |                          |
| <!-- -->                                  |                          |
| ```                                       |                          |
| -   Growth hormone therapy (GHT)          |                          |
+-------------------------------------------+--------------------------+
| > **Physical and occupational therapies** |                          |
+-------------------------------------------+--------------------------+
| -   Services of the following are         | > Nothing                |
|     covered:                              |                          |
|                                           |                          |
| > \- qualified physical therapists;       |                          |
| >                                         |                          |
| > \- occupational therapists.             |                          |
| >                                         |                          |
| > Note: We only cover therapy to restore  |                          |
| > bodily function when there has been a   |                          |
| > total or partial loss of bodily         |                          |
| > function due to illness or injury.      |                          |
| >                                         |                          |
| > Note: Occupational Therapy is limited   |                          |
| > to services to achieve and maintain     |                          |
| > self-care and improved functioning in   |                          |
| > activities of daily living.             |                          |
+-------------------------------------------+--------------------------+
| > **Speech Therapy**                      |                          |
+-------------------------------------------+--------------------------+
| -   Services for speech therapy are       | > Nothing                |
|     covered.                              |                          |
+-------------------------------------------+--------------------------+

+-------------------------------------------+--------------------------+
| **Hearing Services (testing, treatment,   | **You pay**              |
| and supplies)**                           |                          |
+-------------------------------------------+--------------------------+
| -   First hearing aid and testing only    | > \$10 per office visit  |
|     when necessitated by accidental       |                          |
|     injury                                |                          |
|                                           |                          |
| -   Hearing testing for children through  |                          |
|     age 17 (see Preventive care,          |                          |
|     children)                             |                          |
+-------------------------------------------+--------------------------+
| > *Not covered:*                          | > *All charges*          |
|                                           |                          |
| -   *all other hearing testing*           |                          |
|                                           |                          |
| -   *hearing aids, testing and            |                          |
|     examinations for them*                |                          |
+-------------------------------------------+--------------------------+
| > **Vision services (testing, treatment,  |                          |
| > and supplies)**                         |                          |
+-------------------------------------------+--------------------------+
| > One pair of eyeglasses or contact       | > \$10 per office visit  |
| > lenses to correct an impairment         |                          |
| > directly caused by accidental ocular    |                          |
| > injury or intraocular surgery (such as  |                          |
| > for cataracts)                          |                          |
+-------------------------------------------+--------------------------+
| -   Eye exam to determine the need for    | > \$10 per office visit  |
|     vision correction (see preventive     |                          |
|     care)                                 |                          |
|                                           |                          |
| -   Annual eye refractions                |                          |
+-------------------------------------------+--------------------------+
| > *Not covered:*                          | > *All charges*          |
|                                           |                          |
| -   *Eyeglasses or contact lenses*        |                          |
|                                           |                          |
| -   *Eye exercises and orthoptics*        |                          |
|                                           |                          |
| -   *Radial keratotomy and other          |                          |
|     refractive surgery*                   |                          |
|                                           |                          |
| -   *Eyeglasses or contact lenses after   |                          |
|     Interocular lens implant*             |                          |
+-------------------------------------------+--------------------------+
| ######## Foot care                        |                          |
+-------------------------------------------+--------------------------+
| > Routine foot care when you are under    | > \$10 per office visit  |
| > active treatment for a metabolic or     |                          |
| > peripheral vascular disease, such as    |                          |
| > diabetes.                               |                          |
| >                                         |                          |
| > See orthopedic and prosthetic devices   |                          |
| > for information on podiatric shoe       |                          |
| > inserts.                                |                          |
+-------------------------------------------+--------------------------+
| > *Not covered:*                          | > *All charges*          |
|                                           |                          |
| -   *Cutting, trimming or removal of      |                          |
|     corns, calluses, or the free edge of  |                          |
|     toenails, and similar routine         |                          |
|     treatment of conditions of the foot,  |                          |
|     except as stated above*               |                          |
|                                           |                          |
| -   *Treatment of weak, strained or flat  |                          |
|     feet or bunions or spurs; and of any  |                          |
|     instability, imbalance or subluxation |                          |
|     of the foot (unless the treatment is  |                          |
|     by open cutting surgery)*             |                          |
+-------------------------------------------+--------------------------+

+--------------------------------------------+-------------------------+
| > **Orthopedic and prosthetic devices**    | **You pay**             |
+--------------------------------------------+-------------------------+
| -   Artificial limbs and eyes; stump hose  | > Nothing               |
|                                            |                         |
| ```{=html}                                 |                         |
| <!-- -->                                   |                         |
| ```                                        |                         |
| -   Externally worn breast prostheses and  |                         |
|     surgical bras, including necessary     |                         |
|     replacements, following a mastectomy   |                         |
|                                            |                         |
| -   Visual aids (excluding eyewear) to     |                         |
|     assist the visually impaired with      |                         |
|     proper dosing of insulin               |                         |
|                                            |                         |
| -   Internal prosthetic devices, such as   |                         |
|     artificial joints, pacemakers,         |                         |
|     cochlear implants, and surgically      |                         |
|     implanted breast implant following     |                         |
|     mastectomy. Note: See 5(b) for         |                         |
|     coverage of the surgery to insert the  |                         |
|     device.                                |                         |
|                                            |                         |
| ```{=html}                                 |                         |
| <!-- -->                                   |                         |
| ```                                        |                         |
| -   Corrective orthopedic appliances for   |                         |
|     non-dental treatment of                |                         |
|     temporomandibular joint (TMJ) pain     |                         |
|     dysfunction syndrome.                  |                         |
+--------------------------------------------+-------------------------+
| > *Not covered:*                           | > *All charges*         |
|                                            |                         |
| -   *orthopedic and corrective shoes*      |                         |
|                                            |                         |
| -   *arch supports*                        |                         |
|                                            |                         |
| -   *foot orthotics, except when they have |                         |
|     been incorporated into a cast, splint, |                         |
|     brace or strapping of the foot*        |                         |
|                                            |                         |
| -   *heel pads and heel cups*              |                         |
|                                            |                         |
| -   *lumbosacral supports*                 |                         |
|                                            |                         |
| -   *corsets, trusses, elastic stockings,  |                         |
|     support hose, and other supportive     |                         |
|     devices*                               |                         |
|                                            |                         |
| -   *prosthetic replacements provided less |                         |
|     than 3 years after the last one we     |                         |
|     covered*                               |                         |
+--------------------------------------------+-------------------------+
| ######## Durable medical equipment (DME)   |                         |
+--------------------------------------------+-------------------------+
| > Rental or purchase, at our option,       | > Nothing               |
| > including repair and adjustment, of      |                         |
| > durable medical equipment prescribed by  |                         |
| > your Plan physician, such as oxygen and  |                         |
| > dialysis equipment. Under this benefit,  |                         |
| > we also cover:                           |                         |
|                                            |                         |
| -   hospital beds;                         |                         |
|                                            |                         |
| -   standard wheelchairs, electric         |                         |
|     wheelchairs if medically necessary;    |                         |
|                                            |                         |
| -   crutches;                              |                         |
|                                            |                         |
| -   walkers;                               |                         |
|                                            |                         |
| -   blood glucose monitors; and            |                         |
|                                            |                         |
| ```{=html}                                 |                         |
| <!-- -->                                   |                         |
| ```                                        |                         |
| -   insulin pumps.                         |                         |
+--------------------------------------------+-------------------------+
| ######## Dur                               | ######## You pay        |
| able medical equipment (DME) *(continued)* |                         |
+--------------------------------------------+-------------------------+
| > *Not covered:*                           | > *All charges*         |
|                                            |                         |
| -   *Exercise equipment.*                  |                         |
|                                            |                         |
| -   *Hygienic equipment and supplies (to   |                         |
|     achieve cleanliness even when related  |                         |
|     to other covered medical services.*    |                         |
|                                            |                         |
| -   *Stockings*                            |                         |
|                                            |                         |
| -   *Surgical dressings, except primary    |                         |
|     dressings that are applied by a Plan   |                         |
|     physician or a Hospital to lesions of  |                         |
|     the skin or surgical incisions*        |                         |
|                                            |                         |
| -   *Jacuzzis and whirlpools*              |                         |
|                                            |                         |
| -   *Orthotics which are not custom made   |                         |
|     to fit your body (Orthotics are        |                         |
|     supports or braces for weak or         |                         |
|     ineffective joints or muscles.)*       |                         |
|                                            |                         |
| -   *Foot orthotic, except when they have  |                         |
|     been incorporated into a cast, splint, |                         |
|     brace or strapping of the foot.*       |                         |
+--------------------------------------------+-------------------------+
| ######## Home health services              |                         |
+--------------------------------------------+-------------------------+
| -   Home health care ordered by a Plan     | > Nothing for the first |
|     physician and provided by a registered | > 30 visits, \$10 per   |
|     nurse (R.N.), licensed practical nurse | > visit thereafter      |
|     (L.P.N.), licensed vocational nurse    |                         |
|     (L.V.N.), or home health aide.         |                         |
|                                            |                         |
| -   Services include oxygen therapy,       |                         |
|     intravenous therapy and medications.   |                         |
|                                            |                         |
| > Note: Your Plan physician will review    |                         |
| > the home health service program for      |                         |
| > continuing appropriateness.              |                         |
+--------------------------------------------+-------------------------+
| > Not covered:                             | > *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.*                       |                         |
+--------------------------------------------+-------------------------+
| ######## Chiropractic treatments           |                         |
+--------------------------------------------+-------------------------+
| > Chiropractic services -- by the          | > \$10 per office visit |
| > chiropractors that participate in the    |                         |
| > American Specialty Health Plan (ASHP)    |                         |
| > network.                                 |                         |
| >                                          |                         |
| > 20 visits per calendar year are covered  |                         |
| > for these services without a referral    |                         |
| > from the Plan physician.                 |                         |
+--------------------------------------------+-------------------------+
| > Chiropractic appliances are covered up   | > All charges above     |
| > to \$50 per calendar year.               | > \$50 per calendar     |
|                                            | > year                  |
+--------------------------------------------+-------------------------+

+--------------------------------------------+-------------------------+
| ######## Alternative treatments            | ######## You Pay        |
+--------------------------------------------+-------------------------+
| > Acupuncture -- if referred by your       | > \$10 per office visit |
| > primary care physician                   |                         |
+--------------------------------------------+-------------------------+
| ## *Not covered:*                          | *All charges*           |
|                                            |                         |
| ## *naturopathic services*                 |                         |
|                                            |                         |
| ## *hypnotherapy*                          |                         |
|                                            |                         |
| ## *biofeedback*                           |                         |
+--------------------------------------------+-------------------------+
| #### **Educational classes and programs**  |                         |
+--------------------------------------------+-------------------------+
| > Coverage is limited to:                  | > Nothing               |
|                                            |                         |
| -   Diabetes self-management               |                         |
|                                            |                         |
| -   Wellness programs provided by your     |                         |
|     selected Participating Physician Group |                         |
|                                            |                         |
| -   Quitting Matters Smoking Cessation     |                         |
|     Program                                |                         |
|                                            |                         |
| -   Teen Health Website                    |                         |
|                                            |                         |
| -   Prenatal Program with Gift Certificate |                         |
|     upon completion                        |                         |
|                                            |                         |
| -   Women Matter Website                   |                         |
|                                            |                         |
| > Please visit our website at              |                         |
| > [www                                     |                         |
| .healthnet.com](http://www.healthnet.com/) |                         |
| > for more information.                    |                         |
+--------------------------------------------+-------------------------+
| #### **Clinical Trials**                   | **You Pay**             |
+--------------------------------------------+-------------------------+
| ####                                       | > Your cost sharing     |
|  Routine patient care costs for patients d | > responsibilities are  |
| iagnosed with cancer who are accepted into | > no greater than for   |
|  phase I, II, III or IV clinical trials ar | > other covered         |
| e covered when medically necessary, recomm | > services              |
| ended by the Member's treating Physician a |                         |
| nd authorized by Health Net of California. |                         |
|                                            |                         |
| -   The Physician must determine that      |                         |
|     participation has a meaningful         |                         |
|     potential to benefit the Member and    |                         |
|     the trial has therapeutic intent.      |                         |
|                                            |                         |
| -   Services rendered as part of a         |                         |
|     clinical trial that involves either a  |                         |
|     drug that is exempt from Federal       |                         |
|     regulation in relation to a new drug   |                         |
|     application, or is approved by one of  |                         |
|     the following:                         |                         |
|                                            |                         |
| ```{=html}                                 |                         |
| <!-- -->                                   |                         |
| ```                                        |                         |
| -   The National Institutes of Health;     |                         |
|                                            |                         |
| -   The FDA as an investigational new drug |                         |
|     application;                           |                         |
|                                            |                         |
| -   The Department of Defense; or          |                         |
|                                            |                         |
| -   The Veterans' Administration           |                         |
|                                            |                         |
| > Note: "Routine patient care costs"       |                         |
| > include drugs, items, devices and        |                         |
| > services that would normally be covered  |                         |
| > under this plan if they were not         |                         |
| > provided in connection with a clinical   |                         |
| > trials program.                          |                         |
|                                            |                         |
| ####                                       |                         |
+--------------------------------------------+-------------------------+
| > *Not covered:*                           | > *All charges*         |
| >                                          |                         |
| > *Coverage for clinical trials does not   |                         |
| > include the following items:*            |                         |
|                                            |                         |
| -   *Drugs or devices that are not         |                         |
|     approved by the FDA*                   |                         |
|                                            |                         |
| -   *Services other than health care       |                         |
|     services, including but not limited to |                         |
|     cost of travel, or costs of other      |                         |
|     non-clinical expenses*                 |                         |
|                                            |                         |
| -   *Services provided to satisfy data     |                         |
|     collection and analysis needs which    |                         |
|     are not used for clinical management*  |                         |
|                                            |                         |
| -   *Items and services provided free of   |                         |
|     charge by the research sponsors to     |                         |
|     Members in the trial.*                 |                         |
+--------------------------------------------+-------------------------+

+---+---+------------------------------------+-------------------+---+---+
| * |   |                                    |                   |   |   |
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| * |   |                                    |                   |   |   |
| * |   |                                    |                   |   |   |
+---+---+------------------------------------+-------------------+---+---+
|   | * | > **Here are some important things |                   | * |   |
|   | * | > to keep in mind about these      |                   | * |   |
|   | I | > benefits:**                      |                   | I |   |
|   | * |                                    |                   | * |   |
|   | * | -   Please remember that all       |                   | * |   |
|   |   |     benefits are subject to the    |                   |   |   |
|   | * |     definitions, limitations, and  |                   | * |   |
|   | * |     exclusions in this brochure    |                   | * |   |
|   | M |     and are payable only when we   |                   | M |   |
|   | * |     determine they are medically   |                   | * |   |
|   | * |     necessary.                     |                   | * |   |
|   |   |                                    |                   |   |   |
|   | * | -   Plan physicians must provide   |                   | * |   |
|   | * |     or arrange your care.          |                   | * |   |
|   | P |                                    |                   | P |   |
|   | * | -   We have no calendar year       |                   | * |   |
|   | * |     deductible*.*                  |                   | * |   |
|   |   |                                    |                   |   |   |
|   | * | -   Be sure to read Section 4,     |                   | * |   |
|   | * |     *Your costs for covered        |                   | * |   |
|   | O |     services,* for valuable        |                   | O |   |
|   | * |     information about how cost     |                   | * |   |
|   | * |     sharing works. Also read       |                   | * |   |
|   |   |     Section 9 about coordinating   |                   |   |   |
|   | * |     benefits with other coverage,  |                   | * |   |
|   | * |     including with Medicare.       |                   | * |   |
|   | R |                                    |                   | R |   |
|   | * | -   The amounts listed below are   |                   | * |   |
|   | * |     for the charges billed by a    |                   | * |   |
|   |   |     physician or other health care |                   |   |   |
|   | * |     professional for your surgical |                   | * |   |
|   | * |     care. Look in Section 5(c) for |                   | * |   |
|   | T |     charges associated with the    |                   | T |   |
|   | * |     facility (i.e. hospital,       |                   | * |   |
|   | * |     surgical center, etc.)         |                   | * |   |
|   |   |                                    |                   |   |   |
|   | * |                                    |                   | * |   |
|   | * |                                    |                   | * |   |
|   | A |                                    |                   | A |   |
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|   | * |                                    |                   | * |   |
|   | * |                                    |                   | * |   |
+---+---+------------------------------------+-------------------+---+---+
| > |   |                                    | **You pay**       |   |   |
|   |   |                                    |                   |   |   |
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| * |   |                                    |                   |   |   |
| * |   |                                    |                   |   |   |
+---+---+------------------------------------+-------------------+---+---+
| > |   |                                    |                   |   |   |
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+---+---+------------------------------------+-------------------+---+---+
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+---+---+------------------------------------+-------------------+---+---+
| - |   |                                    | > \$150           |   |   |
|   |   |                                    |                   |   |   |
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+---+---+------------------------------------+-------------------+---+---+
| - |   |                                    | > \$50            |   |   |
|   |   |                                    |                   |   |   |
|   |   |                                    |                   |   |   |
|   |   |                                    |                   |   |   |
| V |   |                                    |                   |   |   |
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| ) |   |                                    |                   |   |   |
+---+---+------------------------------------+-------------------+---+---+

*Surgical procedures continued on next page*

+------------------------------------------+---------------------------+
| > **Surgical procedures** *(Continued)*  | > **You pay**             |
+------------------------------------------+---------------------------+
| > *Not covered:*                         | > *All charges*           |
|                                          |                           |
| -   *Reversal of voluntary               |                           |
|     sterilization*                       |                           |
|                                          |                           |
| -   *Routine treatment of conditions of  |                           |
|     the foot; see Foot care.*            |                           |
+------------------------------------------+---------------------------+
| > **Reconstructive surgery**             |                           |
+------------------------------------------+---------------------------+
| -   Surgery to correct a functional      | > Nothing                 |
|     defect                               |                           |
|                                          |                           |
| -   Surgery to correct a condition       |                           |
|     caused by injury or illness if:      |                           |
|                                          |                           |
| > \- the condition produced a major      |                           |
| > effect on the member's appearance and  |                           |
| >                                        |                           |
| > \- the condition can reasonably be     |                           |
| > expected to be corrected by such       |                           |
| > surgery                                |                           |
|                                          |                           |
| -   Surgery to correct a condition that  |                           |
|     existed at or from birth and is a    |                           |
|     significant deviation from the       |                           |
|     common form or norm. Examples of     |                           |
|     congenital anomalies are protruding  |                           |
|     ear deformities, cleft lip, cleft    |                           |
|     palate, birth marks, webbed fingers, |                           |
|     and webbed toes.                     |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   All stages of breast reconstruction  |                           |
|     surgery following a mastectomy, such |                           |
|     as:                                  |                           |
|                                          |                           |
| > \- surgery to produce a symmetrical    |                           |
| > appearance on the other breast;        |                           |
| >                                        |                           |
| > \- treatment of any physical           |                           |
| > complications, such as lymphedemas;    |                           |
| >                                        |                           |
| > \- breast prostheses and surgical bras |                           |
| > and replacements (see Prosthetic       |                           |
| > devices)                               |                           |
|                                          |                           |
| -   Note: If you need a mastectomy, you  |                           |
|     may choose to have this procedure    |                           |
|     performed on an inpatient basis and  |                           |
|     remain in the hospital up to 48      |                           |
|     hours after the procedure.           |                           |
+------------------------------------------+---------------------------+
| > *Not covered:*                         | > *All charges*           |
|                                          |                           |
| -   *Cosmetic surgery -- any surgical    |                           |
|     procedure (or any portion of a       |                           |
|     procedure) performed primarily to    |                           |
|     improve physical appearance through  |                           |
|     change in bodily form, except repair |                           |
|     of accidental injury*                |                           |
|                                          |                           |
| -   *Surgeries related to sex            |                           |
|     transformation*                      |                           |
+------------------------------------------+---------------------------+

+-------------------------------------------+--------------------------+
| > **Oral and maxillofacial surgery**      | > **You pay**            |
+-------------------------------------------+--------------------------+
| > Oral surgical procedures, limited to:   | > Nothing                |
|                                           |                          |
| -   Reduction of fractures of the jaws or |                          |
|     facial bones;                         |                          |
|                                           |                          |
| -   Surgical correction of cleft lip,     |                          |
|     cleft palate or severe functional     |                          |
|     malocclusion;                         |                          |
|                                           |                          |
| -   Removal of stones from salivary       |                          |
|     ducts;                                |                          |
|                                           |                          |
| -   Excision of leukoplakia or            |                          |
|     malignancies;                         |                          |
|                                           |                          |
| -   Excision of cysts and incision of     |                          |
|     abscesses when done as independent    |                          |
|     procedures; and                       |                          |
|                                           |                          |
| -   Other surgical procedures that do not |                          |
|     involve the teeth or their supporting |                          |
|     structures.                           |                          |
+-------------------------------------------+--------------------------+
| > *Not covered:*                          | > *All charges*          |
|                                           |                          |
| -   *Oral implants and transplants*       |                          |
|                                           |                          |
| -   *Procedures that involve the teeth or |                          |
|     their supporting structures (such as  |                          |
|     the periodontal membrane, gingival,   |                          |
|     and alveolar bone)*                   |                          |
+-------------------------------------------+--------------------------+

+------------------------------------------+---------------------------+
| > **Organ/tissue transplants**           | > **You pay**             |
+------------------------------------------+---------------------------+
| > Limited to:                            | > Nothing                 |
|                                          |                           |
| -   Cornea                               |                           |
|                                          |                           |
| -   Heart                                |                           |
|                                          |                           |
| -   Heart/lung                           |                           |
|                                          |                           |
| -   Kidney                               |                           |
|                                          |                           |
| -   Kidney/Pancreas                      |                           |
|                                          |                           |
| -   Liver                                |                           |
|                                          |                           |
| -   Lung: Single --Double                |                           |
|                                          |                           |
| -   Pancreas                             |                           |
|                                          |                           |
| -   Allogeneic (donor) bone marrow       |                           |
|     transplants                          |                           |
|                                          |                           |
| -   Autologous bone marrow transplants   |                           |
|     (autologous stem cell and peripheral |                           |
|     stem cell support) for the following |                           |
|     conditions: acute lymphocytic or     |                           |
|     non-lymphocytic leukemia; advanced   |                           |
|     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.         |                           |
|                                          |                           |
| > Limited Benefits -- Treatment for      |                           |
| > breast cancer, multiple myeloma, and   |                           |
| > epithelial ovarian cancer may be       |                           |
| > provided in an NCI- or NIH-approved    |                           |
| > clinical trial at a Plan-designated    |                           |
| > center of excellence and if approved   |                           |
| > by the Plan's medical director in      |                           |
| > accordance with the Plan's protocols.  |                           |
| >                                        |                           |
| > Note: We cover related medical and     |                           |
| > hospital expenses of the donor when we |                           |
| > cover the recipient.                   |                           |
+------------------------------------------+---------------------------+
| > *Not covered:*                         | > *All charges*           |
|                                          |                           |
| -   *Donor screening tests and donor     |                           |
|     search expenses, except those        |                           |
|     performed for the actual donor*      |                           |
|                                          |                           |
| -   *Implants of artificial organs*      |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   *Transplants not listed as covered*  |                           |
+------------------------------------------+---------------------------+
| > **Anesthesia**                         |                           |
+------------------------------------------+---------------------------+
| > Professional services provided in --   | > Nothing                 |
|                                          |                           |
| -   Hospital (inpatient)                 |                           |
|                                          |                           |
| > Professional services provided in --   |                           |
|                                          |                           |
| -   Hospital outpatient department       |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   Skilled nursing facility             |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   Ambulatory surgical center           |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   Office                               |                           |
+------------------------------------------+---------------------------+

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

Inpatient hospital continued on next page

+------------------------------------------+---------------------------+
| #                                        | ######## You pay          |
| ####### Inpatient hospital *(Continued)* |                           |
+------------------------------------------+---------------------------+
| #### Other                               | > Nothing                 |
| hospital services and supplies, such as: |                           |
|                                          |                           |
| -   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, if not        |                           |
|     donated or replaced                  |                           |
|                                          |                           |
| -   Dressings, splints, casts, and       |                           |
|     sterile tray services                |                           |
|                                          |                           |
| -   Medical supplies and equipment,      |                           |
|     including oxygen                     |                           |
|                                          |                           |
| -   Anesthetics, including nurse         |                           |
|     anesthetist services                 |                           |
|                                          |                           |
| -   Take-home items                      |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   Medical supplies, appliances,        |                           |
|     medical equipment, and any covered   |                           |
|     items billed by a hospital for use   |                           |
|     at home                              |                           |
+------------------------------------------+---------------------------+
| > *Not covered:*                         | > *All charges*           |
|                                          |                           |
| -   *Custodial care*                     |                           |
|                                          |                           |
| -   *Non-covered facilities, such as     |                           |
|     nursing homes, schools*              |                           |
|                                          |                           |
| -   *Personal comfort items, such as     |                           |
|     telephone, television, barber        |                           |
|     services, guest meals and beds*      |                           |
|                                          |                           |
| -   *Private nursing care*               |                           |
+------------------------------------------+---------------------------+
| #### **Outpatient                        | ####                      |
| hospital or ambulatory surgical center** |                           |
+------------------------------------------+---------------------------+
| > Operating, Recovery and other          | > \$100 per admission     |
| > treatment rooms used in connection     |                           |
| > with outpatient surgery                |                           |
+------------------------------------------+---------------------------+
| #### Prescribed drugs and medicines      | > Nothing                 |
|                                          |                           |
| -   Diagnostic laboratory tests, X-rays, |                           |
|     and pathology services               |                           |
|                                          |                           |
| -   Administration of blood, blood       |                           |
|     plasma, and other biologicals        |                           |
|                                          |                           |
| -   Blood and blood plasma, if not       |                           |
|     donated or replaced                  |                           |
|                                          |                           |
| -   Pre-surgical testing                 |                           |
|                                          |                           |
| -   Dressings, casts, and sterile tray   |                           |
|     services                             |                           |
|                                          |                           |
| -   Medical supplies, including oxygen   |                           |
|                                          |                           |
| -   Anesthetics and anesthesia service   |                           |
|                                          |                           |
| > NOTE: -- We cover hospital services    |                           |
| > and supplies related to dental         |                           |
| > procedures when necessitated by a      |                           |
| > non-dental physical impairment. We do  |                           |
| > not cover the dental procedures.       |                           |
| > Conditions for which hospitalization   |                           |
| > would be covered include hemophilia    |                           |
| > and heart disease: the need for        |                           |
| > anesthesia by itself is not such a     |                           |
| > condition.                             |                           |
+------------------------------------------+---------------------------+
| # *Not covered: blood and b              | > *All charges*           |
| lood derivatives replaced by the member* |                           |
+------------------------------------------+---------------------------+

+------------------------------------------+---------------------------+
| ######## Extended care benefit           | ######## You pay          |
| s/Skilled nursing care facility benefits |                           |
+------------------------------------------+---------------------------+
| > Extended care/Skilled nursing facility | > \$100 per admission     |
| > (SNF): Up to 100 days per calendar     |                           |
| > year for services such as:             |                           |
|                                          |                           |
| -   Bed, board and general nursing care  |                           |
|                                          |                           |
| -   Drugs, biologicals, supplies, and    |                           |
|     equipment ordinarily provided or     |                           |
|     arranged by the skilled nursing      |                           |
|     facility when prescribed by a Plan   |                           |
|     doctor                               |                           |
+------------------------------------------+---------------------------+
| > Not covered: custodial care and        | > *All charges*           |
| > personal comfort items such as         |                           |
| > telephone and television.              |                           |
+------------------------------------------+---------------------------+
| #### **Hospice care**                    | ####                      |
+------------------------------------------+---------------------------+
| ###### Hospice ca                        | > Nothing                 |
| re: Up to 210 days for services such as: |                           |
|                                          |                           |
| ###### Inpatient and outpatient care     |                           |
|                                          |                           |
| -   Family counseling                    |                           |
|                                          |                           |
| > Note: Hospice care services are        |                           |
| > provided under the direction of a Plan |                           |
| > doctor who certifies that the patient  |                           |
| > is in the terminal stages of illness,  |                           |
| > with a life expectancy of              |                           |
| > approximately six months or less       |                           |
+------------------------------------------+---------------------------+
| > *Not covered: Independent nursing,     | > *All charges*           |
| > homemaker services*                    |                           |
+------------------------------------------+---------------------------+
| ######## Ambulance                       | ########                  |
+------------------------------------------+---------------------------+
| -   Local professional ground and air    | > Nothing                 |
|     ambulance service when medically     |                           |
|     appropriate                          |                           |
+------------------------------------------+---------------------------+

+---+---+-------------------------------------------------------+---+---+
| # |   |                                                       |   |   |
| # |   |                                                       |   |   |
| # |   |                                                       |   |   |
| # |   |                                                       |   |   |
| # |   |                                                       |   |   |
|   |   |                                                       |   |   |
| S |   |                                                       |   |   |
| e |   |                                                       |   |   |
| c |   |                                                       |   |   |
| t |   |                                                       |   |   |
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|   |   |                                                       |   |   |
| 5 |   |                                                       |   |   |
|   |   |                                                       |   |   |
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|   |   |                                                       |   |   |
| E |   |                                                       |   |   |
| m |   |                                                       |   |   |
| e |   |                                                       |   |   |
| r |   |                                                       |   |   |
| g |   |                                                       |   |   |
| e |   |                                                       |   |   |
| n |   |                                                       |   |   |
| c |   |                                                       |   |   |
| y |   |                                                       |   |   |
|   |   |                                                       |   |   |
| s |   |                                                       |   |   |
| e |   |                                                       |   |   |
| r |   |                                                       |   |   |
| v |   |                                                       |   |   |
| i |   |                                                       |   |   |
| c |   |                                                       |   |   |
| e |   |                                                       |   |   |
| s |   |                                                       |   |   |
| / |   |                                                       |   |   |
| a |   |                                                       |   |   |
| c |   |                                                       |   |   |
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| d |   |                                                       |   |   |
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| n |   |                                                       |   |   |
| t |   |                                                       |   |   |
| s |   |                                                       |   |   |
+---+---+-------------------------------------------------------+---+---+
|   | * | > Here are some important things to keep in mind      | * | # |
|   | * | > about these benefits:                               | * | # |
|   | I |                                                       | I | # |
|   | * | -   Please remember that all benefits are subject to  | * | # |
|   | * |     the definitions, limitations, and exclusions in   | * | # |
|   |   |     this brochure and are payable only when we        |   |   |
|   | * |     determine they are medically necessary.           | * |   |
|   | * |                                                       | * |   |
|   | M | -   We have no calendar year deductible.              | M |   |
|   | * |                                                       | * |   |
|   | * | -   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,        | * |   |
|   | P |     including with Medicare.                          | P |   |
|   | * |                                                       | * |   |
|   | * | #####                                                 | * |   |
|   |   |                                                       |   |   |
|   | * |                                                       | * |   |
|   | * |                                                       | * |   |
|   | O |                                                       | O |   |
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|   |   |                                                       |   |   |
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|   | * |                                                       | * |   |
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|   | * |                                                       | * |   |
|   | * |                                                       | * |   |
+---+---+-------------------------------------------------------+---+---+
| > |   |                                                       |   |   |
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| p |   |                                                       |   |   |
| r |   |                                                       |   |   |
| o |   |                                                       |   |   |
| v |   |                                                       |   |   |
| i |   |                                                       |   |   |
| d |   |                                                       |   |   |
| e |   |                                                       |   |   |
| r |   |                                                       |   |   |
| s |   |                                                       |   |   |
| . |   |                                                       |   |   |
+---+---+-------------------------------------------------------+---+---+

+------------------------------------------+---------------------------+
| > **Benefit Description**                | **You pay**               |
+------------------------------------------+---------------------------+
| > **Emergency within our service area**  |                           |
+------------------------------------------+---------------------------+
| -   Emergency care at your primary care  | \$10 per office visit     |
|     physician's office                   |                           |
|                                          |                           |
| -   Emergency care at your participating |                           |
|     physician group's urgent care center |                           |
+------------------------------------------+---------------------------+
| -   Emergency care at an emergency room  | \$100 per visit           |
|                                          |                           |
| -   Emergency care as an outpatient or   |                           |
|     inpatient at a hospital, including   |                           |
|     doctors\' services                   |                           |
|                                          |                           |
| > Note: If the emergency results in      |                           |
| > admission to a hospital, the copay is  |                           |
| > waived                                 |                           |
+------------------------------------------+---------------------------+
| -   Emergency care at an urgent care     | > \$35 per visit          |
|     center                               |                           |
+------------------------------------------+---------------------------+
| > *Not covered: Elective care or         | > *All charges*           |
| > non-emergency care*                    |                           |
+------------------------------------------+---------------------------+
| ###                                      |                           |
| ##### Emergency outside our service area |                           |
+------------------------------------------+---------------------------+
| -   Emergency care at a doctor\'s office | > \$35 per visit          |
|                                          |                           |
| -   Emergency care at an urgent care     |                           |
|     center                               |                           |
|                                          |                           |
| ########                                 |                           |
+------------------------------------------+---------------------------+
| -   Emergency care at an emergency room  | > \$100 per visit         |
|                                          |                           |
| -   Emergency care as an outpatient or   |                           |
|     inpatient at a hospital, including   |                           |
|     doctors\' services                   |                           |
|                                          |                           |
| Note: If the emergency results in        |                           |
| admission to a hospital, the copay is    |                           |
| waived                                   |                           |
+------------------------------------------+---------------------------+
| > *Not covered:*                         | > *All charges*           |
|                                          |                           |
| -   *Elective care or non-emergency      |                           |
|     care*                                |                           |
|                                          |                           |
| -   *Emergency care provided outside the |                           |
|     service area if the need for care    |                           |
|     could have been foreseen before      |                           |
|     leaving the service area*            |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   *Follow-up care not authorized by    |                           |
|     your participating physician group.* |                           |
|                                          |                           |
| ########                                 |                           |
+------------------------------------------+---------------------------+
| > **Ambulance**                          |                           |
+------------------------------------------+---------------------------+
| > Professional ground and air ambulance  | > Nothing                 |
| > service when medically appropriate.    |                           |
| >                                        |                           |
| > See 5(c) for non-emergency service.    |                           |
+------------------------------------------+---------------------------+

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

> *Mental health and substance abuse -- Continued on next page*

+------------------------------------------+---------------------------+
| ### **Mental health and s                | ### **You pay**           |
| ubstance abuse benefits** *(Continued)*  |                           |
+------------------------------------------+---------------------------+
| -   Diagnostic tests                     | > Nothing if you receive  |
|                                          | > these services during   |
|                                          | > your office visit;      |
|                                          | > otherwise \$10 per      |
|                                          | > visit                   |
+------------------------------------------+---------------------------+
| -   Inpatient services provided by a     | > \$100 per admission     |
|     hospital or other facility           |                           |
+------------------------------------------+---------------------------+
| -   Services in approved alternative     | > Nothing                 |
|     care settings such as partial        |                           |
|     hospitalization, half-way house,     |                           |
|     residential treatment, full-day      |                           |
|     hospitalization, facility based      |                           |
|     intensive outpatient treatment       |                           |
|                                          |                           |
| ##                                       |                           |
+------------------------------------------+---------------------------+
| ## *Not                                  | > *All charges*           |
| covered: Services we have not approved.* |                           |
|                                          |                           |
| ## *Note: OPM will base its revie        |                           |
| w of disputes about treatment plans on t |                           |
| he treatment plan\'s clinical appropriat |                           |
| eness. OPM will generally not order us t |                           |
| o pay or provide one clinically appropri |                           |
| ate treatment plan in favor of another.* |                           |
+------------------------------------------+---------------------------+
| **Preauthorization** To be eligible to   |                           |
| receive these benefits you must obtain a |                           |
| treatment plan and follow all of the     |                           |
| following authorization processes.       |                           |
| Contact MHN toll-free at 1-888-779-2236  |                           |
| twenty-four hours a day, seven days a    |                           |
| week and MHN will direct you to the      |                           |
| appropriate provider of care.            |                           |
+------------------------------------------+---------------------------+

**Limitation** We may limit your benefits if you do not obtain a
treatment plan.

+-----+---+----------------------------------------------------+---+---+
| **S |   |                                                    |   |   |
| ect |   |                                                    |   |   |
| ion |   |                                                    |   |   |
| 5   |   |                                                    |   |   |
| (f) |   |                                                    |   |   |
| Pre |   |                                                    |   |   |
| scr |   |                                                    |   |   |
| ipt |   |                                                    |   |   |
| ion |   |                                                    |   |   |
| d   |   |                                                    |   |   |
| rug |   |                                                    |   |   |
| b   |   |                                                    |   |   |
| ene |   |                                                    |   |   |
| fit |   |                                                    |   |   |
| s** |   |                                                    |   |   |
+-----+---+----------------------------------------------------+---+---+
|     | * | **Here are some important things to keep in mind   | * |   |
|     | * | about these benefits:**                            | * |   |
|     | I |                                                    | I |   |
|     | * | -   We cover prescribed drugs and medications, as  | * |   |
|     | * |     described in the chart beginning on the next   | * |   |
|     |   |     page.                                          |   |   |
|     | * |                                                    | * |   |
|     | * | -   All benefits are subject to the definitions,   | * |   |
|     | M |     limitations and exclusions in this brochure    | M |   |
|     | * |     and are payable only when we determine they    | * |   |
|     | * |     are medically necessary.                       | * |   |
|     |   |                                                    |   |   |
|     | * | ```{=html}                                         | * |   |
|     | * | <!-- -->                                           | * |   |
|     | P | ```                                                | P |   |
|     | * | -   We do not have a deductible.                   | * |   |
|     | * |                                                    | * |   |
|     |   | ```{=html}                                         |   |   |
|     | * | <!-- -->                                           | * |   |
|     | * | ```                                                | * |   |
|     | O | -   Some formulary and non-formulary drugs require | O |   |
|     | * |     prior authorization from us. Contact us at     | * |   |
|     | * |     1-800-522-0088 to find out if your medication  | * |   |
|     |   |     requires it and for information on what your   |   |   |
|     | * |     physician must do to obtain prior              | * |   |
|     | * |     authorization.                                 | * |   |
|     | R |                                                    | R |   |
|     | * | ```{=html}                                         | * |   |
|     | * | <!-- -->                                           | * |   |
|     |   | ```                                                |   |   |
|     | * | -   Be sure to read Section 4, *Your costs for     | * |   |
|     | * |     covered services,* for valuable information    | * |   |
|     | T |     about how cost sharing works. Also read        | T |   |
|     | * |     Section 9 about coordinating benefits with     | * |   |
|     | * |     other coverage, including with Medicare.       | * |   |
|     |   |                                                    |   |   |
|     | * |                                                    | * |   |
|     | * |                                                    | * |   |
|     | A |                                                    | A |   |
|     | * |                                                    | * |   |
|     | * |                                                    | * |   |
|     |   |                                                    |   |   |
|     | * |                                                    | * |   |
|     | * |                                                    | * |   |
|     | N |                                                    | N |   |
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|     | * |                                                    | * |   |
|     | T |                                                    | T |   |
|     | * |                                                    | * |   |
|     | * |                                                    | * |   |
+-----+---+----------------------------------------------------+---+---+
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|     | - |                                                    |   |   |
|     | 8 |                                                    |   |   |
|     | 0 |                                                    |   |   |
|     | 0 |                                                    |   |   |
|     | - |                                                    |   |   |
|     | 5 |                                                    |   |   |
|     | 2 |                                                    |   |   |
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|     | . |                                                    |   |   |
+-----+---+----------------------------------------------------+---+---+

+------------------------------------------+---------------------------+
| > **Benefit Description**                | **You pay**               |
+------------------------------------------+---------------------------+
| > **Covered medications and supplies**   |                           |
+------------------------------------------+---------------------------+
| > We cover the following medications and | > For drugs filled at a   |
| > supplies prescribed by a Plan          | > Plan pharmacy:          |
| > physician and obtained from a Plan     |                           |
| > pharmacy or through our mail order     | -   \$10 for generic      |
| > program:                               |     drugs                 |
|                                          |                           |
| -   Drugs and medicines that by Federal  | -   \$20 for brand name   |
|     law of the United States require a   |     drugs                 |
|     physician's prescription for their   |                           |
|     purchase, except those listed as     | -   \$35 for              |
|     *Not covered.*                       |     non-formulary drugs   |
|                                          |                           |
| -   Insulin                              | > For drugs filled        |
|                                          | > through the mail order  |
| -   Diabetic supplies, such as blood     | > program:                |
|     glucose monitoring strips, Ketone    |                           |
|     test strips and lancet.              | -   \$20 for generic      |
|                                          |     drugs                 |
| -   Disposable needles and syringes for  |                           |
|     the administration of covered        | -   \$40 for brand name   |
|     medications                          |     drugs                 |
|                                          |                           |
| -   Drugs for sexual dysfunction (see    | -   \$70 for              |
|     limits below)                        |     non-formulary drugs   |
|                                          |                           |
| ```{=html}                               | > Note: If there is no    |
| <!-- -->                                 | > generic equivalent      |
| ```                                      | > available, you will     |
| -   Contraceptive drugs and devices such | > still have to pay the   |
|     as diaphragms and cervical caps      | > brand name copay.       |
+------------------------------------------+---------------------------+
| Limited benefits:                        | > 50% of charges          |
|                                          |                           |
| -   Drugs for sexual dysfunction are     |                           |
|     limited to 2 doses per week or 8     |                           |
|     tablets per month.                   |                           |
|                                          |                           |
| -   Fertility drugs associated with      |                           |
|     covered services under the diagnosis |                           |
|     and treatment of infertility are     |                           |
|     covered under the Medical Services   |                           |
|     and Supplies Benefits (see page 20). |                           |
+------------------------------------------+---------------------------+
| > *Not covered:*                         | > *All charges*           |
|                                          |                           |
| -   *Drugs and supplies for cosmetic     |                           |
|     purposes*                            |                           |
|                                          |                           |
| -   *Medical supplies such as dressings  |                           |
|     and antiseptics*                     |                           |
|                                          |                           |
| -   *Vitamins, nutrients and food        |                           |
|     supplements even if a physician      |                           |
|     prescribes or administers them*      |                           |
|                                          |                           |
| -   *Drugs available without a           |                           |
|     prescription or for which there is a |                           |
|     nonprescription equivalent*          |                           |
|                                          |                           |
| -   *Drugs to enhance athletic           |                           |
|     performance*                         |                           |
|                                          |                           |
| -   *Injectable Fertility Drugs*         |                           |
|                                          |                           |
| -   *Drugs obtained at a non-Plan        |                           |
|     pharmacy; except for out-of-area     |                           |
|     emergencies*                         |                           |
|                                          |                           |
| -   *Anorectics (appetite suppressants), |                           |
|     except for treatment of morbid       |                           |
|     obesity.*                            |                           |
|                                          |                           |
| -   *Non-prescription medications*       |                           |
+------------------------------------------+---------------------------+

+-------------------+--------------------------------------------------+
| > Section 5 (g)   |                                                  |
| > Special         |                                                  |
| > features        |                                                  |
+===================+==================================================+
| > **Feature**     | > **Description**                                |
+-------------------+--------------------------------------------------+
| > **Flexible      | > Under the flexible benefits option, we         |
| > benefits        | > determine the most effective way to provide    |
| > option**        | > services.                                      |
|                   |                                                  |
|                   | -   We may identify medically appropriate        |
|                   |     alternatives to traditional care and         |
|                   |     coordinate other benefits as a less costly   |
|                   |     alternative benefit.                         |
|                   |                                                  |
|                   | -   Alternative benefits are subject to our      |
|                   |     ongoing review.                              |
|                   |                                                  |
|                   | -   By approving an alternative benefit, we      |
|                   |     cannot guarantee you will get it in the      |
|                   |     future.                                      |
|                   |                                                  |
|                   | -   The decision to offer an alternative benefit |
|                   |     is solely ours, and we may withdraw it at    |
|                   |     any time and resume regular contract         |
|                   |     benefits.                                    |
|                   |                                                  |
|                   | -   Our decision to offer or withdraw            |
|                   |     alternative benefits is not subject to OPM   |
|                   |     review under the disputed claims process.    |
+-------------------+--------------------------------------------------+
| > **Services for  | > Please contact our Telecommunications Device   |
| > deaf and        | > for the Deaf at                                |
| > hearing         | >                                                |
| > impaired**      | > 1-800-995-0852.                                |
+-------------------+--------------------------------------------------+
| > **Early         | > We encourage our mothers-to-be to participate  |
| > Prenatal        | > in our special prenatal health program. **Upon |
| > Program**       | > successful completion of the** **program,      |
|                   | > participants will receive a gift               |
|                   | > certificate**. Parents learn answers to their  |
|                   | > early pregnancy concerns, such as caffeine or  |
|                   | > alcohol use, tests during pregnancy and other  |
|                   | > general prenatal information. Please call      |
|                   | > 1-800-522-0088 for more information.           |
+-------------------+--------------------------------------------------+
| > **Centers of    | > For organ and tissue transplants, we contract  |
| > Excellence**    | > with premier transplant centers of excellence  |
|                   | > in Northern, Southern and Central California   |
|                   | > that have established their superior ability   |
|                   | > to perform certain transplant procedures. Your |
|                   | > participating physician group will work with   |
|                   | > you to find the best center for your           |
|                   | > condition.                                     |
+-------------------+--------------------------------------------------+

+---+---+------------------------------------+------------------+----+---+
| > |   |                                    |                  |    |   |
|   |   |                                    |                  |    |   |
| S |   |                                    |                  |    |   |
| e |   |                                    |                  |    |   |
| c |   |                                    |                  |    |   |
| t |   |                                    |                  |    |   |
| i |   |                                    |                  |    |   |
| o |   |                                    |                  |    |   |
| n |   |                                    |                  |    |   |
| > |   |                                    |                  |    |   |
|   |   |                                    |                  |    |   |
| 5 |   |                                    |                  |    |   |
| > |   |                                    |                  |    |   |
|   |   |                                    |                  |    |   |
| ( |   |                                    |                  |    |   |
| h |   |                                    |                  |    |   |
| ) |   |                                    |                  |    |   |
| > |   |                                    |                  |    |   |
|   |   |                                    |                  |    |   |
| D |   |                                    |                  |    |   |
| e |   |                                    |                  |    |   |
| n |   |                                    |                  |    |   |
| t |   |                                    |                  |    |   |
| a |   |                                    |                  |    |   |
| l |   |                                    |                  |    |   |
| > |   |                                    |                  |    |   |
|   |   |                                    |                  |    |   |
| b |   |                                    |                  |    |   |
| e |   |                                    |                  |    |   |
| n |   |                                    |                  |    |   |
| e |   |                                    |                  |    |   |
| f |   |                                    |                  |    |   |
| i |   |                                    |                  |    |   |
| t |   |                                    |                  |    |   |
| s |   |                                    |                  |    |   |
+===+===+====================================+==================+====+===+
|   | * | **Here are some important things   |                  | *  |   |
|   | * | to keep in mind about these        |                  | *I |   |
|   | I | benefits:**                        |                  | ** |   |
|   | * |                                    |                  |    |   |
|   | * | -   Please remember that all       |                  | *  |   |
|   |   |     benefits are subject to the    |                  | *M |   |
|   | * |     definitions, limitations, and  |                  | ** |   |
|   | * |     exclusions in this brochure    |                  |    |   |
|   | M |     and are payable only when we   |                  | *  |   |
|   | * |     determine they are medically   |                  | *P |   |
|   | * |     necessary.                     |                  | ** |   |
|   |   |                                    |                  |    |   |
|   | * | -   We have no calendar year       |                  | *  |   |
|   | * |     deductible.                    |                  | *O |   |
|   | P |                                    |                  | ** |   |
|   | * | -   We cover hospitalization for   |                  |    |   |
|   | * |     dental procedures only when a  |                  | *  |   |
|   |   |     non-dental physical impairment |                  | *R |   |
|   | * |     exists which makes             |                  | ** |   |
|   | * |     hospitalization necessary to   |                  |    |   |
|   | O |     safeguard the health of the    |                  | *  |   |
|   | * |     patient; we do not cover the   |                  | *T |   |
|   | * |     dental procedure unless it is  |                  | ** |   |
|   |   |     described below.               |                  |    |   |
|   | * |                                    |                  | *  |   |
|   | * | ```{=html}                         |                  | *A |   |
|   | R | <!-- -->                           |                  | ** |   |
|   | * | ```                                |                  |    |   |
|   | * | -   Be sure to read Section 4,     |                  | *  |   |
|   |   |     *Your costs for covered        |                  | *N |   |
|   | * |     services,* for valuable        |                  | ** |   |
|   | * |     information about how cost     |                  |    |   |
|   | T |     sharing works. Also read       |                  | *  |   |
|   | * |     Section 9 about coordinating   |                  | *T |   |
|   | * |     benefits with other coverage,  |                  | ** |   |
|   |   |     including with Medicare.       |                  |    |   |
|   | * |                                    |                  |    |   |
|   | * |                                    |                  |    |   |
|   | A |                                    |                  |    |   |
|   | * |                                    |                  |    |   |
|   | * |                                    |                  |    |   |
|   |   |                                    |                  |    |   |
|   | * |                                    |                  |    |   |
|   | * |                                    |                  |    |   |
|   | N |                                    |                  |    |   |
|   | * |                                    |                  |    |   |
|   | * |                                    |                  |    |   |
|   |   |                                    |                  |    |   |
|   | * |                                    |                  |    |   |
|   | * |                                    |                  |    |   |
|   | T |                                    |                  |    |   |
|   | * |                                    |                  |    |   |
|   | * |                                    |                  |    |   |
+---+---+------------------------------------+------------------+----+---+
| # |   |                                    | > **You pay**    |    |   |
| # |   |                                    |                  |    |   |
| # |   |                                    |                  |    |   |
|   |   |                                    |                  |    |   |
| * |   |                                    |                  |    |   |
| * |   |                                    |                  |    |   |
| A |   |                                    |                  |    |   |
| c |   |                                    |                  |    |   |
| c |   |                                    |                  |    |   |
| i |   |                                    |                  |    |   |
| d |   |                                    |                  |    |   |
| e |   |                                    |                  |    |   |
| n |   |                                    |                  |    |   |
| t |   |                                    |                  |    |   |
| a |   |                                    |                  |    |   |
| l |   |                                    |                  |    |   |
|   |   |                                    |                  |    |   |
| i |   |                                    |                  |    |   |
| n |   |                                    |                  |    |   |
| j |   |                                    |                  |    |   |
| u |   |                                    |                  |    |   |
| r |   |                                    |                  |    |   |
| y |   |                                    |                  |    |   |
|   |   |                                    |                  |    |   |
| b |   |                                    |                  |    |   |
| e |   |                                    |                  |    |   |
| n |   |                                    |                  |    |   |
| e |   |                                    |                  |    |   |
| f |   |                                    |                  |    |   |
| i |   |                                    |                  |    |   |
| t |   |                                    |                  |    |   |
| * |   |                                    |                  |    |   |
| * |   |                                    |                  |    |   |
+---+---+------------------------------------+------------------+----+---+
| > |   |                                    | > Nothing at the |    |   |
|   |   |                                    | > dentist's      |    |   |
| W |   |                                    | > office and a   |    |   |
| e |   |                                    | > \$100          |    |   |
| > |   |                                    | > copayment at   |    |   |
|   |   |                                    | > the emergency  |    |   |
| c |   |                                    | > room           |    |   |
| o |   |                                    |                  |    |   |
| v |   |                                    |                  |    |   |
| e |   |                                    |                  |    |   |
| r |   |                                    |                  |    |   |
| > |   |                                    |                  |    |   |
|   |   |                                    |                  |    |   |
| t |   |                                    |                  |    |   |
| h |   |                                    |                  |    |   |
| e |   |                                    |                  |    |   |
| > |   |                                    |                  |    |   |
|   |   |                                    |                  |    |   |
| r |   |                                    |                  |    |   |
| e |   |                                    |                  |    |   |
| s |   |                                    |                  |    |   |
| t |   |                                    |                  |    |   |
| o |   |                                    |                  |    |   |
| r |   |                                    |                  |    |   |
| a |   |                                    |                  |    |   |
| t |   |                                    |                  |    |   |
| i |   |                                    |                  |    |   |
| v |   |                                    |                  |    |   |
| e |   |                                    |                  |    |   |
| > |   |                                    |                  |    |   |
|   |   |                                    |                  |    |   |
| s |   |                                    |                  |    |   |
| e |   |                                    |                  |    |   |
| r |   |                                    |                  |    |   |
| v |   |                                    |                  |    |   |
| i |   |                                    |                  |    |   |
| c |   |                                    |                  |    |   |
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| s |   |                                    |                  |    |   |
| > |   |                                    |                  |    |   |
|   |   |                                    |                  |    |   |
| a |   |                                    |                  |    |   |
| n |   |                                    |                  |    |   |
| d |   |                                    |                  |    |   |
| > |   |                                    |                  |    |   |
|   |   |                                    |                  |    |   |
| s |   |                                    |                  |    |   |
| u |   |                                    |                  |    |   |
| p |   |                                    |                  |    |   |
| p |   |                                    |                  |    |   |
| l |   |                                    |                  |    |   |
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| e |   |                                    |                  |    |   |
| s |   |                                    |                  |    |   |
| > |   |                                    |                  |    |   |
|   |   |                                    |                  |    |   |
| n |   |                                    |                  |    |   |
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| c |   |                                    |                  |    |   |
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| s |   |                                    |                  |    |   |
| s |   |                                    |                  |    |   |
| a |   |                                    |                  |    |   |
| r |   |                                    |                  |    |   |
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| p |   |                                    |                  |    |   |
| r |   |                                    |                  |    |   |
| o |   |                                    |                  |    |   |
| m |   |                                    |                  |    |   |
| p |   |                                    |                  |    |   |
| t |   |                                    |                  |    |   |
| l |   |                                    |                  |    |   |
| y |   |                                    |                  |    |   |
| > |   |                                    |                  |    |   |
|   |   |                                    |                  |    |   |
| r |   |                                    |                  |    |   |
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| p |   |                                    |                  |    |   |
| a |   |                                    |                  |    |   |
| i |   |                                    |                  |    |   |
| r |   |                                    |                  |    |   |
| > |   |                                    |                  |    |   |
|   |   |                                    |                  |    |   |
| ( |   |                                    |                  |    |   |
| b |   |                                    |                  |    |   |
| u |   |                                    |                  |    |   |
| t |   |                                    |                  |    |   |
| > |   |                                    |                  |    |   |
|   |   |                                    |                  |    |   |
| n |   |                                    |                  |    |   |
| o |   |                                    |                  |    |   |
| t |   |                                    |                  |    |   |
| > |   |                                    |                  |    |   |
|   |   |                                    |                  |    |   |
| r |   |                                    |                  |    |   |
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| p |   |                                    |                  |    |   |
| l |   |                                    |                  |    |   |
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| ) |   |                                    |                  |    |   |
| > |   |                                    |                  |    |   |
|   |   |                                    |                  |    |   |
| s |   |                                    |                  |    |   |
| o |   |                                    |                  |    |   |
| u |   |                                    |                  |    |   |
| n |   |                                    |                  |    |   |
| d |   |                                    |                  |    |   |
| > |   |                                    |                  |    |   |
|   |   |                                    |                  |    |   |
| n |   |                                    |                  |    |   |
| a |   |                                    |                  |    |   |
| t |   |                                    |                  |    |   |
| u |   |                                    |                  |    |   |
| r |   |                                    |                  |    |   |
| a |   |                                    |                  |    |   |
| l |   |                                    |                  |    |   |
| > |   |                                    |                  |    |   |
|   |   |                                    |                  |    |   |
| t |   |                                    |                  |    |   |
| e |   |                                    |                  |    |   |
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| t |   |                                    |                  |    |   |
| h |   |                                    |                  |    |   |
| . |   |                                    |                  |    |   |
| > |   |                                    |                  |    |   |
|   |   |                                    |                  |    |   |
| T |   |                                    |                  |    |   |
| h |   |                                    |                  |    |   |
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| > |   |                                    |                  |    |   |
|   |   |                                    |                  |    |   |
| n |   |                                    |                  |    |   |
| e |   |                                    |                  |    |   |
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| d |   |                                    |                  |    |   |
| > |   |                                    |                  |    |   |
|   |   |                                    |                  |    |   |
| f |   |                                    |                  |    |   |
| o |   |                                    |                  |    |   |
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| > |   |                                    |                  |    |   |
|   |   |                                    |                  |    |   |
| t |   |                                    |                  |    |   |
| h |   |                                    |                  |    |   |
| e |   |                                    |                  |    |   |
| s |   |                                    |                  |    |   |
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| > |   |                                    |                  |    |   |
|   |   |                                    |                  |    |   |
| s |   |                                    |                  |    |   |
| e |   |                                    |                  |    |   |
| r |   |                                    |                  |    |   |
| v |   |                                    |                  |    |   |
| i |   |                                    |                  |    |   |
| c |   |                                    |                  |    |   |
| e |   |                                    |                  |    |   |
| s |   |                                    |                  |    |   |
| > |   |                                    |                  |    |   |
|   |   |                                    |                  |    |   |
| m |   |                                    |                  |    |   |
| u |   |                                    |                  |    |   |
| s |   |                                    |                  |    |   |
| t |   |                                    |                  |    |   |
| > |   |                                    |                  |    |   |
|   |   |                                    |                  |    |   |
| r |   |                                    |                  |    |   |
| e |   |                                    |                  |    |   |
| s |   |                                    |                  |    |   |
| u |   |                                    |                  |    |   |
| l |   |                                    |                  |    |   |
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| > |   |                                    |                  |    |   |
|   |   |                                    |                  |    |   |
| f |   |                                    |                  |    |   |
| r |   |                                    |                  |    |   |
| o |   |                                    |                  |    |   |
| m |   |                                    |                  |    |   |
| > |   |                                    |                  |    |   |
|   |   |                                    |                  |    |   |
| a |   |                                    |                  |    |   |
| n |   |                                    |                  |    |   |
| > |   |                                    |                  |    |   |
|   |   |                                    |                  |    |   |
| a |   |                                    |                  |    |   |
| c |   |                                    |                  |    |   |
| c |   |                                    |                  |    |   |
| i |   |                                    |                  |    |   |
| d |   |                                    |                  |    |   |
| e |   |                                    |                  |    |   |
| n |   |                                    |                  |    |   |
| t |   |                                    |                  |    |   |
| a |   |                                    |                  |    |   |
| l |   |                                    |                  |    |   |
| > |   |                                    |                  |    |   |
|   |   |                                    |                  |    |   |
| i |   |                                    |                  |    |   |
| n |   |                                    |                  |    |   |
| j |   |                                    |                  |    |   |
| u |   |                                    |                  |    |   |
| r |   |                                    |                  |    |   |
| y |   |                                    |                  |    |   |
| > |   |                                    |                  |    |   |
|   |   |                                    |                  |    |   |
| a |   |                                    |                  |    |   |
| n |   |                                    |                  |    |   |
| d |   |                                    |                  |    |   |
| > |   |                                    |                  |    |   |
|   |   |                                    |                  |    |   |
| t |   |                                    |                  |    |   |
| r |   |                                    |                  |    |   |
| e |   |                                    |                  |    |   |
| a |   |                                    |                  |    |   |
| t |   |                                    |                  |    |   |
| m |   |                                    |                  |    |   |
| e |   |                                    |                  |    |   |
| n |   |                                    |                  |    |   |
| t |   |                                    |                  |    |   |
| > |   |                                    |                  |    |   |
|   |   |                                    |                  |    |   |
| m |   |                                    |                  |    |   |
| u |   |                                    |                  |    |   |
| s |   |                                    |                  |    |   |
| t |   |                                    |                  |    |   |
| > |   |                                    |                  |    |   |
|   |   |                                    |                  |    |   |
| b |   |                                    |                  |    |   |
| e |   |                                    |                  |    |   |
| > |   |                                    |                  |    |   |
|   |   |                                    |                  |    |   |
| g |   |                                    |                  |    |   |
| i |   |                                    |                  |    |   |
| v |   |                                    |                  |    |   |
| e |   |                                    |                  |    |   |
| n |   |                                    |                  |    |   |
| > |   |                                    |                  |    |   |
|   |   |                                    |                  |    |   |
| w |   |                                    |                  |    |   |
| i |   |                                    |                  |    |   |
| t |   |                                    |                  |    |   |
| h |   |                                    |                  |    |   |
| i |   |                                    |                  |    |   |
| n |   |                                    |                  |    |   |
| > |   |                                    |                  |    |   |
|   |   |                                    |                  |    |   |
| 2 |   |                                    |                  |    |   |
| 4 |   |                                    |                  |    |   |
| > |   |                                    |                  |    |   |
|   |   |                                    |                  |    |   |
| h |   |                                    |                  |    |   |
| o |   |                                    |                  |    |   |
| u |   |                                    |                  |    |   |
| r |   |                                    |                  |    |   |
| s |   |                                    |                  |    |   |
| > |   |                                    |                  |    |   |
|   |   |                                    |                  |    |   |
| o |   |                                    |                  |    |   |
| f |   |                                    |                  |    |   |
| > |   |                                    |                  |    |   |
|   |   |                                    |                  |    |   |
| t |   |                                    |                  |    |   |
| h |   |                                    |                  |    |   |
| e |   |                                    |                  |    |   |
| > |   |                                    |                  |    |   |
|   |   |                                    |                  |    |   |
| i |   |                                    |                  |    |   |
| n |   |                                    |                  |    |   |
| j |   |                                    |                  |    |   |
| u |   |                                    |                  |    |   |
| r |   |                                    |                  |    |   |
| y |   |                                    |                  |    |   |
| . |   |                                    |                  |    |   |
+---+---+------------------------------------+------------------+----+---+
| > |   |                                    | > *All charges*  |    |   |
|   |   |                                    |                  |    |   |
| * |   |                                    |                  |    |   |
| N |   |                                    |                  |    |   |
| o |   |                                    |                  |    |   |
| t |   |                                    |                  |    |   |
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| d |   |                                    |                  |    |   |
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| m |   |                                    |                  |    |   |
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| * |   |                                    |                  |    |   |
|   |   |                                    |                  |    |   |
| ` |   |                                    |                  |    |   |
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| { |   |                                    |                  |    |   |
| = |   |                                    |                  |    |   |
| h |   |                                    |                  |    |   |
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| m |   |                                    |                  |    |   |
| l |   |                                    |                  |    |   |
| } |   |                                    |                  |    |   |
| < |   |                                    |                  |    |   |
| ! |   |                                    |                  |    |   |
| - |   |                                    |                  |    |   |
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+---+---+------------------------------------+------------------+----+---+
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+---+---+------------------------------------+------------------+----+---+
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| . |   |                                    |                  |    |   |
+---+---+------------------------------------+------------------+----+---+
| * |   |                                    |                  |    |   |
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|   |   |                                    |                  |    |   |
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|   |   |                                    |                  |    |   |
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|   |   |                                    |                  |    |   |
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|   |   |                                    |                  |    |   |
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| o |   |                                    |                  |    |   |
| w |   |                                    |                  |    |   |
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|   |   |                                    |                  |    |   |
|   |   |                                    |                  |    |   |
|   |   |                                    |                  |    |   |
|   |   |                                    |                  |    |   |
| a |   |                                    |                  |    |   |
| s |   |                                    |                  |    |   |
|   |   |                                    |                  |    |   |
|   |   |                                    |                  |    |   |
|   |   |                                    |                  |    |   |
|   |   |                                    |                  |    |   |
| c |   |                                    |                  |    |   |
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| v |   |                                    |                  |    |   |
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| d |   |                                    |                  |    |   |
| * |   |                                    |                  |    |   |
+---+---+------------------------------------+------------------+----+---+

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

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

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

+---------------+------------------------------------------------------+
| **Optional    | The Vis-A-Dent product from Health Net of California |
| Dental and    | Dental and Vision bundles dental and vision coverage |
| Vision        | together into a plan that provides access to         |
| Coverage**    | affordable, quality services. The plan offers a      |
|               | choice from two dental plans and combines it with a  |
|               | vision plan tailored to meet the needs of            |
|               | individuals and families. Two coverages, one bill.   |
|               |                                                      |
|               | **Please note: The areas where Vis-A-Dent is offered |
|               | may not be the same as the Health Net of California  |
|               | service area. Please call Health Net of California   |
|               | Dental and Vision at 1-800-999-2848 for information  |
|               | about their service area information.**              |
+---------------+------------------------------------------------------+
| **Optional    | Standalone dental insurance is available through     |
| Indemnity     | Health Net of California Dental and Vision. This     |
| Dental        | indemnity dental plan covers a broad range of        |
| Coverage**    | services and allows you complete freedom of choice   |
|               | in selecting your dentist. This plan gives members   |
|               | an attractive combination of coverage, choice, and   |
|               | low cost.                                            |
+---------------+------------------------------------------------------+
| **Medicare    | This Plan offers Medicare recipients the opportunity |
| Prepaid Plan  | to enroll in the Plan (Health Net Seniority Plus     |
| Enrollment**  | program) through Medicare. Annuitants and former     |
|               | spouses with FEHB coverage and Medicare Part B may   |
|               | elect to drop their FEHB coverage and enroll in a    |
|               | Medicare prepaid plan when one is available in their |
|               | area. They may then later reenroll in the FEHB       |
|               | Program. Most Federal annuitants have Medicare Part  |
|               | A. Those without Medicare Part A may join Health Net |
|               | Seniority Plus but will have to pay for Medicare     |
|               | Part A in addition to the Part B premium. Before you |
|               | join the plan, ask whether the plan covers hospital  |
|               | benefits and, if so, what you will have to pay.      |
|               | Contact your retirement system for information on    |
|               | dropping your FEHB enrollment and changing to a      |
|               | Medicare prepaid plan. Contact us at 1-800-596-6565  |
|               | for information on the Health Net Seniority Plus     |
|               | Medicare prepaid plan and the cost of that           |
|               | enrollment. If you are eligible for Medicare and are |
|               | interested in enrolling in a Medicare HMO sponsored  |
|               | by Health Net of California without dropping your    |
|               | enrollment in Health Net's FEHB plan, call           |
|               |                                                      |
|               | 1-800-596-6565 for information on the benefits       |
|               | available under the Medicare HMO.                    |
+---------------+------------------------------------------------------+

+-----------------------------------------------------------------------+
| > Section 6. General exclusions \-- things we don\'t cover            |
+-----------------------------------------------------------------------+

> The exclusions in this section apply to all benefits. **Although we
> may list a specific service as a benefit, we will not cover it unless
> your Plan doctor determines it is medically necessary to prevent,
> diagnose, or treat your illness, disease, injury, or condition.**
>
> We do not cover the following:

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

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

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

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

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

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

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

```{=html}
<!-- -->
```
-   Services, drugs, or supplies you receive from a provider or facility
    barred from the FEHB Program; or

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

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

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

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

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

**Medical and hospital benefits** In most cases, providers and
facilities file claims for you. Physicians must file on the form
HCFA-1500, Health Insurance Claim Form. Facilities will file on the
UB-92 form. For claims questions and assistance, call us at
1-800-522-0088.

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

-   Covered member's name and ID number;

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

-   Dates you received the services or supplies;

-   Diagnosis;

-   Type of each service or supply;

-   The charge for each service or supply;

```{=html}
<!-- -->
```
-   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: Health Net of California, P.O. Box 9103**
>
> **Van Nuys, CA 91409-9103**

**Prescription drugs** When you purchase a prescription drug, and your
Plan ID card is not available, eligibility cannot be determined, or the
prescription is for a medical emergency outside of California, you must
pay for the drug when it is dispensed, and file a claim for
reimbursement. For claims questions and assistance, or to request a
prescription drug claim form call us at 1-800-522-0088.

**Deadline for filing your claim** Send us all of the documents for your
claim as soon as possible. You must submit the claim by December 31 of
the year after the year you received the service, unless timely filing
was prevented by administrative operations of Government or legal
incapacity, provided the claim was submitted as soon as reasonably
possible.

**When we need more information** Please reply promptly when we ask for
additional information. We may delay processing or deny your claim if
you do not respond.

  -----------------------------------------------------------------------
  Section 8. The disputed claims process

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

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

+---+------------------------------------------------------------------+
| * | **Description**                                                  |
| * |                                                                  |
| S |                                                                  |
| t |                                                                  |
| e |                                                                  |
| p |                                                                  |
| * |                                                                  |
| * |                                                                  |
+---+------------------------------------------------------------------+
| * | Ask us in writing to reconsider our initial decision. You must:  |
| * |                                                                  |
| 1 | (a) Write to us within 6 months from the date of our decision;   |
| * |     and                                                          |
| * |                                                                  |
|   | (b) Send your request to us at: Health Net of California, P.O.   |
|   |     Box 9103, Van Nuys, CA 91409-9103; 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.            |
+---+------------------------------------------------------------------+
| * | We have 30 days from the date we receive your request to:        |
| * |                                                                  |
| 2 | (a) Pay the claim (or, if applicable, arrange for the health     |
| * |     care provider to give you the care); or                      |
| * |                                                                  |
|   | (b) Write to you and maintain our denial \-- go to step 4; or    |
|   |                                                                  |
|   | (c) Ask you or your provider for more information. If we ask     |
|   |     your provider, we will send you a copy of our request---go   |
|   |     to step 3.                                                   |
+---+------------------------------------------------------------------+
| * | You or your provider must send the information so that we        |
| * | receive it within 60 days of our request. We will then decide    |
| 3 | within 30 more days.                                             |
| * |                                                                  |
| * | If we do not receive the information within 60 days, we will     |
|   | decide within 30 days of the date the information was due. We    |
|   | will base our decision on the information we already have.       |
|   |                                                                  |
|   | We will write to you with our decision.                          |
+---+------------------------------------------------------------------+
| * | If you do not agree with our decision, you may ask OPM to review |
| * | it.                                                              |
| 4 |                                                                  |
| * |                                                                  |
| * |                                                                  |
+---+------------------------------------------------------------------+
|   | You must write to OPM within:                                    |
|   |                                                                  |
|   | -   90 days after the date of our letter upholding our initial   |
|   |     decision; or                                                 |
|   |                                                                  |
|   | -   120 days after you first wrote to us \-- if we did not       |
|   |     answer that request in some way within 30 days; or           |
|   |                                                                  |
|   | -   120 days after we asked for additional information.          |
+---+------------------------------------------------------------------+
|   | Write to OPM at: Office of Personnel Management, Insurance       |
|   | Services Programs, Health Insurance Group 3, 1900 E. Street, NW, |
|   | Washington, D.C. 20415-3630.                                     |
+---+------------------------------------------------------------------+

+---+------------------------------------------------------------------+
|   | **The Disputed Claims process** *(Continued)*                    |
|   |                                                                  |
|   | Send OPM the following information:                              |
|   |                                                                  |
|   | -   A statement about why you believe our decision was wrong,    |
|   |     based on specific benefit provisions in this brochure;       |
|   |                                                                  |
|   | -   Copies of documents that support your claim, such as         |
|   |     physicians\' letters, operative reports, bills, medical      |
|   |     records, and explanation of benefits (EOB) forms;            |
|   |                                                                  |
|   | -   Copies of all letters you sent to us about the claim;        |
|   |                                                                  |
|   | -   Copies of all letters we sent to you about the claim; and    |
|   |                                                                  |
|   | -   Your daytime phone number and the best time to call.         |
|   |                                                                  |
|   | Note: If you want OPM to review more than one claim, you must    |
|   | clearly identify which documents apply to which claim.           |
+---+------------------------------------------------------------------+
|   | Note: You are the only person who has a right to file a disputed |
|   | claim with OPM. Parties acting as your representative, such as   |
|   | medical providers, must include a copy of your specific written  |
|   | consent with the review request.                                 |
|   |                                                                  |
|   | Note: The above deadlines may be extended if you show that you   |
|   | were unable to meet the deadline because of reasons beyond your  |
|   | control.                                                         |
+---+------------------------------------------------------------------+
| * | OPM will review your disputed claim request and will use the     |
| * | information it collects from you and us to decide whether our    |
| 5 | decision is correct. OPM will send you a final decision within   |
| * | 60 days. There are no other administrative appeals.              |
| * |                                                                  |
+---+------------------------------------------------------------------+
|   | If you do not agree with OPM's decision, your only recourse is   |
|   | to sue. If you decide to sue, you must file the suit against OPM |
|   | in Federal court by December 31 of the third year after the year |
|   | in which you received the disputed services, drugs, or supplies  |
|   | or from the year in which you were denied 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 at 1-800-522-0088 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

```{=html}
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-   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

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

**When you have other health coverage** You must tell us if you or a
covered family member have coverage under another group health plan or
have automobile insurance that pays health care expenses without regard
to fault. This is called "double coverage."

When you have double coverage, one plan normally pays its benefits in
full as the primary payer and the other plan pays a reduced benefit as
the secondary payer. We, like other insurers, determine which coverage
is primary according to the National Association of Insurance
Commissioners\' guidelines.

When we are the primary payer, we will pay the benefits described in
this brochure.

When we are the secondary payer, we will determine our allowance. After
the primary plan pays, we will pay what is left of our allowance, up to
our regular benefit. We will not pay more than our allowance.

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

-   People 65 years of age and older.

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

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```
-   People with End-State 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.

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

> ** Should I enroll in Medicare?** The decision to enroll in Medicare
> is yours. We encourage you to apply for Medicare benefits 3
>
> months before you turn age 65. It's easy. Just call the Social
> Security Administration toll-free number 1-800-772-1213 to set up an
> appointment to apply. If you do not apply for one or both parts of
> Medicare, you can still be covered under the FEHB Program.

If you can get premium-free Part A coverage, we advise you to enroll in
it. Most Federal employees and annuitants are entitled to Medicare Part
A at age 65 without cost. When you don't have to pay premiums for Part
A, it makes good sense to obtain the coverage. It can reduce your
out-of-pocket expenses as well as costs to the FEHB, which can help keep
FEHB premiums down.

Everyone is charged a premium for Medicare Part B coverage. The Social
Security Administration can provide you with premium and benefit
information. Review the information and decide if it makes sense for you
to buy the Medicare Part B coverage.

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

**•The Original Medicare** **Plan**

**(Part A or Part B)** The Original Medicare Plan (Original Medicare) is
available everywhere in the United States. It is the way everyone used
to get Medicare benefits and is the way most people get their Medicare
Part A and Part B benefits now. You may go to any doctor, specialist, or
hospital that accepts Medicare. The Original Medicare Plan pays its
share and you pay your share. Some things are not covered under Original
Medicare, like prescription drugs.

When you are enrolled in Original Medicare along with this Plan, you
still need to follow the rules in this brochure for us to cover your
care.

> We will not waive any of our copayments or coinsurance if we are the
> primary payer. If Medicare is the primary payer, we will waive some
> copayments or coinsurance when the Plan provider can expect to receive
> payment amounting to more than any required copayment.

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

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

```{=html}
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```
-   When Original Medicare is the primary payer, Medicare processes your
    claim first. In most cases, your claims will be coordinated
    automatically and we will pay the balance of covered charges. You
    will not need to do anything. To find out if you need to do
    something about filing your claims, call us at 1-800-522-0088.

> **We do not waive any costs if the Original Medicare Plan is your
> primary payer.**
>
> **(Primary payer chart begins on next page.)**
>
> Medicare always makes the final determination as to whether they are
> the primary payer. The following chart illustrates whether Medicare or
> this Plan should be the primary payer for you according to your
> employment status and other factors determined by Medicare. It is
> critical that you tell us if you or a covered family member has
> Medicare coverage so we can administer these requirements correctly.

+-----------------------------------------------------+--------+---+------+
| > **Primary Payer Chart**                           |        |   |      |
+-----------------------------------------------------+--------+---+------+
| **A. When you \-- or your covered spouse \-- are    | **The  |   |      |
| age 65 or over and have Medicare and you ...**      | p      |   |      |
|                                                     | rimary |   |      |
|                                                     | payer  |   |      |
|                                                     | for    |   |      |
|                                                     | the    |   |      |
|                                                     | indi   |   |      |
|                                                     | vidual |   |      |
|                                                     | with   |   |      |
|                                                     | Me     |   |      |
|                                                     | dicare |   |      |
|                                                     | i      |   |      |
|                                                     | s...** |   |      |
+-----------------------------------------------------+--------+---+------+
|                                                     | **Medi |   | **   |
|                                                     | care** |   | This |
|                                                     |        |   | Pl   |
|                                                     |        |   | an** |
+-----------------------------------------------------+--------+---+------+
| 1)  Are an active employee with the Federal         |        |   | >   |
|     government and ...                              |        |   |      |
|                                                     |        |   |      |
| -   You have FEHB coverage on your own or through   |        |   |      |
|     your spouse who is also an active employee      |        |   |      |
+-----------------------------------------------------+--------+---+------+
| -   You have FEHB coverage through your spouse who  | >     |   |      |
|     is an annuitant                                 |        |   |      |
+-----------------------------------------------------+--------+---+------+
| 2)  Are an annuitant and ...                        | >     |   |      |
|                                                     |        |   |      |
| -   You have FEHB coverage on your own or through   |        |   |      |
|     your spouse who is also an annuitant            |        |   |      |
+-----------------------------------------------------+--------+---+------+
| -   You have FEHB coverage through your spouse who  |        |   | >   |
|     is an active employee                           |        |   |      |
+-----------------------------------------------------+--------+---+------+
| > 3\) Are a reemployed anuuitant with the Federal   | > \*  |   |      |
| > government and your position is excluded from the |        |   |      |
| > FEHB (your employing office will know if this is  |        |   |      |
| > the case)                                         |        |   |      |
+-----------------------------------------------------+--------+---+------+
| 4)  Are a reemployed anuuitant with the Federal     | #      |   | >   |
|     government and your position is not excluded    | #####  |   |      |
|     from the FEHB (your employing office will know  |        |   |      |
|     if this is the case) and...                     |        |   |      |
|                                                     |        |   |      |
| -   You have FEHB coverage on your own or through   |        |   |      |
|     your spouse who is also an active employee      |        |   |      |
+-----------------------------------------------------+--------+---+------+
| -   You have FEHB coverage through your spouse who  | ###    |   |      |
|     is an annuitant                                 | ###   |   |      |
+-----------------------------------------------------+--------+---+------+
| 5)  Are a Federal judge who retired under title 28, | > \*  |   |      |
|     U.S.C., or a Tax Court judge who retired under  |        |   |      |
|     Section 7447 of title 26, U.S.C. (or if your    |        |   |      |
|     covered spouse is this type of judge),          |        |   |      |
+-----------------------------------------------------+--------+---+------+
| 6)  Are enrolled in Part B only, regardless of your |       |   |     |
|     employment status,                              |        |   |      |
|                                                     | (for   |   | (for |
|                                                     | Part B |   | o    |
|                                                     | ser    |   | ther |
|                                                     | vices) |   | s    |
|                                                     |        |   | ervi |
|                                                     |        |   | ces) |
+-----------------------------------------------------+--------+---+------+
| 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**        |        |   |      |
+-----------------------------------------------------+--------+---+------+
| ###### Have Medicare ba                             |        | > |      |
| sed solely on end stage renal disease (ESRD) and... |        |   |      |
|                                                     |        |  |      |
| ###### It is within the fi                          |        |   |      |
| rst 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 famil |        |   |      |
| y member are still entitled to Medicare due to ESRD |        |   |      |
+-----------------------------------------------------+--------+---+------+
| 1)  Become eligible for Medicare due to ESRD while  |        |  |      |
|     already a Medicare beneficiary and ..           |        | f |      |
|                                                     |        | o |      |
| -   This Plan was primary payer before eligibility  |        | r |      |
|     due to ESRD                                     |        | 3 |      |
|                                                     |        | 0 |      |
|                                                     |        | - |      |
|                                                     |        | m |      |
|                                                     |        | o |      |
|                                                     |        | n |      |
|                                                     |        | t |      |
|                                                     |        | h |      |
|                                                     |        | c |      |
|                                                     |        | o |      |
|                                                     |        | o |      |
|                                                     |        | r |      |
|                                                     |        | d |      |
|                                                     |        | i |      |
|                                                     |        | n |      |
|                                                     |        | a |      |
|                                                     |        | t |      |
|                                                     |        | i |      |
|                                                     |        | o |      |
|                                                     |        | n |      |
|                                                     |        | p |      |
|                                                     |        | e |      |
|                                                     |        | r |      |
|                                                     |        | i |      |
|                                                     |        | o |      |
|                                                     |        | d |      |
+-----------------------------------------------------+--------+---+------+
| -   Medicare was the primary payer before           |       |   |      |
|     eligibility due to ESRD                         |        |   |      |
+-----------------------------------------------------+--------+---+------+
| > **C. When either you or your spouse are eligible  |        |   |      |
| > for Medicare solely due to disability and         |        |   |      |
| > you...**                                          |        |   |      |
+-----------------------------------------------------+--------+---+------+
| 1)  Are an active employee with the Federal         |        |  |      |
|     government and...                               |        |   |      |
|                                                     |        |   |      |
| -   You have FEHB coverage on your own or through   |        |   |      |
|     your spouse who is also an active employee      |        |   |      |
+-----------------------------------------------------+--------+---+------+
| -   You have FEHB coverage through y our spouse who |       |   |      |
|     is an annuitant                                 |        |   |      |
+-----------------------------------------------------+--------+---+------+
| 2)  Are an annuitant and ...                        |       |   |      |
|                                                     |        |   |      |
| -   You have FEHB coverage on your own or through   |        |   |      |
|     your spouse who is also an annuitant            |        |   |      |
+-----------------------------------------------------+--------+---+------+
| -   You have FEHB coverage through y our spouse who |        |  |      |
|     is an active employee                           |        |   |      |
+-----------------------------------------------------+--------+---+------+
| ######### D. Are covered under                      |       |   |      |
| the FEHB Spouse Equity provision as a former spouse |        |   |      |
+-----------------------------------------------------+--------+---+------+

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

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

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

If you enroll in a Medicare + Choice plan, the following options are
available to you:

**This Plan and our Medicare + Choice plan:** You may enroll in our
Medicare + Choice plan and also remain enrolled in our FEHB plan. In
this case, we do not waive cost-sharing for your FEHB coverage.

**This Plan and another plan's Medicare + Choice plan:** You may enroll
in another plan's Medicare + Choice plan and also remain enrolled in our
FEHB plan. We will still provide benefits when your Medicare + Choice
plan is primary, even out of the managed care plan's network and/or
service area (if you use our Plan providers), but we will not waive any
of our copayments or coinsurance. If you enroll in a Medicare + Choice
plan, tell us. We will need to know whether you are in the Original
Medicare Plan or in a Medicare + Choice plan so we can correctly
coordinate benefits with Medicare.

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

**• If you do not enroll in** If you do not have one or both Parts of
Medicare, you can still be

**Medicare Part A or Part B** covered under the FEHB Program. We will
not require you to enroll in Medicare Part B and, if you can't get
premium-free Part A, we will not ask you to enroll in it.

**TRICARE and CHAMPVA** TRICARE is the health care program for eligible
dependents of military persons and retirees of the military. TRICARE
includes the CHAMPUS program. CHAMPVA provides health coverage to
disabled Veterans and their eligible dependents. If TRICARE or CHAMPVA
and this Plan cover you, we pay first. See your TRICARE or CHAMPVA
Health Benefits Advisor if you have questions about these programs.

**Suspended FEHB coverage to enroll in TRICARE or CHAMPVA:** If you are
an annuitant or former spouse, you can suspend your FEHB coverage to
enroll in one of these programs, eliminating your FEHB premium. (OPM
does not contribute to any applicable premiums.) For information on
suspending your FEHB enrollment, contact your retirement office. If you
later want to re-enroll in the FEHB Program, generally you may do so
only at the next Open Season unless you involuntarily lose coverage
under the program.

**Workers' Compensation** We do not cover services that:

> • you need because of a workplace-related illness or injury that the
> Office of Workers' Compensation Programs (OWCP) or a similar Federal
> or State agency determines they must provide; or
>
> • OWCP or a similar agency pays for through a third party injury
> settlement or other similar proceeding that is based on a claim you
> filed under OWCP or similar laws.

Once OWCP or similar agency pays its maximum benefits for your
treatment, we will cover your care. You must use our providers.

**Medicaid** When you have this Plan and Medicaid, we pay first.

> **Suspended FEHB coverage to enroll in Medicaid or a similar
> State-sponsored program of medical assistance:** If you are an
> annuitant or former spouse, you can suspend your FEHB coverage to
> enroll in one of these State programs, eliminating your FEHB premium.
> For information on suspending your FEHB enrollment, contact your
> retirement office. If you later want to re-enroll in the FEHB Program,
> generally you may do so only at the next Open Season unless you
> involuntarily lose coverage under the State program.

**When other Government agencies** We do not cover services and supplies
when a local, State,

**are responsible for your care** or Federal Government agency directly
or indirectly pays for them.

**When others are responsible** When you receive money to compensate you
for medical or hospital

**for injuries** care for injuries or illness caused by another person,
you must reimburse us for any expenses we paid. However, we will cover
the cost of treatment that exceeds the amount you received in the
settlement.

If you do not seek damages you must agree to let us try. This is called
subrogation. If you need more information, contact us for our
subrogation procedures.

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

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

**Calendar year** January 1 through December 31 of the same year. For
new enrollees, the calendar year begins on the effective date of their
enrollment and ends on December 31 of the same year.

**Coinsurance** Coinsurance is the percentage of our allowance that you
must pay for your care. See page 15.

**Copayment** A copayment is a fixed amount of money you pay when you
receive covered services. See page 15.

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

**Custodial care** Custodial care is care provided to assist in meeting
the activities of daily living such as help in walking, getting in and
out of bed, bathing, feeding, and supervision of medications which are
ordinarily self-administered. 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. See page 15.

**Experimental or** Experimental or investigational services are
services that are not widely

**investigational services** accepted or recognized within the organized
medical community as standards of care. Our Medical Policy Committee
determines what procedures and services are experimental/investigational
using published peer review medical and surgical literature. The
procedure or service will be evaluated based on its health effects,
safety, quality and cost effectiveness. In some cases, we use an
independent medical review for expert evaluation and determination of
coverage.

**Group health coverage** Health coverage provided through a group
policy, such as the FEHB program.

**Medical necessity** Medical necessity is the criteria used by us and
the participating physician group to provide covered services in the
prevention, diagnosis, and treatment of your illness or condition.
Medically necessary services are determined to be:

-   Not experimental or investigational

-   Appropriate and necessary for the symptoms, diagnosis, or treatment
    of a condition, illness, or injury

-   Provided for the diagnosis or care and treatment of the condition,
    illness, or injury

-   Not primarily for the convenience of the member, member's physician,
    or anyone else

-   The most appropriate supply or level of service that can safely be
    provided. For example, outpatient rather than inpatient surgery may
    be authorized when the setting is safe and adequate.

> Determination of whether services or supplies are medically necessary
> will be made according to procedures we and the participating
> physician group have established.

**Us/We** Us and we refer to Health Net of California

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

![](media/image14.wmf){width="1.8in" height="0.3590277777777778in"}

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

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

**Coverage information**

**No pre-existing condition** We will not refuse to cover the treatment
of a condition that you had

**limitation** before you enrolled in this Plan solely because you had
the condition before you enrolled.

**Where you can get information** See [www.opm.gov/insure]{.underline}.
Also, your employing or retirement office

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

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

> • When you may change your enrollment;
>
> • How you can cover your family members;
>
> • What happens when you transfer to another Federal agency, go on
> leave without pay, enter military service, or retire;
>
> • When your enrollment ends; and
>
> • When the next open season for enrollment begins.

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

**Types of coverage available** Self Only coverage is for you alone.
Self and Family coverage is for

**for you and your family** you, your spouse, and your unmarried
dependent children under age 22, including any foster children or
stepchildren your employing or retirement office authorizes coverage
for. Under certain circumstances, you may also continue coverage for a
disabled child 22 years of age or older who is incapable of
self-support.

If you have a Self Only enrollment, you may change to a Self and Family
enrollment if you marry, give birth, or add a child to your family. You
may change your enrollment 31 days before to 60 days after that event.
The Self and Family enrollment begins on the first day of the pay period
in which the child is born or becomes an eligible family member. When
you change to Self and Family because you marry, the change is effective
on the first day of the pay period that begins after your employing
office receives your enrollment form; benefits will not be available to
your spouse until you marry.

Your employing or retirement office will **not** notify you when a
family member is no longer eligible to receive health benefits, nor will
we. Please tell us immediately when you add or remove family members
from your coverage for any reason, including divorce, or when your child
under age 22 marries or turns 22.

If you or one of your family members is enrolled in one FEHB plan, that
person may not be enrolled in or covered as a family member by another
FEHB plan.

**Children's Equity Act** OPM has implemented the Federal Employees
Health Benefits Children's Equity Act of 2000. This law mandates that
you be enrolled for self and family coverage in the Federal Employees
Health Benefits (FEHB) Program, if you are an employee subject to a
court or administrative order requiring you to provide health benefits
for your child(ren).

If this law applies to you, you must enroll for self and family coverage
in a health plan that provides full benefits in the area where your
children live or provide documentation to your employing office that you
have obtained other health benefits coverage for your children. If you
do not do so, your employing office will enroll you involuntarily as
follows:

-   If you have no FEHB coverage, your employing office will enroll you
    for Self and Family coverage in the option of the Blue Cross and
    Blue Shield Benefit Plan's Basic Option,

-   If you have a Self Only enrollment in a fee-for-service plan or in
    an HMO that serves the area where your children live, your employing
    office will change your enrollment to Self and Family in the same
    option of the same plan; or

-   If you are enrolled in an HMO that does not serve the area where the
    children live, your employing office will change your enrollment to
    Self and Family in the Blue Cross and Blue Shield Service Benefit
    Plan's Basic Option.

> As long as the court/administrative order is in effect, and you have
> at least one child identified in the order who is still eligible under
> the FEHB Program, you cannot cancel your enrollment, change to self
> only, or change to a plan that doesn't serve the area in which your
> children live, unless you provide documentation that you have other
> coverage for the children. If the court/administrative order is still
> in effect when you retire, and you have at least one child still
> eligible for FEHB coverage, you must continue your FEHB coverage into
> retirement (if eligible) and cannot make any changes after retirement.
> Contact your employing office for further information.

**When benefits and** The benefits in this brochure are effective on
January 1. If you joined this plan during

**premiums start** Open Season, your coverage begins on the first day of
your first pay period that starts on or after January 1. If you changed
plans or plan options during Open Season and you receive care between
January 1 and the effective date of coverage under your new plan or
option, your claims will be paid according to the 2004 benefits of your
old plan or option. However, if your old plan left the FEHB Program at
the end of the year, you are covered under that plan's 2003 benefits
until the effective date of your coverage with your new plan.
Annuitants' coverage and premiums begin on January 1. If you joined at
any other time during the year, your employing office will tell you the
effective date of coverage.

**When you retire** When you retire, you can usually stay in the FEHB
Program. Generally, you must have been enrolled in the FEHB Program for
the last five years of your Federal service. If you do not meet this
requirement, you may be eligible for other forms of coverage, such as
temporary continuation of coverage (TCC).

**When you lose benefits**

**•When FEHB coverage ends** You will receive an additional 31 days of
coverage, for no additional premium, when:

-   Your enrollment ends, unless you cancel your enrollment, or

```{=html}
<!-- -->
```
-   You are a family member no longer eligible for coverage.

You may be eligible for spouse equity coverage or Temporary Continuation
of Coverage (TCC), or a conversion policy (a non-FEHB individual
policy).

**• Spouse equity** If you are divorced from a Federal employee or
annuitant, you may not

**coverage** continue to get benefits under your former spouse's
enrollment. This is the case even when the court has ordered your former
spouse to supply health coverage for you. But, you may be eligible for
your own FEHB coverage under the spouse equity law or Temporary
Continuation of Coverage (TCC). If you are recently divorced or are
anticipating a divorce, contact your ex-spouse's employing or retirement
office to get RI 70-5, the *Guide to Federal Employees Health Benefits
Plans for Temporary Continuation of* *Coverage and Former Spouse
Enrollees*, or other information about your coverage choices. You can
also download the guide from OPM's website,
[www.opm.gov/insure]{.underline}.

**•Temporary Continuation**

**of coverage (TCC)** If you leave Federal service, or if you lose
coverage because you no longer qualify as a family member, you may be
eligible for Temporary Continuation of Coverage (TCC). For example, you
can receive TCC if you are not able to continue your FEHB enrollment
after you retire, if you lose your job, if you are a covered dependent
child and you turn 22 or marry, etc.

You may not elect TCC if you are fired from your Federal job due to
gross misconduct.

**Enrolling in TCC.** Get the RI 79-27, which describes TCC, and the RI
70-5, the *Guide to* *Federal Employees Health Benefits Plans for
Temporary Continuation of Coverage and Former Spouse Enrollees*, from
your employing or retirement office or from
[www.opm.gov/insure](http://www.opm.gov/insure). It explains what you
have to do to enroll.

**•Converting to** You may convert to a non-FEHB individual policy if:

**individual coverage**

-   Your coverage under TCC or the spouse equity law ends (If you
    canceled your coverage or did not pay your premium, you cannot
    convert);

```{=html}
<!-- -->
```
-   You decided not to receive coverage under TCC or the spouse equity
    law; or

```{=html}
<!-- -->
```
-   You are not eligible for coverage under TCC or the spouse equity
    law.

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

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

**Getting a Certificate of** The Health Insurance Portability and
Accountability Act of 1996. (HIPAA) is a Federal

**Group Health Plan Coverage** law that offers limited Federal
protections for health coverage availability and continuity to people
who lose employer group coverage. If you leave the FEHB Program, we will
give you a Certificate of Group Health Plan Coverage that indicates how
long you have been enrolled with us. You can use this certificate when
getting health insurance or other health care coverage. Your new plan
must reduce or eliminate waiting periods, limitations, or exclusions for
health related conditions based on the information in the certificate,
as long as you enroll within 63 days of losing coverage under this Plan.
If you have been enrolled with us for less than 12 months, but were
previously enrolled in other FEHB plans, you may also request a
certificate from those plans.

For more information, get OPM pamphlet RI 79-27, Temporary Continuation
of Coverage (TCC) under the FEHB Program. See also the FEHB web site
([www.opm.gov/insure/health);](http://www.opm.gov/insure/health);) refer
to the "TCC and HIPAA" frequently asked questions. These highlight HIPAA
rules, such as the requirement that Federal employees must exhaust any
TCC eligibility as one condition for guaranteed access to individual
health coverage under HIPAA, and have information about Federal and
State agencies you can contact for more information.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

> you and the Plan share costs, and medical services and supplies that
> are not covered by the Plan and for which you must pay. These
> out-of-pocket costs are summarized on page 63 and detailed throughout
> this brochure. Your HCFSA will reimburse you for such costs when they
> are for tax deductible medical care for you and your dependents that
> is NOT covered by this FEHB Plan or any other coverage that you have.
>
> Under this Plan typical out of pocket expenses include: office visit
> copayments, inpatient and outpatient hospitalization copayments and
> prescription copayments.
>
> The IRS governs expenses reimbursable by a HCFSA. See Publication 502
> for a comprehensive list of tax-deductible medical expenses.  **Note:
> While you will see insurance premiums listed in Publication 502, they
> are NOT a reimbursable expense for FSA purposes**.  Publication 502
> can be found on the IRS Web site at
> <http://www.irs.gov/pub/irs-pdf/p502.pdf>.  If you do not see your
> service or expense listed in Publication 502, please call a FSAFEDS
> Benefit Counselor at 1-877-FSAFEDS (372-3337), who will be able to
> answer your specific questions.

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

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

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

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

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

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

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

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

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

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

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

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

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

> may help you decide whether to participate in FSAFEDS.

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

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

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

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

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

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

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

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

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

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

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

**The Federal Long Term Care Insurance Program**

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

Program:

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

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

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

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

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

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

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

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

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

**A**ccidental injury 34, 42

Allergy tests 21

Alternative treatment 25

Allogeneic (donor) bone marrow

Transplant 30

Ambulance 33

Anesthesia 30

Autologous bone marrow

transplant 30

**B**iopsies 27

Blood and blood plasma 32

Breast cancer screening 18

**C**asts 32

Changes for 2004 11

Chemotherapy 21

Childbirth 19

Chiropractic 24

Cholesterol tests 18

Claims 45

Coinsurance 15

Colorectal cancer screening 18

Congenital anomalies 27

Contraceptive devices and drugs 40

Coordination of benefits 48

Covered providers 12

Crutches 23

**D**eductible 15

Definitions 54

Diagnostic services 18

Disputed claims review 46

Donor expenses (transplants) 30

Dressings 32, 40

Durable medical equipment

(DME) 23

**E**ducational classes and programs 25

Effective date of enrollment 56

Emergency 34

Experimental or investigational 54

Eyeglasses 22

**F**amily planning 20

Fecal occult blood test 18

**G**eneral Exclusions 44

Home health services 24

Hospice care 33

Home nursing care 24

Hospital 31

**I**mmunizations 18

Infertility 20

In hospital physician care 17

Inpatient Hospital Benefits 31

Insulin 40

**L**aboratory and pathological

services 18

**M**achine diagnostic tests 18

Magnetic Resonance Imagings

(MRIs) 18

Mail Order Prescription Drugs 40

Mammograms 18

Maternity Benefits 19

Medically necessary 54

Medicare 48

Mental Conditions/Substance

Abuse Benefits 36

**N**ewborn care 19

Non-FEHB Benefits 43

Nurse Licensed Practical Nurse 24

Nursery charges 19

**O**bstetrical care 19

Occupational therapy 21

Ocular injury 22

Oral and maxillofacial surgery 29

Orthopedic devices 23

Outpatient 32

Out-of-pocket maximum 15

Outpatient facility care 32

Oxygen 23

**P**ap Test 18

Physical examination 18

Physical therapy 21

Physician 12

Preventive care, adult 18

Preventive care, children 19

Prescription drugs 38, 44

Preventive services 18

Prior approval 14

Prostate cancer screening 18

Prosthetic devices 23

Psychologist 36

**R**adiation therapy 21

Renal dialysis 21

Room and board 31

**S**econd surgical opinion 17

Skilled nursing facility care 33

Smoking cessation 25

Speech therapy 21

Splints 32

Sterilization procedures 27

Subrogation 53

Substance abuse 36

Surgery 27

Anesthesia 30

Oral 29

Reconstructive 28

Syringes 40

**T**ransplants 30

Treatment therapies 21

**V**ision services 22

**W**ell child care 19

Wheelchairs 23

**W**orkers' compensation 53

**X**-rays 18

  -----------------------------------------------------------------------
  **Summary of benefits for Health Net of California HMO - 2004**

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

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

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

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

+-------------------------------------+--------------------------+----+
| **Benefits**                        | **You Pay**              | ** |
|                                     |                          | Pa |
|                                     |                          | ge |
|                                     |                          | ** |
+-------------------------------------+--------------------------+----+
| Medical services provided by        | Office visit copay: \$10 | >  |
| physicians:                         |                          | 18 |
|                                     |                          |    |
| -   Diagnostic and treatment        |                          |    |
|     services provided in the office |                          |    |
+-------------------------------------+--------------------------+----+
| Services provided by a hospital:    | \$100 copay per          | >  |
|                                     | admission                | 31 |
| -   Inpatient                       |                          | >  |
|                                     | \$100 copay for surgical | >  |
| -   Outpatient                      | procedures, Nothing for  | 32 |
|                                     | all other services       |    |
+-------------------------------------+--------------------------+----+
| Emergency benefits:                 | > \$100 per visit        | >  |
|                                     | > (waived if admitted to | 34 |
| -   In-and-Out-of-area Emergency    | > hospital)              | >  |
|     Room                            | >                        | >  |
|                                     | > \$35 per visit         | 34 |
| -   In-and-Out-of-area Urgent Care  |                          |    |
|     Facility                        |                          |    |
+-------------------------------------+--------------------------+----+
| > Mental health and substance abuse | > Regular cost sharing   | >  |
| > treatment                         |                          | 36 |
+-------------------------------------+--------------------------+----+
| Prescription drugs                  | \$10 copay for a 30 day  | >  |
|                                     | supply of formulary      | 38 |
|                                     | generic drugs - \$20 for |    |
|                                     | a 90 day supply through  |    |
|                                     | mail order.              |    |
|                                     |                          |    |
|                                     | \$20 copay for a 30 day  |    |
|                                     | supply of formulary name |    |
|                                     | brand drugs - \$40 copay |    |
|                                     | for a 90 day supply      |    |
|                                     | through mail order.      |    |
|                                     |                          |    |
|                                     | \$35 copay for a 30 day  |    |
|                                     | supply of non-formulary  |    |
|                                     | drugs - \$70 for a 90    |    |
|                                     | day supply through mail  |    |
|                                     | order                    |    |
+-------------------------------------+--------------------------+----+
| Dental Care                         | > Accidental injury      | >  |
|                                     | > benefit; nothing at    | 42 |
|                                     | > the dentist's office   |    |
|                                     | > or a \$100 copay at    |    |
|                                     | > the emergency room.    |    |
+-------------------------------------+--------------------------+----+
| Vision Care                         | > \$10 per visit; One    | 22 |
|                                     | > refraction annually.   |    |
+-------------------------------------+--------------------------+----+
| > Special features: Early Bird      |                          | >  |
| > Prenatal Program, Case Management |                          | 41 |
| > Services, Telecommunications      |                          |    |
| > Device for the Deaf, Centers of   |                          |    |
| > Excellence                        |                          |    |
+-------------------------------------+--------------------------+----+
| Protection against catastrophic     | Nothing after            | >  |
| costs                               | \$1,500/Self Only or     | 15 |
|                                     | \$4,500/Family           |    |
| (your out-of-pocket maximum)        | enrollment per year      |    |
|                                     |                          |    |
|                                     | Some costs do not count  |    |
|                                     | toward this protection   |    |
+-------------------------------------+--------------------------+----+

**2004 Rate Information for**

**Health Net of California**

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

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

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

  -------------- ---------- -------------- --------- ------------- --------- -------------- ----------
  **Type of\     **Code**   **Non-Postal                                     **Postal       
  Enrollment**              Premium**                                        Premium**      

                            **Biweekly**             **Monthly**             **Biweekly**   

                            **Gov't\       **Your\   **Gov't\      **Your\   **USPS\        **Your\
                            Share**        Share**   Share**       Share**   Share**        Share**
  -------------- ---------- -------------- --------- ------------- --------- -------------- ----------

**Most of California**

  ----------- --------- ---------- --------- ---------- ---------- ---------- ----------
  **Self      **LB1**   \$107.21   \$35.74   \$232.30   \$77.43    \$126.87   \$16.08
  Only**                                                                      

  **Self and  **LB2**   \$253.80   \$84.60   \$549.90   \$183.30   \$300.33   \$38.07
  Family**                                                                    
  ----------- --------- ---------- --------- ---------- ---------- ---------- ----------