# PBP Health Plan ![](media/image1.wmf){width="1.7847222222222223in" height="1.3194444444444444in"}

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# A fee-for-service plan

**with preferred provider organizations**

**Sponsored and administered by**: The National League of Postmasters
(League)

PBP Health Plan utilizes both **Alliance PPO** in 7 Mid-Atlantic States
and Multiplan

PPO in all 50 states.

**Who may enroll in this Plan:** All Federal Employees and annuitants
who are eligible to enroll in the Federal Employee Health Benefits
Program and who are, or become, members or League Benefit Members of the
League.

**To become a member or League Benefit Member:** To be eligible for
membership in the League, you must be an active or retired employee of
the Federal Government or the United States Postal Service.

If you are a non-postal employee/annuitant, you will automatically
become a League Benefit Member of the League upon enrollment in the PBP
Health Plan.

Annuitants (retirees) may enroll in this Plan and Surviving Spouses may
continue as members.

**Membership dues**: \$45 per year for League Benefit membership. The
League will bill new League Benefit Members for the annual dues when it
receives notice of enrollment. The League will also bill continuing
League Benefit Members for the annual membership. Only Postmaster
members must pay dues based on level of office. Dues are paid by payroll
deduction or annually at the option of the members. Continuing
Postmaster members are billed annually for League membership dues.
Regular federal workers and retirees use OPM deductions on a bi-weekly
or monthly basis.

Enrollment codes for this Plan:

> 361 High Option - Self Only
>
> 362 High Option - Self and Family
>
> 364 Standard Option - Self Only
>
> 365 Standard Option - Self and Family

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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/image8.png){width="2.5833333333333335in"
> height="0.7291666666666666in"}
>
> Kay Coles James
>
> Director

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

# Privacy Practices

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

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

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

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

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

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

-   Where required by law.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

-   Get a separate paper copy of this notice.

For more information on exercising your rights set out in this notice,
look at [www.opm.gov/insure](http://www.opm.gov/insure) on the web. You
may also call 202-606-0191 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

Office of Personnel Management

P.O. Box 707

Washington, DC 20004-0707

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

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

+-----------------------------------------------------------------------+
| # Table of Contents                                                   |
+=======================================================================+
+-----------------------------------------------------------------------+

Introduction 4

Plain Language 4

Stop Health Care Fraud! 5

Preventing Medical Mistakes 6

Section 1. Facts about this fee-for-service plan 7

Section 2. How we change for 2004 8

Section 3. How you get care 9

Identification cards 9

Where you get covered care 9

• Covered providers 9

• Covered facilities 9-10

What you must do to get covered care 10

How to get approval for 11

• Your hospital stay (precertification) 11-12

• Other services 13

Section 4. Your costs for covered services 14

• Copayments 14

• Deductible 14

• Coinsurance 14-15

• Differences between our allowance and the bill 15

Your catastrophic protection out-of-pocket maximum 16

When government facilities bill us 16

If we overpay you 16

When you are age 65 or over and you do **not** have Medicare 17

When you have Medicare 18

Section 5. Benefits 19

Overview 19

(a) Medical services and supplies provided by physicians and other
    health care professionals 20-32

(b) Surgical and anesthesia services provided by physicians and other
    health care professionals 34-41

(c) Services provided by a hospital or other facility, and ambulance
    services 42-46

(d) Emergency services/accidents 47-48

(e) Mental health and substance abuse benefits 49-51

(f) Prescription drug benefits 52-54

(g) Special features 55

-   Flexible benefits option 55

-   24-hour nurse line 55

-   Tobacco quit line 55

-   Complex surgery 55

-   Centers of excellence 56

-   Dialysis services 56

-   "Healthier Feds" Hotlines 56

(h) Dental benefits 57-63

(i) Non-FEHB benefits available to Plan members 64

Section 6. General exclusions \-- things we don\'t cover 65-66

Section 7. Filing a claim for covered services 67-68

Section 8. The disputed claims process 69-70

Section 9. Coordinating benefits with other coverage 71

-   When you have other health coverage 71

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-   What is Medicare? 71

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-   Medicare managed care plan 74

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-   TRICARE and CHAMPVA 74

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-   Workers' Compensation 75

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-   Medicaid 75

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-   When other Government agencies are responsible for your care 75

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-   When others are responsible for injuries 75-76

Section 10. Definitions of terms we use in this brochure 77-80

Section 11. FEHB facts 81

Coverage information 81

-   No pre-existing condition limitation 81

-   Where you get information about enrolling in the FEHB Program 81

-   Types of coverage available for you and your family 81

-   Children's Equity Act 82

-   When benefits and premiums start 82

-   When you retire 82

When you lose benefits 82

-   When FEHB coverage ends 82

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-   Spouse equity coverage 83

-   Temporary Continuation of Coverage (TCC) 83

-   Converting to individual coverage 83

-   Getting a Certificate of Group Health Plan Coverage 83-84

Two new Federal Programs complement FEHB benefits 85

The Federal Flexible Spending Account Program - *FSAFEDS* 85-88

The Federal Long Term Care Insurance Program 88-89

Index 90

Summary of Standard Option benefits 91

Summary of High Option benefits 92

Rates Back cover

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

This brochure describes the benefits of the PBP Health Plan under our
contract (CS 1071) with the Office of Personnel Management (OPM), as
authorized by the Federal Employees Health Benefits law. This plan is
underwritten by Union Labor Life and Gerber Life. The address for the
PBP Health Plan administrative offices is:

PBP Health Plan

1019 N. Royal Street

Alexandria, Virginia 22314-1596

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 8. Rates are shown at the end of this brochure.

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

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

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

-   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 us know. Visit OPM\'s \"Rate Us\" feedback area at
[www.opm.gov/insure](http://www.opm.gov/reitre) or e-mail us at
<fehbwebcomments@opm.gov>. You may also write to OPM at the Office of
Personnel Management, Office of Insurance Planning and Evaluation
Division, 1900 E Street, NW Washington, DC 20415-3650.

+-----------------------------------------------------------------------+
| # Stop Health Care Fraud!                                             |
+-----------------------------------------------------------------------+

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

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

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

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

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

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

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

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

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-   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:

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

-   If the provider does not resolve the matter, call us at
    **800-544-7111** and explain the situation.

-   If we do not resolve the issue:

+------------------+---------------------------------------------------+
|                  | **CALL -- THE HEALTH CARE FRAUD HOTLINE**         |
|                  |                                                   |
|                  | **202-418-3300**                                  |
|                  |                                                   |
|                  | **OR WRITE TO:**                                  |
|                  |                                                   |
|                  | The United States Office of Personnel Management  |
|                  |                                                   |
|                  | Office of the Inspector General Fraud Hotline     |
|                  |                                                   |
|                  | 1900 E Street, NW, Room 6400                      |
|                  |                                                   |
|                  | Washington, DC 20415.                             |
+------------------+---------------------------------------------------+

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

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

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

-   If you have any questions about the eligibility of a dependent,
    check with your personnel office if you are employed or with OPM if
    you are retired.

-   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 not enrolled in the Plan.

+-----------------------------------------------------------------------+
| # Preventing medical mistakes                                         |
+-----------------------------------------------------------------------+

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

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

-   Ask questions and make sure you understand the answers.

-   Choose a doctor with whom you feel comfortable talking.

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

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

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

-   Tell them about any drug allergies you have.

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

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

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

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

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

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

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

-   Call your doctor and ask for your results.

-   Ask what the results mean for your care.

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

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

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

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

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

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

-   Ask your surgeon:

    Exactly what will you be doing?

    About how long will it take?

    What will happen after surgery?

    How can I expect to feel during recovery?

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

    Want more information on patient safety?

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-   [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 health care providers and
    improve the quality of care you receive.

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

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

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

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

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

+-----------------------------------------------------------------------+
| # Section 1. Facts about this fee-for-service plan                    |
+-----------------------------------------------------------------------+

This Plan is a fee-for-service (FFS) plan. You can choose your own
physicians, hospitals, and other health care providers.

We reimburse you or your provider for your covered services, usually
based on a percentage of the amount we allow. The type and extent of
covered services, and the amount we allow, may be different from other
plans. Read brochures carefully.

**We also have Preferred Provider Organizations (PPOs):**

Our fee-for-service plan offers services through PPOs. When you use our
PPO providers, you will receive covered services at reduced cost. The
PBP Health Plan is solely responsible for the selection of PPO providers
in your area. Contact us for the names of PPO providers and to verify
their continued participation. You can also go to our web page, which
you can reach through the FEHB website,
[www.opm.gov/insure]{.underline}. Contact the PBP Health Plan to request
a PPO directory.

The non-PPO benefits are the standard benefits of this Plan. PPO
benefits apply only when you use a PPO provider. Provider networks may
be more extensive in some areas than others. We cannot guarantee the
availability of every specialty in all areas. If no PPO provider is
available, or you do not use a PPO provider, the standard non-PPO
benefits apply.

How we pay providers

We make benefits payments to you or your provider, on your behalf. The
benefit payment is the same in both cases. When we pay providers, our
payment is based on the services they provide to you. We make no other
payments to providers. Our payment policy does not include provider
bonuses or financial incentives. Our payment policy does not encourage
your provider to give any more or less medical care than your physical
or mental condition requires.

**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.

-   Compliance or licensing requirements: None apply

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-   Years in existence: 43

-   Profit status: Non-profit

If you want more information about us, call **800-544-7111**, or write
to PBP Health Plan, 1019 North Royal Street, Alexandria, Virginia
22314-1596. You may also contact us by fax at 703-683-5411 or visit our
website at [www.pbp.org](http://www.pbp.org/).

+-----------------------------------------------------------------------+
| # 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.

**Changes to this Plan**

-   The Medically Underserved section is revised.

-   We have added Alliance PPO to our growing list of Network providers.

**Both Options**

-   We increased the benefit for members by adding the "Healthier Feds"
    advice telephone line for diabetes, arthritis and asthma.

-   We clarified our definition of Rehabilitation facilities to include
    the provision of occupational therapy, physical therapy and skilled
    nursing services.

-   We clarified our definition of Skilled Nursing facilities to include
    the provision of skilled nursing services, ventilators, respiratory
    therapy and related services.

**Standard Option**

-   We increased the self only Non-PPO calendar year deductible from
    \$500 to \$600.

-   We increased the self and family PPO calendar year deductible from
    \$500 to \$600.

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-   Your share of the non-Postal premium will increase by \$40% for Self
    Only and by 41% for Self and Family

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-   We increased the self and family Non-PPO calendar year deductible
    from \$1,000 to \$1,200.

**High Option**

-   We increased the self only Non-PPO calendar year deductible from
    \$450 to \$500.

-   We increased the self and family PPO calendar year deductible from
    \$400 to \$500.

-   Your share of the non-Postal premium will increase by 15% for Self
    Only and 15% for Self and Family.

-   We increased the self and family Non-PPO calendar year deductible
    from \$900 to \$1,000.

+-----------------------------------------------------------------------+
| # Section 3. How you get care                                         |
+=======================================================================+
+-----------------------------------------------------------------------+

## **Identification cards**

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
**800-544-7111** or write us at PBP Health Plan, 1019 North Royal
Street, Alexandria, Virginia 22314-1596. You may also request
replacement cards through our website:
[www.pbp.org](http://www.pbp.org/) .

## **Where you get covered care**

### Covered providers

> A licensed doctor of medicine (M.D.) or a licensed doctor of
> osteopathy (D.O.). Other covered providers include: a licensed doctor
> of podiatry (D.P.M.); a licensed dentist (D.D.S or D.M.D.); licensed
> chiropractor (D.C.); licensed or registered physical, occupational and
> speech therapists (R.P.T., R.S.T., R.O.T. and S.P.). Other covered
> providers include a qualified clinical psychologist, clinical social
> worker, optometrist, nurse midwife, Certified Registered Nurse
> Anesthetist (C.R.N.A.), nurse practitioner/clinical specialist and
> nursing school administered clinic.

**Medically underserved areas.** Note: We cover any licensed medical
practitioner for any covered service performed within the scope of that
license in states OPM determines are \"medically underserved.\" For
2004, the states are: Alabama, Idaho, Kentucky, Louisiana, Maine,
Mississippi, Missouri, Montana, New Mexico, North Dakota, South
Carolina, South Dakota, Texas, Utah, West Virginia and Wyoming.

### Covered facilities

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

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

-   Free-standing ambulatory facility

> An out-of-hospital facility such as medical, cancer, dialysis, or
> surgical center or clinic, and licensed outpatient facilities
> accredited by the Joint Commission on Accreditation of Healthcare
> Organization for treatment of substance abuse.

-   Hospice

> A facility whose staff must include a doctor and registered nurse
> (R.N.) and may include social worker, clergy, certified counselor,
> volunteers, clinical psychologists and physical or occupational
> therapists who are able to provide care 24 hours a day.

-   Hospital

(1) An institution that is accredited as a hospital under the hospital
    accreditation program of the Joint Commission on Accreditation of
    Healthcare Organization, or

(2) Any other institution that is operated pursuant to law, under the
    supervision of a staff of doctors, with 24-hour-a-day nursing
    service and that is primarily engaged in providing for sick and
    injured inpatients: general care and treatment through medical,
    diagnostic and major surgical facilities, all of which facilities
    must be provided on its premises or under its control, or
    specialized care and treatment through medical and diagnostic
    facilities (including X-ray and laboratory) on its premises, under
    its control, or through a written agreement with a hospital (as
    defined above) or with a specialized provider of those services.

-   Rehabilitation facilities

> An institution that: (1) meets the "hospital" definition as stated; or
> (2) provides a program for the treatment of alcohol or drug abuse and
> meets one of the following requirements: (a) is affiliated with a
> hospital under a contractual agreement with an established patient
> referral system; (b) is licensed, certified or approved as an alcohol
> or drug abuse rehabilitation facility by the State; or is accredited
> as such a facility by the Joint Commission on Accreditation of
> Healthcare Organizations; (3) provides occupational or physical
> therapy or skilled nursing services primarily or more extensively than
> an acute hospital defined above.

-   Skilled nursing facility

> An institution that (1) is operated pursuant to law and primarily
> engaged in providing the following services for patients recovering
> from an illness or injury: room, board and 24-hour-a-day nursing
> service by professional nurses; (2) is under the fulltime supervision
> of a doctor or registered nurse (R.N.); (3) maintains adequate medical
> records; and (4) has the services of a doctor available under an
> established agreement for 24 hours a day, if not supervised by a
> doctor; (5) provides skilled nursing services, ventilators,
> respiratory therapy or any related services.

## **What you must do to get covered care**

+----------------------+-----------------------------------------------+
| > **Transitional     | **Specialty care:** If you have a chronic or  |
| > Care:**            | disabling condition and                       |
|                      |                                               |
|                      | -   lose access to your specialist because we |
|                      |     drop out of the Federal Employees Health  |
|                      |     Benefits (FEHB) Program and you enroll in |
|                      |     another FEHB Plan, or                     |
|                      |                                               |
|                      | -   lose access to your PPO specialist        |
|                      |     because we terminate our contract with    |
|                      |     your specialist for other than cause,     |
|                      |                                               |
|                      | you may be able to continue seeing your       |
|                      | specialist and receiving any PPO benefits 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 and any PPO benefits continue    |
|                      | > until the end of your postpartum care, even |
|                      | > if it is beyond the 90 days.                |
+----------------------+-----------------------------------------------+

+----------------------+-----------------------------------------------+
|                      | > We pay for covered services from the        |
|                      | > effective date of your enrollment. However, |
|                      | > if you are in the hospital when your        |
|                      | > enrollment in our Plan begins, call our     |
|                      | > Patient Advocate Department immediately at  |
|                      | >                                             |
|                      | > **1-866-218-8317**.                         |
|                      | >                                             |
|                      | > If you changed from another FEHB plan to    |
|                      | > us, your former plan will pay for the       |
|                      | > hospital stay until:                        |
|                      |                                               |
|                      | -   You are discharged, not merely moved to   |
|                      |     an alternative care center; or            |
|                      |                                               |
|                      | -   The day your benefits from your former    |
|                      |     plan run out; or                          |
|                      |                                               |
|                      | -   The 92^nd^ day after you become a member  |
|                      |     of this Plan, whichever happens first.    |
|                      |                                               |
|                      | These provisions apply only to the benefits   |
|                      | of the hospitalized person.                   |
|                      |                                               |
|                      | > If your plan terminates participation in    |
|                      | > the FEHB in whole or in part, or if OPM     |
|                      | > orders an enrollment change, this           |
|                      | > continuation of coverage provision does not |
|                      | > apply. In such case, the hospitalized       |
|                      | > family member's benefits under the new plan |
|                      | > begin on the effective date of enrollment.  |
+----------------------+-----------------------------------------------+

## **How to get approval for...**

### Your hospital stay

### 

In most cases, your physician or hospital will take care of
precertification. Because you are still responsible for ensuring that we
are asked to precertify your care, you should always ask your physician
or hospital whether they have contacted us.

**Warning:** We will reduce our benefits for the inpatient hospital stay
by \$500 if no one contacts us at **1-866-218-8317** for
precertification. If the stay is not medically necessary, we will not
pay any benefits.

**How to precertify an admission:**

-   You, your representative, your doctor, or your hospital must call us
    at 1-866-218-8317 at least 48 hours before an admission.

-   If you have an emergency admission due to a condition that you
    reasonably believe puts your life in danger or could cause serious
    damage to bodily function, you, your representative, the doctor, or
    the hospital must telephone us within two business days following
    the day of the emergency admission, even if you have been discharged
    from the hospital.

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```
-   Provide the following information:

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```
-   Enrollee\'s name and Plan identification number;

-   Patient\'s name, birth date, and phone number;

-   Reason for hospitalization, proposed treatment, or surgery;

-   Name and phone number of admitting doctor;

-   Name of hospital or facility; and

-   Number of planned days of confinement.

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```
-   We will then tell the doctor and/or hospital the number of approved
    inpatient days and we will send written confirmation of our decision
    to you, your doctor, and the hospital.

Maternity care You do not need to precertify a maternity admission for a
routine delivery. However, if your medical condition requires you to
stay more than 72 hours after a vaginal delivery or 96 hours after a
cesarean section, then your physician or the hospital must contact us
for precertification of additional days. Further, if your baby stays
after you are discharged, then your physician or the hospital must
contact us for precertification of additional days for your baby.

**If your hospital stay** If your hospital stay \-- including for
maternity care \-- needs to be

**needs to be extended:** extended, you, your representative, your
doctor or the hospital must ask us to approve the additional days.

+------------------------+---------------------------------------------+
| > **What happens when  | -   If no one contacted us, we will decide  |
| > you**                |     whether the hospital stay was medically |
| >                      |     necessary.                              |
| > **do not follow      |                                             |
| > the**                |                                             |
| >                      |                                             |
| > **precertification   |                                             |
| > rules**              |                                             |
+------------------------+---------------------------------------------+

> -- If we determine that the stay was medically necessary, we will pay
> the inpatient charges, less the \$500 penalty.
>
> -- If we determine that it was not medically necessary for you to be
> an inpatient, we will not pay inpatient hospital benefits. We will
> only pay for any covered medical supplies and services that are
> otherwise payable on an outpatient basis.

-   If we denied the precertification request, we will not pay inpatient
    hospital benefits. We will only pay for any covered medical supplies
    and services that are otherwise payable on an outpatient basis.

-   When we precertified the admission but you remained

> in the hospital beyond the number of days we approved and
>
> did not get the additional days precertified, then:
>
> -- for the part of the admission that was medically necessary, we will
> pay inpatient benefits, but
>
> -- for the part of the admission that was not medically necessary, we
> will pay only medical services and supplies otherwise payable on an
> outpatient basis and will not pay inpatient benefits.

**Exceptions:** You do not need precertification in these cases:

-   You are admitted to a hospital outside the United States.

-   You have another group health insurance policy that is the primary
    payer for the hospital stay.

-   Your Medicare Part A is the primary payer for the hospital stay.
    Note: If you exhaust your Medicare hospital benefits and do not want
    to use your Medicare lifetime reserve days, then we will become the
    primary payer and you **do** need precertification.

### Other services

-   Network mental health and substance abuse - We must pre-approve a
    treatment plan for covered network benefits. Advise your provider to
    [FAX]{.underline} a written treatment plan, for review and approval,
    to the attention of PBP Mental Health Coordinator at
    **301-333-1345** (Fax Only).

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```
-   PET Scan -- We must pre-approve the benefits for PET Scan services.
    Your provider must first provide a letter of medical necessity for
    review by the Plan.

-   Morbid obesity -- We must pre-approve surgical treatment. Your
    provider must first provide a letter of medical necessity and a
    psychiatric evaluation for review by the Plan.

+-----------------------------------------------------------------------+
| # Section 4. Your costs for covered services                          |
+=======================================================================+
+-----------------------------------------------------------------------+

This is what you will pay catastrophic protection out-of-pocket for your
covered care:

## **Copayments** 

> Example: When you see your PPO physician under Standard Option you pay
> a copayment of \$8 per visit and when you go to a hospital, you pay
> \$250 per admission

## **Deductible** 

  --------------- ------------- ------------- ------------- -------------
                  Standard                    High Option   
                  Option                                    

                  PPO           Non-PPO       PPO           Non-PPO

  Per person      \$250         \$600         \$200         \$500

                  or            or            or            or

  Per family      \$600         \$1,200       \$500         \$1,000
  --------------- ------------- ------------- ------------- -------------

-   We also have separate deductibles for:

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```
-   Prescription drugs - \$90 for retail pharmacies per person, per year
    for both High Option and Standard Option.

```{=html}
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```
-   Dental - \$30 per person per year for High Option. There is no
    Standard Option deductible for Dental Benefits.

-   Mental conditions/substance abuse --

  --------------- ------------- ------------- ------------- -------------
                  Standard                    High Option   
                  Option                                    

                  PPO           Non-PPO       PPO           Non-PPO

  Per person      \$250         \$300         \$200         \$275

                  or            or            or            or

  Per family      \$500         \$600         \$400         \$550
  --------------- ------------- ------------- ------------- -------------

Note: If you change plans during open season, you do not have to start a
new deductible under your old plan between January 1 and the effective
date of your new plan. If you change plans at another time during the
year, you must begin a new deductible under your new plan.

And, if you change options in this Plan during the year, we will credit
the amount of covered expenses already applied toward the deductible of
your old option to the deductible of your new option.

## **Coinsurance** 

Example: Under High Option you pay 10% of our allowance for office
visits to a network provider

Note: If your provider routinely waives (does not require you to pay)
your copayments, deductibles, or coinsurance, the provider is misstating
the fee and may be violating the law. In this case, when we calculate
our share, we will reduce the provider's fee by the amount waived.

For example, under High Option, if your physician ordinarily charges
\$100 for a service but routinely waives your 25% coinsurance, the
actual charge is \$75. We will pay \$56.25 (75% of the actual charge of
\$75).

+----------------------+-----------------------------------------------+
| ## **Differen        | Our \"Plan allowance\" is the amount we use   |
| ces between our allo | to calculate our payment for covered          |
| wance and the bill** | services. Fee-for-service plans arrive at     |
|                      | their allowances in different ways, so their  |
|                      | allowances vary. For more information about   |
|                      | how we determine our Plan allowance, see the  |
|                      | definition of Plan allowance in Section 10.   |
+----------------------+-----------------------------------------------+

Often, the provider\'s bill is more than a fee-for-service plan\'s
allowance. Whether or not you have to pay the difference between our
allowance and the bill will depend on the provider you use.

-   **PPO providers** agree to limit what they will bill you. Because of
    that, when you use a preferred provider, your share of covered
    charges consists only of your deductible and coinsurance or
    copayment. Here is a High Option example about coinsurance: You see
    a PPO physician who charges \$150, but our allowance is \$100. If
    you have met your deductible, you are only responsible for your
    coinsurance. That is, you pay just \-- 10% of our \$100 allowance
    (\$10). Because of the agreement, your PPO physician will not bill
    you for the \$50 difference between our allowance and his bill.

```{=html}
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```
-   **Non-PPO providers**, on the other hand, have no agreement to limit
    what they will bill you. When you use a non-PPO provider, you will
    pay your deductible and coinsurance \-- **plus** any difference
    between our allowance and charges on the bill. Here is a High Option
    example: You see a non-PPO physician who charges \$150 and our
    allowance is again \$100. Because you\'ve met your deductible, you
    are responsible for your coinsurance, so you pay 25% of our \$100
    allowance (\$25) under High Option. Plus, because there is no
    agreement between the non-PPO physician and us, he can bill you for
    the \$50 difference between our allowance and his bill.

The following table illustrates the examples of how much you have to pay
out-of-pocket for services from a PPO physician vs. a non-PPO physician.
The table uses our example of a service for which the physician charges
\$150 and our allowance is \$100. The table shows the amount you pay if
you have met your calendar year deductible.

+-----------------+-----------------------+---------------------------+
| **EXAMPLE**     | **PPO physician**     | **Non-PPO physician**     |
+-----------------+-----------------------+---------------------------+
| Physician\'s    | \$150                 | \$150                     |
| charge          |                       |                           |
+-----------------+-----------------------+---------------------------+
| Our allowance   | We set it at: 100     | We set it at: 100         |
+-----------------+-----------------------+---------------------------+
| We pay          | 90% of our allowance: | 75% of our allowance: 75  |
|                 | 90                    |                           |
+-----------------+-----------------------+---------------------------+
| You owe:        | 10% of our allowance: | 25% of our allowance: 25  |
|                 | 10                    |                           |
| Coinsurance     |                       |                           |
+-----------------+-----------------------+---------------------------+
| +Difference up  | No: 0                 | Yes: 50                   |
| to charge?      |                       |                           |
+-----------------+-----------------------+---------------------------+
| **TOTAL YOU     | \$10                  | \$75                      |
| PAY**           |                       |                           |
+-----------------+-----------------------+---------------------------+

+------------------------+---------------------------------------------+
| ## **Your cat          | For those services with coinsurance, other  |
| astrophic protection o | than prescription drug services, we pay     |
| ut-of-pocket maximum** | **100%** of the Plan allowance for the      |
|                        | remainder of the calendar year after your   |
| **for coinsurance**    | catastrophic protection out-of-pocket       |
|                        | expenses for the services shown below for   |
|                        | the calendar year exceed \$5,000 (\$3,500   |
|                        | PPO) per person per year or \$5,500         |
|                        | (\$4,000 PPO) per family under **Standard** |
|                        | **Option** and \$3,500 (\$3,000 PPO) per    |
|                        | person per year or \$4,000 (\$3,500 PPO)    |
|                        | per family under **High Option.**           |
+------------------------+---------------------------------------------+

Catastrophic protection out-of-pocket expenses for the purposes of this
benefit are:

  ----------------------------------- -----------------------------------
  **Standard Option**                 **High Option**

  The 30% you pay for hospital room   The 25% you pay for hospital room
  and board, or 10% you pay for       and board, or the 10% you pay for
  hospital room and board if using a  hospital room and board if using a
  PPO;                                PPO;

  The 30% you pay for medical         The 25% you pay for medical
  services or 9% if using a PPO;      services or 10% if using a PPO;

  The 30% you pay for Emergency Room  The 25% you pay for Emergency Room
  Treatment or 9% if using a PPO;     Treatment or 10% if using a PPO;

  The 30% you pay for hospital        The 25% you pay for hospital
  services or 9% if using a PPO;      services or 10% if using a PPO;

  The 30% you pay for surgical        The 25% you pay for surgical
  services or 9% if using a PPO;      services or 10% if using a PPO;

  The 30% you pay for durable medical The 25% you pay for durable medical
  equipment;                          equipment;

  The 30% PPO and 50% you pay for     The 25% PPO and 45% you pay for
  morbid obesity;                     morbid obesity;

  The balance you pay for non-network The balance you pay for non-network
  dialysis services.                  dialysis services.
  ----------------------------------- -----------------------------------

The following **[cannot]{.underline}** be counted toward catastrophic
protection out-of-pocket expenses:

-   Copayments;

-   Deductibles;

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```
-   Prescription drug expenses;

```{=html}
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```
-   Expenses in excess of the Plan allowances or maximum benefit
    limitations;

```{=html}
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```
-   Expenses for mental conditions / substance abuse (See Section 5
    (e));

-   Expenses for dental care; and

```{=html}
<!-- -->
```
-   Any amounts you pay because benefits have been reduced for
    non-compliance with this Plan's cost containment requirements (see
    page []{.mark}11-12).

+--------------------------+-------------------------------------------+
| ## **When governm        | Facilities of the Department of Veterans  |
| ent facilities bill us** | Affairs, the Department of Defense, and   |
|                          | the Indian Health Service are entitled to |
|                          | seek reimbursement from us for certain    |
|                          | services and supplies they provide to you |
|                          | or a family member. They may not seek     |
|                          | more than their governing laws allow.     |
+--------------------------+-------------------------------------------+

## 

## **If we overpay you** 

## 

## 

## **When you are age 65 or over and you do not have Medicare**

Under the FEHB law, we must limit our payments for those benefits you
would be entitled to if you had Medicare. And, your physician and
hospital must follow Medicare rules and cannot bill you for more than
they could bill you if you had Medicare. The following chart has more
information about the limits.

+------+-------------------------+------------------------------+-----+
| **If |                         |                              |     |
| you. |                         |                              |     |
| ..** |                         |                              |     |
|      |                         |                              |     |
| -    |                         |                              |     |
|  are |                         |                              |     |
|      |                         |                              |     |
|  age |                         |                              |     |
|      |                         |                              |     |
|   65 |                         |                              |     |
|      |                         |                              |     |
|   or |                         |                              |     |
|      |                         |                              |     |
|    o |                         |                              |     |
| ver, |                         |                              |     |
|      |                         |                              |     |
|  and |                         |                              |     |
|      |                         |                              |     |
| -    |                         |                              |     |
|   do |                         |                              |     |
|      |                         |                              |     |
|  not |                         |                              |     |
|      |                         |                              |     |
| have |                         |                              |     |
|      |                         |                              |     |
| Medi |                         |                              |     |
| care |                         |                              |     |
|      |                         |                              |     |
| Part |                         |                              |     |
|      |                         |                              |     |
|   A, |                         |                              |     |
|      |                         |                              |     |
| Part |                         |                              |     |
|      |                         |                              |     |
|   B, |                         |                              |     |
|      |                         |                              |     |
|   or |                         |                              |     |
|      |                         |                              |     |
|    b |                         |                              |     |
| oth; |                         |                              |     |
|      |                         |                              |     |
|  and |                         |                              |     |
|      |                         |                              |     |
| -    |                         |                              |     |
| have |                         |                              |     |
|      |                         |                              |     |
| this |                         |                              |     |
|      |                         |                              |     |
| Plan |                         |                              |     |
|      |                         |                              |     |
|   as |                         |                              |     |
|      |                         |                              |     |
|   an |                         |                              |     |
|      |                         |                              |     |
|    a |                         |                              |     |
| nnui |                         |                              |     |
| tant |                         |                              |     |
|      |                         |                              |     |
|   or |                         |                              |     |
|      |                         |                              |     |
|   as |                         |                              |     |
|      |                         |                              |     |
|    a |                         |                              |     |
|      |                         |                              |     |
|   fo |                         |                              |     |
| rmer |                         |                              |     |
|      |                         |                              |     |
|  spo |                         |                              |     |
| use, |                         |                              |     |
|      |                         |                              |     |
|   ** |                         |                              |     |
| or** |                         |                              |     |
|      |                         |                              |     |
|   as |                         |                              |     |
|      |                         |                              |     |
|    a |                         |                              |     |
|      |                         |                              |     |
|   fa |                         |                              |     |
| mily |                         |                              |     |
|      |                         |                              |     |
|   me |                         |                              |     |
| mber |                         |                              |     |
|      |                         |                              |     |
|   of |                         |                              |     |
|      |                         |                              |     |
|   an |                         |                              |     |
|      |                         |                              |     |
|    a |                         |                              |     |
| nnui |                         |                              |     |
| tant |                         |                              |     |
|      |                         |                              |     |
|   or |                         |                              |     |
|      |                         |                              |     |
|   fo |                         |                              |     |
| rmer |                         |                              |     |
|      |                         |                              |     |
|  spo |                         |                              |     |
| use; |                         |                              |     |
|      |                         |                              |     |
|  and |                         |                              |     |
|      |                         |                              |     |
| -    |                         |                              |     |
|  are |                         |                              |     |
|      |                         |                              |     |
|  not |                         |                              |     |
|      |                         |                              |     |
| empl |                         |                              |     |
| oyed |                         |                              |     |
|      |                         |                              |     |
|   in |                         |                              |     |
|      |                         |                              |     |
|    a |                         |                              |     |
|      |                         |                              |     |
| posi |                         |                              |     |
| tion |                         |                              |     |
|      |                         |                              |     |
| that |                         |                              |     |
|      |                         |                              |     |
|    g |                         |                              |     |
| ives |                         |                              |     |
|      |                         |                              |     |
| FEHB |                         |                              |     |
|      |                         |                              |     |
|    c |                         |                              |     |
| over |                         |                              |     |
| age. |                         |                              |     |
|      |                         |                              |     |
|    ( |                         |                              |     |
| Your |                         |                              |     |
|      |                         |                              |     |
|    e |                         |                              |     |
| mplo |                         |                              |     |
| ying |                         |                              |     |
|      |                         |                              |     |
|   of |                         |                              |     |
| fice |                         |                              |     |
|      |                         |                              |     |
|  can |                         |                              |     |
|      |                         |                              |     |
| tell |                         |                              |     |
|      |                         |                              |     |
|  you |                         |                              |     |
|      |                         |                              |     |
|   if |                         |                              |     |
|      |                         |                              |     |
| this |                         |                              |     |
|      |                         |                              |     |
|    a |                         |                              |     |
| ppli |                         |                              |     |
| es.) |                         |                              |     |
+------+-------------------------+------------------------------+-----+
| **T  |                         |                              |     |
| hen, |                         |                              |     |
| for  |                         |                              |     |
| your |                         |                              |     |
| i    |                         |                              |     |
| npat |                         |                              |     |
| ient |                         |                              |     |
| hosp |                         |                              |     |
| ital |                         |                              |     |
| car  |                         |                              |     |
| e,** |                         |                              |     |
|      |                         |                              |     |
| -    |                         |                              |     |
|  the |                         |                              |     |
|      |                         |                              |     |
|  law |                         |                              |     |
|      |                         |                              |     |
| requ |                         |                              |     |
| ires |                         |                              |     |
|      |                         |                              |     |
|   us |                         |                              |     |
|      |                         |                              |     |
|   to |                         |                              |     |
|      |                         |                              |     |
| base |                         |                              |     |
|      |                         |                              |     |
|  our |                         |                              |     |
|      |                         |                              |     |
|  pay |                         |                              |     |
| ment |                         |                              |     |
|      |                         |                              |     |
|   on |                         |                              |     |
|      |                         |                              |     |
|   an |                         |                              |     |
|      |                         |                              |     |
|   am |                         |                              |     |
| ount |                         |                              |     |
|      |                         |                              |     |
|  \-- |                         |                              |     |
|      |                         |                              |     |
|  the |                         |                              |     |
|      |                         |                              |     |
| \"eq |                         |                              |     |
| uiva |                         |                              |     |
| lent |                         |                              |     |
|      |                         |                              |     |
| Medi |                         |                              |     |
| care |                         |                              |     |
|      |                         |                              |     |
| amou |                         |                              |     |
| nt\" |                         |                              |     |
|      |                         |                              |     |
|  \-- |                         |                              |     |
|      |                         |                              |     |
|  set |                         |                              |     |
|      |                         |                              |     |
|   by |                         |                              |     |
|      |                         |                              |     |
|   Me |                         |                              |     |
| dica |                         |                              |     |
| re's |                         |                              |     |
|      |                         |                              |     |
|    r |                         |                              |     |
| ules |                         |                              |     |
|      |                         |                              |     |
|  for |                         |                              |     |
|      |                         |                              |     |
| what |                         |                              |     |
|      |                         |                              |     |
| Medi |                         |                              |     |
| care |                         |                              |     |
|      |                         |                              |     |
|    w |                         |                              |     |
| ould |                         |                              |     |
|      |                         |                              |     |
| pay, |                         |                              |     |
|      |                         |                              |     |
|  not |                         |                              |     |
|      |                         |                              |     |
|   on |                         |                              |     |
|      |                         |                              |     |
|  the |                         |                              |     |
|      |                         |                              |     |
|   ac |                         |                              |     |
| tual |                         |                              |     |
|      |                         |                              |     |
|  cha |                         |                              |     |
| rge; |                         |                              |     |
|      |                         |                              |     |
| -    |                         |                              |     |
|  you |                         |                              |     |
|      |                         |                              |     |
|  are |                         |                              |     |
|      |                         |                              |     |
|  res |                         |                              |     |
| pons |                         |                              |     |
| ible |                         |                              |     |
|      |                         |                              |     |
|  for |                         |                              |     |
|      |                         |                              |     |
| your |                         |                              |     |
|      |                         |                              |     |
|   ap |                         |                              |     |
| plic |                         |                              |     |
| able |                         |                              |     |
|      |                         |                              |     |
| dedu |                         |                              |     |
| ctib |                         |                              |     |
| les, |                         |                              |     |
|      |                         |                              |     |
|  coi |                         |                              |     |
| nsur |                         |                              |     |
| ance |                         |                              |     |
|      |                         |                              |     |
|   or |                         |                              |     |
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|      |                         |                              |     |
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|      |                         |                              |     |
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|      |                         |                              |     |
|  amo |                         |                              |     |
| unt. |                         |                              |     |
+------+-------------------------+------------------------------+-----+
| **   |                         |                              |     |
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| base |                         |                              |     |
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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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|      |                         |                              |     |
|   is |                         |                              |     |
|      |                         |                              |     |
|    l |                         |                              |     |
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|      |                         |                              |     |
| than |                         |                              |     |
|      |                         |                              |     |
|  the |                         |                              |     |
|      |                         |                              |     |
|    " |                         |                              |     |
| Medi |                         |                              |     |
| care |                         |                              |     |
|      |                         |                              |     |
| appr |                         |                              |     |
| oved |                         |                              |     |
|      |                         |                              |     |
| amou |                         |                              |     |
| nt." |                         |                              |     |
+------+-------------------------+------------------------------+-----+
|      | **If your               | **Then you are responsible   |     |
|      | physician...**          | for...**                     |     |
+------+-------------------------+------------------------------+-----+
|      | Participates with       | your deductibles,            |     |
|      | Medicare or accepts     | coinsurance, and copayments; |     |
|      | Medicare assignment for |                              |     |
|      | the claim and is a      |                              |     |
|      | member of our PPO       |                              |     |
|      | network,                |                              |     |
+------+-------------------------+------------------------------+-----+
|      | Participates with       | your deductibles,            |     |
|      | Medicare and is **not** | coinsurance, copayments, and |     |
|      | in our PPO network,     | any balance up to the        |     |
|      |                         | Medicare approved amount;    |     |
+------+-------------------------+------------------------------+-----+
|      | Does not participate    | your deductibles,            |     |
|      | with Medicare,          | coinsurance, copayments, and |     |
|      |                         | any balance up to 115% of    |     |
|      |                         | the Medicare approved amount |     |
+------+-------------------------+------------------------------+-----+
| It   |                         |                              |     |
| is   |                         |                              |     |
| g    |                         |                              |     |
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| dvan |                         |                              |     |
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| part |                         |                              |     |
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| with |                         |                              |     |
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| edic |                         |                              |     |
| are. |                         |                              |     |
| Such |                         |                              |     |
| ph   |                         |                              |     |
| ysic |                         |                              |     |
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| are  |                         |                              |     |
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| lect |                         |                              |     |
| only |                         |                              |     |
| up   |                         |                              |     |
| to   |                         |                              |     |
| the  |                         |                              |     |
| Medi |                         |                              |     |
| care |                         |                              |     |
| appr |                         |                              |     |
| oved |                         |                              |     |
| amo  |                         |                              |     |
| unt. |                         |                              |     |
|      |                         |                              |     |
| Our  |                         |                              |     |
| exp  |                         |                              |     |
| lana |                         |                              |     |
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| fits |                         |                              |     |
| (    |                         |                              |     |
| EOB) |                         |                              |     |
| form |                         |                              |     |
| will |                         |                              |     |
| tell |                         |                              |     |
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| much |                         |                              |     |
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| p    |                         |                              |     |
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| or   |                         |                              |     |
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| ital |                         |                              |     |
| can  |                         |                              |     |
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| from |                         |                              |     |
| you. |                         |                              |     |
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| than |                         |                              |     |
| all  |                         |                              |     |
| owed |                         |                              |     |
| by   |                         |                              |     |
| law, |                         |                              |     |
| ask  |                         |                              |     |
| the  |                         |                              |     |
| p    |                         |                              |     |
| hysi |                         |                              |     |
| cian |                         |                              |     |
| or   |                         |                              |     |
| hosp |                         |                              |     |
| ital |                         |                              |     |
| to   |                         |                              |     |
| re   |                         |                              |     |
| duce |                         |                              |     |
| the  |                         |                              |     |
| char |                         |                              |     |
| ges. |                         |                              |     |
| If   |                         |                              |     |
| you  |                         |                              |     |
| have |                         |                              |     |
| paid |                         |                              |     |
| more |                         |                              |     |
| than |                         |                              |     |
| allo |                         |                              |     |
| wed, |                         |                              |     |
| ask  |                         |                              |     |
| for  |                         |                              |     |
| a    |                         |                              |     |
| ref  |                         |                              |     |
| und. |                         |                              |     |
| If   |                         |                              |     |
| you  |                         |                              |     |
| need |                         |                              |     |
| fur  |                         |                              |     |
| ther |                         |                              |     |
| ass  |                         |                              |     |
| ista |                         |                              |     |
| nce, |                         |                              |     |
| call |                         |                              |     |
| us.  |                         |                              |     |
+------+-------------------------+------------------------------+-----+

+--------------------------+--------------------------------------------+
| ## **When you have the O | We limit our payment to an amount that     |
| riginal Medicare Plan**  | supplements the benefits that Medicare     |
|                          | would pay under Medicare Part A (Hospital  |
| **(Part A, Part B, or    | insurance) and Medicare Part B (Medical    |
| both)**                  | insurance), regardless of whether Medicare |
|                          | pays. Note: We pay our regular benefits    |
|                          | for emergency services to an institutional |
|                          | provider, such as a hospital, that does    |
|                          | not participate with Medicare and is not   |
|                          | reimbursed by Medicare.                    |
+--------------------------+--------------------------------------------+

If you are covered by Medicare Part B and it is primary, your
catastrophic protection out-of-pocket costs for services that both
Medicare Part B and we cover depend on whether your physician accepts
Medicare assignment for the claim.

-   If your physician accepts Medicare assignment, then you pay nothing
    for covered charges.

-   If your physician does not accept Medicare assignment, then you pay
    the difference between our payment combined with Medicare's payment
    and the charge.

> Note: The physician who does not accept Medicare assignment may not
> bill you for more than 115% of the amount Medicare bases its payment
> on, called the "limiting charge." The Medicare Summary Notice (MSN)
> that Medicare will send you will have more information about the
> limiting charge. If your physician tries to collect more than allowed
> by law, ask the physician to reduce their charges. If the physician
> does not, report the physician to your Medicare carrier who sent you
> the MSN form. Call us if you need further assistance.
>
> 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**. Medicare Part A covers hospital stays,
skilled nursing facility care and other expenses. When you don't have to
pay premiums for Medicare Part A, it makes good sense to obtain the
coverage. It can reduce your out-of-pocket expenses as well as costs to
the FEHB, which can help keep FEHB premiums down.

> Medicare Part B covers doctors' services and outpatient hospital care.
> 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.
>
> **Please see Section 9, Coordinating benefits with other coverage, for
> more information about how we coordinate benefits with Medicare.**

+-----------------------------------------------------------------------+
| # Section 5. Benefits -- OVERVIEW                                     |
|                                                                       |
| ***(See page 8 for how our benefits changed this year and pages 91    |
| and 92 for a benefit summary.)***                                     |
+-----------------------------------------------------------------------+

**NOTE**: This benefits section is divided into subsections. Please read
the important things you should keep in mind at the beginning of each
subsection. Also read the General Exclusions in Section 6; they apply to
the benefits in the following subsections. To obtain claim forms, claims
filing advice, or more information about our benefits, contact us at
**800-544-7111** or at our website
[www.pbp.org](http://www.pbphealthplan.org/)

(a) Medical services and supplies provided by physicians and other
    health care professionals 20-32

+--------------------------------+-------------------------------------+
| -   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          |
| ```{=html}                     |                                     |
| <!-- -->                       | -   Educational classes and         |
| ```                            |     programs                        |
| -   Physical and occupational  |                                     |
|     therapy                    |                                     |
+--------------------------------+-------------------------------------+

(b) Surgical and anesthesia services provided by physicians and other
    health care professionals 33-40

+--------------------------------+-------------------------------------+
| -   Surgical procedures        | -   Organ/tissue transplants        |
|                                |                                     |
| -   Reconstructive surgery     | ```{=html}                          |
|                                | <!-- -->                            |
| ```{=html}                     | ```                                 |
| <!-- -->                       | -   Anesthesia                      |
| ```                            |                                     |
| -   Oral and maxillofacial     |                                     |
|     surgery                    |                                     |
+--------------------------------+-------------------------------------+

(c) Services provided by a hospital or other facility, and ambulance
    services . 41-45

+--------------------------------+-------------------------------------+
| -   Inpatient hospital         | -   Hospice care                    |
|                                |                                     |
| ```{=html}                     | -   Ambulance                       |
| <!-- -->                       |                                     |
| ```                            |                                     |
| -   Outpatient hospital or     |                                     |
|     ambulatory surgical center |                                     |
|                                |                                     |
| ```{=html}                     |                                     |
| <!-- -->                       |                                     |
| ```                            |                                     |
| -   Extended care              |                                     |
|     benefits/Skilled nursing   |                                     |
|     care facility benefits     |                                     |
+--------------------------------+-------------------------------------+

(d) Emergency services/Accidents 46-47

+--------------------------------+-------------------------------------+
| -   Accidental injury          | -   Ambulance                       |
|                                |                                     |
| -   Medical emergency          |                                     |
+--------------------------------+-------------------------------------+

(e) Mental health and substance abuse benefits 48-50

(f) Prescription drug benefits 51-53

(g) Special features 54-55

+--------------------------------+-------------------------------------+
| -   Flexible benefits option   | -   Complex surgery (MAYO Clinics)  |
|                                |                                     |
| -   24 hour nurse line (MAYO   | ```{=html}                          |
|     Clinics)                   | <!-- -->                            |
|                                | ```                                 |
| -   Tobacco Quit line (MAYO    | -   Centers of excellence for       |
|     Clinics)                   |     transplants (MAYO)              |
|                                |                                     |
| -   "Healthier Feds" Hotlines  | -   Travel and Hotel to and from    |
|                                |     MAYO Clinics                    |
|                                |                                     |
|                                | -   Dialysis services               |
+--------------------------------+-------------------------------------+

(h) Dental benefits 56-62

(i) Non-FEHB benefits available to Plan members 63

*SUMMARY OF BENEFITS*......
\...................................................................................................85-86

+---+---+---------------------+---------------------+---------------+---+---+
| # |   |                     |                     |               |   |   |
| # |   |                     |                     |               |   |   |
|   |   |                     |                     |               |   |   |
| * |   |                     |                     |               |   |   |
| * |   |                     |                     |               |   |   |
| S |   |                     |                     |               |   |   |
| e |   |                     |                     |               |   |   |
| c |   |                     |                     |               |   |   |
| t |   |                     |                     |               |   |   |
| i |   |                     |                     |               |   |   |
| o |   |                     |                     |               |   |   |
| n |   |                     |                     |               |   |   |
|   |   |                     |                     |               |   |   |
| 5 |   |                     |                     |               |   |   |
|   |   |                     |                     |               |   |   |
| ( |   |                     |                     |               |   |   |
| a |   |                     |                     |               |   |   |
| ) |   |                     |                     |               |   |   |
| . |   |                     |                     |               |   |   |
|   |   |                     |                     |               |   |   |
| M |   |                     |                     |               |   |   |
| e |   |                     |                     |               |   |   |
| d |   |                     |                     |               |   |   |
| i |   |                     |                     |               |   |   |
| c |   |                     |                     |               |   |   |
| a |   |                     |                     |               |   |   |
| l |   |                     |                     |               |   |   |
|   |   |                     |                     |               |   |   |
| s |   |                     |                     |               |   |   |
| e |   |                     |                     |               |   |   |
| r |   |                     |                     |               |   |   |
| v |   |                     |                     |               |   |   |
| i |   |                     |                     |               |   |   |
| c |   |                     |                     |               |   |   |
| e |   |                     |                     |               |   |   |
| s |   |                     |                     |               |   |   |
|   |   |                     |                     |               |   |   |
| a |   |                     |                     |               |   |   |
| n |   |                     |                     |               |   |   |
| d |   |                     |                     |               |   |   |
|   |   |                     |                     |               |   |   |
| s |   |                     |                     |               |   |   |
| u |   |                     |                     |               |   |   |
| p |   |                     |                     |               |   |   |
| p |   |                     |                     |               |   |   |
| l |   |                     |                     |               |   |   |
| i |   |                     |                     |               |   |   |
| e |   |                     |                     |               |   |   |
| s |   |                     |                     |               |   |   |
|   |   |                     |                     |               |   |   |
| p |   |                     |                     |               |   |   |
| r |   |                     |                     |               |   |   |
| o |   |                     |                     |               |   |   |
| v |   |                     |                     |               |   |   |
| i |   |                     |                     |               |   |   |
| d |   |                     |                     |               |   |   |
| e |   |                     |                     |               |   |   |
| d |   |                     |                     |               |   |   |
|   |   |                     |                     |               |   |   |
| b |   |                     |                     |               |   |   |
| y |   |                     |                     |               |   |   |
|   |   |                     |                     |               |   |   |
| p |   |                     |                     |               |   |   |
| h |   |                     |                     |               |   |   |
| y |   |                     |                     |               |   |   |
| s |   |                     |                     |               |   |   |
| i |   |                     |                     |               |   |   |
| c |   |                     |                     |               |   |   |
| i |   |                     |                     |               |   |   |
| a |   |                     |                     |               |   |   |
| n |   |                     |                     |               |   |   |
| s |   |                     |                     |               |   |   |
|   |   |                     |                     |               |   |   |
| a |   |                     |                     |               |   |   |
| n |   |                     |                     |               |   |   |
| d |   |                     |                     |               |   |   |
|   |   |                     |                     |               |   |   |
| o |   |                     |                     |               |   |   |
| t |   |                     |                     |               |   |   |
| h |   |                     |                     |               |   |   |
| e |   |                     |                     |               |   |   |
| r |   |                     |                     |               |   |   |
|   |   |                     |                     |               |   |   |
| h |   |                     |                     |               |   |   |
| e |   |                     |                     |               |   |   |
| a |   |                     |                     |               |   |   |
| l |   |                     |                     |               |   |   |
| t |   |                     |                     |               |   |   |
| h |   |                     |                     |               |   |   |
|   |   |                     |                     |               |   |   |
| c |   |                     |                     |               |   |   |
| a |   |                     |                     |               |   |   |
| r |   |                     |                     |               |   |   |
| e |   |                     |                     |               |   |   |
|   |   |                     |                     |               |   |   |
| p |   |                     |                     |               |   |   |
| r |   |                     |                     |               |   |   |
| o |   |                     |                     |               |   |   |
| f |   |                     |                     |               |   |   |
| e |   |                     |                     |               |   |   |
| s |   |                     |                     |               |   |   |
| s |   |                     |                     |               |   |   |
| i |   |                     |                     |               |   |   |
| o |   |                     |                     |               |   |   |
| n |   |                     |                     |               |   |   |
| a |   |                     |                     |               |   |   |
| l |   |                     |                     |               |   |   |
| s |   |                     |                     |               |   |   |
| * |   |                     |                     |               |   |   |
| * |   |                     |                     |               |   |   |
+---+---+---------------------+---------------------+---------------+---+---+
|   | * | **Here are some     |                     |               | * |   |
|   | * | important things    |                     |               | * |   |
|   | I | you should keep in  |                     |               | I |   |
|   | * | mind about these    |                     |               | * |   |
|   | * | benefits:**         |                     |               | * |   |
|   |   |                     |                     |               |   |   |
|   | * | -   Please remember |                     |               | * |   |
|   | * |     that all        |                     |               | * |   |
|   | M |     benefits are    |                     |               | M |   |
|   | * |     subject to the  |                     |               | * |   |
|   | * |     definitions,    |                     |               | * |   |
|   |   |     limitations,    |                     |               |   |   |
|   | * |     and exclusions  |                     |               | * |   |
|   | * |     in this         |                     |               | * |   |
|   | P |     brochure and    |                     |               | P |   |
|   | * |     are payable     |                     |               | * |   |
|   | * |     only when we    |                     |               | * |   |
|   |   |     determine they  |                     |               |   |   |
|   | * |     are medically   |                     |               | * |   |
|   | * |     necessary.      |                     |               | * |   |
|   | O |                     |                     |               | O |   |
|   | * | -   The calendar    |                     |               | * |   |
|   | * |     year deductible |                     |               | * |   |
|   |   |     is:             |                     |               |   |   |
|   | * |                     |                     |               | * |   |
|   | * | The calendar year   |                     |               | * |   |
|   | R | deductible applies  |                     |               | R |   |
|   | * | to almost all       |                     |               | * |   |
|   | * | benefits in this    |                     |               | * |   |
|   |   | Section. We added   |                     |               |   |   |
|   | * | "(No deductible)"   |                     |               | * |   |
|   | * | to show when the    |                     |               | * |   |
|   | T | calendar year       |                     |               | T |   |
|   | * | deductible does not |                     |               | * |   |
|   | * | apply.              |                     |               | * |   |
|   |   |                     |                     |               |   |   |
|   | * | -   The non-PPO     |                     |               | * |   |
|   | * |     benefits are    |                     |               | * |   |
|   | A |     the standard    |                     |               | A |   |
|   | * |     benefits of     |                     |               | * |   |
|   | * |     this Plan. PPO  |                     |               | * |   |
|   |   |     benefits apply  |                     |               |   |   |
|   | * |     only when you   |                     |               | * |   |
|   | * |     use a PPO       |                     |               | * |   |
|   | N |     provider. When  |                     |               | N |   |
|   | * |     no PPO provider |                     |               | * |   |
|   | * |     is available,   |                     |               | * |   |
|   |   |     non-PPO         |                     |               |   |   |
|   | * |     benefits apply. |                     |               | * |   |
|   | * |                     |                     |               | * |   |
|   | T | ```{=html}          |                     |               | T |   |
|   | * | <!-- -->            |                     |               | * |   |
|   | * | ```                 |                     |               | * |   |
|   |   | -   Be sure to read |                     |               |   |   |
|   |   |     Section 4,      |                     |               |   |   |
|   |   |     *Your costs for |                     |               |   |   |
|   |   |     covered         |                     |               |   |   |
|   |   |     services*, for  |                     |               |   |   |
|   |   |     valuable        |                     |               |   |   |
|   |   |     information     |                     |               |   |   |
|   |   |     about how cost  |                     |               |   |   |
|   |   |     sharing works,  |                     |               |   |   |
|   |   |     with special    |                     |               |   |   |
|   |   |     sections for    |                     |               |   |   |
|   |   |     members who are |                     |               |   |   |
|   |   |     age 65 or over. |                     |               |   |   |
|   |   |     Also read       |                     |               |   |   |
|   |   |     Section 9 about |                     |               |   |   |
|   |   |     coordinating    |                     |               |   |   |
|   |   |     benefits with   |                     |               |   |   |
|   |   |     other coverage, |                     |               |   |   |
|   |   |     including with  |                     |               |   |   |
|   |   |     Medicare.       |                     |               |   |   |
+---+---+---------------------+---------------------+---------------+---+---+
| * |   |                     | **You pay**         |               |   |   |
| * |   |                     |                     |               |   |   |
| B |   |                     | **After the         |               |   |   |
| e |   |                     | calendar year       |               |   |   |
| n |   |                     | deductible...**     |               |   |   |
| e |   |                     |                     |               |   |   |
| f |   |                     |                     |               |   |   |
| i |   |                     |                     |               |   |   |
| t |   |                     |                     |               |   |   |
| D |   |                     |                     |               |   |   |
| e |   |                     |                     |               |   |   |
| s |   |                     |                     |               |   |   |
| c |   |                     |                     |               |   |   |
| r |   |                     |                     |               |   |   |
| i |   |                     |                     |               |   |   |
| p |   |                     |                     |               |   |   |
| t |   |                     |                     |               |   |   |
| i |   |                     |                     |               |   |   |
| o |   |                     |                     |               |   |   |
| n |   |                     |                     |               |   |   |
| * |   |                     |                     |               |   |   |
| * |   |                     |                     |               |   |   |
+---+---+---------------------+---------------------+---------------+---+---+
| * |   |                     |                     |               |   |   |
| * |   |                     |                     |               |   |   |
| N |   |                     |                     |               |   |   |
| O |   |                     |                     |               |   |   |
| T |   |                     |                     |               |   |   |
| E |   |                     |                     |               |   |   |
| : |   |                     |                     |               |   |   |
| T |   |                     |                     |               |   |   |
| h |   |                     |                     |               |   |   |
| e |   |                     |                     |               |   |   |
| c |   |                     |                     |               |   |   |
| a |   |                     |                     |               |   |   |
| l |   |                     |                     |               |   |   |
| e |   |                     |                     |               |   |   |
| n |   |                     |                     |               |   |   |
| d |   |                     |                     |               |   |   |
| a |   |                     |                     |               |   |   |
| r |   |                     |                     |               |   |   |
| y |   |                     |                     |               |   |   |
| e |   |                     |                     |               |   |   |
| a |   |                     |                     |               |   |   |
| r |   |                     |                     |               |   |   |
| d |   |                     |                     |               |   |   |
| e |   |                     |                     |               |   |   |
| d |   |                     |                     |               |   |   |
| u |   |                     |                     |               |   |   |
| c |   |                     |                     |               |   |   |
| t |   |                     |                     |               |   |   |
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| b |   |                     |                     |               |   |   |
| l |   |                     |                     |               |   |   |
| e |   |                     |                     |               |   |   |
| a |   |                     |                     |               |   |   |
| p |   |                     |                     |               |   |   |
| p |   |                     |                     |               |   |   |
| l |   |                     |                     |               |   |   |
| i |   |                     |                     |               |   |   |
| e |   |                     |                     |               |   |   |
| s |   |                     |                     |               |   |   |
| t |   |                     |                     |               |   |   |
| o |   |                     |                     |               |   |   |
| a |   |                     |                     |               |   |   |
| l |   |                     |                     |               |   |   |
| m |   |                     |                     |               |   |   |
| o |   |                     |                     |               |   |   |
| s |   |                     |                     |               |   |   |
| t |   |                     |                     |               |   |   |
| a |   |                     |                     |               |   |   |
| l |   |                     |                     |               |   |   |
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| b |   |                     |                     |               |   |   |
| e |   |                     |                     |               |   |   |
| n |   |                     |                     |               |   |   |
| e |   |                     |                     |               |   |   |
| f |   |                     |                     |               |   |   |
| i |   |                     |                     |               |   |   |
| t |   |                     |                     |               |   |   |
| s |   |                     |                     |               |   |   |
| i |   |                     |                     |               |   |   |
| n |   |                     |                     |               |   |   |
| t |   |                     |                     |               |   |   |
| h |   |                     |                     |               |   |   |
| i |   |                     |                     |               |   |   |
| s |   |                     |                     |               |   |   |
| S |   |                     |                     |               |   |   |
| e |   |                     |                     |               |   |   |
| c |   |                     |                     |               |   |   |
| t |   |                     |                     |               |   |   |
| i |   |                     |                     |               |   |   |
| o |   |                     |                     |               |   |   |
| n |   |                     |                     |               |   |   |
| . |   |                     |                     |               |   |   |
| * |   |                     |                     |               |   |   |
| * |   |                     |                     |               |   |   |
|   |   |                     |                     |               |   |   |
| * |   |                     |                     |               |   |   |
| * |   |                     |                     |               |   |   |
| W |   |                     |                     |               |   |   |
| e |   |                     |                     |               |   |   |
| s |   |                     |                     |               |   |   |
| a |   |                     |                     |               |   |   |
| y |   |                     |                     |               |   |   |
| " |   |                     |                     |               |   |   |
| ( |   |                     |                     |               |   |   |
| N |   |                     |                     |               |   |   |
| o |   |                     |                     |               |   |   |
| d |   |                     |                     |               |   |   |
| e |   |                     |                     |               |   |   |
| d |   |                     |                     |               |   |   |
| u |   |                     |                     |               |   |   |
| c |   |                     |                     |               |   |   |
| t |   |                     |                     |               |   |   |
| i |   |                     |                     |               |   |   |
| b |   |                     |                     |               |   |   |
| l |   |                     |                     |               |   |   |
| e |   |                     |                     |               |   |   |
| ) |   |                     |                     |               |   |   |
| " |   |                     |                     |               |   |   |
| w |   |                     |                     |               |   |   |
| h |   |                     |                     |               |   |   |
| e |   |                     |                     |               |   |   |
| n |   |                     |                     |               |   |   |
| i |   |                     |                     |               |   |   |
| t |   |                     |                     |               |   |   |
| d |   |                     |                     |               |   |   |
| o |   |                     |                     |               |   |   |
| e |   |                     |                     |               |   |   |
| s |   |                     |                     |               |   |   |
| n |   |                     |                     |               |   |   |
| o |   |                     |                     |               |   |   |
| t |   |                     |                     |               |   |   |
| a |   |                     |                     |               |   |   |
| p |   |                     |                     |               |   |   |
| p |   |                     |                     |               |   |   |
| l |   |                     |                     |               |   |   |
| y |   |                     |                     |               |   |   |
| . |   |                     |                     |               |   |   |
| * |   |                     |                     |               |   |   |
| * |   |                     |                     |               |   |   |
+---+---+---------------------+---------------------+---------------+---+---+
| > |   |                     | **You pay -         | **You pay -   |   |   |
|   |   |                     | Standard Option**   | High Option** |   |   |
| * |   |                     |                     |               |   |   |
| * |   |                     |                     |               |   |   |
| D |   |                     |                     |               |   |   |
| i |   |                     |                     |               |   |   |
| a |   |                     |                     |               |   |   |
| g |   |                     |                     |               |   |   |
| n |   |                     |                     |               |   |   |
| o |   |                     |                     |               |   |   |
| s |   |                     |                     |               |   |   |
| t |   |                     |                     |               |   |   |
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|   |   |                     |                     |               |   |   |
| a |   |                     |                     |               |   |   |
| n |   |                     |                     |               |   |   |
| d |   |                     |                     |               |   |   |
| > |   |                     |                     |               |   |   |
|   |   |                     |                     |               |   |   |
| t |   |                     |                     |               |   |   |
| r |   |                     |                     |               |   |   |
| e |   |                     |                     |               |   |   |
| a |   |                     |                     |               |   |   |
| t |   |                     |                     |               |   |   |
| m |   |                     |                     |               |   |   |
| e |   |                     |                     |               |   |   |
| n |   |                     |                     |               |   |   |
| t |   |                     |                     |               |   |   |
| > |   |                     |                     |               |   |   |
|   |   |                     |                     |               |   |   |
| s |   |                     |                     |               |   |   |
| e |   |                     |                     |               |   |   |
| r |   |                     |                     |               |   |   |
| v |   |                     |                     |               |   |   |
| i |   |                     |                     |               |   |   |
| c |   |                     |                     |               |   |   |
| e |   |                     |                     |               |   |   |
| s |   |                     |                     |               |   |   |
| * |   |                     |                     |               |   |   |
| * |   |                     |                     |               |   |   |
+---+---+---------------------+---------------------+---------------+---+---+
| > |   |                     | PPO: \$8 copayment  | PPO: 10% of   |   |   |
|   |   |                     | (No deductible)     | the Plan      |   |   |
| P |   |                     |                     | allowance     |   |   |
| r |   |                     | Non-PPO: 30% of the |               |   |   |
| o |   |                     | Plan allowance and  | Non-PPO: 25%  |   |   |
| f |   |                     | any difference      | of the Plan   |   |   |
| e |   |                     | between our         | allowance and |   |   |
| s |   |                     | allowance and the   | any           |   |   |
| s |   |                     | billed amount       | difference    |   |   |
| i |   |                     |                     | between our   |   |   |
| o |   |                     |                     | allowance and |   |   |
| n |   |                     |                     | the billed    |   |   |
| a |   |                     |                     | amount.       |   |   |
| l |   |                     |                     |               |   |   |
| > |   |                     |                     |               |   |   |
|   |   |                     |                     |               |   |   |
| s |   |                     |                     |               |   |   |
| e |   |                     |                     |               |   |   |
| r |   |                     |                     |               |   |   |
| v |   |                     |                     |               |   |   |
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| c |   |                     |                     |               |   |   |
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| s |   |                     |                     |               |   |   |
| > |   |                     |                     |               |   |   |
|   |   |                     |                     |               |   |   |
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| > |   |                     |                     |               |   |   |
|   |   |                     |                     |               |   |   |
| p |   |                     |                     |               |   |   |
| h |   |                     |                     |               |   |   |
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| b |   |                     |                     |               |   |   |
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| b |   |                     |                     |               |   |   |
| y |   |                     |                     |               |   |   |
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| r |   |                     |                     |               |   |   |
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| s |   |                     |                     |               |   |   |
| > |   |                     |                     |               |   |   |
|   |   |                     |                     |               |   |   |
| o |   |                     |                     |               |   |   |
| t |   |                     |                     |               |   |   |
| h |   |                     |                     |               |   |   |
| e |   |                     |                     |               |   |   |
| r |   |                     |                     |               |   |   |
| > |   |                     |                     |               |   |   |
|   |   |                     |                     |               |   |   |
| t |   |                     |                     |               |   |   |
| h |   |                     |                     |               |   |   |
| a |   |                     |                     |               |   |   |
| n |   |                     |                     |               |   |   |
| > |   |                     |                     |               |   |   |
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| p |   |                     |                     |               |   |   |
| h |   |                     |                     |               |   |   |
| y |   |                     |                     |               |   |   |
| s |   |                     |                     |               |   |   |
| i |   |                     |                     |               |   |   |
| c |   |                     |                     |               |   |   |
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| s |   |                     |                     |               |   |   |
+---+---+---------------------+---------------------+---------------+---+---+

*Diagnostic and treatment services -- Continued on next page []{.mark}*

+--------------------------+---------------------+---------------------+
| > **Diagnostic and       | **You pay --        | **You pay - High    |
| > treatment services**   | Standard Option**   | Option**            |
| > -- *continued*         |                     |                     |
+--------------------------+---------------------+---------------------+
| > Professional services  | PPO: 9% of the Plan | PPO: 10% of the     |
| > of physicians          | allowance           | Plan allowance      |
|                          |                     |                     |
| -   In an urgent care    | Non-PPO: 30% of the | Non-PPO: 25% of the |
|     center               | Plan allowance and  | Plan allowance and  |
|                          | any difference      | any difference      |
| -   During a hospital    | between our         | between our         |
|     stay                 | allowance and the   | allowance and the   |
|                          | billed amount       | billed amount.      |
| -   In a skilled nursing |                     |                     |
|     facility             |                     |                     |
|                          |                     |                     |
| -   Medical              |                     |                     |
|     consultations        |                     |                     |
|                          |                     |                     |
| ```{=html}               |                     |                     |
| <!-- -->                 |                     |                     |
| ```                      |                     |                     |
| -   Second surgical      |                     |                     |
|     opinion              |                     |                     |
|                          |                     |                     |
| -   Cardiac              |                     |                     |
|     rehabilitation       |                     |                     |
|                          |                     |                     |
| -   Initial inpatient    |                     |                     |
|     examination of a     |                     |                     |
|     newborn child        |                     |                     |
|     covered under a      |                     |                     |
|     family enrollment    |                     |                     |
+--------------------------+---------------------+---------------------+
| > **Lab, X-ray and other |                     |                     |
| > diagnostic tests**     |                     |                     |
+--------------------------+---------------------+---------------------+
| > Tests, such as:        | PPO: 9% of the Plan | PPO: 10% of the     |
|                          | allowance           | Plan allowance      |
| -   Blood tests          |                     |                     |
|                          | Non-PPO: 30% of the | Non-PPO: 25% of the |
| -   Urinalysis           | Plan allowance and  | Plan allowance and  |
|                          | any difference      | any difference      |
| -   Non-routine pap      | between our         | between our         |
|     tests                | allowance and the   | allowance and the   |
|                          | billed amount       | billed amount.      |
| -   Pathology            |                     |                     |
|                          |                     |                     |
| -   X-rays               |                     |                     |
|                          |                     |                     |
| -   Non-routine          |                     |                     |
|     Mammograms           |                     |                     |
|                          |                     |                     |
| -   CAT Scans/MRI        |                     |                     |
|                          |                     |                     |
| -   PET scan (requires   |                     |                     |
|     Plan's pre-approval) |                     |                     |
|                          |                     |                     |
| -   Ultrasound           |                     |                     |
|                          |                     |                     |
| -   Electrocardiogram    |                     |                     |
|     and EEG              |                     |                     |
|                          |                     |                     |
| > Note: If your PPO      |                     |                     |
| > provider uses a        |                     |                     |
| > non-PPO lab or         |                     |                     |
| > radiologist, we will   |                     |                     |
| > pay non-PPO benefits   |                     |                     |
| > for any lab and X-ray  |                     |                     |
| > charges.               |                     |                     |
+--------------------------+---------------------+---------------------+

+--------------------------+---------------------+---------------------+
| > **Preventive care,     | **You pay --        | **You pay - High    |
| > adult**                | Standard Option**   | Option**            |
+--------------------------+---------------------+---------------------+
| > Routine screenings,    | PPO: 9% of the Plan | PPO: 10% of the     |
| > limited to:            | allowance           | Plan allowance      |
|                          |                     |                     |
| -   Hepatitis            | Non-PPO: 30% of the | Non-PPO: 25% of the |
|     vaccinations, when   | Plan allowance and  | Plan allowance and  |
|     pre-approved by the  | any difference      | any difference      |
|     Plan, for high-risk  | between our         | between our         |
|     individuals. Call us | allowance and the   | allowance and the   |
|     at                   | billed amount       | billed amount       |
|     **1-866-218-8317**   |                     |                     |
|     for information      |                     |                     |
|     about pre-approval   |                     |                     |
|                          |                     |                     |
| -   Serim Pylo tests --  |                     |                     |
|     twice per year       |                     |                     |
|                          |                     |                     |
| -   Strep A tests --     |                     |                     |
|     twice per year       |                     |                     |
|                          |                     |                     |
| -   Chemstrip Micral     |                     |                     |
|     tests -- twice per   |                     |                     |
|     year                 |                     |                     |
|                          |                     |                     |
| -   Quick Vue Flu tests  |                     |                     |
|     -- twice per year    |                     |                     |
|                          |                     |                     |
| -   Total Blood          |                     |                     |
|     Cholesterol -- once  |                     |                     |
|     every five years,    |                     |                     |
|     age 20 and older     |                     |                     |
|                          |                     |                     |
| -   Physical exams-      |                     |                     |
|     (including a         |                     |                     |
|     complete history and |                     |                     |
|     workup) once every   |                     |                     |
|     two years, age 13    |                     |                     |
|     through 39; and once |                     |                     |
|     every year, age 40   |                     |                     |
|     and above.           |                     |                     |
|                          |                     |                     |
| -   Chlamydial infection |                     |                     |
|     for sexually active  |                     |                     |
|     females under 25     |                     |                     |
|                          |                     |                     |
| ```{=html}               |                     |                     |
| <!-- -->                 |                     |                     |
| ```                      |                     |                     |
| -   Colorectal Cancer    |                     |                     |
|     Screening, including |                     |                     |
|                          |                     |                     |
| > -- One annual fecal    |                     |                     |
| > occult blood test, age |                     |                     |
| > 40 and older.          |                     |                     |
| >                        |                     |                     |
| > -- One colonoscopy     |                     |                     |
| > every ten years, age   |                     |                     |
| > 50 and older           |                     |                     |
| >                        |                     |                     |
| > -- One barium enema    |                     |                     |
| > every five years, age  |                     |                     |
| > 50 and older           |                     |                     |
+--------------------------+---------------------+---------------------+
| > -- Sigmoidoscopy,      | PPO: 9% of the Plan | PPO:10% of the Plan |
| > screening -- One every | allowance           | allowance           |
| > five years starting at |                     |                     |
| > age 50                 | Non-PPO: 30% of the | Non-PPO: 25% of the |
|                          | Plan allowance and  | Plan allowance and  |
|                          | any difference      | any difference      |
|                          | between our         | between our         |
|                          | allowance and the   | allowance and the   |
|                          | billed amount       | billed amount.      |
+--------------------------+---------------------+---------------------+
| > Routine Prostate       | PPO: 9% of the Plan | PPO: 10% of the     |
| > Specific Antigen (PSA) | allowance           | Plan allowance      |
| > test -- One annually   |                     |                     |
| > for men age 40 and     | Non-PPO: 30% of the | Non-PPO: 25% of the |
| > older                  | Plan allowance and  | Plan allowance and  |
|                          | any difference      | any difference      |
|                          | between our         | between our         |
|                          | allowance and the   | allowance and the   |
|                          | billed amount       | billed amount       |
+--------------------------+---------------------+---------------------+

*Preventive care, adult -- Continued on next page []{.mark}*

+--------------------------+---------------------+---------------------+
| > **Preventive care,     | **You pay -         | **You pay-High      |
| > adult** -- *continued* | Standard Option**   | Option**            |
+--------------------------+---------------------+---------------------+
| > Routine pap test --    | PPO: Nothing. (No   | PPO: Nothing. (No   |
| > One annually for women | deductible)         | deductible)         |
| > age 18 and older.      |                     |                     |
| >                        | Non-PPO: 30% of the | Non-PPO: 25% of the |
| > Note: The office visit | Plan allowance and  | Plan allowance and  |
| > is covered if pap test | any difference      | any difference      |
| > is received on the     | between our         | between our         |
| > same day; see          | allowance and the   | allowance and the   |
| > Diagnosis and          | billed amount       | billed amount       |
| > Treatment, above.      |                     |                     |
+--------------------------+---------------------+---------------------+
| > Routine mammogram --   | PPO: Nothing. (No   | PPO: Nothing. (No   |
| > covered for women age  | deductible)         | deductible)         |
| > 35 and older, as       |                     |                     |
| > follows:               | Non-PPO: 30% of the | Non-PPO: 25% of the |
|                          | Plan allowance and  | Plan allowance and  |
| -   From age 35 through  | any difference      | any difference      |
|     39, one during this  | between our         | between our         |
|     five year period     | allowance and the   | allowance and the   |
|                          | billed amount       | billed amount.      |
| ```{=html}               |                     |                     |
| <!-- -->                 |                     |                     |
| ```                      |                     |                     |
| -   From age 40 through  |                     |                     |
|     64, one every        |                     |                     |
|     calendar year        |                     |                     |
|                          |                     |                     |
| -   At age 65 and older, |                     |                     |
|     one every two        |                     |                     |
|     consecutive calendar |                     |                     |
|     years                |                     |                     |
+--------------------------+---------------------+---------------------+
| > Routine immunizations, | PPO: Nothing (No    | PPO: Nothing (No    |
| > limited to:            | deductible)         | deductible)         |
|                          |                     |                     |
| -   Influenza vaccine -- | Non-PPO: Any        | Non-PPO: Any        |
|     one annually         | difference between  | difference between  |
|                          | our allowance and   | our allowance and   |
| -   Pneumococcal         | the billed amount   | the billed amount   |
|     vaccine, age 65 and  | (No deductible)     | (No deductible)     |
|     older                |                     |                     |
+--------------------------+---------------------+---------------------+
| > *Not covered: Physical | *All charges.*      | *All charges*       |
| > exams for school,      |                     |                     |
| > sports, employment or  |                     |                     |
| > travel*                |                     |                     |
+--------------------------+---------------------+---------------------+

+--------------------------+---------------------+---------------------+
| > **Preventive care,     | **You pay -         | > **You pay - High  |
| > children**             | Standard Option**   | > Option**          |
+--------------------------+---------------------+---------------------+
| -   Childhood            | PPO: Nothing (No    | PPO: Nothing (No    |
|     immunizations        | deductible)         | deductible)         |
|     recommended by the   |                     |                     |
|     American Academy of  | Non-PPO: Any        | Non-PPO: Any        |
|     Pediatrics           | difference between  | difference between  |
|                          | our allowance and   | our allowance and   |
| **NOTE:** Covered for    | the billed amount   | the billed amount   |
| dependent children under | (No deductible)     | (No deductible)     |
| age 22                   |                     |                     |
|                          | PPO: Any difference | PO: Any difference  |
| -   For well-child care  | between our \$125   | between the \$150   |
|     charges for routine  | calendar year       | calendar year       |
|     examinations,        | allowance and the   | allowance and the   |
|     immunizations and    | billed amount. (No  | billed amount. (No  |
|     care (to age 3)      | deductible).        | deductible).        |
|                          |                     |                     |
| ```{=html}               | Non-PPO: Any        | Non-PPO: Any        |
| <!-- -->                 | difference between  | difference between  |
| ```                      | our \$125 calendar  | the \$150 calendar  |
| -   Examinations,        | year allowance and  | year allowance and  |
|     limited to:          | the billed amount.  | the billed amount.  |
|                          | (No deductible).    | (No deductible).    |
| > \--Examinations for    |                     |                     |
| > amblyopia and          | PPO: \$15 copayment | PPO: \$10 copayment |
| > strabismus -- limited  | (No deductible)     | (No deductible)     |
| > to one screening       |                     |                     |
| > examination (ages 2    | Non-PPO: 15% of the | Non-PPO: 10% of the |
| > through 6)             | Plan allowance and  | Plan allowance and  |
| >                        | any difference      | any difference      |
| > \--Examinations done   | between our         | between our         |
| > on the day of          | allowance and the   | allowance and the   |
| > immunizations (ages 3  | billed amount       | billed amount       |
| > up to age 22)          |                     |                     |
+--------------------------+---------------------+---------------------+

+--------------------------+---------------------+---------------------+
| > **Maternity care**     | **You pay -         | > **You pay - High  |
|                          | Standard Option**   | > Option**          |
+--------------------------+---------------------+---------------------+
| > Complete maternity     | PPO: 9% of the Plan | PPO: 10% of the     |
| > (obstetrical) care,    | allowance           | Plan allowance      |
| > such as:               |                     |                     |
|                          | Non-PPO: 30% of the | Non-PPO: 25% of the |
| -   Delivery             | Plan allowance and  | Plan allowance and  |
|                          | any difference      | any difference      |
| -   Postnatal care       | between our         | between our         |
|                          | allowance and the   | allowance and the   |
| > Note: Here are some    | billed amount.      | billed amount.      |
| > things to keep in      |                     |                     |
| > mind:                  |                     |                     |
|                          |                     |                     |
| -   You do not need to   |                     |                     |
|     precertify your      |                     |                     |
|     normal delivery. See |                     |                     |
|     *Section 3, How you  |                     |                     |
|     get care*, for other |                     |                     |
|     circumstances, such  |                     |                     |
|     as extended stays    |                     |                     |
|     for you or your      |                     |                     |
|     baby.                |                     |                     |
|                          |                     |                     |
| -   You may remain in    |                     |                     |
|     the hospital up to   |                     |                     |
|     72 hours after a     |                     |                     |
|     regular delivery and |                     |                     |
|     96 hours after a     |                     |                     |
|     cesarean delivery.   |                     |                     |
|     We will cover an     |                     |                     |
|     extended stay if     |                     |                     |
|     medically necessary, |                     |                     |
|     but you, your        |                     |                     |
|     representative, your |                     |                     |
|     doctor, or your      |                     |                     |
|     hospital must        |                     |                     |
|     precertify.          |                     |                     |
|                          |                     |                     |
| -   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 if we      |                     |                     |
|     cover the infant     |                     |                     |
|     under a Self and     |                     |                     |
|     Family enrollment.   |                     |                     |
|     There are no         |                     |                     |
|     maternity benefits   |                     |                     |
|     for circumcision.    |                     |                     |
|     Surgical benefits    |                     |                     |
|     may be available.    |                     |                     |
+--------------------------+---------------------+---------------------+

*Maternity care --Continued on next page*

+--------------------------+---------------------+---------------------+
| > **Maternity care** --  | **You pay -         | > **You pay - High  |
| > c*ontinued*            | Standard Option**   | > Option**          |
+--------------------------+---------------------+---------------------+
| -   Prenatal care        | PPO: Nothing. (No   | PPO: Nothing. (No   |
|                          | deductible)         | deductible)         |
|                          |                     |                     |
|                          | Non-PPO: 30% of the | Non-PPO: 25% of the |
|                          | Plan allowance and  | Plan allowance and  |
|                          | any difference      | any difference      |
|                          | between our         | between our         |
|                          | allowance and the   | allowance and the   |
|                          | billed amount       | billed amount.      |
+--------------------------+---------------------+---------------------+
| -   We cover routine     | PPO: 9% of the Plan | PPO: 10% of the     |
|     sonograms during     | allowance           | Plan allowance      |
|     pregnancy to         |                     |                     |
|     determine age and    | Non-PPO: 30% of the | Non-PPO: 25% of the |
|     size.                | Plan allowance and  | Plan allowance and  |
|                          | any difference      | any difference      |
| -   Stand-by doctor      | between our         | between our         |
|     charges will be      | allowance and the   | allowance and the   |
|     covered only if      | billed amount       | billed amount.      |
|     medically necessary  |                     |                     |
|     treatment is         |                     |                     |
|     actually rendered to |                     |                     |
|     the child by the     |                     |                     |
|     doctor.              |                     |                     |
|                          |                     |                     |
| -   We pay               |                     |                     |
|     hospitalization and  |                     |                     |
|     surgeon services     |                     |                     |
|     (delivery) the same  |                     |                     |
|     as for illness and   |                     |                     |
|     injury. See Hospital |                     |                     |
|     benefits Section     |                     |                     |
|     5 (c) and Surgery    |                     |                     |
|     benefits Section 5   |                     |                     |
|     (b)*.*               |                     |                     |
+--------------------------+---------------------+---------------------+
| > *Not covered: Routine  | *All charges*       | *All Charges*       |
| > sonograms to determine |                     |                     |
| > sex*                   |                     |                     |
+--------------------------+---------------------+---------------------+
| > **Family planning**    |                     |                     |
+--------------------------+---------------------+---------------------+
| > A range of voluntary   | PPO: 9% of the Plan | PPO: 10% of the     |
| > family planning        | allowance           | Plan allowance      |
| > services, limited to:  |                     |                     |
|                          | Non-PPO: 30% of the | Non-PPO: 25% of the |
| -   Voluntary            | Plan allowance and  | Plan allowance and  |
|     sterilization (See   | any difference      | any difference      |
|     Surgical procedures  | between our         | between our         |
|     Section 5 (b))       | allowance and the   | allowance and the   |
|                          | billed amount       | billed amount.      |
| -   Surgically implanted |                     |                     |
|     contraceptives (such |                     |                     |
|     as Norplant)         |                     |                     |
+--------------------------+---------------------+---------------------+
| -   Injectable           | > PPO: 9% of the    | ###### PPO: 10% of  |
|     contraceptive drugs  | > Plan allowance    |  the Plan allowance |
|     (Such as Depo        | >                   |                     |
|     provera)             | > Non-PPO: 30% of   | > Non-PPO: 25% of   |
|                          | > the Plan          | > the Plan          |
| -   Intrauterine devices | > allowance and any | > allowance and any |
|     (IUDs)               | > difference        | > difference        |
|                          | > between our       | > between our       |
| -   Diaphragms           | > allowance and the | > allowance and the |
|                          | > billed amount     | > billed amount.    |
| > Note: We cover oral    |                     |                     |
| > contraceptives and     |                     |                     |
| > patches under the      |                     |                     |
| > prescription drug      |                     |                     |
| > benefit. Section 5     |                     |                     |
| > (f).                   |                     |                     |
+--------------------------+---------------------+---------------------+
| > *Not covered:*         | *All charges*       | *All Charges*       |
| > *Reversal of voluntary |                     |                     |
| > surgical               |                     |                     |
| > sterilization, genetic |                     |                     |
| > counseling*            |                     |                     |
+--------------------------+---------------------+---------------------+
| > **Infertility          | **You pay -         | > **You pay--High   |
| > services**             | Standard Option**   | > Option**          |
+--------------------------+---------------------+---------------------+
| > Diagnosis and          | PPO: 9% of the Plan | PPO: 10% of the     |
| > treatment of           | allowance           | Plan allowance      |
| > infertility, including |                     |                     |
| > up to two ovulation    | Non-PPO: 30% of the | Non-PPO: 25% of the |
| > tests per year, except | Plan allowance and  | Plan allowance and  |
| > as shown in Not        | any difference      | any difference      |
| > covered.               | between our         | between our         |
|                          | allowance and the   | allowance and the   |
|                          | billed amount       | billed amount       |
+--------------------------+---------------------+---------------------+
| > *Not covered:*         | > *All charges.*    | ###### All Charges  |
|                          |                     |                     |
| -   *Infertility         |                     |                     |
|     services after       |                     |                     |
|     voluntary            |                     |                     |
|     sterilization*       |                     |                     |
|                          |                     |                     |
| -   *Assisted            |                     |                     |
|     reproductive         |                     |                     |
|     technology (ART)     |                     |                     |
|     procedures, such     |                     |                     |
|     as:*                 |                     |                     |
|                          |                     |                     |
| > *-- artificial         |                     |                     |
| > insemination*          |                     |                     |
| >                        |                     |                     |
| > *-- in vitro           |                     |                     |
| > fertilization*         |                     |                     |
| >                        |                     |                     |
| > *-- embryo transfer    |                     |                     |
| > and (GIFT)*            |                     |                     |
| >                        |                     |                     |
| > *-- Intravaginal       |                     |                     |
| > insemination (IVI)*    |                     |                     |
| >                        |                     |                     |
| > *-- Intracervical      |                     |                     |
| > insemination (ICI)*    |                     |                     |
| >                        |                     |                     |
| > *-- Intrauterine       |                     |                     |
| > insemination (IUI)*    |                     |                     |
|                          |                     |                     |
| -   *Services and        |                     |                     |
|     supplies related to  |                     |                     |
|     ART procedures.*     |                     |                     |
|                          |                     |                     |
| -   *Cost of donor       |                     |                     |
|     sperm*               |                     |                     |
|                          |                     |                     |
| -   *Cost of donor egg*  |                     |                     |
+--------------------------+---------------------+---------------------+
| > **Allergy care**       |                     |                     |
+--------------------------+---------------------+---------------------+
| -   Testing and          | PPO: 9% of the Plan | PPO: 10% of the     |
|     treatment, including | allowance           | Plan allowance      |
|     materials (such as   |                     |                     |
|     allergy serum)       | Non-PPO: 30% of the | Non-PPO: 25% of the |
|                          | Plan allowance and  | Plan allowance and  |
| -   Allergy injections   | any difference      | any difference      |
|                          | between our         | between our         |
|                          | allowance and the   | allowance and the   |
|                          | billed amount       | billed amount       |
+--------------------------+---------------------+---------------------+
| > *Not covered:          | *All charges*       | *All charges*       |
| > provocative food       |                     |                     |
| > testing and sublingual |                     |                     |
| > allergy                |                     |                     |
| > desensitization*       |                     |                     |
+--------------------------+---------------------+---------------------+

+--------------------------+---------------------+---------------------+
| > **Treatment            | **You pay -         | > **You pay - High  |
| > therapies**            | Standard Option**   | > Option**          |
+--------------------------+---------------------+---------------------+
| -   Chemotherapy and     | PPO: 9% of the Plan | PPO: 10% of the     |
|     radiation therapy    | allowance           | Plan allowance      |
|                          |                     |                     |
| > Note: High dose        | Non-PPO: 30% of the | Non-PPO: 25% of the |
| > chemotherapy in        | Plan allowance and  | Plan allowance and  |
| > association with       | any difference      | any difference      |
| > autologous bone marrow | between our         | between our         |
| > transplants is limited | allowance and the   | allowance and the   |
| > to those transplants   | billed amount       | billed amount       |
| > listed on page 39.     |                     |                     |
|                          |                     |                     |
| -   Intravenous          |                     |                     |
|     (IV)/Infusion        |                     |                     |
|     Therapy -- Home IV   |                     |                     |
|     and antibiotic       |                     |                     |
|     therapy              |                     |                     |
|                          |                     |                     |
| -   Growth hormone       |                     |                     |
|     therapy (GHT), when  |                     |                     |
|     preauthorized by the |                     |                     |
|     Plan                 |                     |                     |
|                          |                     |                     |
| > Note: Preauthorized    |                     |                     |
| > growth hormone is      |                     |                     |
| > covered under the      |                     |                     |
| > prescription drug      |                     |                     |
| > benefit.               |                     |                     |
| >                        |                     |                     |
| > Note: -- We only cover |                     |                     |
| > GHT when we            |                     |                     |
| > preauthorize the       |                     |                     |
| > treatment. To obtain   |                     |                     |
| > preauthorization, you  |                     |                     |
| > may call our customer  |                     |                     |
| > service department at  |                     |                     |
| > **800-544-7111** and   |                     |                     |
| > have your physician    |                     |                     |
| > submit the complete    |                     |                     |
| > medical information to |                     |                     |
| > the Plan. If we        |                     |                     |
| > determine GHT is not   |                     |                     |
| > medically necessary we |                     |                     |
| > will not preauthorize  |                     |                     |
| > the GHT or any related |                     |                     |
| > services and supplies. |                     |                     |
| >                        |                     |                     |
| > Respiratory and        |                     |                     |
| > inhalation therapies   |                     |                     |
+--------------------------+---------------------+---------------------+
| > *Not covered:*         | > *All charges*     | > *All charges*     |
|                          |                     |                     |
| -   *Chelation therapy,  |                     |                     |
|     except for acute     |                     |                     |
|     arsenic, gold, lead  |                     |                     |
|     or mercury           |                     |                     |
|     poisoning.*          |                     |                     |
|                          |                     |                     |
| -   *Dialysis --         |                     |                     |
|     hemodialysis and     |                     |                     |
|     peritoneal dialysis. |                     |                     |
|     See Special features |                     |                     |
|     for covered          |                     |                     |
|     benefits.*           |                     |                     |
+--------------------------+---------------------+---------------------+
| > **Physical and         |                     |                     |
| > occupational           |                     |                     |
| > therapies**            |                     |                     |
+--------------------------+---------------------+---------------------+
| > Covered under          |                     | ######              |
| > Alternative treatment  |                     |                     |
+--------------------------+---------------------+---------------------+
| > **Speech therapy**     |                     |                     |
+--------------------------+---------------------+---------------------+
| > Covered under          |                     |                     |
| > Alternative treatment  |                     |                     |
+--------------------------+---------------------+---------------------+

+--------------------------+---------------------+---------------------+
| > **Hearing services     | **You pay -         | > **You pay - High  |
| > (testing, treatment,   | Standard Option**   | > Option**          |
| > and supplies)**        |                     |                     |
+--------------------------+---------------------+---------------------+
| > Hearing aids,          | PPO: Same as        | PPO: Same as        |
| > including exams, tests | non-PPO             | non-PPO             |
| > and adjustments to     |                     |                     |
| > hearing devices when   | Non-PPO: 30% of the | Non-PPO: 25% of the |
| > necessitated by        | Plan allowance and  | Plan allowance and  |
| > accidental injury or   | any difference      | any difference      |
| > surgery                | between our         | between our         |
| >                        | allowance and the   | allowance and the   |
| > Note: Must be obtained | billed amount       | billed amount       |
| > within 120 days of the |                     |                     |
| > surgery or injury      |                     |                     |
+--------------------------+---------------------+---------------------+
| > *Not covered:*         | > *All charges.*    | *All charges*       |
|                          |                     |                     |
| -   *routine hearing     |                     |                     |
|     testing*             |                     |                     |
|                          |                     |                     |
| -   *hearing aids,       |                     |                     |
|     testing and          |                     |                     |
|     examinations and     |                     |                     |
|     batteries for them,  |                     |                     |
|     except for           |                     |                     |
|     accidental injury or |                     |                     |
|     surgery*             |                     |                     |
+--------------------------+---------------------+---------------------+
| > **Vision services      |                     |                     |
| > (testing, treatment,   |                     |                     |
| > and supplies)**        |                     |                     |
+--------------------------+---------------------+---------------------+
| -   One pair of          | PPO: Same as        | PPO: Same as        |
|     eyeglasses or        | non-PPO             | non-PPO             |
|     contact lenses to    |                     |                     |
|     correct an           | Non-PPO: 30% of the | Non-PPO: 25% of the |
|     impairment directly  | Plan allowance and  | Plan allowance and  |
|     caused by accidental | any difference      | any difference      |
|     ocular injury or     | between our         | between our         |
|     intraocular surgery  | allowance and the   | allowance and the   |
|     (such as for         | billed amount       | billed amount       |
|     cataracts).          |                     |                     |
+--------------------------+---------------------+---------------------+
| > *Not covered:*         | > *All charges*     | *All charges*       |
|                          |                     |                     |
| -   *Eyeglasses or       |                     |                     |
|     contact lenses and   |                     |                     |
|     examinations for     |                     |                     |
|     them except as noted |                     |                     |
|     as covered*          |                     |                     |
|                          |                     |                     |
| -   *Eye exercises and   |                     |                     |
|     orthoptics (visual   |                     |                     |
|     training)*           |                     |                     |
|                          |                     |                     |
| -   *Radial keratotomy   |                     |                     |
|     and other refractive |                     |                     |
|     surgery*             |                     |                     |
+--------------------------+---------------------+---------------------+

+--------------------------+---------------------+---------------------+
| > **Foot care**          | **You pay -         | > **You pay - High  |
|                          | Standard Option**   | > Option**          |
+--------------------------+---------------------+---------------------+
| > Routine foot care when | PPO: 9% of the Plan | PPO: 10% of the     |
| > you are under active   | allowance           | Plan allowance      |
| > treatment for a        |                     |                     |
| > metabolic or           | Non-PPO: 30% of the | Non-PPO: 25% of the |
| > peripheral vascular    | Plan allowance and  | Plan allowance and  |
| > disease, such as       | any difference      | any difference      |
| > diabetes.              | between our         | between our         |
|                          | allowance and the   | allowance and the   |
|                          | billed amount       | billed amount       |
+--------------------------+---------------------+---------------------+
| *Not covered:*           | *All charges*       | *All charges*       |
|                          |                     |                     |
| -   *Removal or          |                     |                     |
|     treatment of corns,  |                     |                     |
|     calluses, free edge  |                     |                     |
|     of toenails, and     |                     |                     |
|     foot subluxations*   |                     |                     |
|                          |                     |                     |
| -   *Foot orthotics*     |                     |                     |
|                          |                     |                     |
| -   *Arch supports*      |                     |                     |
|                          |                     |                     |
| -   *Orthopedic and      |                     |                     |
|     corrective shoes*    |                     |                     |
|                          |                     |                     |
| -   *Heel pads and heel  |                     |                     |
|     cups*                |                     |                     |
+--------------------------+---------------------+---------------------+
| > **Orthopedic and       |                     |                     |
| > prosthetic devices**   |                     |                     |
+--------------------------+---------------------+---------------------+
| -   Artificial limbs and | PPO: Same as        | PPO: Same as        |
|     eyes; stump hose     | non-PPO             | non-PPO             |
|                          |                     |                     |
| ```{=html}               | Non-PPO: 30% of the | Non-PPO: 25% of the |
| <!-- -->                 | Plan allowance and  | Plan allowance and  |
| ```                      | any difference      | any difference      |
| -   Externally worn      | between our         | between our         |
|     breast prostheses    | allowance and the   | allowance and the   |
|     and surgical bras,   | billed amount       | billed amount       |
|     including necessary  |                     |                     |
|     replacements         |                     |                     |
|     following a          |                     |                     |
|     mastectomy           |                     |                     |
|                          |                     |                     |
| > Internal prosthetic    |                     |                     |
| > devices, such as       |                     |                     |
| > artificial joints,     |                     |                     |
| > pacemakers, cochlear   |                     |                     |
| > implants, and          |                     |                     |
| > surgically implanted   |                     |                     |
| > breast implants        |                     |                     |
| > following mastectomy.  |                     |                     |
| > Note: See Section 5    |                     |                     |
| > (b) for coverage of    |                     |                     |
| > the surgery to insert  |                     |                     |
| > the device, and        |                     |                     |
| > Section 5 (c) for      |                     |                     |
| > inpatient and          |                     |                     |
| > outpatient hospital    |                     |                     |
| > charges.               |                     |                     |
+--------------------------+---------------------+---------------------+
| > *Not covered:*         | *All charges.*      | *All charges.*      |
|                          |                     |                     |
| -   *Orthopedic and      |                     |                     |
|     corrective shoes*    |                     |                     |
|                          |                     |                     |
| -   *Arch supports*      |                     |                     |
|                          |                     |                     |
| -   *Foot orthotics*     |                     |                     |
|                          |                     |                     |
| -   *Heel pads and heel  |                     |                     |
|     cups*                |                     |                     |
|                          |                     |                     |
| -   *Corsets, trusses,   |                     |                     |
|     elastic stockings,   |                     |                     |
|     support hose, and    |                     |                     |
|     other supportive     |                     |                     |
|     devices*             |                     |                     |
|                          |                     |                     |
| -   *Lumbosacral         |                     |                     |
|     supports*            |                     |                     |
+--------------------------+---------------------+---------------------+

+--------------------------+---------------------+---------------------+
| > **Durable medical      | **You pay -         | **You pay - High    |
| > equipment (DME)**      | Standard Option**   | Option**            |
+--------------------------+---------------------+---------------------+
| > Durable medical        | PPO: Same as        | PPO: Same as        |
| > equipment (DME) is     | non-PPO (No         | non-PPO (No         |
| > equipment and supplies | deductible)         | deductible)         |
| > that:                  |                     |                     |
|                          | Non-PPO: \$100      | Non-PPO: \$100      |
| 1.  Are prescribed by    | copayment per       | copayment per       |
|     your attending       | device and 30% of   | device and 25% of   |
|     physician (i.e., the | the Plan allowance  | the Plan allowance  |
|     physician who is     | and any difference  | and any difference  |
|     treating your        | between our         | between our         |
|     illness or injury);  | allowance and the   | allowance and the   |
|                          | billed amount (No   | billed amount (No   |
| 2.  Are medically        | deductible)         | deductible)         |
|     necessary;           |                     |                     |
|                          | Non-PPO: 30% of the | Non-PPO: 25% of the |
| 3.  Are primarily and    | Plan allowance and  | Plan allowance and  |
|     customarily used     | any difference      | any difference      |
|     only for a medical   | between our         | between our         |
|     purpose;             | allowance and the   | allowance and the   |
|                          | billed amount for   | billed amount for   |
| 4.  Are generally useful | supplies received   | supplies received   |
|     only to a person     | independently of a  | independently of a  |
|     with an illness or   | device.             | device.             |
|     injury;              |                     |                     |
|                          |                     |                     |
| 5.  Are designed for     |                     |                     |
|     prolonged use; and   |                     |                     |
|                          |                     |                     |
| 6.  Serve a specific     |                     |                     |
|     therapeutic purpose  |                     |                     |
|     in the treatment of  |                     |                     |
|     an illness or        |                     |                     |
|     injury.              |                     |                     |
|                          |                     |                     |
| > We cover rental or     |                     |                     |
| > purchase, at our       |                     |                     |
| > option, including      |                     |                     |
| > repair and adjustment, |                     |                     |
| > of durable medical     |                     |                     |
| > equipment, such as     |                     |                     |
| > oxygen and dialysis    |                     |                     |
| > equipment. Under this  |                     |                     |
| > benefit, we also       |                     |                     |
| > cover:                 |                     |                     |
|                          |                     |                     |
| -   Hospital beds;       |                     |                     |
|                          |                     |                     |
| ```{=html}               |                     |                     |
| <!-- -->                 |                     |                     |
| ```                      |                     |                     |
| -   Wheelchairs;         |                     |                     |
|                          |                     |                     |
| -   Crutches; and        |                     |                     |
|                          |                     |                     |
| -   Walkers.             |                     |                     |
|                          |                     |                     |
| > Note: Call us at       |                     |                     |
| > **866-218-8317** for   |                     |                     |
| > information on how to  |                     |                     |
| > get pre-approval for   |                     |                     |
| > lease or purchase.     |                     |                     |
| >                        |                     |                     |
| > Note: A purchase of    |                     |                     |
| > durable medical        |                     |                     |
| > equipment in excess of |                     |                     |
| > \$600 must be          |                     |                     |
| > supported by a letter  |                     |                     |
| > of medical necessity   |                     |                     |
| > and pre-approved by    |                     |                     |
| > the Plan to be         |                     |                     |
| > covered.               |                     |                     |
+--------------------------+---------------------+---------------------+
| > *Not covered:*         | *All charges*       | *All charges*       |
|                          |                     |                     |
| -   *Sun or heat lamps;  |                     |                     |
|     heating pads;*       |                     |                     |
|                          |                     |                     |
| -   *Air conditioners,   |                     |                     |
|     purifiers and        |                     |                     |
|     humidifiers;*        |                     |                     |
|                          |                     |                     |
| -   *Exercise, safety,   |                     |                     |
|     computer,            |                     |                     |
|     communication and    |                     |                     |
|     convenience          |                     |                     |
|     equipment;*          |                     |                     |
|                          |                     |                     |
| -   *Whirlpools, saunas  |                     |                     |
|     and similar          |                     |                     |
|     household items*     |                     |                     |
+--------------------------+---------------------+---------------------+

*Durable medical equipment (DME) -- Continued on next page*

+--------------------------+---------------------+---------------------+
| > **Durable medical      | **You pay -         | **You pay - High    |
| > equipment (DME)** --   | Standard Option**   | Option**            |
| > *continued*            |                     |                     |
+--------------------------+---------------------+---------------------+
| > *Not covered:*         | *All charges*       | *All charges*       |
|                          |                     |                     |
| -   *Stair glides,       |                     |                     |
|     ramps, liftchairs,   |                     |                     |
|     elevators and other  |                     |                     |
|     modifications or     |                     |                     |
|     alterations to       |                     |                     |
|     vehicles or          |                     |                     |
|     households;*         |                     |                     |
+--------------------------+---------------------+---------------------+
| > **Home health          |                     |                     |
| > services**             |                     |                     |
+--------------------------+---------------------+---------------------+
| > Nursing services and   | > PPO: Same as      | > PPO: Same as      |
| > home health care when: | > non-PPO           | > non-PPO           |
|                          | >                   | >                   |
| -   A registered nurse   | > Non-PPO: 30% of   | > Non-PPO: 25% of   |
|     (R.N.), licensed     | > the Plan          | > the Plan          |
|     practical nurse      | > allowance and any | > allowance and any |
|     (L.P.N.) or licensed | > difference        | > difference        |
|     vocational nurse     | > between the       | > between the       |
|     (L.V.N.) provides    | > \$10,000 per      | > \$10,000 per      |
|     the services;        | > person, per year, | > person, per year, |
|                          | > maximum Plan      | > maximum Plan      |
| -   A home health aide,  | > payment and the   | > payment and the   |
|     that is part of a    | > billed amount     | > billed amount     |
|     home health care     |                     |                     |
|     plan after discharge |                     |                     |
|     from covered         |                     |                     |
|     hospital confinement |                     |                     |
|     provides the         |                     |                     |
|     services             |                     |                     |
|                          |                     |                     |
| ```{=html}               |                     |                     |
| <!-- -->                 |                     |                     |
| ```                      |                     |                     |
| -   The attending        |                     |                     |
|     physician orders the |                     |                     |
|     care;                |                     |                     |
|                          |                     |                     |
| -   The physician        |                     |                     |
|     identifies the       |                     |                     |
|     specific             |                     |                     |
|     professional skills  |                     |                     |
|     required by the      |                     |                     |
|     patient and the      |                     |                     |
|     medical necessity    |                     |                     |
|     for skilled          |                     |                     |
|     services; and        |                     |                     |
|                          |                     |                     |
| -   The physician        |                     |                     |
|     indicates the length |                     |                     |
|     of time the services |                     |                     |
|     are needed.          |                     |                     |
+--------------------------+---------------------+---------------------+
| > *Not covered:*         | > *All charges.*    | > *All charges*     |
|                          |                     |                     |
| -   *Nursing care        |                     |                     |
|     requested by, or for |                     |                     |
|     the convenience of,  |                     |                     |
|     the patient or the   |                     |                     |
|     patient's family;*   |                     |                     |
|                          |                     |                     |
| -   *Services primarily  |                     |                     |
|     for hygiene,         |                     |                     |
|     feeding, exercising, |                     |                     |
|     moving the patient,  |                     |                     |
|     homemaking,          |                     |                     |
|     companionship or     |                     |                     |
|     giving oral          |                     |                     |
|     medication;*         |                     |                     |
|                          |                     |                     |
| ```{=html}               |                     |                     |
| <!-- -->                 |                     |                     |
| ```                      |                     |                     |
| -   *Private duty        |                     |                     |
|     nursing care while   |                     |                     |
|     confined in a        |                     |                     |
|     hospital*            |                     |                     |
+--------------------------+---------------------+---------------------+
| > **Chiropractic**       |                     |                     |
+--------------------------+---------------------+---------------------+
| > Covered under          |                     |                     |
| > Alternative treatment  |                     |                     |
+--------------------------+---------------------+---------------------+

+--------------------------+---------------------+---------------------+
| > **Alternative          | **You pay -         | > **You pay - High  |
| > treatments**           | Standard Option**   | > Option**          |
+--------------------------+---------------------+---------------------+
| > Acupuncture by a       | PPO: 9% of the Plan | PPO: 10% of the     |
| > doctor of medicine,    | allowance and any   | Plan allowance and  |
| > osteopathy, or         | difference between  | any difference      |
| > licensed acupuncturist | the \$2,000 per     | between the \$2,000 |
| > for anesthesia, pain   | person , per year   | per person , per    |
| > relief, or therapeutic | maximum Plan        | year maximum Plan   |
| > treatment              | payment and the     | payment and the     |
| >                        | billed amount       | billed amount       |
| > Physical therapy       |                     |                     |
| >                        | Non-PPO: 30% of the | Non-PPO: 25% of the |
| > Occupational therapy   | Plan allowance and  | Plan allowance and  |
| >                        | any difference      | any difference      |
| > Speech therapy         | between our         | between our         |
| >                        | allowance and the   | allowance and the   |
| > Chiropractic services  | billed amount and   | billed amount and   |
| >                        | any difference      | any difference      |
| > Cardiovascular,        | between the \$2,000 | between the \$2,000 |
| > metabolic and          | per person , per    | per person , per    |
| > pulmonary conditioning | year maximum Plan   | year maximum Plan   |
| > when we approve a      | payment and the     | payment and the     |
| > supporting letter of   | billed amount       | billed amount       |
| > medical necessity from |                     |                     |
| > your doctor.           |                     |                     |
+--------------------------+---------------------+---------------------+
| *Not covered:*           | *All charges*       | *All charges*       |
|                          |                     |                     |
| -   *Long-term           |                     |                     |
|     rehabilitative       |                     |                     |
|     therapy, except      |                     |                     |
|     speech therapy*      |                     |                     |
|                          |                     |                     |
| -   *Exercise programs*  |                     |                     |
|                          |                     |                     |
| -   *Maintenance cardiac |                     |                     |
|     rehabilitation*      |                     |                     |
+--------------------------+---------------------+---------------------+
| > **Educational classes  |                     |                     |
| > and programs**         |                     |                     |
+--------------------------+---------------------+---------------------+
| > Coverage is limited    | > PPO: Same as      | > PPO: Same as      |
| > to:                    | > non-PPO           | > non-PPO           |
|                          | >                   | >                   |
| -   Smoking Cessation    | > Non-PPO: Any      | > Non-PPO: Any      |
|                          | > difference        | > difference        |
| > Non-PPO -- Up to \$200 | > between the \$200 | > between the \$200 |
| > for one smoking        | > per person per    | > per person per    |
| > cessation program per  | > lifetime Plan     | > lifetime Plan     |
| > person per lifetime.   | > allowance and the | > allowance and the |
| >                        | > billed amount     | > billed amount     |
| > Note -- Smoking        | >                   | >                   |
| > cessation drugs and    | > See Section 5 (g) | > See Section 5 (g) |
| > medications, including | > for additional    | > for additional    |
| > nicotine patches are   | > Mayo Clinic       | > Mayo Clinic       |
| > not available under    | > benefits.         | > benefits.         |
| > any other Plan         |                     |                     |
| > provisions.            |                     |                     |
+--------------------------+---------------------+---------------------+
| -   Diabetes             | > PPO: Nothing (No  | > PPO: Nothing (No  |
|     self-management.     | > deductible)       | > deductible)       |
|                          | >                   | >                   |
|                          | > Non-PPO: 30% of   | > Non-PPO: 25% of   |
|                          | > the Plan          | > the Plan          |
|                          | > allowance and any | > allowance and any |
|                          | > difference        | > difference        |
|                          | > between our       | > between our       |
|                          | > allowance and the | > allowance and the |
|                          | > billed amount     | > billed amount     |
+--------------------------+---------------------+---------------------+

+---+---+--------------------+--------------------+---------------+---+---+---+---+
| # |   |                    |                    |               |   |   |   |   |
| # |   |                    |                    |               |   |   |   |   |
|   |   |                    |                    |               |   |   |   |   |
| * |   |                    |                    |               |   |   |   |   |
| * |   |                    |                    |               |   |   |   |   |
| S |   |                    |                    |               |   |   |   |   |
| e |   |                    |                    |               |   |   |   |   |
| c |   |                    |                    |               |   |   |   |   |
| t |   |                    |                    |               |   |   |   |   |
| i |   |                    |                    |               |   |   |   |   |
| o |   |                    |                    |               |   |   |   |   |
| n |   |                    |                    |               |   |   |   |   |
|   |   |                    |                    |               |   |   |   |   |
| 5 |   |                    |                    |               |   |   |   |   |
|   |   |                    |                    |               |   |   |   |   |
| ( |   |                    |                    |               |   |   |   |   |
| b |   |                    |                    |               |   |   |   |   |
| ) |   |                    |                    |               |   |   |   |   |
| . |   |                    |                    |               |   |   |   |   |
|   |   |                    |                    |               |   |   |   |   |
| S |   |                    |                    |               |   |   |   |   |
| u |   |                    |                    |               |   |   |   |   |
| r |   |                    |                    |               |   |   |   |   |
| g |   |                    |                    |               |   |   |   |   |
| i |   |                    |                    |               |   |   |   |   |
| c |   |                    |                    |               |   |   |   |   |
| a |   |                    |                    |               |   |   |   |   |
| l |   |                    |                    |               |   |   |   |   |
|   |   |                    |                    |               |   |   |   |   |
| a |   |                    |                    |               |   |   |   |   |
| n |   |                    |                    |               |   |   |   |   |
| d |   |                    |                    |               |   |   |   |   |
|   |   |                    |                    |               |   |   |   |   |
| a |   |                    |                    |               |   |   |   |   |
| n |   |                    |                    |               |   |   |   |   |
| e |   |                    |                    |               |   |   |   |   |
| s |   |                    |                    |               |   |   |   |   |
| t |   |                    |                    |               |   |   |   |   |
| h |   |                    |                    |               |   |   |   |   |
| e |   |                    |                    |               |   |   |   |   |
| s |   |                    |                    |               |   |   |   |   |
| i |   |                    |                    |               |   |   |   |   |
| a |   |                    |                    |               |   |   |   |   |
|   |   |                    |                    |               |   |   |   |   |
| s |   |                    |                    |               |   |   |   |   |
| e |   |                    |                    |               |   |   |   |   |
| r |   |                    |                    |               |   |   |   |   |
| v |   |                    |                    |               |   |   |   |   |
| i |   |                    |                    |               |   |   |   |   |
| c |   |                    |                    |               |   |   |   |   |
| e |   |                    |                    |               |   |   |   |   |
| s |   |                    |                    |               |   |   |   |   |
|   |   |                    |                    |               |   |   |   |   |
| p |   |                    |                    |               |   |   |   |   |
| r |   |                    |                    |               |   |   |   |   |
| o |   |                    |                    |               |   |   |   |   |
| v |   |                    |                    |               |   |   |   |   |
| i |   |                    |                    |               |   |   |   |   |
| d |   |                    |                    |               |   |   |   |   |
| e |   |                    |                    |               |   |   |   |   |
| d |   |                    |                    |               |   |   |   |   |
|   |   |                    |                    |               |   |   |   |   |
| b |   |                    |                    |               |   |   |   |   |
| y |   |                    |                    |               |   |   |   |   |
|   |   |                    |                    |               |   |   |   |   |
| p |   |                    |                    |               |   |   |   |   |
| h |   |                    |                    |               |   |   |   |   |
| y |   |                    |                    |               |   |   |   |   |
| s |   |                    |                    |               |   |   |   |   |
| i |   |                    |                    |               |   |   |   |   |
| c |   |                    |                    |               |   |   |   |   |
| i |   |                    |                    |               |   |   |   |   |
| a |   |                    |                    |               |   |   |   |   |
| n |   |                    |                    |               |   |   |   |   |
| s |   |                    |                    |               |   |   |   |   |
|   |   |                    |                    |               |   |   |   |   |
| a |   |                    |                    |               |   |   |   |   |
| n |   |                    |                    |               |   |   |   |   |
| d |   |                    |                    |               |   |   |   |   |
|   |   |                    |                    |               |   |   |   |   |
| o |   |                    |                    |               |   |   |   |   |
| t |   |                    |                    |               |   |   |   |   |
| h |   |                    |                    |               |   |   |   |   |
| e |   |                    |                    |               |   |   |   |   |
| r |   |                    |                    |               |   |   |   |   |
|   |   |                    |                    |               |   |   |   |   |
| h |   |                    |                    |               |   |   |   |   |
| e |   |                    |                    |               |   |   |   |   |
| a |   |                    |                    |               |   |   |   |   |
| l |   |                    |                    |               |   |   |   |   |
| t |   |                    |                    |               |   |   |   |   |
| h |   |                    |                    |               |   |   |   |   |
|   |   |                    |                    |               |   |   |   |   |
| c |   |                    |                    |               |   |   |   |   |
| a |   |                    |                    |               |   |   |   |   |
| r |   |                    |                    |               |   |   |   |   |
| e |   |                    |                    |               |   |   |   |   |
|   |   |                    |                    |               |   |   |   |   |
| p |   |                    |                    |               |   |   |   |   |
| r |   |                    |                    |               |   |   |   |   |
| o |   |                    |                    |               |   |   |   |   |
| f |   |                    |                    |               |   |   |   |   |
| e |   |                    |                    |               |   |   |   |   |
| s |   |                    |                    |               |   |   |   |   |
| s |   |                    |                    |               |   |   |   |   |
| i |   |                    |                    |               |   |   |   |   |
| o |   |                    |                    |               |   |   |   |   |
| n |   |                    |                    |               |   |   |   |   |
| a |   |                    |                    |               |   |   |   |   |
| l |   |                    |                    |               |   |   |   |   |
| s |   |                    |                    |               |   |   |   |   |
| * |   |                    |                    |               |   |   |   |   |
| * |   |                    |                    |               |   |   |   |   |
+---+---+--------------------+--------------------+---------------+---+---+---+---+
|   | * | **Here are some    |                    |               | * |   |   |   |
|   | * | important things   |                    |               | * |   |   |   |
|   | I | you should keep in |                    |               | I |   |   |   |
|   | * | mind about these   |                    |               | * |   |   |   |
|   | * | benefits:**        |                    |               | * |   |   |   |
|   |   |                    |                    |               |   |   |   |   |
|   | * | -   Please         |                    |               | * |   |   |   |
|   | * |     remember that  |                    |               | * |   |   |   |
|   | M |     all benefits   |                    |               | M |   |   |   |
|   | * |     are subject to |                    |               | * |   |   |   |
|   | * |     the            |                    |               | * |   |   |   |
|   |   |     definitions,   |                    |               |   |   |   |   |
|   | * |     limitations,   |                    |               | * |   |   |   |
|   | * |     and exclusions |                    |               | * |   |   |   |
|   | P |     in this        |                    |               | P |   |   |   |
|   | * |     brochure and   |                    |               | * |   |   |   |
|   | * |     are payable    |                    |               | * |   |   |   |
|   |   |     only when we   |                    |               |   |   |   |   |
|   | * |     determine they |                    |               | * |   |   |   |
|   | * |     are medically  |                    |               | * |   |   |   |
|   | O |     necessary.     |                    |               | O |   |   |   |
|   | * |                    |                    |               | * |   |   |   |
|   | * | ```{=html}         |                    |               | * |   |   |   |
|   |   | <!-- -->           |                    |               |   |   |   |   |
|   | * | ```                |                    |               | * |   |   |   |
|   | * | -   The calendar   |                    |               | * |   |   |   |
|   | R |     year           |                    |               | R |   |   |   |
|   | * |     deductible is: |                    |               | * |   |   |   |
|   | * |                    |                    |               | * |   |   |   |
|   |   | > The calendar     |                    |               |   |   |   |   |
|   | * | > year deductible  |                    |               | * |   |   |   |
|   | * | > applies to       |                    |               | * |   |   |   |
|   | T | > almost all       |                    |               | T |   |   |   |
|   | * | > benefits in this |                    |               | * |   |   |   |
|   | * | > Section. We      |                    |               | * |   |   |   |
|   |   | > added "(No       |                    |               |   |   |   |   |
|   | * | > deductible)" to  |                    |               | * |   |   |   |
|   | * | > show when the    |                    |               | * |   |   |   |
|   | A | > calendar year    |                    |               | A |   |   |   |
|   | * | > deductible does  |                    |               | * |   |   |   |
|   | * | > not apply.       |                    |               | * |   |   |   |
|   |   |                    |                    |               |   |   |   |   |
|   | * | -   The non-PPO    |                    |               | * |   |   |   |
|   | * |     benefits are   |                    |               | * |   |   |   |
|   | N |     the standard   |                    |               | N |   |   |   |
|   | * |     benefits of    |                    |               | * |   |   |   |
|   | * |     this Plan. PPO |                    |               | * |   |   |   |
|   |   |     benefits apply |                    |               |   |   |   |   |
|   | * |     only when you  |                    |               | * |   |   |   |
|   | * |     use a PPO      |                    |               | * |   |   |   |
|   | T |     provider. When |                    |               | T |   |   |   |
|   | * |     no PPO         |                    |               | * |   |   |   |
|   | * |     provider is    |                    |               | * |   |   |   |
|   |   |     available,     |                    |               |   |   |   |   |
|   |   |     non-PPO        |                    |               |   |   |   |   |
|   |   |     benefits       |                    |               |   |   |   |   |
|   |   |     apply.         |                    |               |   |   |   |   |
|   |   |                    |                    |               |   |   |   |   |
|   |   | -   Be sure to     |                    |               |   |   |   |   |
|   |   |     read Section   |                    |               |   |   |   |   |
|   |   |     4, *Your costs |                    |               |   |   |   |   |
|   |   |     for covered    |                    |               |   |   |   |   |
|   |   |     services*, for |                    |               |   |   |   |   |
|   |   |     valuable       |                    |               |   |   |   |   |
|   |   |     information    |                    |               |   |   |   |   |
|   |   |     about how cost |                    |               |   |   |   |   |
|   |   |     sharing works, |                    |               |   |   |   |   |
|   |   |     with special   |                    |               |   |   |   |   |
|   |   |     sections for   |                    |               |   |   |   |   |
|   |   |     members who    |                    |               |   |   |   |   |
|   |   |     are age 65 or  |                    |               |   |   |   |   |
|   |   |     over. Also     |                    |               |   |   |   |   |
|   |   |     read Section 9 |                    |               |   |   |   |   |
|   |   |     about          |                    |               |   |   |   |   |
|   |   |     coordinating   |                    |               |   |   |   |   |
|   |   |     benefits with  |                    |               |   |   |   |   |
|   |   |     other          |                    |               |   |   |   |   |
|   |   |     coverage,      |                    |               |   |   |   |   |
|   |   |     including with |                    |               |   |   |   |   |
|   |   |     Medicare.      |                    |               |   |   |   |   |
|   |   |                    |                    |               |   |   |   |   |
|   |   | ```{=html}         |                    |               |   |   |   |   |
|   |   | <!-- -->           |                    |               |   |   |   |   |
|   |   | ```                |                    |               |   |   |   |   |
|   |   | -   The amounts    |                    |               |   |   |   |   |
|   |   |     listed below   |                    |               |   |   |   |   |
|   |   |     are for the    |                    |               |   |   |   |   |
|   |   |     charges billed |                    |               |   |   |   |   |
|   |   |     by a physician |                    |               |   |   |   |   |
|   |   |     or other       |                    |               |   |   |   |   |
|   |   |     health care    |                    |               |   |   |   |   |
|   |   |     professional   |                    |               |   |   |   |   |
|   |   |     for your       |                    |               |   |   |   |   |
|   |   |     surgical care. |                    |               |   |   |   |   |
|   |   |     Look in        |                    |               |   |   |   |   |
|   |   |     Section 5 (c)  |                    |               |   |   |   |   |
|   |   |     for charges    |                    |               |   |   |   |   |
|   |   |     associated     |                    |               |   |   |   |   |
|   |   |     with the       |                    |               |   |   |   |   |
|   |   |     facility (i.e. |                    |               |   |   |   |   |
|   |   |     hospital,      |                    |               |   |   |   |   |
|   |   |     surgical       |                    |               |   |   |   |   |
|   |   |     center, etc.)  |                    |               |   |   |   |   |
+---+---+--------------------+--------------------+---------------+---+---+---+---+
| * |   |                    | **You pay**        |               |   |   |   |   |
| * |   |                    |                    |               |   |   |   |   |
| B |   |                    | **After the        |               |   |   |   |   |
| e |   |                    | calendar year      |               |   |   |   |   |
| n |   |                    | deductible...**    |               |   |   |   |   |
| e |   |                    |                    |               |   |   |   |   |
| f |   |                    |                    |               |   |   |   |   |
| i |   |                    |                    |               |   |   |   |   |
| t |   |                    |                    |               |   |   |   |   |
| D |   |                    |                    |               |   |   |   |   |
| e |   |                    |                    |               |   |   |   |   |
| s |   |                    |                    |               |   |   |   |   |
| c |   |                    |                    |               |   |   |   |   |
| r |   |                    |                    |               |   |   |   |   |
| i |   |                    |                    |               |   |   |   |   |
| p |   |                    |                    |               |   |   |   |   |
| t |   |                    |                    |               |   |   |   |   |
| i |   |                    |                    |               |   |   |   |   |
| o |   |                    |                    |               |   |   |   |   |
| n |   |                    |                    |               |   |   |   |   |
| * |   |                    |                    |               |   |   |   |   |
| * |   |                    |                    |               |   |   |   |   |
+---+---+--------------------+--------------------+---------------+---+---+---+---+
| * |   |                    |                    |               |   |   |   |   |
| * |   |                    |                    |               |   |   |   |   |
| N |   |                    |                    |               |   |   |   |   |
| O |   |                    |                    |               |   |   |   |   |
| T |   |                    |                    |               |   |   |   |   |
| E |   |                    |                    |               |   |   |   |   |
| : |   |                    |                    |               |   |   |   |   |
| T |   |                    |                    |               |   |   |   |   |
| h |   |                    |                    |               |   |   |   |   |
| e |   |                    |                    |               |   |   |   |   |
| c |   |                    |                    |               |   |   |   |   |
| a |   |                    |                    |               |   |   |   |   |
| l |   |                    |                    |               |   |   |   |   |
| e |   |                    |                    |               |   |   |   |   |
| n |   |                    |                    |               |   |   |   |   |
| d |   |                    |                    |               |   |   |   |   |
| a |   |                    |                    |               |   |   |   |   |
| r |   |                    |                    |               |   |   |   |   |
| y |   |                    |                    |               |   |   |   |   |
| e |   |                    |                    |               |   |   |   |   |
| a |   |                    |                    |               |   |   |   |   |
| r |   |                    |                    |               |   |   |   |   |
| d |   |                    |                    |               |   |   |   |   |
| e |   |                    |                    |               |   |   |   |   |
| d |   |                    |                    |               |   |   |   |   |
| u |   |                    |                    |               |   |   |   |   |
| c |   |                    |                    |               |   |   |   |   |
| t |   |                    |                    |               |   |   |   |   |
| i |   |                    |                    |               |   |   |   |   |
| b |   |                    |                    |               |   |   |   |   |
| l |   |                    |                    |               |   |   |   |   |
| e |   |                    |                    |               |   |   |   |   |
| a |   |                    |                    |               |   |   |   |   |
| p |   |                    |                    |               |   |   |   |   |
| p |   |                    |                    |               |   |   |   |   |
| l |   |                    |                    |               |   |   |   |   |
| i |   |                    |                    |               |   |   |   |   |
| e |   |                    |                    |               |   |   |   |   |
| s |   |                    |                    |               |   |   |   |   |
| t |   |                    |                    |               |   |   |   |   |
| o |   |                    |                    |               |   |   |   |   |
| a |   |                    |                    |               |   |   |   |   |
| l |   |                    |                    |               |   |   |   |   |
| m |   |                    |                    |               |   |   |   |   |
| o |   |                    |                    |               |   |   |   |   |
| s |   |                    |                    |               |   |   |   |   |
| t |   |                    |                    |               |   |   |   |   |
| a |   |                    |                    |               |   |   |   |   |
| l |   |                    |                    |               |   |   |   |   |
| l |   |                    |                    |               |   |   |   |   |
| b |   |                    |                    |               |   |   |   |   |
| e |   |                    |                    |               |   |   |   |   |
| n |   |                    |                    |               |   |   |   |   |
| e |   |                    |                    |               |   |   |   |   |
| f |   |                    |                    |               |   |   |   |   |
| i |   |                    |                    |               |   |   |   |   |
| t |   |                    |                    |               |   |   |   |   |
| s |   |                    |                    |               |   |   |   |   |
| i |   |                    |                    |               |   |   |   |   |
| n |   |                    |                    |               |   |   |   |   |
| t |   |                    |                    |               |   |   |   |   |
| h |   |                    |                    |               |   |   |   |   |
| i |   |                    |                    |               |   |   |   |   |
| s |   |                    |                    |               |   |   |   |   |
| S |   |                    |                    |               |   |   |   |   |
| e |   |                    |                    |               |   |   |   |   |
| c |   |                    |                    |               |   |   |   |   |
| t |   |                    |                    |               |   |   |   |   |
| i |   |                    |                    |               |   |   |   |   |
| o |   |                    |                    |               |   |   |   |   |
| n |   |                    |                    |               |   |   |   |   |
| . |   |                    |                    |               |   |   |   |   |
| * |   |                    |                    |               |   |   |   |   |
| * |   |                    |                    |               |   |   |   |   |
|   |   |                    |                    |               |   |   |   |   |
| * |   |                    |                    |               |   |   |   |   |
| * |   |                    |                    |               |   |   |   |   |
| W |   |                    |                    |               |   |   |   |   |
| e |   |                    |                    |               |   |   |   |   |
| s |   |                    |                    |               |   |   |   |   |
| a |   |                    |                    |               |   |   |   |   |
| y |   |                    |                    |               |   |   |   |   |
| " |   |                    |                    |               |   |   |   |   |
| ( |   |                    |                    |               |   |   |   |   |
| N |   |                    |                    |               |   |   |   |   |
| o |   |                    |                    |               |   |   |   |   |
| d |   |                    |                    |               |   |   |   |   |
| e |   |                    |                    |               |   |   |   |   |
| d |   |                    |                    |               |   |   |   |   |
| u |   |                    |                    |               |   |   |   |   |
| c |   |                    |                    |               |   |   |   |   |
| t |   |                    |                    |               |   |   |   |   |
| i |   |                    |                    |               |   |   |   |   |
| b |   |                    |                    |               |   |   |   |   |
| l |   |                    |                    |               |   |   |   |   |
| e |   |                    |                    |               |   |   |   |   |
| ) |   |                    |                    |               |   |   |   |   |
| " |   |                    |                    |               |   |   |   |   |
| w |   |                    |                    |               |   |   |   |   |
| h |   |                    |                    |               |   |   |   |   |
| e |   |                    |                    |               |   |   |   |   |
| n |   |                    |                    |               |   |   |   |   |
| i |   |                    |                    |               |   |   |   |   |
| t |   |                    |                    |               |   |   |   |   |
| d |   |                    |                    |               |   |   |   |   |
| o |   |                    |                    |               |   |   |   |   |
| e |   |                    |                    |               |   |   |   |   |
| s |   |                    |                    |               |   |   |   |   |
| n |   |                    |                    |               |   |   |   |   |
| o |   |                    |                    |               |   |   |   |   |
| t |   |                    |                    |               |   |   |   |   |
| a |   |                    |                    |               |   |   |   |   |
| p |   |                    |                    |               |   |   |   |   |
| p |   |                    |                    |               |   |   |   |   |
| l |   |                    |                    |               |   |   |   |   |
| y |   |                    |                    |               |   |   |   |   |
| . |   |                    |                    |               |   |   |   |   |
| * |   |                    |                    |               |   |   |   |   |
| * |   |                    |                    |               |   |   |   |   |
+---+---+--------------------+--------------------+---------------+---+---+---+---+
| > |   |                    | **You pay -        | **You pay -   |   |   |   |   |
|   |   |                    | Standard Option**  | High Option** |   |   |   |   |
| * |   |                    |                    |               |   |   |   |   |
| * |   |                    |                    |               |   |   |   |   |
| S |   |                    |                    |               |   |   |   |   |
| u |   |                    |                    |               |   |   |   |   |
| r |   |                    |                    |               |   |   |   |   |
| g |   |                    |                    |               |   |   |   |   |
| i |   |                    |                    |               |   |   |   |   |
| c |   |                    |                    |               |   |   |   |   |
| a |   |                    |                    |               |   |   |   |   |
| l |   |                    |                    |               |   |   |   |   |
| > |   |                    |                    |               |   |   |   |   |
|   |   |                    |                    |               |   |   |   |   |
| p |   |                    |                    |               |   |   |   |   |
| r |   |                    |                    |               |   |   |   |   |
| o |   |                    |                    |               |   |   |   |   |
| c |   |                    |                    |               |   |   |   |   |
| e |   |                    |                    |               |   |   |   |   |
| d |   |                    |                    |               |   |   |   |   |
| u |   |                    |                    |               |   |   |   |   |
| r |   |                    |                    |               |   |   |   |   |
| e |   |                    |                    |               |   |   |   |   |
| s |   |                    |                    |               |   |   |   |   |
| * |   |                    |                    |               |   |   |   |   |
| * |   |                    |                    |               |   |   |   |   |
+---+---+--------------------+--------------------+---------------+---+---+---+---+
| > |   |                    | PPO: 9% of the     | PPO: 10% of   |   |   |   |   |
|   |   |                    | Plan allowance     | the Plan      |   |   |   |   |
| A |   |                    |                    | allowance     |   |   |   |   |
| > |   |                    | Non-PPO: 30% of    |               |   |   |   |   |
|   |   |                    | the Plan allowance | Non-PPO: 25%  |   |   |   |   |
| c |   |                    | and any difference | of the Plan   |   |   |   |   |
| o |   |                    | between our        | allowance and |   |   |   |   |
| m |   |                    | allowance and the  | any           |   |   |   |   |
| p |   |                    | billed amount      | difference    |   |   |   |   |
| r |   |                    |                    | between our   |   |   |   |   |
| e |   |                    |                    | allowance and |   |   |   |   |
| h |   |                    |                    | the billed    |   |   |   |   |
| e |   |                    |                    | amount.       |   |   |   |   |
| n |   |                    |                    |               |   |   |   |   |
| s |   |                    |                    |               |   |   |   |   |
| i |   |                    |                    |               |   |   |   |   |
| v |   |                    |                    |               |   |   |   |   |
| e |   |                    |                    |               |   |   |   |   |
| > |   |                    |                    |               |   |   |   |   |
|   |   |                    |                    |               |   |   |   |   |
| r |   |                    |                    |               |   |   |   |   |
| a |   |                    |                    |               |   |   |   |   |
| n |   |                    |                    |               |   |   |   |   |
| g |   |                    |                    |               |   |   |   |   |
| e |   |                    |                    |               |   |   |   |   |
| > |   |                    |                    |               |   |   |   |   |
|   |   |                    |                    |               |   |   |   |   |
| o |   |                    |                    |               |   |   |   |   |
| f |   |                    |                    |               |   |   |   |   |
| > |   |                    |                    |               |   |   |   |   |
|   |   |                    |                    |               |   |   |   |   |
| s |   |                    |                    |               |   |   |   |   |
| e |   |                    |                    |               |   |   |   |   |
| r |   |                    |                    |               |   |   |   |   |
| v |   |                    |                    |               |   |   |   |   |
| i |   |                    |                    |               |   |   |   |   |
| c |   |                    |                    |               |   |   |   |   |
| e |   |                    |                    |               |   |   |   |   |
| s |   |                    |                    |               |   |   |   |   |
| , |   |                    |                    |               |   |   |   |   |
| > |   |                    |                    |               |   |   |   |   |
|   |   |                    |                    |               |   |   |   |   |
| s |   |                    |                    |               |   |   |   |   |
| u |   |                    |                    |               |   |   |   |   |
| c |   |                    |                    |               |   |   |   |   |
| h |   |                    |                    |               |   |   |   |   |
| > |   |                    |                    |               |   |   |   |   |
|   |   |                    |                    |               |   |   |   |   |
| a |   |                    |                    |               |   |   |   |   |
| s |   |                    |                    |               |   |   |   |   |
| : |   |                    |                    |               |   |   |   |   |
|   |   |                    |                    |               |   |   |   |   |
| - |   |                    |                    |               |   |   |   |   |
|   |   |                    |                    |               |   |   |   |   |
|   |   |                    |                    |               |   |   |   |   |
|   |   |                    |                    |               |   |   |   |   |
| O |   |                    |                    |               |   |   |   |   |
| p |   |                    |                    |               |   |   |   |   |
| e |   |                    |                    |               |   |   |   |   |
| r |   |                    |                    |               |   |   |   |   |
| a |   |                    |                    |               |   |   |   |   |
| t |   |                    |                    |               |   |   |   |   |
| i |   |                    |                    |               |   |   |   |   |
| v |   |                    |                    |               |   |   |   |   |
| e |   |                    |                    |               |   |   |   |   |
|   |   |                    |                    |               |   |   |   |   |
|   |   |                    |                    |               |   |   |   |   |
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|   |   |                    |                    |               |   |   |   |   |
| p |   |                    |                    |               |   |   |   |   |
| r |   |                    |                    |               |   |   |   |   |
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| c |   |                    |                    |               |   |   |   |   |
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| d |   |                    |                    |               |   |   |   |   |
| u |   |                    |                    |               |   |   |   |   |
| r |   |                    |                    |               |   |   |   |   |
| e |   |                    |                    |               |   |   |   |   |
| s |   |                    |                    |               |   |   |   |   |
|   |   |                    |                    |               |   |   |   |   |
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| T |   |                    |                    |               |   |   |   |   |
| r |   |                    |                    |               |   |   |   |   |
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| m |   |                    |                    |               |   |   |   |   |
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| n |   |                    |                    |               |   |   |   |   |
| d |   |                    |                    |               |   |   |   |   |
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| p |   |                    |                    |               |   |   |   |   |
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| s |   |                    |                    |               |   |   |   |   |
| t |   |                    |                    |               |   |   |   |   |
| - |   |                    |                    |               |   |   |   |   |
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| p |   |                    |                    |               |   |   |   |   |
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| r |   |                    |                    |               |   |   |   |   |
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| v |   |                    |                    |               |   |   |   |   |
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|   |   |                    |                    |               |   |   |   |   |
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| c |   |                    |                    |               |   |   |   |   |
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| r |   |                    |                    |               |   |   |   |   |
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|   |   |                    |                    |               |   |   |   |   |
|   |   |                    |                    |               |   |   |   |   |
|   |   |                    |                    |               |   |   |   |   |
|   |   |                    |                    |               |   |   |   |   |
| b |   |                    |                    |               |   |   |   |   |
| y |   |                    |                    |               |   |   |   |   |
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| t |   |                    |                    |               |   |   |   |   |
| h |   |                    |                    |               |   |   |   |   |
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| s |   |                    |                    |               |   |   |   |   |
| u |   |                    |                    |               |   |   |   |   |
| r |   |                    |                    |               |   |   |   |   |
| g |   |                    |                    |               |   |   |   |   |
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| n |   |                    |                    |               |   |   |   |   |
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|   |   |                    |                    |               |   |   |   |   |
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| s |   |                    |                    |               |   |   |   |   |
| u |   |                    |                    |               |   |   |   |   |
| r |   |                    |                    |               |   |   |   |   |
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| ) |   |                    |                    |               |   |   |   |   |
+---+---+--------------------+--------------------+---------------+---+---+---+---+

*Surgical procedures - Continued on next page*

+--------------------------+---------------------+---------------------+
| > **Surgical             | **You pay -         | **You pay - High    |
| > procedures** ***--**   | Standard Option**   | Option**            |
| > continued*             |                     |                     |
+--------------------------+---------------------+---------------------+
| -   Insertion of         | > PPO: 9% of the    | > PPO: 10% of the   |
|     internal prosthetic  | > Plan allowance    | > Plan allowance    |
|     devices. See 5(a) -- | >                   | >                   |
|     Orthopedic and       | > Non-PPO: 30% of   | > Non-PPO: 25% of   |
|     prosthetic devices   | > the Plan          | > the Plan          |
|     for device coverage  | > allowance and any | > allowance and any |
|     information          | > difference        | > difference        |
|                          | > between our       | > between our       |
| -   Voluntary            | > allowance and the | > allowance and the |
|     sterilization (e.g., | > billed amount.    | > billed amount     |
|     Tubal ligation,      |                     |                     |
|     Vasectomy)           |                     |                     |
|                          |                     |                     |
| -   Norplant (a          |                     |                     |
|     surgically implanted |                     |                     |
|     contraceptive), and  |                     |                     |
|     intrauterine devices |                     |                     |
|     (IUDs)               |                     |                     |
|                          |                     |                     |
| -   Treatment of burns   |                     |                     |
+--------------------------+---------------------+---------------------+
| -   Assistant surgeons   | > PPO: Nothing      | PPO: Nothing        |
|     -- We cover up to    | >                   |                     |
|     20% of the Plan      | > Non-PPO: Any      | Non-PPO: Any        |
|     allowance for the    | > difference        | difference between  |
|     primary surgical     | > between our       | our allowance and   |
|     charge               | > allowance and the | the billed amount   |
|                          | > billed amount.    |                     |
+--------------------------+---------------------+---------------------+
| > When multiple or       | > PPO: 9% of the    | > PPO: 10% of the   |
| > bilateral surgical     | > Plan allowance    | > Plan allowance    |
| > procedures performed   | > for the primary   | > for the primary   |
| > during the same        | > procedure and any | > procedure and any |
| > operative session add  | > difference        | > difference        |
| > time or complexity to  | > between our 50%   | > between our 50%   |
| > patient care, the plan | > allowance and the | > allowance and the |
| > allowance for all      | > billed amount for | > billed amount for |
| > procedures after the   | > subsequent        | > subsequent        |
| > primary procedure is   | > procedures.       | > procedures        |
| > half of the allowance  | >                   | >                   |
| > the procedure would    | > Non-PPO: 30% of   | > Non-PPO: 25% of   |
| > have if it were a      | > the Plan          | > allowance for the |
| > primary procedure.     | > allowance for the | > primary procedure |
| >                        | > primary procedure | > and any           |
| > Note: Multiple or      | > and any           | > difference        |
| > bilateral surgical     | > difference        | > between our 50%   |
| > procedures performed   | > between our 50%   | > allowance and the |
| > through the same       | > allowance and the | > billed amount for |
| > incision are           | > billed amount for | > subsequent        |
| > "incidental" to the    | > subsequent        | > procedures        |
| > primary surgery, i.e., | > procedures        |                     |
| > the procedure would    |                     |                     |
| > not add time or        |                     |                     |
| > complexity to patient  |                     |                     |
| > care. We do not pay    |                     |                     |
| > extra for incidental   |                     |                     |
| > procedures.            |                     |                     |
+--------------------------+---------------------+---------------------+
| > Surgical treatment of  | > PPO: 30% of the   | > PPO: 25% of the   |
| > morbid obesity \-- a   | > Plan allowance.   | > Plan allowance.   |
| > condition in which an  | >                   | >                   |
| > individual weighs 100  | > Non-PPO: 50% of   | > Non-PPO: 45% of   |
| > pounds or 100% over    | > the Plan          | > the Plan          |
| > his or her normal      | > allowance and any | > allowance and any |
| > weight according to    | > difference        | > difference        |
| > current underwriting   | > between our       | > between our       |
| > standards; eligible    | > allowance and the | > allowance and the |
| > members must be age 18 | > billed amount.    | > billed amount.    |
| > or over. We must       |                     |                     |
| > pre-approve surgery    |                     |                     |
| > for benefit to be      |                     |                     |
| > available.             |                     |                     |
+--------------------------+---------------------+---------------------+

*Surgical procedures - Continued on next page*

+--------------------------+--------------------+---------------------+
| > **Surgical             | **You pay -        | **You pay - High    |
| > procedures** **--**    | Standard Option**  | Option**            |
| > *continued*            |                    |                     |
+--------------------------+--------------------+---------------------+
| > *Not covered:*         | > *All charges.*   | > *All charges.*    |
|                          |                    |                     |
| -   *Reversal of         |                    |                     |
|     voluntary            |                    |                     |
|     sterilization*       |                    |                     |
|                          |                    |                     |
| ```{=html}               |                    |                     |
| <!-- -->                 |                    |                     |
| ```                      |                    |                     |
| -   *Services of a       |                    |                     |
|     standby surgeon,     |                    |                     |
|     except during        |                    |                     |
|     angioplasty*         |                    |                     |
|                          |                    |                     |
| -   *All procedures      |                    |                     |
|     associated with      |                    |                     |
|     treatment of         |                    |                     |
|     temporomandibular    |                    |                     |
|     disorders*           |                    |                     |
|                          |                    |                     |
| -   *Assistant surgery   |                    |                     |
|     services provided by |                    |                     |
|     a non-physician      |                    |                     |
|     provider such as a   |                    |                     |
|     Physician Assistant  |                    |                     |
|     (P.A.), Certified    |                    |                     |
|     Registered Nurse     |                    |                     |
|     First Assistant      |                    |                     |
|     (C.R.N.F.A.) and a   |                    |                     |
|     Certified Surgical   |                    |                     |
|     Technologist         |                    |                     |
|     (C.S.T.)*            |                    |                     |
+--------------------------+--------------------+---------------------+

+--------------------------+--------------------+---------------------+
| > **Reconstructive       | **You pay -        | **You pay - High    |
| > surgery**              | Standard Option**  | Option**            |
+--------------------------+--------------------+---------------------+
| -   Surgery to correct a | PPO: 9% of the     | PPO: 10% of the     |
|     functional defect    | Plan allowance     | Plan allowance      |
|                          |                    |                     |
| -   Surgery to correct a | Non-PPO: 30% of    | Non-PPO: 25% of the |
|     condition caused by  | the Plan allowance | Plan allowance and  |
|     injury or illness    | and any difference | any difference      |
|     if:                  | between our        | between our         |
|                          | allowance and the  | allowance and the   |
| > -- the condition       | billed amount      | billed amount       |
| > 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; and     |                    |                     |
|     webbed fingers and   |                    |                     |
|     toes.                |                    |                     |
|                          |                    |                     |
| **NOTE: PBP pays 100% at |                    |                     |
| MAYO Clinics.**          |                    |                     |
|                          |                    |                     |
| -   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 for |                    |                     |
| > coverage)              |                    |                     |
| >                        |                    |                     |
| > Note: We pay for       |                    |                     |
| > internal breast        |                    |                     |
| > prostheses as hospital |                    |                     |
| > benefits when the      |                    |                     |
| > hospital is billing    |                    |                     |
| > for the prostheses.    |                    |                     |
| >                        |                    |                     |
| > Note: If you need a    |                    |                     |
| > mastectomy, you may    |                    |                     |
| > choose to have the     |                    |                     |
| > procedure performed on |                    |                     |
| > an inpatient basis and |                    |                     |
| > remain in the hospital |                    |                     |
| > up to 72 hours after   |                    |                     |
| > the procedure.         |                    |                     |
+--------------------------+--------------------+---------------------+

*Reconstructive surgery -- Continued on next page*

+--------------------------+---------------------+---------------------+
| > **Reconstructive       | **You pay -         | **You pay - High    |
| > surgery** --           | Standard Option**   | Option**            |
| > con*tinued*            |                     |                     |
+--------------------------+---------------------+---------------------+
| *Not covered:*           | > *All charges*     | > *All charges*     |
|                          |                     |                     |
| -   *Cosmetic surgery -- |                     |                     |
|     any surgical         |                     |                     |
|     procedure (or any    |                     |                     |
|     portion of a         |                     |                     |
|     procedure) performed |                     |                     |
|     primarily to improve |                     |                     |
|     physical appearance  |                     |                     |
|     through change in    |                     |                     |
|     bodily form,         |                     |                     |
|     **except** repair of |                     |                     |
|     accidental injury or |                     |                     |
|     for the correction   |                     |                     |
|     of congenital        |                     |                     |
|     anomalies*           |                     |                     |
|                          |                     |                     |
| -   *Injections of       |                     |                     |
|     silicone, collagens, |                     |                     |
|     botoxin, and similar |                     |                     |
|     substances*          |                     |                     |
|                          |                     |                     |
| ```{=html}               |                     |                     |
| <!-- -->                 |                     |                     |
| ```                      |                     |                     |
| -   *Surgeries related   |                     |                     |
|     to sex               |                     |                     |
|     transformation or    |                     |                     |
|     sexual dysfunction   |                     |                     |
|     or sexual            |                     |                     |
|     inadequacy.*         |                     |                     |
+--------------------------+---------------------+---------------------+
| > **Oral and             |                     |                     |
| > maxillofacial          |                     |                     |
| > surgery**              |                     |                     |
+--------------------------+---------------------+---------------------+
| Oral surgical            | PPO: 9% of the Plan | PPO: 10% of the     |
| procedures, limited to:  | allowance           | Plan allowance      |
|                          |                     |                     |
| -   Reduction of         | > Non-PPO: 30% of   | > Non-PPO: 25% of   |
|     fractures of the     | > the Plan          | > the Plan          |
|     jaws or facial bones | > allowance and any | > allowance and any |
|                          | > difference        | > difference        |
| -   Surgical correction  | > between our       | > between our       |
|     of cleft lip, cleft  | > allowance and the | > allowance and the |
|     palate or severe     | > billed amount     | > billed amount     |
|     functional           |                     |                     |
|     malocclusion         |                     |                     |
|                          |                     |                     |
| -   Removal of stones    |                     |                     |
|     from salivary ducts  |                     |                     |
|                          |                     |                     |
| -   Excision of tori,    |                     |                     |
|     leukoplakia or       |                     |                     |
|     malignancies         |                     |                     |
|                          |                     |                     |
| -   Excision of cysts    |                     |                     |
|     and incision of      |                     |                     |
|     abscesses not        |                     |                     |
|     involving the teeth  |                     |                     |
|                          |                     |                     |
| -   Other surgical       |                     |                     |
|     procedures that do   |                     |                     |
|     not involve the      |                     |                     |
|     teeth or their       |                     |                     |
|     supporting           |                     |                     |
|     structures           |                     |                     |
|                          |                     |                     |
| -   Removal of impacted  |                     |                     |
|     teeth                |                     |                     |
|                          |                     |                     |
| > Note: When multiple or |                     |                     |
| > bilateral oral         |                     |                     |
| > maxillofacial surgical |                     |                     |
| > procedures that add    |                     |                     |
| > time or complexity to  |                     |                     |
| > patient care are       |                     |                     |
| > performed during the   |                     |                     |
| > same operative         |                     |                     |
| > session, the Plan pays |                     |                     |
| > the same benefits as   |                     |                     |
| > indicated under        |                     |                     |
| > Multiple surgical      |                     |                     |
| > procedures for the     |                     |                     |
| > above listed           |                     |                     |
| > procedures.            |                     |                     |
| >                        |                     |                     |
| > Note: Removal of       |                     |                     |
| > impacted teeth are not |                     |                     |
| > considered multiple    |                     |                     |
| > procedures.            |                     |                     |
+--------------------------+---------------------+---------------------+
| > *Not covered:*         | > *All charges*     | > *All charges*     |
|                          |                     |                     |
| -   *Oral implants and   |                     |                     |
|     transplants*         |                     |                     |
|                          |                     |                     |
| ```{=html}               |                     |                     |
| <!-- -->                 |                     |                     |
| ```                      |                     |                     |
| -   *Procedures that     |                     |                     |
|     involve the teeth    |                     |                     |
|     (other than impacted |                     |                     |
|     teeth) or their      |                     |                     |
|     supporting           |                     |                     |
|     structures (such as  |                     |                     |
|     the periodontal      |                     |                     |
|     membrane, gingiva,   |                     |                     |
|     and alveolar bone -- |                     |                     |
|     See dental           |                     |                     |
|     benefits)*           |                     |                     |
+--------------------------+---------------------+---------------------+

+--------------------------+---------------------+---------------------+
| > **Organ/tissue         | **You pay -         | > **You pay - High  |
| > transplants**          | Standard Option**   | > Option**          |
+--------------------------+---------------------+---------------------+
| > Limited to:            | > A portion of the  | > A portion of the  |
|                          | > Plan allowance    | > Plan allowance    |
| -   Cornea               | > for covered       | > for covered       |
|                          | > services and any  | > services and any  |
| -   Heart                | > amount over our   | > amount over our   |
|                          | > \$100,000 maximum | > \$100,000 maximum |
| -   Heart/lung           | > per transplant.   | > per transplant.   |
|                          | >                   | >                   |
| -   Kidney               | > See Sections 5    | > See Sections 5    |
|                          | > (a), 5 (b) and 5  | > (a), 5 (b) and 5  |
| -   Kidney/Pancreas      | > (c) for the       | > (c) for the       |
|                          | > portion you pay.  | > portion you pay   |
| -   Liver                | >                   | >                   |
|                          | > See National      | > See National      |
| -   Single lung          | > Transplant        | > Transplant        |
|                          | > Program.          | > Program.          |
| -   Double lung          |                     |                     |
|                          |                     |                     |
| -   Intestinal           |                     |                     |
|     transplants (small   |                     |                     |
|     intestine) and the   |                     |                     |
|     small intestine with |                     |                     |
|     the liver or small   |                     |                     |
|     intestine with       |                     |                     |
|     multiple organs such |                     |                     |
|     as the liver,        |                     |                     |
|     stomach, and         |                     |                     |
|     pancreas.            |                     |                     |
|                          |                     |                     |
| -   Bone marrow          |                     |                     |
|     transplants and stem |                     |                     |
|     cell support as      |                     |                     |
|     follows:             |                     |                     |
|                          |                     |                     |
| > Allogeneic bone marrow |                     |                     |
| > for acute leukemia,    |                     |                     |
| > advanced Hodgkin's     |                     |                     |
| > lymphoma, advanced     |                     |                     |
| > non-Hodgkins lymphoma, |                     |                     |
| > advanced neuroblastoma |                     |                     |
| > (children over age     |                     |                     |
| > one), aplastic anemia, |                     |                     |
| > chronic myelogenous    |                     |                     |
| > leukemia, infantile    |                     |                     |
| > malignant              |                     |                     |
| > osteopetrosis, severe  |                     |                     |
| > combined               |                     |                     |
| > immunodeficiency,      |                     |                     |
| > thalassemia major, and |                     |                     |
| > Wiskott-Aldrich        |                     |                     |
| > syndrome.              |                     |                     |
| >                        |                     |                     |
| > Autologous bone marrow |                     |                     |
| > transplants            |                     |                     |
| > (autologous stem cell  |                     |                     |
| > and peripheral stem    |                     |                     |
| > support) for the       |                     |                     |
| > following conditions:  |                     |                     |
| > acute lymphocytic or   |                     |                     |
| > nonlymphocytic         |                     |                     |
| > leukemia; advanced     |                     |                     |
| > Hodgkins lymphoma and  |                     |                     |
| > advanced non-Hodgkins  |                     |                     |
| > lymphoma; advanced     |                     |                     |
| > neuroblastoma;         |                     |                     |
| > testicular,            |                     |                     |
| > mediastinal,           |                     |                     |
| > retroperitoneal and    |                     |                     |
| > ovarian germ cell      |                     |                     |
| > tumors; breast cancer, |                     |                     |
| > multiple myeloma; and  |                     |                     |
| > epithelial ovarian     |                     |                     |
| > cancer.                |                     |                     |
+--------------------------+---------------------+---------------------+

*Organ/tissue transplants -- Continued on next page*

[]{.mark}

+--------------------------+---------------------+---------------------+
| > **Organ/tissue         | **You pay -         | > **You pay - High  |
| > transplants --**       | Standard Option**   | > Option**          |
| > *continued*            |                     |                     |
+--------------------------+---------------------+---------------------+
| > Limited Benefits --    | > A portion of the  | > A portion of the  |
| > Benefits apply only if | > Plan allowance    | > Plan allowance    |
| > we cover the recipient | > for covered       | > for covered       |
| > and are limited to     | > services and any  | > services and any  |
| > \$100,000 per          | > amount over our   | > amount over our   |
| > transplant. This       | > \$100,000 maximum | > \$100,000 maximum |
| > limitation includes    | > per transplant.   | > per transplant.   |
| > costs for hospitals;   | >                   | >                   |
| > doctors; laboratory;   | > See Sections 5    | > See Sections 5    |
| > radiology;             | > (a), 5 (b) and 5  | > (a), 5 (b) and 5  |
| > medications; ancillary | > (c) for the       | > (c) for the       |
| > charges;               | > portion you pay.  | > portion you pay   |
| > pre-transplant         |                     | >                   |
| > examinations, tests,   | See National        | > See National      |
| > diagnosis and related  | Transplant Program. | > Transplant        |
| > charges; cadaver       |                     | > Program.          |
| > procurement; and any   |                     |                     |
| > donor costs. We must   |                     |                     |
| > approve all related    |                     |                     |
| > expenses prior to the  |                     |                     |
| > surgery, including     |                     |                     |
| > charges for            |                     |                     |
| > procurement of cadaver |                     |                     |
| > organs.                |                     |                     |
| >                        |                     |                     |
| > Note: We cover related |                     |                     |
| > medical and hospital   |                     |                     |
| > expenses of the donor  |                     |                     |
| > when we cover the      |                     |                     |
| > recipient.             |                     |                     |
+--------------------------+---------------------+---------------------+
| > National Transplant    | Nothing             | Nothing             |
| > Program-               |                     |                     |
| >                        |                     |                     |
| > Limited to the         |                     |                     |
| > following performed at |                     |                     |
| > the MAYO Clinics:      |                     |                     |
|                          |                     |                     |
| -   Bone marrow          |                     |                     |
|                          |                     |                     |
| -   Heart                |                     |                     |
|                          |                     |                     |
| -   Kidney/pancreas      |                     |                     |
|                          |                     |                     |
| -   Liver                |                     |                     |
|                          |                     |                     |
| -   Heart/lung           |                     |                     |
|                          |                     |                     |
| -   Single lung          |                     |                     |
|                          |                     |                     |
| -   Double lung          |                     |                     |
|                          |                     |                     |
| > Note: Benefits include |                     |                     |
| > pre-approved           |                     |                     |
| > transportation and     |                     |                     |
| > lodging. Call us at    |                     |                     |
| > **800-544-7111** for   |                     |                     |
| > more details.          |                     |                     |
+--------------------------+---------------------+---------------------+

*Organ/tissue transplants -- Continued on next page*

+--------------------------+---------------------+---------------------+
| > **Organ/tissue         | **You pay -         | > **You pay - High  |
| > transplants --**       | Standard Option**   | > Option**          |
| > *continued*            |                     |                     |
+--------------------------+---------------------+---------------------+
| *Not covered:*           | > *All charges*     | > *All charges*     |
|                          |                     |                     |
| -   *Donor screening     |                     |                     |
|     tests and donor      |                     |                     |
|     search expenses,     |                     |                     |
|     except those         |                     |                     |
|     performed for the    |                     |                     |
|     actual donor*        |                     |                     |
|                          |                     |                     |
| ```{=html}               |                     |                     |
| <!-- -->                 |                     |                     |
| ```                      |                     |                     |
| -   *Services or         |                     |                     |
|     supplies for or      |                     |                     |
|     related to           |                     |                     |
|     organ/tissue         |                     |                     |
|     transplants for any  |                     |                     |
|     diagnosis not        |                     |                     |
|     specifically listed  |                     |                     |
|     as covered including |                     |                     |
|     chemotherapy and/or  |                     |                     |
|     radiation therapy    |                     |                     |
|     when supported by    |                     |                     |
|     allogeneic or        |                     |                     |
|     autologous bone      |                     |                     |
|     marrow or stem cell  |                     |                     |
|     transplants, drugs   |                     |                     |
|     or medications       |                     |                     |
|     administered to      |                     |                     |
|     stimulate or         |                     |                     |
|     mobilize stem cells  |                     |                     |
|     for transplant, and  |                     |                     |
|     all other services   |                     |                     |
|     or supplies which    |                     |                     |
|     are not medically    |                     |                     |
|     necessary or         |                     |                     |
|     appropriate but for  |                     |                     |
|     the non-covered      |                     |                     |
|     procedure.*          |                     |                     |
|                          |                     |                     |
| -   *Allogeneic and      |                     |                     |
|     autologus bone       |                     |                     |
|     marrow and stem cell |                     |                     |
|     transplants for      |                     |                     |
|     solid tumors except  |                     |                     |
|     as noted above.*     |                     |                     |
|                          |                     |                     |
| -   *Implants of         |                     |                     |
|     artificial organs*   |                     |                     |
|                          |                     |                     |
| ```{=html}               |                     |                     |
| <!-- -->                 |                     |                     |
| ```                      |                     |                     |
| -   *Transplants not     |                     |                     |
|     listed as covered*   |                     |                     |
+--------------------------+---------------------+---------------------+
| > **Anesthesia**         |                     |                     |
+--------------------------+---------------------+---------------------+
| Professional services    | PPO: 9% of the Plan | PPO: 10% of Plan    |
| provided in --           | allowance           | allowance           |
|                          |                     |                     |
| -   Hospital (inpatient) | Non-PPO: 30% of the | Non-PPO: 25% of the |
|                          | Plan allowance and  | Plan allowance and  |
|                          | any difference      | any difference      |
|                          | between our         | between our         |
|                          | allowance and the   | allowance and the   |
|                          | billed amount.      | billed amount.      |
+--------------------------+---------------------+---------------------+
| Professional services    | PPO: 9% of the Plan | PPO: 10% of the     |
| provided in --           | allowance           | Plan allowance      |
|                          |                     |                     |
| -   Hospital outpatient  | Non-PPO: 30% of the | Non-PPO: 25% of the |
|     department           | Plan allowance and  | Plan allowance and  |
|                          | any difference      | any difference      |
| -   Skilled nursing      | between our         | between our         |
|     facility             | allowance and the   | allowance and       |
|                          | billed amount.      | billed amount.      |
| -   Ambulatory surgical  |                     |                     |
|     center               | Note: If your PPO   | Note: If your PPO   |
|                          | provider uses a     | provider uses a     |
| -   Office               | non-PPO             | non-PPO             |
|                          | anesthesiologist,   | anesthesiologist,   |
|                          | we will pay non-PPO | we will             |
|                          | benefits for any    |                     |
|                          | anesthesia charges. | pay non-PPO         |
|                          |                     | benefits for any    |
|                          |                     | anesthesia charges. |
+--------------------------+---------------------+---------------------+

+---+---+---------------------+--------------------+--------------+---+---+---+---+
| # |   |                     |                    |              |   |   |   |   |
| # |   |                     |                    |              |   |   |   |   |
|   |   |                     |                    |              |   |   |   |   |
| * |   |                     |                    |              |   |   |   |   |
| * |   |                     |                    |              |   |   |   |   |
| S |   |                     |                    |              |   |   |   |   |
| e |   |                     |                    |              |   |   |   |   |
| c |   |                     |                    |              |   |   |   |   |
| t |   |                     |                    |              |   |   |   |   |
| i |   |                     |                    |              |   |   |   |   |
| o |   |                     |                    |              |   |   |   |   |
| n |   |                     |                    |              |   |   |   |   |
|   |   |                     |                    |              |   |   |   |   |
| 5 |   |                     |                    |              |   |   |   |   |
|   |   |                     |                    |              |   |   |   |   |
| ( |   |                     |                    |              |   |   |   |   |
| c |   |                     |                    |              |   |   |   |   |
| ) |   |                     |                    |              |   |   |   |   |
| . |   |                     |                    |              |   |   |   |   |
|   |   |                     |                    |              |   |   |   |   |
| S |   |                     |                    |              |   |   |   |   |
| e |   |                     |                    |              |   |   |   |   |
| r |   |                     |                    |              |   |   |   |   |
| v |   |                     |                    |              |   |   |   |   |
| i |   |                     |                    |              |   |   |   |   |
| c |   |                     |                    |              |   |   |   |   |
| e |   |                     |                    |              |   |   |   |   |
| s |   |                     |                    |              |   |   |   |   |
|   |   |                     |                    |              |   |   |   |   |
| p |   |                     |                    |              |   |   |   |   |
| r |   |                     |                    |              |   |   |   |   |
| o |   |                     |                    |              |   |   |   |   |
| v |   |                     |                    |              |   |   |   |   |
| i |   |                     |                    |              |   |   |   |   |
| d |   |                     |                    |              |   |   |   |   |
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| d |   |                     |                    |              |   |   |   |   |
|   |   |                     |                    |              |   |   |   |   |
| b |   |                     |                    |              |   |   |   |   |
| y |   |                     |                    |              |   |   |   |   |
|   |   |                     |                    |              |   |   |   |   |
| a |   |                     |                    |              |   |   |   |   |
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| p |   |                     |                    |              |   |   |   |   |
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| t |   |                     |                    |              |   |   |   |   |
| a |   |                     |                    |              |   |   |   |   |
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| a |   |                     |                    |              |   |   |   |   |
| m |   |                     |                    |              |   |   |   |   |
| b |   |                     |                    |              |   |   |   |   |
| u |   |                     |                    |              |   |   |   |   |
| l |   |                     |                    |              |   |   |   |   |
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|   |   |                     |                    |              |   |   |   |   |
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| * |   |                     |                    |              |   |   |   |   |
| * |   |                     |                    |              |   |   |   |   |
+---+---+---------------------+--------------------+--------------+---+---+---+---+
|   | * | **Here are some     |                    |              | * |   |   |   |
|   | * | important things    |                    |              | * |   |   |   |
|   | I | you should keep in  |                    |              | I |   |   |   |
|   | * | mind about these    |                    |              | * |   |   |   |
|   | * | benefits:**         |                    |              | * |   |   |   |
|   |   |                     |                    |              |   |   |   |   |
|   | * | -   Please remember |                    |              | * |   |   |   |
|   | * |     that all        |                    |              | * |   |   |   |
|   | M |     benefits are    |                    |              | M |   |   |   |
|   | * |     subject to the  |                    |              | * |   |   |   |
|   | * |     definitions,    |                    |              | * |   |   |   |
|   |   |     limitations,    |                    |              |   |   |   |   |
|   | * |     and exclusions  |                    |              | * |   |   |   |
|   | * |     in this         |                    |              | * |   |   |   |
|   | P |     brochure and    |                    |              | P |   |   |   |
|   | * |     are payable     |                    |              | * |   |   |   |
|   | * |     only when we    |                    |              | * |   |   |   |
|   |   |     determine they  |                    |              |   |   |   |   |
|   | * |     are medically   |                    |              | * |   |   |   |
|   | * |     necessary.      |                    |              | * |   |   |   |
|   | O |                     |                    |              | O |   |   |   |
|   | * | ```{=html}          |                    |              | * |   |   |   |
|   | * | <!-- -->            |                    |              | * |   |   |   |
|   |   | ```                 |                    |              |   |   |   |   |
|   | * | -   In this         |                    |              | * |   |   |   |
|   | * |     Section, unlike |                    |              | * |   |   |   |
|   | R |     Sections 5(a)   |                    |              | R |   |   |   |
|   | * |     and 5(b), the   |                    |              | * |   |   |   |
|   | * |     calendar year   |                    |              | * |   |   |   |
|   |   |     deductible      |                    |              |   |   |   |   |
|   | * |     applies to only |                    |              | * |   |   |   |
|   | * |     a few benefits. |                    |              | * |   |   |   |
|   | T |     In that case,   |                    |              | T |   |   |   |
|   | * |     we added        |                    |              | * |   |   |   |
|   | * |     "(calendar year |                    |              | * |   |   |   |
|   |   |     deductible      |                    |              |   |   |   |   |
|   | * |     applies)". The  |                    |              | * |   |   |   |
|   | * |     calendar year   |                    |              | * |   |   |   |
|   | A |     deductible is:  |                    |              | A |   |   |   |
|   | * |                     |                    |              | * |   |   |   |
|   | * | Standard Option     |                    |              | * |   |   |   |
|   |   |                     |                    |              |   |   |   |   |
|   | * | High Option         |                    |              | * |   |   |   |
|   | * |                     |                    |              | * |   |   |   |
|   | N | -   The non-PPO     |                    |              | N |   |   |   |
|   | * |     benefits are    |                    |              | * |   |   |   |
|   | * |     the standard    |                    |              | * |   |   |   |
|   |   |     benefits of     |                    |              |   |   |   |   |
|   | * |     this Plan. PPO  |                    |              | * |   |   |   |
|   | * |     benefits apply  |                    |              | * |   |   |   |
|   | T |     only when you   |                    |              | T |   |   |   |
|   | * |     use a PPO       |                    |              | * |   |   |   |
|   | * |     provider. When  |                    |              | * |   |   |   |
|   |   |     no PPO provider |                    |              |   |   |   |   |
|   |   |     is available,   |                    |              |   |   |   |   |
|   |   |     non-PPO         |                    |              |   |   |   |   |
|   |   |     benefits apply. |                    |              |   |   |   |   |
|   |   |                     |                    |              |   |   |   |   |
|   |   | ```{=html}          |                    |              |   |   |   |   |
|   |   | <!-- -->            |                    |              |   |   |   |   |
|   |   | ```                 |                    |              |   |   |   |   |
|   |   | -   Be sure to read |                    |              |   |   |   |   |
|   |   |     Section 4,      |                    |              |   |   |   |   |
|   |   |     *Your costs for |                    |              |   |   |   |   |
|   |   |     covered         |                    |              |   |   |   |   |
|   |   |     services,* for  |                    |              |   |   |   |   |
|   |   |     valuable        |                    |              |   |   |   |   |
|   |   |     information     |                    |              |   |   |   |   |
|   |   |     about how cost  |                    |              |   |   |   |   |
|   |   |     sharing works,  |                    |              |   |   |   |   |
|   |   |     with special    |                    |              |   |   |   |   |
|   |   |     sections for    |                    |              |   |   |   |   |
|   |   |     members who are |                    |              |   |   |   |   |
|   |   |     age 65 or over. |                    |              |   |   |   |   |
|   |   |     Also read       |                    |              |   |   |   |   |
|   |   |     Section 9 about |                    |              |   |   |   |   |
|   |   |     coordinating    |                    |              |   |   |   |   |
|   |   |     benefits with   |                    |              |   |   |   |   |
|   |   |     other coverage, |                    |              |   |   |   |   |
|   |   |     including with  |                    |              |   |   |   |   |
|   |   |     Medicare.       |                    |              |   |   |   |   |
|   |   |                     |                    |              |   |   |   |   |
|   |   | ```{=html}          |                    |              |   |   |   |   |
|   |   | <!-- -->            |                    |              |   |   |   |   |
|   |   | ```                 |                    |              |   |   |   |   |
|   |   | -   The amounts     |                    |              |   |   |   |   |
|   |   |     listed below    |                    |              |   |   |   |   |
|   |   |     are for the     |                    |              |   |   |   |   |
|   |   |     charges billed  |                    |              |   |   |   |   |
|   |   |     by the facility |                    |              |   |   |   |   |
|   |   |     (i.e. hospital  |                    |              |   |   |   |   |
|   |   |     or surgical     |                    |              |   |   |   |   |
|   |   |     center) or      |                    |              |   |   |   |   |
|   |   |     ambulance       |                    |              |   |   |   |   |
|   |   |     service for     |                    |              |   |   |   |   |
|   |   |     your surgery or |                    |              |   |   |   |   |
|   |   |     care. Any costs |                    |              |   |   |   |   |
|   |   |     associated with |                    |              |   |   |   |   |
|   |   |     the             |                    |              |   |   |   |   |
|   |   |     professional    |                    |              |   |   |   |   |
|   |   |     charge (i.e.    |                    |              |   |   |   |   |
|   |   |     physicians,     |                    |              |   |   |   |   |
|   |   |     etc.) are in    |                    |              |   |   |   |   |
|   |   |     Sections 5 (a)  |                    |              |   |   |   |   |
|   |   |     or (b).         |                    |              |   |   |   |   |
|   |   |                     |                    |              |   |   |   |   |
|   |   | ```{=html}          |                    |              |   |   |   |   |
|   |   | <!-- -->            |                    |              |   |   |   |   |
|   |   | ```                 |                    |              |   |   |   |   |
|   |   | -   **YOU MUST GET  |                    |              |   |   |   |   |
|   |   |                     |                    |              |   |   |   |   |
|   |   |    PRECERTIFICATION |                    |              |   |   |   |   |
|   |   |     OF HOSPITAL     |                    |              |   |   |   |   |
|   |   |     STAYS; FAILURE  |                    |              |   |   |   |   |
|   |   |     TO DO SO WILL   |                    |              |   |   |   |   |
|   |   |     RESULT IN A     |                    |              |   |   |   |   |
|   |   |     MINIMUM \$500   |                    |              |   |   |   |   |
|   |   |     PENALTY.**      |                    |              |   |   |   |   |
|   |   |     Please refer to |                    |              |   |   |   |   |
|   |   |     the             |                    |              |   |   |   |   |
|   |   |                     |                    |              |   |   |   |   |
|   |   |    precertification |                    |              |   |   |   |   |
|   |   |     information     |                    |              |   |   |   |   |
|   |   |     shown in        |                    |              |   |   |   |   |
|   |   |     Section 3 to be |                    |              |   |   |   |   |
|   |   |     sure which      |                    |              |   |   |   |   |
|   |   |     services        |                    |              |   |   |   |   |
|   |   |     require         |                    |              |   |   |   |   |
|   |   |                     |                    |              |   |   |   |   |
|   |   |   precertification. |                    |              |   |   |   |   |
+---+---+---------------------+--------------------+--------------+---+---+---+---+
| * |   |                     | **You pay**        |              |   |   |   |   |
| * |   |                     |                    |              |   |   |   |   |
| B |   |                     |                    |              |   |   |   |   |
| e |   |                     |                    |              |   |   |   |   |
| n |   |                     |                    |              |   |   |   |   |
| e |   |                     |                    |              |   |   |   |   |
| f |   |                     |                    |              |   |   |   |   |
| i |   |                     |                    |              |   |   |   |   |
| t |   |                     |                    |              |   |   |   |   |
| D |   |                     |                    |              |   |   |   |   |
| e |   |                     |                    |              |   |   |   |   |
| s |   |                     |                    |              |   |   |   |   |
| c |   |                     |                    |              |   |   |   |   |
| r |   |                     |                    |              |   |   |   |   |
| i |   |                     |                    |              |   |   |   |   |
| p |   |                     |                    |              |   |   |   |   |
| t |   |                     |                    |              |   |   |   |   |
| i |   |                     |                    |              |   |   |   |   |
| o |   |                     |                    |              |   |   |   |   |
| n |   |                     |                    |              |   |   |   |   |
| * |   |                     |                    |              |   |   |   |   |
| * |   |                     |                    |              |   |   |   |   |
+---+---+---------------------+--------------------+--------------+---+---+---+---+
| * |   |                     |                    |              |   |   |   |   |
| * |   |                     |                    |              |   |   |   |   |
| N |   |                     |                    |              |   |   |   |   |
| O |   |                     |                    |              |   |   |   |   |
| T |   |                     |                    |              |   |   |   |   |
| E |   |                     |                    |              |   |   |   |   |
| : |   |                     |                    |              |   |   |   |   |
| T |   |                     |                    |              |   |   |   |   |
| h |   |                     |                    |              |   |   |   |   |
| e |   |                     |                    |              |   |   |   |   |
| c |   |                     |                    |              |   |   |   |   |
| a |   |                     |                    |              |   |   |   |   |
| l |   |                     |                    |              |   |   |   |   |
| e |   |                     |                    |              |   |   |   |   |
| n |   |                     |                    |              |   |   |   |   |
| d |   |                     |                    |              |   |   |   |   |
| a |   |                     |                    |              |   |   |   |   |
| r |   |                     |                    |              |   |   |   |   |
| y |   |                     |                    |              |   |   |   |   |
| e |   |                     |                    |              |   |   |   |   |
| a |   |                     |                    |              |   |   |   |   |
| r |   |                     |                    |              |   |   |   |   |
| d |   |                     |                    |              |   |   |   |   |
| e |   |                     |                    |              |   |   |   |   |
| d |   |                     |                    |              |   |   |   |   |
| u |   |                     |                    |              |   |   |   |   |
| c |   |                     |                    |              |   |   |   |   |
| t |   |                     |                    |              |   |   |   |   |
| i |   |                     |                    |              |   |   |   |   |
| b |   |                     |                    |              |   |   |   |   |
| l |   |                     |                    |              |   |   |   |   |
| e |   |                     |                    |              |   |   |   |   |
| a |   |                     |                    |              |   |   |   |   |
| p |   |                     |                    |              |   |   |   |   |
| p |   |                     |                    |              |   |   |   |   |
| l |   |                     |                    |              |   |   |   |   |
| i |   |                     |                    |              |   |   |   |   |
| e |   |                     |                    |              |   |   |   |   |
| s |   |                     |                    |              |   |   |   |   |
| O |   |                     |                    |              |   |   |   |   |
| N |   |                     |                    |              |   |   |   |   |
| L |   |                     |                    |              |   |   |   |   |
| Y |   |                     |                    |              |   |   |   |   |
| w |   |                     |                    |              |   |   |   |   |
| h |   |                     |                    |              |   |   |   |   |
| e |   |                     |                    |              |   |   |   |   |
| n |   |                     |                    |              |   |   |   |   |
| w |   |                     |                    |              |   |   |   |   |
| e |   |                     |                    |              |   |   |   |   |
| s |   |                     |                    |              |   |   |   |   |
| a |   |                     |                    |              |   |   |   |   |
| y |   |                     |                    |              |   |   |   |   |
| b |   |                     |                    |              |   |   |   |   |
| e |   |                     |                    |              |   |   |   |   |
| l |   |                     |                    |              |   |   |   |   |
| o |   |                     |                    |              |   |   |   |   |
| w |   |                     |                    |              |   |   |   |   |
| : |   |                     |                    |              |   |   |   |   |
| " |   |                     |                    |              |   |   |   |   |
| ( |   |                     |                    |              |   |   |   |   |
| c |   |                     |                    |              |   |   |   |   |
| a |   |                     |                    |              |   |   |   |   |
| l |   |                     |                    |              |   |   |   |   |
| e |   |                     |                    |              |   |   |   |   |
| n |   |                     |                    |              |   |   |   |   |
| d |   |                     |                    |              |   |   |   |   |
| a |   |                     |                    |              |   |   |   |   |
| r |   |                     |                    |              |   |   |   |   |
| y |   |                     |                    |              |   |   |   |   |
| e |   |                     |                    |              |   |   |   |   |
| a |   |                     |                    |              |   |   |   |   |
| r |   |                     |                    |              |   |   |   |   |
| d |   |                     |                    |              |   |   |   |   |
| e |   |                     |                    |              |   |   |   |   |
| d |   |                     |                    |              |   |   |   |   |
| u |   |                     |                    |              |   |   |   |   |
| c |   |                     |                    |              |   |   |   |   |
| t |   |                     |                    |              |   |   |   |   |
| i |   |                     |                    |              |   |   |   |   |
| b |   |                     |                    |              |   |   |   |   |
| l |   |                     |                    |              |   |   |   |   |
| e |   |                     |                    |              |   |   |   |   |
| a |   |                     |                    |              |   |   |   |   |
| p |   |                     |                    |              |   |   |   |   |
| p |   |                     |                    |              |   |   |   |   |
| l |   |                     |                    |              |   |   |   |   |
| i |   |                     |                    |              |   |   |   |   |
| e |   |                     |                    |              |   |   |   |   |
| s |   |                     |                    |              |   |   |   |   |
| ) |   |                     |                    |              |   |   |   |   |
| " |   |                     |                    |              |   |   |   |   |
| * |   |                     |                    |              |   |   |   |   |
| * |   |                     |                    |              |   |   |   |   |
+---+---+---------------------+--------------------+--------------+---+---+---+---+
| > |   |                     | **You pay -        | **You pay -  |   |   |   |   |
|   |   |                     | Standard Option**  | High         |   |   |   |   |
| * |   |                     |                    | Option**     |   |   |   |   |
| * |   |                     |                    |              |   |   |   |   |
| I |   |                     |                    |              |   |   |   |   |
| n |   |                     |                    |              |   |   |   |   |
| p |   |                     |                    |              |   |   |   |   |
| a |   |                     |                    |              |   |   |   |   |
| t |   |                     |                    |              |   |   |   |   |
| i |   |                     |                    |              |   |   |   |   |
| e |   |                     |                    |              |   |   |   |   |
| n |   |                     |                    |              |   |   |   |   |
| t |   |                     |                    |              |   |   |   |   |
| > |   |                     |                    |              |   |   |   |   |
|   |   |                     |                    |              |   |   |   |   |
| h |   |                     |                    |              |   |   |   |   |
| o |   |                     |                    |              |   |   |   |   |
| s |   |                     |                    |              |   |   |   |   |
| p |   |                     |                    |              |   |   |   |   |
| i |   |                     |                    |              |   |   |   |   |
| t |   |                     |                    |              |   |   |   |   |
| a |   |                     |                    |              |   |   |   |   |
| l |   |                     |                    |              |   |   |   |   |
| * |   |                     |                    |              |   |   |   |   |
| * |   |                     |                    |              |   |   |   |   |
+---+---+---------------------+--------------------+--------------+---+---+---+---+
| > |   |                     | PPO: 10% of the    | PPO: 10% of  |   |   |   |   |
|   |   |                     | Plan allowance     | the Plan     |   |   |   |   |
| R |   |                     |                    | allowance    |   |   |   |   |
| o |   |                     | Non-PPO: \$250 per |              |   |   |   |   |
| o |   |                     | admission          | Non-PPO:     |   |   |   |   |
| m |   |                     | copayment and 30%  | \$150 per    |   |   |   |   |
| > |   |                     | of the Plan's      | admission    |   |   |   |   |
|   |   |                     | covered charges    | copayment    |   |   |   |   |
| a |   |                     | and any difference | and 25% of   |   |   |   |   |
| n |   |                     | between our        | the Plan's   |   |   |   |   |
| d |   |                     | covered charges    | covered      |   |   |   |   |
| > |   |                     | and the billed     | charges and  |   |   |   |   |
|   |   |                     | amount.            | any          |   |   |   |   |
| b |   |                     |                    | difference   |   |   |   |   |
| o |   |                     | Note: If you use a | between our  |   |   |   |   |
| a |   |                     | PPO provider and a | covered      |   |   |   |   |
| r |   |                     | PPO facility, we   | charges and  |   |   |   |   |
| d |   |                     | may still pay      | the billed   |   |   |   |   |
| , |   |                     | non-PPO benefits   | amount.      |   |   |   |   |
| > |   |                     | if you receive     |              |   |   |   |   |
|   |   |                     | treatment from a   | Note: If you |   |   |   |   |
| s |   |                     | radiologist,       | use a PPO    |   |   |   |   |
| u |   |                     | pathologist, or    | provider and |   |   |   |   |
| c |   |                     | anesthesiologist   | a PPO        |   |   |   |   |
| h |   |                     | that is not a PPO  | facility, we |   |   |   |   |
| > |   |                     | provider.          | may still    |   |   |   |   |
|   |   |                     |                    | pay non-PPO  |   |   |   |   |
| a |   |                     | Note: If you are   | benefits if  |   |   |   |   |
| s |   |                     | hospitalized at    | you receive  |   |   |   |   |
|   |   |                     | the MAYO Clinics   | treatment    |   |   |   |   |
| - |   |                     | for an accepted    | from a       |   |   |   |   |
|   |   |                     | covered transplant | radiologist, |   |   |   |   |
|   |   |                     | or an accepted     | pathologist, |   |   |   |   |
|   |   |                     | complex surgery,   | or           |   |   |   |   |
| w |   |                     | you pay nothing.   | anes         |   |   |   |   |
| a |   |                     |                    | thesiologist |   |   |   |   |
| r |   |                     |                    | that is not  |   |   |   |   |
| d |   |                     |                    | a PPO        |   |   |   |   |
| , |   |                     |                    | provider.    |   |   |   |   |
|   |   |                     |                    |              |   |   |   |   |
|   |   |                     |                    | Note: If you |   |   |   |   |
|   |   |                     |                    | are          |   |   |   |   |
|   |   |                     |                    | hospitalized |   |   |   |   |
| s |   |                     |                    | at the MAYO  |   |   |   |   |
| e |   |                     |                    | Clinics for  |   |   |   |   |
| m |   |                     |                    | an accepted  |   |   |   |   |
| i |   |                     |                    | covered      |   |   |   |   |
| p |   |                     |                    | transplant   |   |   |   |   |
| r |   |                     |                    | or an        |   |   |   |   |
| i |   |                     |                    | accepted     |   |   |   |   |
| v |   |                     |                    | complex      |   |   |   |   |
| a |   |                     |                    | surgery, you |   |   |   |   |
| t |   |                     |                    | pay nothing. |   |   |   |   |
| e |   |                     |                    |              |   |   |   |   |
| , |   |                     |                    |              |   |   |   |   |
|   |   |                     |                    |              |   |   |   |   |
|   |   |                     |                    |              |   |   |   |   |
|   |   |                     |                    |              |   |   |   |   |
|   |   |                     |                    |              |   |   |   |   |
| o |   |                     |                    |              |   |   |   |   |
| r |   |                     |                    |              |   |   |   |   |
|   |   |                     |                    |              |   |   |   |   |
|   |   |                     |                    |              |   |   |   |   |
|   |   |                     |                    |              |   |   |   |   |
|   |   |                     |                    |              |   |   |   |   |
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| n |   |                     |                    |              |   |   |   |   |
| s |   |                     |                    |              |   |   |   |   |
| ; |   |                     |                    |              |   |   |   |   |
|   |   |                     |                    |              |   |   |   |   |
| - |   |                     |                    |              |   |   |   |   |
|   |   |                     |                    |              |   |   |   |   |
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|   |   |                     |                    |              |   |   |   |   |
| g |   |                     |                    |              |   |   |   |   |
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| l |   |                     |                    |              |   |   |   |   |
|   |   |                     |                    |              |   |   |   |   |
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| n |   |                     |                    |              |   |   |   |   |
| g |   |                     |                    |              |   |   |   |   |
|   |   |                     |                    |              |   |   |   |   |
|   |   |                     |                    |              |   |   |   |   |
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| r |   |                     |                    |              |   |   |   |   |
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|   |   |                     |                    |              |   |   |   |   |
| c |   |                     |                    |              |   |   |   |   |
| h |   |                     |                    |              |   |   |   |   |
| a |   |                     |                    |              |   |   |   |   |
| r |   |                     |                    |              |   |   |   |   |
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| . |   |                     |                    |              |   |   |   |   |
+---+---+---------------------+--------------------+--------------+---+---+---+---+

*Inpatient hospital -- Continued on next page*

+--------------------------+--------------------+---------------------+
| > **Inpatient hospital** | **You pay -        | **You pay - High    |
| > *- continued*          | Standard Option**  | Option**            |
+--------------------------+--------------------+---------------------+
| ###                      | > PPO: 10% of the  | > PPO: 10% of the   |
| # Other hospital service | > Plan allowance   | > Plan allowance    |
| s and supplies, such as: |                    |                     |
|                          | Non-PPO: \$250 per | Non-PPO: \$150 per  |
| -   Operating, recovery, | admission          | admission copayment |
|     maternity, and other | copayment and 30%  | and 25% of the      |
|     treatment rooms      | of the Plan's      | Plan's covered      |
|                          | covered charges    | charges and any     |
| -   Prescribed drugs and | and any difference | difference between  |
|     medicines            | between our        | our covered charges |
|                          | covered charges    | and the billed      |
| -   Diagnostic           | and the billed     | amount.             |
|     laboratory tests and | amount.            |                     |
|     X-rays               |                    | Note: If you are    |
|                          | Note: If you are   | hospitalized at the |
| -   Blood or blood       | hospitalized at    | MAYO Clinics for a  |
|     plasma, if not       | the MAYO Clinics   | covered transplant  |
|     donated or replaced  | for a covered      | or an accepted      |
|                          | transplant or an   | complex surgery,    |
| -   Dressings, splints,  | accepted complex   | you pay nothing.    |
|     casts, and sterile   | surgery, you pay   |                     |
|     tray services        | nothing..          |                     |
|                          |                    |                     |
| -   Medical supplies and |                    |                     |
|     equipment, including |                    |                     |
|     oxygen               |                    |                     |
|                          |                    |                     |
| -   Anesthetics          |                    |                     |
|                          |                    |                     |
| -   Take home items      |                    |                     |
|     (including           |                    |                     |
|     prescription drugs)  |                    |                     |
|                          |                    |                     |
| > Note: Medical          |                    |                     |
| > supplies, appliances,  |                    |                     |
| > medical equipment, and |                    |                     |
| > covered items billed   |                    |                     |
| > by a hospital for use  |                    |                     |
| > at home are covered    |                    |                     |
| > under Section 5 (a)    |                    |                     |
|                          |                    |                     |
| -   Prosthetic devices   |                    |                     |
|     such as artificial   |                    |                     |
|     joints and           |                    |                     |
|     pacemakers.          |                    |                     |
+--------------------------+--------------------+---------------------+
| > *Not covered:*         | > *All charges.*   | > *All charges.*    |
|                          |                    |                     |
| -   *Any part of a       |                    |                     |
|     hospital admission   |                    |                     |
|     that is not          |                    |                     |
|     medically necessary  |                    |                     |
|     (see definition),    |                    |                     |
|     such as when you do  |                    |                     |
|     not need acute       |                    |                     |
|     hospital inpatient   |                    |                     |
|     (overnight) care,    |                    |                     |
|     but could receive    |                    |                     |
|     care in some other   |                    |                     |
|     setting without      |                    |                     |
|     adversely affecting  |                    |                     |
|     your condition or    |                    |                     |
|     the quality of your  |                    |                     |
|     medical care. Note:  |                    |                     |
|     In this event, we    |                    |                     |
|     pay benefits for     |                    |                     |
|     services and         |                    |                     |
|     supplies other than  |                    |                     |
|     room and board at    |                    |                     |
|     the level they would |                    |                     |
|     have been covered if |                    |                     |
|     provided in an       |                    |                     |
|     alternative setting* |                    |                     |
|                          |                    |                     |
| -   *Custodial care; see |                    |                     |
|     definition.*         |                    |                     |
|                          |                    |                     |
| -   *Non-covered         |                    |                     |
|     facilities, such as  |                    |                     |
|     nursing homes,       |                    |                     |
|     extended care        |                    |                     |
|     facilities (except   |                    |                     |
|     when Medicare A is   |                    |                     |
|     primary) and         |                    |                     |
|     schools*             |                    |                     |
|                          |                    |                     |
| -   *Personal comfort    |                    |                     |
|     items, such as       |                    |                     |
|     telephone,           |                    |                     |
|     television, barber   |                    |                     |
|     services, guest      |                    |                     |
|     meals and beds*      |                    |                     |
|                          |                    |                     |
| -   *Private nursing     |                    |                     |
|     care*                |                    |                     |
|                          |                    |                     |
| -   *Surcharges made by  |                    |                     |
|     hospitals*           |                    |                     |
+--------------------------+--------------------+---------------------+

+--------------------------+--------------------+---------------------+
| > **Outpatient hospital  | **You pay -        | > **You pay - High  |
| > or ambulatory surgical | Standard Option**  | > Option**          |
| > center**               |                    |                     |
+--------------------------+--------------------+---------------------+
| -   Operating, recovery, | > PPO: 9% of the   | > PPO: 10% of the   |
|     and other treatment  | > Plan allowance   | > Plan allowance    |
|     rooms                | > (calendar year   | > (calendar year    |
|                          | > deductible       | > deductible        |
| -   Prescribed drugs and | > applies)         | > applies)          |
|     medicines            | >                  | >                   |
|                          | > Non-PPO: 30% of  | > Non-PPO: 25% of   |
| ```{=html}               | > the Plan         | > the Plan          |
| <!-- -->                 | > allowance and    | > allowance and any |
| ```                      | > any difference   | > difference        |
| -   Diagnostic           | > between our      | > between our       |
|     laboratory tests,    | > allowance and    | > allowance and the |
|     X-rays, and          | > the billed       | > billed amount     |
|     pathology services   | > amount (calendar | > (calendar year    |
|                          | > year deductible  | > deductible        |
| -   Administration of    | > applies)         | > applies)          |
|     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          |                    |                     |
|                          |                    |                     |
| -   Prosthetic devices   |                    |                     |
|     such as artificial   |                    |                     |
|     joints and           |                    |                     |
|     pacemakers           |                    |                     |
|                          |                    |                     |
| > NOTE: -- We cover      |                    |                     |
| > hospital services and  |                    |                     |
| > supplies related to    |                    |                     |
| > dental procedures when |                    |                     |
| > necessitated by a      |                    |                     |
| > non-dental physical    |                    |                     |
| > impairment. We cover   |                    |                     |
| > dental procedures      |                    |                     |
| > under the dental       |                    |                     |
| > benefit. See Section 5 |                    |                     |
| > (h).                   |                    |                     |
+--------------------------+--------------------+---------------------+
| > **Extended care        |                    |                     |
| > benefits/Skilled       |                    |                     |
| > nursing care facility  |                    |                     |
| > benefits**             |                    |                     |
+--------------------------+--------------------+---------------------+
| > No benefit unless      | PPO: Nothing       | PPO: Nothing        |
| > covered under Medicare |                    |                     |
| > Part A. Once Medicare  | Non-PPO: Nothing   | Non-PPO: Nothing    |
| > has made their primary |                    |                     |
| > payment, we provide    |                    |                     |
| > secondary benefits for |                    |                     |
| > the appropriate        |                    |                     |
| > Medicare Part A        |                    |                     |
| > deductible and         |                    |                     |
| > coinsurance in full.   |                    |                     |
| >                        |                    |                     |
| > Note: Our coverage of  |                    |                     |
| > any form of            |                    |                     |
| > ventilation or         |                    |                     |
| > respiratory therapy is |                    |                     |
| > limited to this        |                    |                     |
| > benefit.               |                    |                     |
+--------------------------+--------------------+---------------------+
| > *Not covered:*         | *All charges.*     | *All charges*       |
|                          |                    |                     |
| -   *Custodial care*     |                    |                     |
|                          |                    |                     |
| -   *Services and        |                    |                     |
|     supplies for which   |                    |                     |
|     Medicare Part A did  |                    |                     |
|     not provide          |                    |                     |
|     benefits*            |                    |                     |
+--------------------------+--------------------+---------------------+

+--------------------------+--------------------+---------------------+
| > **Hospice care**       | **You pay -        | > **You pay - High  |
|                          | Standard Option**  | > Option**          |
+--------------------------+--------------------+---------------------+
| > Hospice is a           | PPO: Same as       | PPO: Same as        |
| > coordinated program of | non-PPO            | non-PPO             |
| > maintenance and        |                    |                     |
| > supportive care for    | Non-PPO: Any       | Non-PPO: Any        |
| > the terminally ill     | difference between | difference between  |
| > provided by a          | the Plan allowance | the Plan allowance  |
| > medically supervised   | and the billed     | and the billed      |
| > team under the         | amount             | amount              |
| > direction of a doctor. |                    |                     |
| >                        | Note: The Plan     | Note: The Plan      |
| > The hospice team may   | allowance is:      | allowance is:       |
| > also include social    |                    |                     |
| > workers, members of    | -   \$300 per day  | -   \$300 per day   |
| > the clergy, certified  |     up to \$3,000  |     up to \$3,000   |
| > counselors,            |     per period of  |     per period of   |
| > volunteers, clinical   |     inpatient care |     inpatient care  |
| > psychologists,         |                    |                     |
| > physical and           | ```{=html}         | ```{=html}          |
| > occupational           | <!-- -->           | <!-- -->            |
| > therapists.            | ```                | ```                 |
| >                        | -   100% of        | -   100% of covered |
| > The hospice care       |     covered        |     charges up to   |
| > program must begin     |     charges up to  |     \$2,000 per     |
| > after a person's       |     \$2,000 per    |     period of       |
| > primary doctor         |     period of      |     outpatient      |
| > certifies terminal     |     outpatient     |     care.           |
| > illness and life       |     care.          |                     |
| > expectancy of six      |                    |                     |
| > months or less.        |                    |                     |
| > Hospice care must be:  |                    |                     |
|                          |                    |                     |
| -   Ordered by the       |                    |                     |
|     supervising doctor,  |                    |                     |
|     and                  |                    |                     |
|                          |                    |                     |
| -   Charged by the       |                    |                     |
|     hospice care         |                    |                     |
|     program, and         |                    |                     |
|                          |                    |                     |
| -   Provided within six  |                    |                     |
|     months from the date |                    |                     |
|     the person entered   |                    |                     |
|     (or re-entered after |                    |                     |
|     a period of          |                    |                     |
|     remission) a hospice |                    |                     |
|     care program.        |                    |                     |
|                          |                    |                     |
| > Note: If you are in    |                    |                     |
| > remission and          |                    |                     |
| > discharged from a      |                    |                     |
| > hospice care program,  |                    |                     |
| > a readmission within   |                    |                     |
| > three months of a      |                    |                     |
| > prior discharge is     |                    |                     |
| > considered as part of  |                    |                     |
| > the same period of     |                    |                     |
| > care. A new period     |                    |                     |
| > begins three months    |                    |                     |
| > after a prior          |                    |                     |
| > discharge with maximum |                    |                     |
| > benefits available.    |                    |                     |
+--------------------------+--------------------+---------------------+
| > Bereavement benefit:   | > PPO: Same as     | > PPO: Same as      |
| >                        | > non-PPO          | > non-PPO           |
| > Family bereavement     | >                  | >                   |
| > counseling and         | > Non-PPO: Any     | > Non-PPO: Any      |
| > supportive services if | > difference       | > difference        |
| > the covered family     | > between the      | > between the \$250 |
| > members receive the    | > \$250 Plan       | > Plan allowance    |
| > services from a        | > allowance and    | > and the billed    |
| > hospice care program   | > the billed       | > amount            |
| > within three months    | > amount           |                     |
| > following the death of |                    |                     |
| > a covered family       |                    |                     |
| > member who received    |                    |                     |
| > hospice care benefits  |                    |                     |
| > under the Plan.        |                    |                     |
+--------------------------+--------------------+---------------------+
| > *Not covered:*         | > *All charges.*   | > *All charges.*    |
| >                        |                    |                     |
| > *Independent nursing,  |                    |                     |
| > homemaker*             |                    |                     |
+--------------------------+--------------------+---------------------+

+---------------------------+--------------------+--------------------+
| > **Ambulance**           | **You pay --**     | > **You pay --**   |
|                           |                    | >                  |
|                           | **Standard         | > **High Option**  |
|                           | Option**           |                    |
+---------------------------+--------------------+--------------------+
| -   Local professional    | > PPO: Same as     | > PPO: Same as     |
|     ambulance service     | > non-PPO          | > non-PPO          |
|     when medically        | >                  | >                  |
|     appropriate           | > Non-PPO: 30% of  | > Non-PPO: 25% of  |
|                           | > the Plan         | > the Plan         |
|                           | > allowance and    | > allowance and    |
|                           | > any difference   | > any difference   |
|                           | > between our      | > between our      |
|                           | > allowance and    | > allowance and    |
|                           | > the billed       | > the billed       |
|                           | > amount (calendar | > amount (calendar |
|                           | > year deductible  | > year deductible  |
|                           | > applies)         | > applies)         |
+---------------------------+--------------------+--------------------+

+---+---+---------------------+--------------------+---------------+---+---+
| # |   |                     |                    |               |   |   |
| # |   |                     |                    |               |   |   |
|   |   |                     |                    |               |   |   |
| * |   |                     |                    |               |   |   |
| * |   |                     |                    |               |   |   |
| S |   |                     |                    |               |   |   |
| e |   |                     |                    |               |   |   |
| c |   |                     |                    |               |   |   |
| t |   |                     |                    |               |   |   |
| i |   |                     |                    |               |   |   |
| o |   |                     |                    |               |   |   |
| n |   |                     |                    |               |   |   |
|   |   |                     |                    |               |   |   |
| 5 |   |                     |                    |               |   |   |
|   |   |                     |                    |               |   |   |
| ( |   |                     |                    |               |   |   |
| d |   |                     |                    |               |   |   |
| ) |   |                     |                    |               |   |   |
| . |   |                     |                    |               |   |   |
|   |   |                     |                    |               |   |   |
| E |   |                     |                    |               |   |   |
| m |   |                     |                    |               |   |   |
| e |   |                     |                    |               |   |   |
| r |   |                     |                    |               |   |   |
| g |   |                     |                    |               |   |   |
| e |   |                     |                    |               |   |   |
| n |   |                     |                    |               |   |   |
| c |   |                     |                    |               |   |   |
| y |   |                     |                    |               |   |   |
|   |   |                     |                    |               |   |   |
| s |   |                     |                    |               |   |   |
| e |   |                     |                    |               |   |   |
| r |   |                     |                    |               |   |   |
| v |   |                     |                    |               |   |   |
| i |   |                     |                    |               |   |   |
| c |   |                     |                    |               |   |   |
| e |   |                     |                    |               |   |   |
| s |   |                     |                    |               |   |   |
| / |   |                     |                    |               |   |   |
| a |   |                     |                    |               |   |   |
| c |   |                     |                    |               |   |   |
| c |   |                     |                    |               |   |   |
| i |   |                     |                    |               |   |   |
| d |   |                     |                    |               |   |   |
| e |   |                     |                    |               |   |   |
| n |   |                     |                    |               |   |   |
| t |   |                     |                    |               |   |   |
| s |   |                     |                    |               |   |   |
| * |   |                     |                    |               |   |   |
| * |   |                     |                    |               |   |   |
+---+---+---------------------+--------------------+---------------+---+---+
| # | * | **Here are some     |                    |               | * |   |
| # | * | important things to |                    |               | * |   |
| # | I | keep in mind about  |                    |               | I |   |
| # | * | these benefits:**   |                    |               | * |   |
| # | * |                     |                    |               | * |   |
|   |   | -   Please remember |                    |               |   |   |
|   | * |     that all        |                    |               | * |   |
|   | * |     benefits are    |                    |               | * |   |
|   | M |     subject to the  |                    |               | M |   |
|   | * |     definitions,    |                    |               | * |   |
|   | * |     limitations,    |                    |               | * |   |
|   |   |     and exclusions  |                    |               |   |   |
|   | * |     in this         |                    |               | * |   |
|   | * |     brochure and    |                    |               | * |   |
|   | P |     are payable     |                    |               | P |   |
|   | * |     only when we    |                    |               | * |   |
|   | * |     determine they  |                    |               | * |   |
|   |   |     are medically   |                    |               |   |   |
|   | * |     necessary.      |                    |               | * |   |
|   | * |                     |                    |               | * |   |
|   | O | -   The calendar    |                    |               | O |   |
|   | * |     year deductible |                    |               | * |   |
|   | * |     is:             |                    |               | * |   |
|   |   |                     |                    |               |   |   |
|   | * | > The calendar year |                    |               | * |   |
|   | * | > deductible        |                    |               | * |   |
|   | R | > applies to almost |                    |               | R |   |
|   | * | > all benefits in   |                    |               | * |   |
|   | * | > this Section. We  |                    |               | * |   |
|   |   | > added "(No        |                    |               |   |   |
|   | * | > deductible)" to   |                    |               | * |   |
|   | * | > show when the     |                    |               | * |   |
|   | T | > calendar year     |                    |               | T |   |
|   | * | > deductible does   |                    |               | * |   |
|   | * | > not apply.        |                    |               | * |   |
|   |   |                     |                    |               |   |   |
|   | * | -   The non-PPO     |                    |               | * |   |
|   | * |     benefits are    |                    |               | * |   |
|   | A |     the standard    |                    |               | A |   |
|   | * |     benefits of     |                    |               | * |   |
|   | * |     this Plan. PPO  |                    |               | * |   |
|   |   |     benefits apply  |                    |               |   |   |
|   | * |     only when you   |                    |               | * |   |
|   | * |     use a PPO       |                    |               | * |   |
|   | N |     provider. When  |                    |               | N |   |
|   | * |     no PPO provider |                    |               | * |   |
|   | * |     is available,   |                    |               | * |   |
|   |   |     non-PPO         |                    |               |   |   |
|   | * |     benefits apply. |                    |               | * |   |
|   | * |                     |                    |               | * |   |
|   | T | -   Be sure to read |                    |               | T |   |
|   | * |     Section 4,      |                    |               | * |   |
|   | * |     Y*our costs for |                    |               | * |   |
|   |   |     covered         |                    |               |   |   |
|   |   |     services,* for  |                    |               |   |   |
|   |   |     valuable        |                    |               |   |   |
|   |   |     information     |                    |               |   |   |
|   |   |     about how cost  |                    |               |   |   |
|   |   |     sharing works,  |                    |               |   |   |
|   |   |     with special    |                    |               |   |   |
|   |   |     sections for    |                    |               |   |   |
|   |   |     members who are |                    |               |   |   |
|   |   |     age 65 or over. |                    |               |   |   |
|   |   |     Also read       |                    |               |   |   |
|   |   |     Section 9 about |                    |               |   |   |
|   |   |     coordinating    |                    |               |   |   |
|   |   |     benefits with   |                    |               |   |   |
|   |   |     other coverage, |                    |               |   |   |
|   |   |     including with  |                    |               |   |   |
|   |   |     Medicare.       |                    |               |   |   |
|   |   |                     |                    |               |   |   |
|   |   | #####               |                    |               |   |   |
+---+---+---------------------+--------------------+---------------+---+---+
| * |   |                     |                    |               |   |   |
| * |   |                     |                    |               |   |   |
| W |   |                     |                    |               |   |   |
| h |   |                     |                    |               |   |   |
| a |   |                     |                    |               |   |   |
| t |   |                     |                    |               |   |   |
| i |   |                     |                    |               |   |   |
| s |   |                     |                    |               |   |   |
| a |   |                     |                    |               |   |   |
| c |   |                     |                    |               |   |   |
| c |   |                     |                    |               |   |   |
| i |   |                     |                    |               |   |   |
| d |   |                     |                    |               |   |   |
| e |   |                     |                    |               |   |   |
| n |   |                     |                    |               |   |   |
| t |   |                     |                    |               |   |   |
| a |   |                     |                    |               |   |   |
| l |   |                     |                    |               |   |   |
| i |   |                     |                    |               |   |   |
| n |   |                     |                    |               |   |   |
| j |   |                     |                    |               |   |   |
| u |   |                     |                    |               |   |   |
| r |   |                     |                    |               |   |   |
| y |   |                     |                    |               |   |   |
| / |   |                     |                    |               |   |   |
| m |   |                     |                    |               |   |   |
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| d |   |                     |                    |               |   |   |
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| c |   |                     |                    |               |   |   |
| a |   |                     |                    |               |   |   |
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| c |   |                     |                    |               |   |   |
| y |   |                     |                    |               |   |   |
| ? |   |                     |                    |               |   |   |
| * |   |                     |                    |               |   |   |
| * |   |                     |                    |               |   |   |
|   |   |                     |                    |               |   |   |
| A |   |                     |                    |               |   |   |
| m |   |                     |                    |               |   |   |
| e |   |                     |                    |               |   |   |
| d |   |                     |                    |               |   |   |
| i |   |                     |                    |               |   |   |
| c |   |                     |                    |               |   |   |
| a |   |                     |                    |               |   |   |
| l |   |                     |                    |               |   |   |
| e |   |                     |                    |               |   |   |
| m |   |                     |                    |               |   |   |
| e |   |                     |                    |               |   |   |
| r |   |                     |                    |               |   |   |
| g |   |                     |                    |               |   |   |
| e |   |                     |                    |               |   |   |
| n |   |                     |                    |               |   |   |
| c |   |                     |                    |               |   |   |
| y |   |                     |                    |               |   |   |
| i |   |                     |                    |               |   |   |
| s |   |                     |                    |               |   |   |
| t |   |                     |                    |               |   |   |
| h |   |                     |                    |               |   |   |
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| u |   |                     |                    |               |   |   |
| d |   |                     |                    |               |   |   |
| d |   |                     |                    |               |   |   |
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| d |   |                     |                    |               |   |   |
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| e |   |                     |                    |               |   |   |
| x |   |                     |                    |               |   |   |
| p |   |                     |                    |               |   |   |
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| s |   |                     |                    |               |   |   |
| e |   |                     |                    |               |   |   |
| r |   |                     |                    |               |   |   |
| i |   |                     |                    |               |   |   |
| o |   |                     |                    |               |   |   |
| u |   |                     |                    |               |   |   |
| s |   |                     |                    |               |   |   |
| ; |   |                     |                    |               |   |   |
| e |   |                     |                    |               |   |   |
| x |   |                     |                    |               |   |   |
| a |   |                     |                    |               |   |   |
| m |   |                     |                    |               |   |   |
| p |   |                     |                    |               |   |   |
| l |   |                     |                    |               |   |   |
| e |   |                     |                    |               |   |   |
| s |   |                     |                    |               |   |   |
| i |   |                     |                    |               |   |   |
| n |   |                     |                    |               |   |   |
| c |   |                     |                    |               |   |   |
| l |   |                     |                    |               |   |   |
| u |   |                     |                    |               |   |   |
| d |   |                     |                    |               |   |   |
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| d |   |                     |                    |               |   |   |
| e |   |                     |                    |               |   |   |
| e |   |                     |                    |               |   |   |
| p |   |                     |                    |               |   |   |
| c |   |                     |                    |               |   |   |
| u |   |                     |                    |               |   |   |
| t |   |                     |                    |               |   |   |
| s |   |                     |                    |               |   |   |
| a |   |                     |                    |               |   |   |
| n |   |                     |                    |               |   |   |
| d |   |                     |                    |               |   |   |
| b |   |                     |                    |               |   |   |
| r |   |                     |                    |               |   |   |
| o |   |                     |                    |               |   |   |
| k |   |                     |                    |               |   |   |
| e |   |                     |                    |               |   |   |
| n |   |                     |                    |               |   |   |
| b |   |                     |                    |               |   |   |
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| n |   |                     |                    |               |   |   |
| e |   |                     |                    |               |   |   |
| s |   |                     |                    |               |   |   |
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| t |   |                     |                    |               |   |   |
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| r |   |                     |                    |               |   |   |
| s |   |                     |                    |               |   |   |
| a |   |                     |                    |               |   |   |
| r |   |                     |                    |               |   |   |
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| e |   |                     |                    |               |   |   |
| m |   |                     |                    |               |   |   |
| e |   |                     |                    |               |   |   |
| r |   |                     |                    |               |   |   |
| g |   |                     |                    |               |   |   |
| e |   |                     |                    |               |   |   |
| n |   |                     |                    |               |   |   |
| c |   |                     |                    |               |   |   |
| i |   |                     |                    |               |   |   |
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| s |   |                     |                    |               |   |   |
| b |   |                     |                    |               |   |   |
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| c |   |                     |                    |               |   |   |
| a |   |                     |                    |               |   |   |
| u |   |                     |                    |               |   |   |
| s |   |                     |                    |               |   |   |
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| t |   |                     |                    |               |   |   |
| h |   |                     |                    |               |   |   |
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| l |   |                     |                    |               |   |   |
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| s |   |                     |                    |               |   |   |
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| d |   |                     |                    |               |   |   |
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| m |   |                     |                    |               |   |   |
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| n |   |                     |                    |               |   |   |
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| s |   |                     |                    |               |   |   |
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| h |   |                     |                    |               |   |   |
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| d |   |                     |                    |               |   |   |
| f |   |                     |                    |               |   |   |
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| q |   |                     |                    |               |   |   |
| u |   |                     |                    |               |   |   |
| i |   |                     |                    |               |   |   |
| c |   |                     |                    |               |   |   |
| k |   |                     |                    |               |   |   |
| a |   |                     |                    |               |   |   |
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+---+---+---------------------+--------------------+---------------+---+---+
| * |   |                     |                    |               |   |   |
| * |   |                     |                    |               |   |   |
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| n |   |                     |                    |               |   |   |
| d |   |                     |                    |               |   |   |
| p |   |                     |                    |               |   |   |
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| g |   |                     |                    |               |   |   |
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| . |   |                     |                    |               |   |   |
+---+---+---------------------+--------------------+---------------+---+---+
| * |   |                     | **You pay**        |               |   |   |
| * |   |                     |                    |               |   |   |
| B |   |                     | **After the        |               |   |   |
| e |   |                     | calendar year      |               |   |   |
| n |   |                     | deductible...**    |               |   |   |
| e |   |                     |                    |               |   |   |
| f |   |                     |                    |               |   |   |
| i |   |                     |                    |               |   |   |
| t |   |                     |                    |               |   |   |
| D |   |                     |                    |               |   |   |
| e |   |                     |                    |               |   |   |
| s |   |                     |                    |               |   |   |
| c |   |                     |                    |               |   |   |
| r |   |                     |                    |               |   |   |
| i |   |                     |                    |               |   |   |
| p |   |                     |                    |               |   |   |
| t |   |                     |                    |               |   |   |
| i |   |                     |                    |               |   |   |
| o |   |                     |                    |               |   |   |
| n |   |                     |                    |               |   |   |
| * |   |                     |                    |               |   |   |
| * |   |                     |                    |               |   |   |
+---+---+---------------------+--------------------+---------------+---+---+
| > |   |                     |                    |               |   |   |
|   |   |                     |                    |               |   |   |
| * |   |                     |                    |               |   |   |
| * |   |                     |                    |               |   |   |
| N |   |                     |                    |               |   |   |
| O |   |                     |                    |               |   |   |
| T |   |                     |                    |               |   |   |
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| : |   |                     |                    |               |   |   |
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|   |   |                     |                    |               |   |   |
| T |   |                     |                    |               |   |   |
| h |   |                     |                    |               |   |   |
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| > |   |                     |                    |               |   |   |
|   |   |                     |                    |               |   |   |
| c |   |                     |                    |               |   |   |
| a |   |                     |                    |               |   |   |
| l |   |                     |                    |               |   |   |
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| n |   |                     |                    |               |   |   |
| d |   |                     |                    |               |   |   |
| a |   |                     |                    |               |   |   |
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| d |   |                     |                    |               |   |   |
| u |   |                     |                    |               |   |   |
| c |   |                     |                    |               |   |   |
| t |   |                     |                    |               |   |   |
| i |   |                     |                    |               |   |   |
| b |   |                     |                    |               |   |   |
| l |   |                     |                    |               |   |   |
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|   |   |                     |                    |               |   |   |
| a |   |                     |                    |               |   |   |
| p |   |                     |                    |               |   |   |
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| a |   |                     |                    |               |   |   |
| l |   |                     |                    |               |   |   |
| m |   |                     |                    |               |   |   |
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| a |   |                     |                    |               |   |   |
| y |   |                     |                    |               |   |   |
| > |   |                     |                    |               |   |   |
|   |   |                     |                    |               |   |   |
| " |   |                     |                    |               |   |   |
| ( |   |                     |                    |               |   |   |
| N |   |                     |                    |               |   |   |
| o |   |                     |                    |               |   |   |
| > |   |                     |                    |               |   |   |
|   |   |                     |                    |               |   |   |
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| d |   |                     |                    |               |   |   |
| u |   |                     |                    |               |   |   |
| c |   |                     |                    |               |   |   |
| t |   |                     |                    |               |   |   |
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| l |   |                     |                    |               |   |   |
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| ) |   |                     |                    |               |   |   |
| " |   |                     |                    |               |   |   |
| > |   |                     |                    |               |   |   |
|   |   |                     |                    |               |   |   |
| w |   |                     |                    |               |   |   |
| h |   |                     |                    |               |   |   |
| e |   |                     |                    |               |   |   |
| n |   |                     |                    |               |   |   |
| > |   |                     |                    |               |   |   |
|   |   |                     |                    |               |   |   |
| i |   |                     |                    |               |   |   |
| t |   |                     |                    |               |   |   |
| > |   |                     |                    |               |   |   |
|   |   |                     |                    |               |   |   |
| d |   |                     |                    |               |   |   |
| o |   |                     |                    |               |   |   |
| e |   |                     |                    |               |   |   |
| s |   |                     |                    |               |   |   |
| > |   |                     |                    |               |   |   |
|   |   |                     |                    |               |   |   |
| n |   |                     |                    |               |   |   |
| o |   |                     |                    |               |   |   |
| t |   |                     |                    |               |   |   |
| > |   |                     |                    |               |   |   |
|   |   |                     |                    |               |   |   |
| a |   |                     |                    |               |   |   |
| p |   |                     |                    |               |   |   |
| p |   |                     |                    |               |   |   |
| l |   |                     |                    |               |   |   |
| y |   |                     |                    |               |   |   |
| . |   |                     |                    |               |   |   |
| * |   |                     |                    |               |   |   |
| * |   |                     |                    |               |   |   |
+---+---+---------------------+--------------------+---------------+---+---+
| > |   |                     | **You pay -        | **You pay -   |   |   |
|   |   |                     | Standard Option**  | High Option** |   |   |
| * |   |                     |                    |               |   |   |
| * |   |                     |                    |               |   |   |
| A |   |                     |                    |               |   |   |
| c |   |                     |                    |               |   |   |
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| d |   |                     |                    |               |   |   |
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| l |   |                     |                    |               |   |   |
| > |   |                     |                    |               |   |   |
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| n |   |                     |                    |               |   |   |
| j |   |                     |                    |               |   |   |
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| r |   |                     |                    |               |   |   |
| y |   |                     |                    |               |   |   |
| * |   |                     |                    |               |   |   |
| * |   |                     |                    |               |   |   |
+---+---+---------------------+--------------------+---------------+---+---+
| > |   |                     | PPO: Nothing (No   | PPO: Nothing  |   |   |
|   |   |                     | deductible)        | (No           |   |   |
| I |   |                     |                    | deductible)   |   |   |
| f |   |                     | Non-PPO: The       |               |   |   |
| > |   |                     | difference between | Non-PPO: The  |   |   |
|   |   |                     | the Plan allowance | difference    |   |   |
| y |   |                     | and the billed     | between the   |   |   |
| o |   |                     | amount (No         | Plan          |   |   |
| u |   |                     | deductible)        | allowance and |   |   |
| > |   |                     |                    | the billed    |   |   |
|   |   |                     |                    | amount (No    |   |   |
| r |   |                     |                    | deductible)   |   |   |
| e |   |                     |                    |               |   |   |
| c |   |                     |                    |               |   |   |
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|   |   |                     |                    |               |   |   |
| a |   |                     |                    |               |   |   |
| r |   |                     |                    |               |   |   |
| e |   |                     |                    |               |   |   |
| > |   |                     |                    |               |   |   |
|   |   |                     |                    |               |   |   |
| a |   |                     |                    |               |   |   |
| d |   |                     |                    |               |   |   |
| m |   |                     |                    |               |   |   |
| i |   |                     |                    |               |   |   |
| t |   |                     |                    |               |   |   |
| t |   |                     |                    |               |   |   |
| e |   |                     |                    |               |   |   |
| d |   |                     |                    |               |   |   |
| . |   |                     |                    |               |   |   |
+---+---+---------------------+--------------------+---------------+---+---+

*Accidental injury \-- Continued on next page*

+---------------------------+--------------------+--------------------+
| > **Accidental injury** - | **You pay -        | **You pay - High   |
| > *continued*             | Standard Option**  | Option**           |
+---------------------------+--------------------+--------------------+
| > If you receive care for | PPO: 9% of the     | PPO: 10% of the    |
| > your accidental injury  | Plan allowance     | Plan allowance     |
| > after 72 hours, we      |                    |                    |
| > cover:                  | Non-PPO: 30% of    | Non-PPO: 25% of    |
|                           | the Plan allowance | the Plan allowance |
| -   Non-surgical          | and any difference | and any difference |
|     physician services    | between our        | between our        |
|     and supplies          | allowance and the  | allowance and the  |
|                           | billed amount      | billed amount      |
| -   Related outpatient    |                    |                    |
|     hospital services     |                    |                    |
|                           |                    |                    |
| > Note: We pay Hospital   |                    |                    |
| > benefits if you are     |                    |                    |
| > admitted. See Section 5 |                    |                    |
| > (c) for other hospital  |                    |                    |
| > benefits and Section 5  |                    |                    |
| > (b) for surgical        |                    |                    |
| > benefits.               |                    |                    |
+---------------------------+--------------------+--------------------+
| > **Medical emergency**   |                    |                    |
+---------------------------+--------------------+--------------------+
| > Outpatient medical or   | PPO: 9% of the     | PPO: 10% of the    |
| > surgical services and   | Plan allowance and | Plan allowance and |
| > supplies provided in a  | a \$50 copayment   | a \$50 copayment   |
| > hospital emergency      | per access to care | per access to care |
| > room.                   | (No deductible)    | (No deductible)    |
|                           |                    |                    |
|                           | Non-PPO: 30% of    | Non-PPO: 25% of    |
|                           | the Plan allowance | the Plan allowance |
|                           | and a \$50         | and a \$50         |
|                           | copayment per      | copayment per      |
|                           | access to care and | access to care and |
|                           | any difference     | any difference     |
|                           | between the sum of | between the sum of |
|                           | our allowance plus | our allowance plus |
|                           | the copayment and  | the copayment and  |
|                           | the billed amount  | the billed amount  |
|                           | (No deductible)    | (No deductible)    |
+---------------------------+--------------------+--------------------+
| > **Ambulance**           |                    |                    |
+---------------------------+--------------------+--------------------+
| > Professional ambulance  | PPO: Same as       | PPO: Same as       |
| > service provided for    | non-PPO            | non-PPO            |
| > accidental injury is    |                    |                    |
| > covered under the       | Non-PPO: 30% of    | Non-PPO: 25% of    |
| > accidental injury       | the Plan allowance | the Plan allowance |
| > benefit.                | and any difference | and any difference |
| >                         | between our        | between our        |
| > When a patient is       | allowance and the  | allowance and the  |
| > provided ambulance      | billed amount (No  | billed amount (No  |
| > service to an           | deductible)        | deductible)        |
| > outpatient hospital     |                    |                    |
| > emergency room for a    |                    |                    |
| > medical emergency       |                    |                    |
| > (non-accidental), we    |                    |                    |
| > will cover as indicated |                    |                    |
| > in this section.        |                    |                    |
| >                         |                    |                    |
| > Note: We cover air      |                    |                    |
| > ambulance only when it  |                    |                    |
| > is medically necessary  |                    |                    |
| > and the physician       |                    |                    |
| > provides a letter of    |                    |                    |
| > medical necessity.      |                    |                    |
| >                         |                    |                    |
| > Note: 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 |   |                                   |                     |   |   |
| * |   |                                   |                     |   |   |
| * |   |                                   |                     |   |   |
+---+---+-----------------------------------+---------------------+---+---+
|   | * | You may choose to get care        |                     | * |   |
|   | * | Out-of-Network or In-Network.     |                     | * |   |
|   | I | When you receive In-Network care, |                     | I |   |
|   | * | you must get our approval for     |                     | * |   |
|   | * | services and follow a treatment   |                     | * |   |
|   |   | plan we approve. If you do,       |                     |   |   |
|   | * | cost-sharing and limitations for  |                     | * |   |
|   | * | In-Network mental health and      |                     | * |   |
|   | M | substance abuse benefits will be  |                     | M |   |
|   | * | no greater than for similar       |                     | * |   |
|   | * | benefits for other illnesses and  |                     | * |   |
|   |   | conditions.                       |                     |   |   |
|   | * |                                   |                     | * |   |
|   | * | **Here are some important things  |                     | * |   |
|   | P | to keep in mind about these       |                     | P |   |
|   | * | benefits:**                       |                     | * |   |
|   | * |                                   |                     | * |   |
|   |   | • All benefits are subject to the |                     |   |   |
|   | * | definitions, limitations, and     |                     | * |   |
|   | * | exclusions in this brochure and   |                     | * |   |
|   | O | are payable only when we          |                     | O |   |
|   | * | determine they are medically      |                     | * |   |
|   | * | necessary.                        |                     | * |   |
|   |   |                                   |                     |   |   |
|   | * | -   The mental health and         |                     | * |   |
|   | * |     substance abuse calendar year |                     | * |   |
|   | R |     deductible or, for facility   |                     | R |   |
|   | * |     care, the inpatient           |                     | * |   |
|   | * |     deductible apply to almost    |                     | * |   |
|   |   |     all benefits in this Section. |                     |   |   |
|   | * |     We added "(No deductible)" to |                     | * |   |
|   | * |     show when a deductible does   |                     | * |   |
|   | T |     not apply.                    |                     | T |   |
|   | * |                                   |                     | * |   |
|   | * | -   Be sure to read Section 4,    |                     | * |   |
|   |   |     *Your costs for covered       |                     |   |   |
|   | * |     services,* for valuable       |                     | * |   |
|   | * |     information about how cost    |                     | * |   |
|   | A |     sharing works. Also read      |                     | A |   |
|   | * |     Section 9 about coordinating  |                     | * |   |
|   | * |     benefits with other coverage, |                     | * |   |
|   |   |     including with Medicare.      |                     |   |   |
|   | * |                                   |                     | * |   |
|   | * | • **YOU MUST GET PREAUTHORIZATION |                     | * |   |
|   | N | OF THESE IN-NETWORK SERVICES.**   |                     | N |   |
|   | * | See the instructions after the    |                     | * |   |
|   | * | benefits descriptions below.      |                     | * |   |
|   |   |                                   |                     |   |   |
|   | * | • In-Network mental health and    |                     | * |   |
|   | * | substance abuse benefits are      |                     | * |   |
|   | T | shown below, then Out-of-Network  |                     | T |   |
|   | * | benefits begin on page 51.        |                     | * |   |
|   | * |                                   |                     | * |   |
+---+---+-----------------------------------+---------------------+---+---+
| > |   |                                   | **You pay**         |   |   |
|   |   |                                   |                     |   |   |
| * |   |                                   | **After the mental  |   |   |
| * |   |                                   | health and          |   |   |
| B |   |                                   | substance abuse     |   |   |
| e |   |                                   | calendar year       |   |   |
| n |   |                                   | deductible**        |   |   |
| e |   |                                   |                     |   |   |
| f |   |                                   |                     |   |   |
| i |   |                                   |                     |   |   |
| t |   |                                   |                     |   |   |
| > |   |                                   |                     |   |   |
|   |   |                                   |                     |   |   |
| D |   |                                   |                     |   |   |
| e |   |                                   |                     |   |   |
| s |   |                                   |                     |   |   |
| c |   |                                   |                     |   |   |
| r |   |                                   |                     |   |   |
| i |   |                                   |                     |   |   |
| p |   |                                   |                     |   |   |
| t |   |                                   |                     |   |   |
| i |   |                                   |                     |   |   |
| o |   |                                   |                     |   |   |
| n |   |                                   |                     |   |   |
| * |   |                                   |                     |   |   |
| * |   |                                   |                     |   |   |
+---+---+-----------------------------------+---------------------+---+---+
| > |   |                                   |                     |   |   |
|   |   |                                   |                     |   |   |
| * |   |                                   |                     |   |   |
| * |   |                                   |                     |   |   |
| N |   |                                   |                     |   |   |
| O |   |                                   |                     |   |   |
| T |   |                                   |                     |   |   |
| E |   |                                   |                     |   |   |
| : |   |                                   |                     |   |   |
| > |   |                                   |                     |   |   |
|   |   |                                   |                     |   |   |
| T |   |                                   |                     |   |   |
| h |   |                                   |                     |   |   |
| 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 |   |                                   |                     |   |   |
| > |   |                                   |                     |   |   |
|   |   |                                   |                     |   |   |
| c |   |                                   |                     |   |   |
| a |   |                                   |                     |   |   |
| l |   |                                   |                     |   |   |
| e |   |                                   |                     |   |   |
| n |   |                                   |                     |   |   |
| d |   |                                   |                     |   |   |
| a |   |                                   |                     |   |   |
| r |   |                                   |                     |   |   |
| > |   |                                   |                     |   |   |
|   |   |                                   |                     |   |   |
| y |   |                                   |                     |   |   |
| e |   |                                   |                     |   |   |
| a |   |                                   |                     |   |   |
| r |   |                                   |                     |   |   |
| > |   |                                   |                     |   |   |
|   |   |                                   |                     |   |   |
| d |   |                                   |                     |   |   |
| e |   |                                   |                     |   |   |
| d |   |                                   |                     |   |   |
| u |   |                                   |                     |   |   |
| c |   |                                   |                     |   |   |
| t |   |                                   |                     |   |   |
| i |   |                                   |                     |   |   |
| b |   |                                   |                     |   |   |
| l |   |                                   |                     |   |   |
| e |   |                                   |                     |   |   |
| > |   |                                   |                     |   |   |
|   |   |                                   |                     |   |   |
| a |   |                                   |                     |   |   |
| p |   |                                   |                     |   |   |
| p |   |                                   |                     |   |   |
| l |   |                                   |                     |   |   |
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| s |   |                                   |                     |   |   |
| > |   |                                   |                     |   |   |
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| t |   |                                   |                     |   |   |
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| a |   |                                   |                     |   |   |
| l |   |                                   |                     |   |   |
| m |   |                                   |                     |   |   |
| o |   |                                   |                     |   |   |
| s |   |                                   |                     |   |   |
| t |   |                                   |                     |   |   |
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| a |   |                                   |                     |   |   |
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| t |   |                                   |                     |   |   |
| > |   |                                   |                     |   |   |
|   |   |                                   |                     |   |   |
| d |   |                                   |                     |   |   |
| o |   |                                   |                     |   |   |
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| s |   |                                   |                     |   |   |
| > |   |                                   |                     |   |   |
|   |   |                                   |                     |   |   |
| n |   |                                   |                     |   |   |
| o |   |                                   |                     |   |   |
| t |   |                                   |                     |   |   |
| > |   |                                   |                     |   |   |
|   |   |                                   |                     |   |   |
| a |   |                                   |                     |   |   |
| p |   |                                   |                     |   |   |
| p |   |                                   |                     |   |   |
| l |   |                                   |                     |   |   |
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| . |   |                                   |                     |   |   |
| * |   |                                   |                     |   |   |
| * |   |                                   |                     |   |   |
+---+---+-----------------------------------+---------------------+---+---+
| > |   |                                   |                     |   |   |
|   |   |                                   |                     |   |   |
| * |   |                                   |                     |   |   |
| * |   |                                   |                     |   |   |
| I |   |                                   |                     |   |   |
| n |   |                                   |                     |   |   |
| - |   |                                   |                     |   |   |
| N |   |                                   |                     |   |   |
| e |   |                                   |                     |   |   |
| t |   |                                   |                     |   |   |
| w |   |                                   |                     |   |   |
| o |   |                                   |                     |   |   |
| r |   |                                   |                     |   |   |
| k |   |                                   |                     |   |   |
| > |   |                                   |                     |   |   |
|   |   |                                   |                     |   |   |
| b |   |                                   |                     |   |   |
| e |   |                                   |                     |   |   |
| n |   |                                   |                     |   |   |
| e |   |                                   |                     |   |   |
| f |   |                                   |                     |   |   |
| i |   |                                   |                     |   |   |
| t |   |                                   |                     |   |   |
| s |   |                                   |                     |   |   |
| * |   |                                   |                     |   |   |
| * |   |                                   |                     |   |   |
+---+---+-----------------------------------+---------------------+---+---+
| > |   |                                   | > Your cost sharing |   |   |
|   |   |                                   | > responsibilities  |   |   |
| A |   |                                   | > are no greater    |   |   |
| l |   |                                   | > than for other    |   |   |
| l |   |                                   | > illness or        |   |   |
| > |   |                                   | > conditions.       |   |   |
|   |   |                                   |                     |   |   |
| d |   |                                   |                     |   |   |
| i |   |                                   |                     |   |   |
| a |   |                                   |                     |   |   |
| g |   |                                   |                     |   |   |
| n |   |                                   |                     |   |   |
| o |   |                                   |                     |   |   |
| s |   |                                   |                     |   |   |
| t |   |                                   |                     |   |   |
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| c |   |                                   |                     |   |   |
| > |   |                                   |                     |   |   |
|   |   |                                   |                     |   |   |
| a |   |                                   |                     |   |   |
| n |   |                                   |                     |   |   |
| d |   |                                   |                     |   |   |
| > |   |                                   |                     |   |   |
|   |   |                                   |                     |   |   |
| t |   |                                   |                     |   |   |
| r |   |                                   |                     |   |   |
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| a |   |                                   |                     |   |   |
| t |   |                                   |                     |   |   |
| m |   |                                   |                     |   |   |
| e |   |                                   |                     |   |   |
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+---+---+-----------------------------------+---------------------+---+---+
| - |   |                                   | 9% under Standard   |   |   |
|   |   |                                   | Option or 10% under |   |   |
|   |   |                                   | High Option of our  |   |   |
|   |   |                                   | allowance, after a  |   |   |
| P |   |                                   | mental              |   |   |
| r |   |                                   | condition/substance |   |   |
| o |   |                                   | abuse calendar year |   |   |
| f |   |                                   | deductible of \$250 |   |   |
| e |   |                                   | under Standard      |   |   |
| s |   |                                   | Option or \$200     |   |   |
| s |   |                                   | under High Option.  |   |   |
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| 5 |   |                                   |                     |   |   |
|   |   |                                   |                     |   |   |
|   |   |                                   |                     |   |   |
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| r |   |                                   |                     |   |   |
| t |   |                                   |                     |   |   |
| h |   |                                   |                     |   |   |
| e |   |                                   |                     |   |   |
| P |   |                                   |                     |   |   |
| r |   |                                   |                     |   |   |
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| s |   |                                   |                     |   |   |
| c |   |                                   |                     |   |   |
| r |   |                                   |                     |   |   |
| i |   |                                   |                     |   |   |
| p |   |                                   |                     |   |   |
| t |   |                                   |                     |   |   |
| i |   |                                   |                     |   |   |
| o |   |                                   |                     |   |   |
| n |   |                                   |                     |   |   |
| d |   |                                   |                     |   |   |
| r |   |                                   |                     |   |   |
| u |   |                                   |                     |   |   |
| g |   |                                   |                     |   |   |
| b |   |                                   |                     |   |   |
| e |   |                                   |                     |   |   |
| n |   |                                   |                     |   |   |
| e |   |                                   |                     |   |   |
| f |   |                                   |                     |   |   |
| i |   |                                   |                     |   |   |
| t |   |                                   |                     |   |   |
| . |   |                                   |                     |   |   |
| S |   |                                   |                     |   |   |
| e |   |                                   |                     |   |   |
| e |   |                                   |                     |   |   |
| S |   |                                   |                     |   |   |
| e |   |                                   |                     |   |   |
| c |   |                                   |                     |   |   |
| t |   |                                   |                     |   |   |
| i |   |                                   |                     |   |   |
| o |   |                                   |                     |   |   |
| n |   |                                   |                     |   |   |
| 5 |   |                                   |                     |   |   |
| ( |   |                                   |                     |   |   |
| f |   |                                   |                     |   |   |
| ) |   |                                   |                     |   |   |
+---+---+-----------------------------------+---------------------+---+---+

*In-Network benefits \-- Continued on next page.*

+------------------+----------------------+---------------------------+
| > **In-Network   |                      | **You pay**               |
| > benefits** --  |                      |                           |
| > *continued*    |                      |                           |
+------------------+----------------------+---------------------------+
| -   Diagnostic   |                      | > 9% under Standard       |
|     tests --     |                      | > Option or 10% under     |
|     psychiatric  |                      | > High Option of our      |
|                  |                      | > allowance, after a      |
| -   Diagnostic   |                      | > mental                  |
|     tests --     |                      | > condition/substance     |
|     medical are  |                      | > abuse calendar year     |
|     paid as      |                      | > deductible of \$250     |
|     medical. See |                      | > under Standard Option   |
|     Section 5    |                      | > or \$200 under High     |
|     (a)          |                      | > Option.                 |
+------------------+----------------------+---------------------------+
| -   Inpatient    |                      | > 10% of the Plan         |
|     services     |                      | > allowance.              |
|     provided by  |                      |                           |
|     a hospital   |                      |                           |
|     or other     |                      |                           |
|     facility     |                      |                           |
|                  |                      |                           |
| -   Inpatient    |                      |                           |
|     services in  |                      |                           |
|     approved     |                      |                           |
|     alternative  |                      |                           |
|     care         |                      |                           |
|     settings     |                      |                           |
+------------------+----------------------+---------------------------+
| -   Outpatient   |                      | > 9% of the Plan          |
|     services     |                      | > allowance under         |
|     provided by  |                      | > Standard Option or 10%  |
|     a hospital   |                      | > of the Plan allowance   |
|     or other     |                      | > under High Option,      |
|     facility     |                      | > after a mental          |
|                  |                      | > condition/ substance    |
| -   Outpatient   |                      | > abuse calendar year     |
|     services in  |                      | > deductible of \$250     |
|     approved     |                      | > under Standard Option   |
|     alternative  |                      | > or \$200 under High     |
|     care         |                      | > Option                  |
|     settings     |                      |                           |
+------------------+----------------------+---------------------------+
| > *Not covered:  |                      | > *All charges*           |
| > Services we    |                      |                           |
| > have not       |                      |                           |
| > approved.*     |                      |                           |
| >                |                      |                           |
| > *NOTE: OPM     |                      |                           |
| > will base its  |                      |                           |
| > review of      |                      |                           |
| > disputes about |                      |                           |
| > treatment      |                      |                           |
| > plans on the   |                      |                           |
| > treatment      |                      |                           |
| > plan\'s        |                      |                           |
| > clinical       |                      |                           |
| >                |                      |                           |
| appropriateness. |                      |                           |
| > OPM will       |                      |                           |
| > generally not  |                      |                           |
| > order us to    |                      |                           |
| > pay or provide |                      |                           |
| > one clinically |                      |                           |
| > appropriate    |                      |                           |
| > treatment plan |                      |                           |
| > in favor of    |                      |                           |
| > another.*      |                      |                           |
+------------------+----------------------+---------------------------+
| > **Pr           |                      |                           |
| eauthorization** |                      |                           |
| > To be eligible |                      |                           |
| > to receive     |                      |                           |
| > these enhanced |                      |                           |
| > mental health  |                      |                           |
| > and substance  |                      |                           |
| > abuse benefits |                      |                           |
| > you must       |                      |                           |
| > follow your    |                      |                           |
| > treatment plan |                      |                           |
| > and all of the |                      |                           |
| > following      |                      |                           |
| > network        |                      |                           |
| > authorization  |                      |                           |
| > processes:     |                      |                           |
| >                |                      |                           |
| > Advise your    |                      |                           |
| > provider to    |                      |                           |
| > fax a written  |                      |                           |
| > treatment      |                      |                           |
| > plan, for      |                      |                           |
| > review and     |                      |                           |
| > approval, to   |                      |                           |
| > the attention: |                      |                           |
| > PBP Mental     |                      |                           |
| > Health         |                      |                           |
| > Coordinator at |                      |                           |
| >                |                      |                           |
| **301-333-1345** |                      |                           |
| > (Fax Only), to |                      |                           |
| > initiate       |                      |                           |
| > consideration  |                      |                           |
| > of your case.  |                      |                           |
| > To identify    |                      |                           |
| > network        |                      |                           |
| > providers,     |                      |                           |
| > call           |                      |                           |
| > **             |                      |                           |
| 1-800-672-2140** |                      |                           |
| > for Multiplan  |                      |                           |
| > PPO providers  |                      |                           |
| > and            |                      |                           |
| > **             |                      |                           |
| 1-800-342-3289** |                      |                           |
| > for Alliance   |                      |                           |
| > PPO providers. |                      |                           |
+------------------+----------------------+---------------------------+
| > **Network      | > If you do not      |                           |
| > limitation**   | > obtain an approved |                           |
|                  | > treatment plan, we |                           |
|                  | > will provide only  |                           |
|                  | > Out-of-Network     |                           |
|                  | > benefits           |                           |
+------------------+----------------------+---------------------------+
| > **Catastrophic | > For those services |                           |
| > protection     | > with coinsurance,  |                           |
| > out-of-pocket  | > we pay **100%** of |                           |
| > limit**        | > the Plan allowance |                           |
|                  | > for the remainder  |                           |
|                  | > of the calendar    |                           |
|                  | > year after         |                           |
|                  | > catastrophic       |                           |
|                  | > protection         |                           |
|                  | > out-of-pocket      |                           |
|                  | > expenses for the   |                           |
|                  | > mental health and  |                           |
|                  | > substance abuse    |                           |
|                  | > coinsurance for    |                           |
|                  | > that calendar year |                           |
|                  | > exceed \$3,500 per |                           |
|                  | > person per year or |                           |
|                  | > \$4,000 per family |                           |
|                  | > under **Standard** |                           |
|                  | > **Option** and     |                           |
|                  | > \$3,000 per person |                           |
|                  | > per year or        |                           |
|                  | > \$3,500 per family |                           |
|                  | > under **High       |                           |
|                  | > Option.**          |                           |
+------------------+----------------------+---------------------------+

+------------------------------------------+---------------------------+
| > **Out-of-Network benefits**            | **You pay**               |
+------------------------------------------+---------------------------+
| > For mental conditions, we cover        | > A \$300 annual          |
| > inpatient doctor visits provided       | > deductible and 50% of   |
| > during a covered admission.            | > the Standard Option     |
|                                          | > Plan allowance or a     |
|                                          | > \$275 annual deductible |
|                                          | > and 20% of the High     |
|                                          | > Option Plan allowance,  |
|                                          | > and any difference      |
|                                          | > between our allowance   |
|                                          | > and the billed charges. |
+------------------------------------------+---------------------------+
| > For mental conditions, we cover        | A \$500 per admission     |
| > inpatient room and board and other     | copayment, 40% of the     |
| > hospital charges for up to 100 days    | Standard Option Plan      |
| > per covered person each calendar year. | allowance or 30% of the   |
| >                                        | High Option Plan          |
| > Note: For individual cases, we may     | allowance, and any        |
| > agree to cover hospital day treatment  | difference between our    |
| > (partial hospitalization) the same as  | allowance and the billed  |
| > inpatient care. We consider two        | charges.                  |
| > admissions separated by less than 30   |                           |
| > calendar days to be one admission.     |                           |
+------------------------------------------+---------------------------+
| > For mental conditions, we allow up to  | > A \$300 annual          |
| > \$100 per visit for 25 outpatient      | > deductible and 50% of   |
| > visits per person per year.            | > the Standard Option     |
| >                                        | > Plan allowance or a     |
| > Note: Visits used to meet the          | > \$275 annual deductible |
| > deductible amount are not counted as   | > and 50% of the High     |
| > part of the 25 visits.                 | > Option Plan allowance   |
|                                          | > and any difference      |
|                                          | > between our allowance   |
|                                          | > and the billed charges  |
+------------------------------------------+---------------------------+
| > For substance abuse, we cover hospital | > A \$500 annual          |
| > inpatient care and services,           | > deductible, 30% of the  |
| > outpatient services and supplies, and  | > Plan allowance, and     |
| > rehabilitation. This benefit is        | > charges in excess of    |
| > limited to a maximum.                  | > our allowance and the   |
|                                          | > \$3,500 per person per  |
|                                          | > year maximum benefit.   |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges*             |
|                                          |                           |
| -   *Treatment related to marital        |                           |
|     discord*                             |                           |
|                                          |                           |
| -   *Personal comfort items such as      |                           |
|     telephone and television, guest      |                           |
|     meals and beds, barber and beauty    |                           |
|     services*                            |                           |
|                                          |                           |
| -   *Custodial care (see page77)*        |                           |
|                                          |                           |
| -   *Treatment for learning              |                           |
|     disabilities*                        |                           |
|                                          |                           |
| -   *Services rendered or billed by      |                           |
|     schools, residential treatment       |                           |
|     centers or halfway houses or members |                           |
|     of their staffs*                     |                           |
+------------------------------------------+---------------------------+
| **Precertification** The medical         |                           |
| necessity of your admission to a         |                           |
| hospital or other covered facility must  |                           |
| be precertified for you to receive these |                           |
| Out-of-Network benefits. Emergency       |                           |
| admissions should be reported            |                           |
| immediately, but no more than two        |                           |
| business days following the day of       |                           |
| admission even if you have been          |                           |
| discharged. Otherwise, the benefits      |                           |
| payable will be reduced by \$500. See    |                           |
| Section 3 for details.                   |                           |
+------------------------------------------+---------------------------+
| See these sections of the brochure for   |                           |
| more valuable information about these    |                           |
| benefits:                                |                           |
|                                          |                           |
| -   *Section 5 (e), Mental health and    |                           |
|     substance abuse benefits provides    |                           |
|     the full information about the       |                           |
|     catastrophic protection for these    |                           |
|     benefits.*                           |                           |
|                                          |                           |
| -   *Section 7, Filing a claim for       |                           |
|     covered services for information     |                           |
|     about submitting out-of-network      |                           |
|     claims.*                             |                           |
+------------------------------------------+---------------------------+

+---+---+--------------------+--------------------+---------------+---+---+
| # |   |                    |                    |               |   |   |
| # |   |                    |                    |               |   |   |
|   |   |                    |                    |               |   |   |
| * |   |                    |                    |               |   |   |
| * |   |                    |                    |               |   |   |
| S |   |                    |                    |               |   |   |
| e |   |                    |                    |               |   |   |
| c |   |                    |                    |               |   |   |
| t |   |                    |                    |               |   |   |
| i |   |                    |                    |               |   |   |
| o |   |                    |                    |               |   |   |
| n |   |                    |                    |               |   |   |
|   |   |                    |                    |               |   |   |
| 5 |   |                    |                    |               |   |   |
|   |   |                    |                    |               |   |   |
| ( |   |                    |                    |               |   |   |
| f |   |                    |                    |               |   |   |
| ) |   |                    |                    |               |   |   |
| . |   |                    |                    |               |   |   |
|   |   |                    |                    |               |   |   |
| P |   |                    |                    |               |   |   |
| r |   |                    |                    |               |   |   |
| e |   |                    |                    |               |   |   |
| s |   |                    |                    |               |   |   |
| c |   |                    |                    |               |   |   |
| r |   |                    |                    |               |   |   |
| i |   |                    |                    |               |   |   |
| p |   |                    |                    |               |   |   |
| t |   |                    |                    |               |   |   |
| i |   |                    |                    |               |   |   |
| o |   |                    |                    |               |   |   |
| n |   |                    |                    |               |   |   |
|   |   |                    |                    |               |   |   |
| d |   |                    |                    |               |   |   |
| r |   |                    |                    |               |   |   |
| u |   |                    |                    |               |   |   |
| g |   |                    |                    |               |   |   |
|   |   |                    |                    |               |   |   |
| b |   |                    |                    |               |   |   |
| e |   |                    |                    |               |   |   |
| n |   |                    |                    |               |   |   |
| e |   |                    |                    |               |   |   |
| f |   |                    |                    |               |   |   |
| i |   |                    |                    |               |   |   |
| t |   |                    |                    |               |   |   |
| s |   |                    |                    |               |   |   |
| * |   |                    |                    |               |   |   |
| * |   |                    |                    |               |   |   |
+---+---+--------------------+--------------------+---------------+---+---+
|   | * | **Here are some    |                    |               | * |   |
|   | * | important things   |                    |               | * |   |
|   | I | to keep in mind    |                    |               | I |   |
|   | * | about these        |                    |               | * |   |
|   | * | benefits:**        |                    |               | * |   |
|   |   |                    |                    |               |   |   |
|   | * | -   We cover       |                    |               | * |   |
|   | * |     prescribed     |                    |               | * |   |
|   | M |     drugs and      |                    |               | M |   |
|   | * |     medications,   |                    |               | * |   |
|   | * |     as described   |                    |               | * |   |
|   |   |     in the chart   |                    |               |   |   |
|   | * |     beginning on   |                    |               | * |   |
|   | * |     the next page. |                    |               | * |   |
|   | P |                    |                    |               | P |   |
|   | * | -   All benefits   |                    |               | * |   |
|   | * |     are subject to |                    |               | * |   |
|   |   |     the            |                    |               |   |   |
|   | * |     definitions,   |                    |               | * |   |
|   | * |     limitations    |                    |               | * |   |
|   | O |     and exclusions |                    |               | O |   |
|   | * |     in this        |                    |               | * |   |
|   | * |     brochure and   |                    |               | * |   |
|   |   |     are payable    |                    |               |   |   |
|   | * |     only when we   |                    |               | * |   |
|   | * |     determine they |                    |               | * |   |
|   | R |     are medically  |                    |               | R |   |
|   | * |     necessary.     |                    |               | * |   |
|   | * |                    |                    |               | * |   |
|   |   | -   The annual     |                    |               |   |   |
|   | * |     drug           |                    |               | * |   |
|   | * |     deductible is  |                    |               | * |   |
|   | T |     \$90 per       |                    |               | T |   |
|   | * |     person for     |                    |               | * |   |
|   | * |     network or     |                    |               | * |   |
|   |   |     non-network    |                    |               |   |   |
|   | * |     retail         |                    |               | * |   |
|   | * |     pharmacies for |                    |               | * |   |
|   | A |     both Standard  |                    |               | A |   |
|   | * |     Option and     |                    |               | * |   |
|   | * |     High Option.   |                    |               | * |   |
|   |   |     The annual     |                    |               |   |   |
|   | * |     drug           |                    |               | * |   |
|   | * |     deductible     |                    |               | * |   |
|   | N |     applies to     |                    |               | N |   |
|   | * |     almost all     |                    |               | * |   |
|   | * |     benefits in    |                    |               | * |   |
|   |   |     this section.  |                    |               |   |   |
|   | * |     We added "(No  |                    |               | * |   |
|   | * |     deductible)"   |                    |               | * |   |
|   | T |     to show when   |                    |               | T |   |
|   | * |     the annual     |                    |               | * |   |
|   | * |     drug           |                    |               | * |   |
|   |   |     deductible     |                    |               |   |   |
|   |   |     does not       |                    |               |   |   |
|   |   |     apply.         |                    |               |   |   |
|   |   |                    |                    |               |   |   |
|   |   | ```{=html}         |                    |               |   |   |
|   |   | <!-- -->           |                    |               |   |   |
|   |   | ```                |                    |               |   |   |
|   |   | -   Be sure to     |                    |               |   |   |
|   |   |     read Section   |                    |               |   |   |
|   |   |     4, *Your costs |                    |               |   |   |
|   |   |     for covered    |                    |               |   |   |
|   |   |     services* for  |                    |               |   |   |
|   |   |     valuable       |                    |               |   |   |
|   |   |     information    |                    |               |   |   |
|   |   |     about how cost |                    |               |   |   |
|   |   |     sharing works, |                    |               |   |   |
|   |   |     with special   |                    |               |   |   |
|   |   |     sections for   |                    |               |   |   |
|   |   |     members who    |                    |               |   |   |
|   |   |     are age 65 or  |                    |               |   |   |
|   |   |     over. Also     |                    |               |   |   |
|   |   |     read Section 9 |                    |               |   |   |
|   |   |     about          |                    |               |   |   |
|   |   |     coordinating   |                    |               |   |   |
|   |   |     benefits with  |                    |               |   |   |
|   |   |     other          |                    |               |   |   |
|   |   |     coverage,      |                    |               |   |   |
|   |   |     including with |                    |               |   |   |
|   |   |     Medicare.      |                    |               |   |   |
+---+---+--------------------+--------------------+---------------+---+---+
|   | * |                    |                    |               |   |   |
|   | * |                    |                    |               |   |   |
|   | T |                    |                    |               |   |   |
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+---+---+--------------------+--------------------+---------------+---+---+
| # |   |                    | **You Pay**        |               |   |   |
| # |   |                    |                    |               |   |   |
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| # |   |                    |  After the annual  |               |   |   |
| # |   |                    | drug deductible... |               |   |   |
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+---+---+--------------------+--------------------+---------------+---+---+
| > |   |                    | **You pay -        | **You pay -   |   |   |
|   |   |                    | Standard Option**  | High Option** |   |   |
| * |   |                    |                    |               |   |   |
| * |   |                    |                    |               |   |   |
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+---+---+--------------------+--------------------+---------------+---+---+
| > |   |                    | Network Retail:    | Network       |   |   |
|   |   |                    | \$4 generic        | Retail: \$3   |   |   |
| E |   |                    |                    | generic       |   |   |
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|   |   |                    |                    |               |   |   |
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| e |   |                    |                    |               |   |   |
| d |   |                    |                    |               |   |   |
| i |   |                    |                    |               |   |   |
| c |   |                    |                    |               |   |   |
| a |   |                    |                    |               |   |   |
| r |   |                    |                    |               |   |   |
| e |   |                    |                    |               |   |   |
|   |   |                    |                    |               |   |   |
|   |   |                    |                    |               |   |   |
|   |   |                    |                    |               |   |   |
|   |   |                    |                    |               |   |   |
| g |   |                    |                    |               |   |   |
| u |   |                    |                    |               |   |   |
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| s |   |                    |                    |               |   |   |
| . |   |                    |                    |               |   |   |
+---+---+--------------------+--------------------+---------------+---+---+
|   |   |                    | Network Retail     | Network       |   |   |
|   |   |                    | Formulary Brand    | Retail        |   |   |
|   |   |                    | Name: The greater  | Formulary     |   |   |
|   |   |                    | of \$30 or 20% of  | Brand Name:   |   |   |
|   |   |                    | that Brand name    | The greater   |   |   |
|   |   |                    |                    | of \$25 or    |   |   |
|   |   |                    |                    | 20% of that   |   |   |
|   |   |                    |                    | Brand name    |   |   |
+---+---+--------------------+--------------------+---------------+---+---+
|   |   |                    | Network Retail     | Network       |   |   |
|   |   |                    | Non-Formulary      | Retail        |   |   |
|   |   |                    | Brand Name Drugs:  | Non-Formulary |   |   |
|   |   |                    | The greater of     | Brand Name    |   |   |
|   |   |                    | \$40 or 20% of     | Drugs: The    |   |   |
|   |   |                    | non-formulary      | greater of    |   |   |
|   |   |                    | brand name         | \$40 or 20%   |   |   |
|   |   |                    |                    | of            |   |   |
|   |   |                    |                    | non-formulary |   |   |
|   |   |                    |                    | brand name    |   |   |
+---+---+--------------------+--------------------+---------------+---+---+
|   |   |                    | Non-Network        | Non-Network   |   |   |
|   |   |                    | Retail: 30% of the | Retail: 20%   |   |   |
|   |   |                    | Plan allowance for | of the Plan   |   |   |
|   |   |                    | a network pharmacy | allowance for |   |   |
|   |   |                    | and any difference | a network     |   |   |
|   |   |                    | between our        | pharmacy and  |   |   |
|   |   |                    | allowance and the  | any           |   |   |
|   |   |                    | billed amount.     | difference    |   |   |
|   |   |                    |                    | between our   |   |   |
|   |   |                    |                    | allowance and |   |   |
|   |   |                    |                    | the billed    |   |   |
|   |   |                    |                    | amount.       |   |   |
+---+---+--------------------+--------------------+---------------+---+---+
|   |   |                    | Non-Network Retail | Non-Network   |   |   |
|   |   |                    | Medicare: Same as  | Retail        |   |   |
|   |   |                    | Non-Network Retail | Medicare:     |   |   |
|   |   |                    | for non-Medicare.  | Same as       |   |   |
|   |   |                    |                    | Non-Network   |   |   |
|   |   |                    |                    | Retail for    |   |   |
|   |   |                    |                    | non-Medicare. |   |   |
+---+---+--------------------+--------------------+---------------+---+---+

Covered medications and supplies -- Continued on next page

+---------------------------+--------------------+---------------------+
| > **Covered medications   | **You pay --       | **You pay - High    |
| > and supplies** --       | Standard Option**  | Option**            |
| > *continued*             |                    |                     |
+---------------------------+--------------------+---------------------+
| > Each new enrollee will  | Network Mail       | Network Mail Order: |
| > receive a description   | Order: \$8 generic | \$6 generic         |
| > of our prescription     |                    |                     |
| > drug program, a         | Network Mail Order | Network Mail Order  |
| > prescription drug       | Formulary Brand    | Formulary Brand     |
| > identification card, a  | Name: The greater  | Name: The greater   |
| > mail order form/patient | of \$30 or 20% of  | of \$30 or 20% of   |
| > profile and a           | that Brand name.   | that Brand name.    |
| > preaddressed reply      |                    |                     |
| > envelope.               | Network Mail Order | Network Mail Order  |
| >                         | Non-Formulary      | Non-Formulary Brand |
| > You may purchase the    | Brand Name: The    | Name: The greater   |
| > following medications   | greater of \$40 or | of \$40 or 20% of   |
| > and supplies prescribed | 20% of             | non-formulary brand |
| > by a physician from     | non-formulary      | name. (No           |
| > either a pharmacy or by | brand name. (No    | deductible)         |
| > mail:                   | deductible)        |                     |
|                           |                    | Network Mail Order  |
| -   Drugs and medicines   | Network Mail Order | Medicare: \$7       |
|     (including those      | Medicare: \$7      | generic             |
|     administered during a | generic            |                     |
|     non-covered admission |                    | Network Mail Order  |
|     or in a non-covered   | Network Mail Order | Medicare Formulary  |
|     facility) that by     | Medicare Formulary | Brand Name: the     |
|     Federal law of the    | Brand Name: the    | greater of \$15 or  |
|     United States require | greater of \$15 or | 20% of that Brand   |
|     a physician's         | 20% of that Brand  | name.               |
|     prescription for      | name.              |                     |
|     their purchase,       |                    | Network Mail Order  |
|     except those listed   | Network Mail Order | Medicare            |
|     as Not covered.       | Medicare           | Non-Formulary Brand |
|                           | Non-Formulary      | Name: the greater   |
| -   Preauthorized growth  | Brand Name: the    | of \$25 or 20% of   |
|     hormone               | greater of \$25 or | non-formulary brand |
|                           | 20% of             | name. (No           |
| -   Insulin               | non-formulary      | deductible)         |
|                           | brand name. (No    |                     |
| -   Needles and syringes  | deductible)        | Note: If there is   |
|     for the               |                    | no generic          |
|     administration of     | Note: If there is  | equivalent          |
|     covered medications   | no generic         | available, you will |
|                           | equivalent         | still have to pay   |
| ```{=html}                | available, you     | the brand name      |
| <!-- -->                  | will still have to | copayment.          |
| ```                       | pay the brand name |                     |
| -   Contraceptive drugs   | copayment.         |                     |
|     and devices           |                    |                     |
|                           |                    |                     |
| -   TPN (Total Parenteral |                    |                     |
|     Nutrition) that       |                    |                     |
|     complies with         |                    |                     |
|     Medicare guidelines.  |                    |                     |
|                           |                    |                     |
| > Note: The Medicare      |                    |                     |
| > level of benefits       |                    |                     |
| > applies only when you   |                    |                     |
| > are covered by Medicare |                    |                     |
| > Part B.                 |                    |                     |
+---------------------------+--------------------+---------------------+
| > *Not covered:*          | *All Charges*      | *All Charges*       |
|                           |                    |                     |
| -   *Drugs and supplies   |                    |                     |
|     for cosmetic          |                    |                     |
|     purposes*             |                    |                     |
|                           |                    |                     |
| -   *Vitamins, nutrients  |                    |                     |
|     and food supplements  |                    |                     |
|     even if a physician   |                    |                     |
|     prescribes or         |                    |                     |
|     administers them*     |                    |                     |
|                           |                    |                     |
| -   *Nonprescription      |                    |                     |
|     medicines*            |                    |                     |
|                           |                    |                     |
| -   *Drugs to aid in      |                    |                     |
|     smoking cessation     |                    |                     |
|     other than those      |                    |                     |
|     covered under the     |                    |                     |
|     smoking cessation     |                    |                     |
|     benefit.*             |                    |                     |
|                           |                    |                     |
| -   *Medical supplies     |                    |                     |
|     such as dressings and |                    |                     |
|     antiseptics*          |                    |                     |
+---------------------------+--------------------+---------------------+

+-------------------------+--------------------------------------------+
| ## **Section 5          |                                            |
| (g). Special features** |                                            |
+=========================+============================================+
| > **Special features**  | > **Description**                          |
+-------------------------+--------------------------------------------+
| ### F                   | > Under the flexible benefits option, we   |
| lexible benefits option | > determine the most effective way to      |
|                         | > provide services.                        |
|                         |                                            |
|                         | -   We may identify medically appropriate  |
|                         |     alternatives to traditional care and   |
|                         |     coordinate other benefits as a less    |
|                         |     costly alternative benefit.            |
|                         |                                            |
|                         | -   Alternative benefits are subject to    |
|                         |     our ongoing review.                    |
|                         |                                            |
|                         | -   By approving an alternative benefit,   |
|                         |     we cannot guarantee you will get it in |
|                         |     the future.                            |
|                         |                                            |
|                         | -   The decision to offer an alternative   |
|                         |     benefit is solely ours, and we may     |
|                         |     withdraw it at any time and resume     |
|                         |     regular contract benefits.             |
|                         |                                            |
|                         | ```{=html}                                 |
|                         | <!-- -->                                   |
|                         | ```                                        |
|                         | -   Our decision to offer or withdraw      |
|                         |     alternative benefits is not subject to |
|                         |     OPM review under the disputed claims   |
|                         |     process                                |
+-------------------------+--------------------------------------------+
| ### 24 hour nurse line  | > "Ask MAYO Clinic" is the name of our     |
|                         | > program. The MAYO Clinics provide their  |
|                         | > registered nurses to discuss any of your |
|                         | > health concerns, 24 hours a day, 7 days  |
|                         | > a week. You may call **1-866-300-8717**  |
|                         | > and talk with a MAYO Clinic registered   |
|                         | > nurse who will discuss treatment options |
|                         | > and answer your health questions.        |
+-------------------------+--------------------------------------------+
| ###                     | > You can call "Ask MAYO Clinic" 24 hours  |
| Tobacco Quit phone line | > a day, 7 days a week at                  |
|                         | > **1-866-300-8717**. Select option #2 for |
|                         | > a specialized guidance counselor trained |
|                         | > to help you quit smoking through         |
|                         | > personal counseling and a series of      |
|                         | > related publications.                    |
+-------------------------+--------------------------------------------+
| ### Complex surgery     | > On a case-by-case basis, we may decide   |
|                         | > to provide benefits under the special    |
|                         | > features provision for complex surgery.  |
|                         | > The MAYO Clinics operate three           |
|                         | > facilities (Minnesota, Florida and       |
|                         | > Arizona) that specialize in providing    |
|                         | > effective and economical complex         |
|                         | > surgical care for a limited number of    |
|                         | > surgical services under certain          |
|                         | > circumstances. These surgical services   |
|                         | > could include hip/knee replacements,     |
|                         | > coronary bypass, heart valve             |
|                         | > replacement, or mastectomy. If the MAYO  |
|                         | > Clinics accept your particular case, you |
|                         | > pay nothing for the hospital and         |
|                         | > surgical care they render. If the MAYO   |
|                         | > Clinics do not accept your case, you pay |
|                         | > as described in Sections 5 (b) and 5 (c) |
|                         | > of this brochure. This benefit includes  |
|                         | > transportation and lodging that we       |
|                         | > pre-approve. Call us at **800-544-7111** |
|                         | > for details about seeking care at the    |
|                         | > MAYO Clinics.                            |
|                         | >                                          |
|                         | > Note: We may provide benefits for        |
|                         | > pre-approved transportation to the MAYO  |
|                         | > Clinics, with appropriate lodging, even  |
|                         | > if Medicare is the primary payer.        |
+-------------------------+--------------------------------------------+

+-------------------------+--------------------------------------------+
| > **Special features**  | > **Description**                          |
+-------------------------+--------------------------------------------+
| ###                     | > See National Transplant Program under    |
|  Centers of excellence  | > Organ/Tissue transplant in Section 5     |
|                         | > (b). The MAYO Clinics operate three      |
|                         | > facilities (Minnesota, Florida and       |
|                         | > Arizona) that specialize in providing    |
|                         | > effective and economical transplants for |
|                         | > most organ transplants. If you receive a |
|                         | > transplant, listed as covered under the  |
|                         | > Transplant Program, at the MAYO Clinics, |
|                         | > you pay nothing for the hospital and     |
|                         | > surgical care they render. Call us at    |
|                         | > **800-544-7111** for details about       |
|                         | > seeking care at the MAYO Clinics.        |
+-------------------------+--------------------------------------------+
| ### Dialysis services   | > You pay nothing for dialysis services    |
|                         | > and related drugs or medications         |
|                         | > provided by a GAMBRO or DAVITA dialysis  |
|                         | > center. If you get these services from a |
|                         | > provider or facility other than GAMBRO   |
|                         | > or DAVITA, you pay all billed charges    |
|                         | > that are more than the Plan's limit. The |
|                         | > Plan's limit for non-GAMBRO/DAVITA       |
|                         | > dialysis services and related drugs or   |
|                         | > medications is twice the Medicare        |
|                         | > allowance for those services. After the  |
|                         | > catastrophic provision limit is met, you |
|                         | > pay nothing.                             |
+-------------------------+--------------------------------------------+
| ### "Healthier          | > "Ask MAYO Clinic" is the name of our     |
|  Feds" - Asthma Hotline | > program. The MAYO Clinics provide their  |
|                         | > registered nurses to discuss any of your |
|                         | > health concerns, 24 hours a day, 7 days  |
|                         | > a week. You may call **1-866-300-8717**  |
|                         | > and talk with a MAYO Clinic registered   |
|                         | > nurse who will discuss treatment options |
|                         | > and answer your health questions.        |
+-------------------------+--------------------------------------------+
| ### "Healthier Fe       | > "Ask MAYO Clinic" is the name of our     |
| ds" - Arthritis Hotline | > program. The MAYO Clinics provide their  |
|                         | > registered nurses to discuss any of your |
|                         | > health concerns, 24 hours a day, 7 days  |
|                         | > a week. You may call **1-866-300-8717**  |
|                         | > and talk with a MAYO Clinic registered   |
|                         | > nurse who will discuss treatment options |
|                         | > and answer your health questions.        |
+-------------------------+--------------------------------------------+
| ### "Healthier F        | > "Ask MAYO Clinic" is the name of our     |
| eds" - Diabetes Hotline | > program. The MAYO Clinics provide their  |
|                         | > registered nurses to discuss any of your |
|                         | > health concerns, 24 hours a day, 7 days  |
|                         | > a week. You may call **1-866-300-8717**  |
|                         | > and talk with a MAYO Clinic registered   |
|                         | > nurse who will discuss treatment options |
|                         | > and answer your health questions.        |
+-------------------------+--------------------------------------------+

+---+---+----------------------+--------------------+-------------+---+---+
| # |   |                      |                    |             |   |   |
| # |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| * |   |                      |                    |             |   |   |
| * |   |                      |                    |             |   |   |
| 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  |                    |             | * |   |
|   | I | keep in mind about   |                    |             | I |   |
|   | * | these benefits:**    |                    |             | * |   |
|   | * |                      |                    |             | * |   |
|   |   | -   Please remember  |                    |             |   |   |
|   | * |     that all         |                    |             | * |   |
|   | * |     benefits are     |                    |             | * |   |
|   | M |     subject to the   |                    |             | M |   |
|   | * |     definitions,     |                    |             | * |   |
|   | * |     limitations, and |                    |             | * |   |
|   |   |     exclusions in    |                    |             |   |   |
|   | * |     this brochure    |                    |             | * |   |
|   | * |     and are payable  |                    |             | * |   |
|   | P |     only when we     |                    |             | P |   |
|   | * |     determine they   |                    |             | * |   |
|   | * |     are medically    |                    |             | * |   |
|   |   |     necessary.       |                    |             |   |   |
|   | * |                      |                    |             | * |   |
|   | * | -   There is a \$30  |                    |             | * |   |
|   | O |     per person       |                    |             | O |   |
|   | * |     annual dental    |                    |             | * |   |
|   | * |     deductible under |                    |             | * |   |
|   |   |     High Option.     |                    |             |   |   |
|   | * |     There is no      |                    |             | * |   |
|   | * |     dental           |                    |             | * |   |
|   | R |     deductible under |                    |             | R |   |
|   | * |     Standard Option. |                    |             | * |   |
|   | * |                      |                    |             | * |   |
|   |   | -   Be sure to read  |                    |             |   |   |
|   | * |     Section 4, *Your |                    |             | * |   |
|   | * |     costs for        |                    |             | * |   |
|   | T |     covered          |                    |             | T |   |
|   | * |     services,* for   |                    |             | * |   |
|   | * |     valuable         |                    |             | * |   |
|   |   |     information      |                    |             |   |   |
|   | * |     about how cost   |                    |             | * |   |
|   | * |     sharing works,   |                    |             | * |   |
|   | A |     with special     |                    |             | A |   |
|   | * |     sections for     |                    |             | * |   |
|   | * |     members who are  |                    |             | * |   |
|   |   |     age 65 or over.  |                    |             |   |   |
|   | * |     Also read        |                    |             | * |   |
|   | * |     Section 9 about  |                    |             | * |   |
|   | N |     coordinating     |                    |             | N |   |
|   | * |     benefits with    |                    |             | * |   |
|   | * |     other coverage,  |                    |             | * |   |
|   |   |     including with   |                    |             |   |   |
|   | * |     Medicare.        |                    |             | * |   |
|   | * |                      |                    |             | * |   |
|   | T | ```{=html}           |                    |             | T |   |
|   | * | <!-- -->             |                    |             | * |   |
|   | * | ```                  |                    |             | * |   |
|   |   | -   Note: We cover   |                    |             |   |   |
|   |   |     hospitalization  |                    |             |   |   |
|   |   |     for dental       |                    |             |   |   |
|   |   |     procedures only  |                    |             |   |   |
|   |   |     when the patient |                    |             |   |   |
|   |   |     has a non-dental |                    |             |   |   |
|   |   |     physical         |                    |             |   |   |
|   |   |     impairment which |                    |             |   |   |
|   |   |     makes            |                    |             |   |   |
|   |   |     hospitalization  |                    |             |   |   |
|   |   |     necessary to     |                    |             |   |   |
|   |   |     safeguard the    |                    |             |   |   |
|   |   |     patient's        |                    |             |   |   |
|   |   |     health. See      |                    |             |   |   |
|   |   |     Section 5 (c)    |                    |             |   |   |
|   |   |     for inpatient    |                    |             |   |   |
|   |   |     hospital         |                    |             |   |   |
|   |   |     benefits.        |                    |             |   |   |
+---+---+----------------------+--------------------+-------------+---+---+
| > |   |                      | **You pay -        | **You pay - |   |   |
|   |   |                      | Standard Option**  | High        |   |   |
| * |   |                      |                    | Option**    |   |   |
| * |   |                      |                    |             |   |   |
| A |   |                      |                    |             |   |   |
| c |   |                      |                    |             |   |   |
| c |   |                      |                    |             |   |   |
| i |   |                      |                    |             |   |   |
| d |   |                      |                    |             |   |   |
| e |   |                      |                    |             |   |   |
| n |   |                      |                    |             |   |   |
| t |   |                      |                    |             |   |   |
| a |   |                      |                    |             |   |   |
| l |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| i |   |                      |                    |             |   |   |
| n |   |                      |                    |             |   |   |
| j |   |                      |                    |             |   |   |
| u |   |                      |                    |             |   |   |
| r |   |                      |                    |             |   |   |
| y |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| b |   |                      |                    |             |   |   |
| e |   |                      |                    |             |   |   |
| n |   |                      |                    |             |   |   |
| e |   |                      |                    |             |   |   |
| f |   |                      |                    |             |   |   |
| i |   |                      |                    |             |   |   |
| t |   |                      |                    |             |   |   |
| * |   |                      |                    |             |   |   |
| * |   |                      |                    |             |   |   |
+---+---+----------------------+--------------------+-------------+---+---+
| > |   |                      | Any amount over    | Any amount  |   |   |
|   |   |                      | the High Option    | over the    |   |   |
| W |   |                      | Schedule of        | High Option |   |   |
| e |   |                      | allowances.        | Schedule of |   |   |
| > |   |                      |                    | allowances. |   |   |
|   |   |                      |                    |             |   |   |
| c |   |                      |                    |             |   |   |
| o |   |                      |                    |             |   |   |
| v |   |                      |                    |             |   |   |
| e |   |                      |                    |             |   |   |
| r |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| r |   |                      |                    |             |   |   |
| e |   |                      |                    |             |   |   |
| s |   |                      |                    |             |   |   |
| t |   |                      |                    |             |   |   |
| o |   |                      |                    |             |   |   |
| r |   |                      |                    |             |   |   |
| a |   |                      |                    |             |   |   |
| t |   |                      |                    |             |   |   |
| i |   |                      |                    |             |   |   |
| v |   |                      |                    |             |   |   |
| e |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| s |   |                      |                    |             |   |   |
| e |   |                      |                    |             |   |   |
| r |   |                      |                    |             |   |   |
| v |   |                      |                    |             |   |   |
| i |   |                      |                    |             |   |   |
| c |   |                      |                    |             |   |   |
| e |   |                      |                    |             |   |   |
| s |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| a |   |                      |                    |             |   |   |
| n |   |                      |                    |             |   |   |
| d |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| s |   |                      |                    |             |   |   |
| u |   |                      |                    |             |   |   |
| p |   |                      |                    |             |   |   |
| p |   |                      |                    |             |   |   |
| l |   |                      |                    |             |   |   |
| i |   |                      |                    |             |   |   |
| e |   |                      |                    |             |   |   |
| s |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| n |   |                      |                    |             |   |   |
| e |   |                      |                    |             |   |   |
| c |   |                      |                    |             |   |   |
| e |   |                      |                    |             |   |   |
| s |   |                      |                    |             |   |   |
| s |   |                      |                    |             |   |   |
| a |   |                      |                    |             |   |   |
| r |   |                      |                    |             |   |   |
| y |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| t |   |                      |                    |             |   |   |
| o |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| p |   |                      |                    |             |   |   |
| r |   |                      |                    |             |   |   |
| o |   |                      |                    |             |   |   |
| m |   |                      |                    |             |   |   |
| p |   |                      |                    |             |   |   |
| t |   |                      |                    |             |   |   |
| l |   |                      |                    |             |   |   |
| y |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| r |   |                      |                    |             |   |   |
| e |   |                      |                    |             |   |   |
| p |   |                      |                    |             |   |   |
| a |   |                      |                    |             |   |   |
| i |   |                      |                    |             |   |   |
| r |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| ( |   |                      |                    |             |   |   |
| b |   |                      |                    |             |   |   |
| u |   |                      |                    |             |   |   |
| t |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| n |   |                      |                    |             |   |   |
| o |   |                      |                    |             |   |   |
| t |   |                      |                    |             |   |   |
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|   |   |                      |                    |             |   |   |
| r |   |                      |                    |             |   |   |
| e |   |                      |                    |             |   |   |
| p |   |                      |                    |             |   |   |
| l |   |                      |                    |             |   |   |
| a |   |                      |                    |             |   |   |
| c |   |                      |                    |             |   |   |
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| ) |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
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| s |   |                      |                    |             |   |   |
| o |   |                      |                    |             |   |   |
| u |   |                      |                    |             |   |   |
| n |   |                      |                    |             |   |   |
| d |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| n |   |                      |                    |             |   |   |
| a |   |                      |                    |             |   |   |
| t |   |                      |                    |             |   |   |
| u |   |                      |                    |             |   |   |
| r |   |                      |                    |             |   |   |
| a |   |                      |                    |             |   |   |
| l |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| t |   |                      |                    |             |   |   |
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| h |   |                      |                    |             |   |   |
| . |   |                      |                    |             |   |   |
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|   |   |                      |                    |             |   |   |
| T |   |                      |                    |             |   |   |
| h |   |                      |                    |             |   |   |
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|   |   |                      |                    |             |   |   |
| n |   |                      |                    |             |   |   |
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| d |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
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| f |   |                      |                    |             |   |   |
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| t |   |                      |                    |             |   |   |
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| s |   |                      |                    |             |   |   |
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| s |   |                      |                    |             |   |   |
| e |   |                      |                    |             |   |   |
| r |   |                      |                    |             |   |   |
| v |   |                      |                    |             |   |   |
| i |   |                      |                    |             |   |   |
| c |   |                      |                    |             |   |   |
| e |   |                      |                    |             |   |   |
| s |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| m |   |                      |                    |             |   |   |
| u |   |                      |                    |             |   |   |
| s |   |                      |                    |             |   |   |
| t |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| r |   |                      |                    |             |   |   |
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| s |   |                      |                    |             |   |   |
| u |   |                      |                    |             |   |   |
| l |   |                      |                    |             |   |   |
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| m |   |                      |                    |             |   |   |
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|   |   |                      |                    |             |   |   |
| a |   |                      |                    |             |   |   |
| n |   |                      |                    |             |   |   |
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|   |   |                      |                    |             |   |   |
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| d |   |                      |                    |             |   |   |
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| n |   |                      |                    |             |   |   |
| t |   |                      |                    |             |   |   |
| a |   |                      |                    |             |   |   |
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| > |   |                      |                    |             |   |   |
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| n |   |                      |                    |             |   |   |
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| o |   |                      |                    |             |   |   |
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| > |   |                      |                    |             |   |   |
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| n |   |                      |                    |             |   |   |
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| d |   |                      |                    |             |   |   |
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| n |   |                      |                    |             |   |   |
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| f |   |                      |                    |             |   |   |
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| h |   |                      |                    |             |   |   |
| i |   |                      |                    |             |   |   |
| s |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| p |   |                      |                    |             |   |   |
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| v |   |                      |                    |             |   |   |
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| . |   |                      |                    |             |   |   |
+---+---+----------------------+--------------------+-------------+---+---+
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| * |   |                      |                    |             |   |   |
| * |   |                      |                    |             |   |   |
| D |   |                      |                    |             |   |   |
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| n |   |                      |                    |             |   |   |
| t |   |                      |                    |             |   |   |
| a |   |                      |                    |             |   |   |
| l |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| b |   |                      |                    |             |   |   |
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| n |   |                      |                    |             |   |   |
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| s |   |                      |                    |             |   |   |
| * |   |                      |                    |             |   |   |
| * |   |                      |                    |             |   |   |
+---+---+----------------------+--------------------+-------------+---+---+
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| W |   |                      |                    |             |   |   |
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| w |   |                      |                    |             |   |   |
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| c |   |                      |                    |             |   |   |
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| r |   |                      |                    |             |   |   |
| g |   |                      |                    |             |   |   |
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| w |   |                      |                    |             |   |   |
| a |   |                      |                    |             |   |   |
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| c |   |                      |                    |             |   |   |
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| d |   |                      |                    |             |   |   |
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| d |   |                      |                    |             |   |   |
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| a |   |                      |                    |             |   |   |
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| i |   |                      |                    |             |   |   |
| m |   |                      |                    |             |   |   |
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|   |   |                      |                    |             |   |   |
| t |   |                      |                    |             |   |   |
| h |   |                      |                    |             |   |   |
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|   |   |                      |                    |             |   |   |
| n |   |                      |                    |             |   |   |
| u |   |                      |                    |             |   |   |
| m |   |                      |                    |             |   |   |
| b |   |                      |                    |             |   |   |
| e |   |                      |                    |             |   |   |
| r |   |                      |                    |             |   |   |
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|   |   |                      |                    |             |   |   |
| c |   |                      |                    |             |   |   |
| a |   |                      |                    |             |   |   |
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| n |   |                      |                    |             |   |   |
| d |   |                      |                    |             |   |   |
| a |   |                      |                    |             |   |   |
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|   |   |                      |                    |             |   |   |
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| n |   |                      |                    |             |   |   |
| d |   |                      |                    |             |   |   |
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| d |   |                      |                    |             |   |   |
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| n |   |                      |                    |             |   |   |
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|   |   |                      |                    |             |   |   |
| i |   |                      |                    |             |   |   |
| n |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| t |   |                      |                    |             |   |   |
| h |   |                      |                    |             |   |   |
| e |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| S |   |                      |                    |             |   |   |
| c |   |                      |                    |             |   |   |
| h |   |                      |                    |             |   |   |
| e |   |                      |                    |             |   |   |
| d |   |                      |                    |             |   |   |
| u |   |                      |                    |             |   |   |
| l |   |                      |                    |             |   |   |
| e |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| o |   |                      |                    |             |   |   |
| f |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| d |   |                      |                    |             |   |   |
| e |   |                      |                    |             |   |   |
| n |   |                      |                    |             |   |   |
| t |   |                      |                    |             |   |   |
| a |   |                      |                    |             |   |   |
| l |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| a |   |                      |                    |             |   |   |
| l |   |                      |                    |             |   |   |
| l |   |                      |                    |             |   |   |
| o |   |                      |                    |             |   |   |
| w |   |                      |                    |             |   |   |
| a |   |                      |                    |             |   |   |
| n |   |                      |                    |             |   |   |
| c |   |                      |                    |             |   |   |
| e |   |                      |                    |             |   |   |
| s |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| m |   |                      |                    |             |   |   |
| a |   |                      |                    |             |   |   |
| y |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| b |   |                      |                    |             |   |   |
| e |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| a |   |                      |                    |             |   |   |
| p |   |                      |                    |             |   |   |
| p |   |                      |                    |             |   |   |
| l |   |                      |                    |             |   |   |
| i |   |                      |                    |             |   |   |
| e |   |                      |                    |             |   |   |
| d |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| t |   |                      |                    |             |   |   |
| o |   |                      |                    |             |   |   |
| w |   |                      |                    |             |   |   |
| a |   |                      |                    |             |   |   |
| r |   |                      |                    |             |   |   |
| d |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| t |   |                      |                    |             |   |   |
| h |   |                      |                    |             |   |   |
| e |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| d |   |                      |                    |             |   |   |
| e |   |                      |                    |             |   |   |
| n |   |                      |                    |             |   |   |
| t |   |                      |                    |             |   |   |
| a |   |                      |                    |             |   |   |
| l |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| d |   |                      |                    |             |   |   |
| e |   |                      |                    |             |   |   |
| d |   |                      |                    |             |   |   |
| u |   |                      |                    |             |   |   |
| c |   |                      |                    |             |   |   |
| t |   |                      |                    |             |   |   |
| i |   |                      |                    |             |   |   |
| b |   |                      |                    |             |   |   |
| l |   |                      |                    |             |   |   |
| e |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| o |   |                      |                    |             |   |   |
| r |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| t |   |                      |                    |             |   |   |
| h |   |                      |                    |             |   |   |
| e |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| m |   |                      |                    |             |   |   |
| a |   |                      |                    |             |   |   |
| x |   |                      |                    |             |   |   |
| i |   |                      |                    |             |   |   |
| m |   |                      |                    |             |   |   |
| u |   |                      |                    |             |   |   |
| m |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| p |   |                      |                    |             |   |   |
| a |   |                      |                    |             |   |   |
| y |   |                      |                    |             |   |   |
| a |   |                      |                    |             |   |   |
| b |   |                      |                    |             |   |   |
| l |   |                      |                    |             |   |   |
| e |   |                      |                    |             |   |   |
| . |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
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|   |   |                      |                    |             |   |   |
| T |   |                      |                    |             |   |   |
| h |   |                      |                    |             |   |   |
| e |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| f |   |                      |                    |             |   |   |
| o |   |                      |                    |             |   |   |
| l |   |                      |                    |             |   |   |
| l |   |                      |                    |             |   |   |
| o |   |                      |                    |             |   |   |
| w |   |                      |                    |             |   |   |
| i |   |                      |                    |             |   |   |
| n |   |                      |                    |             |   |   |
| g |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| S |   |                      |                    |             |   |   |
| c |   |                      |                    |             |   |   |
| h |   |                      |                    |             |   |   |
| e |   |                      |                    |             |   |   |
| d |   |                      |                    |             |   |   |
| u |   |                      |                    |             |   |   |
| l |   |                      |                    |             |   |   |
| e |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| o |   |                      |                    |             |   |   |
| f |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| d |   |                      |                    |             |   |   |
| e |   |                      |                    |             |   |   |
| n |   |                      |                    |             |   |   |
| t |   |                      |                    |             |   |   |
| a |   |                      |                    |             |   |   |
| l |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| a |   |                      |                    |             |   |   |
| l |   |                      |                    |             |   |   |
| l |   |                      |                    |             |   |   |
| o |   |                      |                    |             |   |   |
| w |   |                      |                    |             |   |   |
| a |   |                      |                    |             |   |   |
| n |   |                      |                    |             |   |   |
| c |   |                      |                    |             |   |   |
| e |   |                      |                    |             |   |   |
| s |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| i |   |                      |                    |             |   |   |
| s |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| a |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| c |   |                      |                    |             |   |   |
| o |   |                      |                    |             |   |   |
| m |   |                      |                    |             |   |   |
| p |   |                      |                    |             |   |   |
| l |   |                      |                    |             |   |   |
| e |   |                      |                    |             |   |   |
| t |   |                      |                    |             |   |   |
| e |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| l |   |                      |                    |             |   |   |
| i |   |                      |                    |             |   |   |
| s |   |                      |                    |             |   |   |
| t |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| o |   |                      |                    |             |   |   |
| f |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| c |   |                      |                    |             |   |   |
| o |   |                      |                    |             |   |   |
| v |   |                      |                    |             |   |   |
| e |   |                      |                    |             |   |   |
| r |   |                      |                    |             |   |   |
| e |   |                      |                    |             |   |   |
| d |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| d |   |                      |                    |             |   |   |
| e |   |                      |                    |             |   |   |
| n |   |                      |                    |             |   |   |
| t |   |                      |                    |             |   |   |
| a |   |                      |                    |             |   |   |
| l |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| s |   |                      |                    |             |   |   |
| e |   |                      |                    |             |   |   |
| r |   |                      |                    |             |   |   |
| v |   |                      |                    |             |   |   |
| i |   |                      |                    |             |   |   |
| c |   |                      |                    |             |   |   |
| e |   |                      |                    |             |   |   |
| s |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| a |   |                      |                    |             |   |   |
| v |   |                      |                    |             |   |   |
| a |   |                      |                    |             |   |   |
| i |   |                      |                    |             |   |   |
| l |   |                      |                    |             |   |   |
| a |   |                      |                    |             |   |   |
| b |   |                      |                    |             |   |   |
| l |   |                      |                    |             |   |   |
| e |   |                      |                    |             |   |   |
| . |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| * |   |                      |                    |             |   |   |
| * |   |                      |                    |             |   |   |
| N |   |                      |                    |             |   |   |
| o |   |                      |                    |             |   |   |
| t |   |                      |                    |             |   |   |
| e |   |                      |                    |             |   |   |
| : |   |                      |                    |             |   |   |
| * |   |                      |                    |             |   |   |
| * |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| W |   |                      |                    |             |   |   |
| e |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| p |   |                      |                    |             |   |   |
| a |   |                      |                    |             |   |   |
| y |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| a |   |                      |                    |             |   |   |
| c |   |                      |                    |             |   |   |
| t |   |                      |                    |             |   |   |
| u |   |                      |                    |             |   |   |
| a |   |                      |                    |             |   |   |
| l |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| c |   |                      |                    |             |   |   |
| h |   |                      |                    |             |   |   |
| a |   |                      |                    |             |   |   |
| r |   |                      |                    |             |   |   |
| g |   |                      |                    |             |   |   |
| e |   |                      |                    |             |   |   |
| s |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| u |   |                      |                    |             |   |   |
| p |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| t |   |                      |                    |             |   |   |
| o |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| t |   |                      |                    |             |   |   |
| h |   |                      |                    |             |   |   |
| e |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| s |   |                      |                    |             |   |   |
| c |   |                      |                    |             |   |   |
| h |   |                      |                    |             |   |   |
| e |   |                      |                    |             |   |   |
| d |   |                      |                    |             |   |   |
| u |   |                      |                    |             |   |   |
| l |   |                      |                    |             |   |   |
| e |   |                      |                    |             |   |   |
| d |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| a |   |                      |                    |             |   |   |
| l |   |                      |                    |             |   |   |
| l |   |                      |                    |             |   |   |
| o |   |                      |                    |             |   |   |
| w |   |                      |                    |             |   |   |
| a |   |                      |                    |             |   |   |
| n |   |                      |                    |             |   |   |
| c |   |                      |                    |             |   |   |
| e |   |                      |                    |             |   |   |
| s |   |                      |                    |             |   |   |
| . |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| D |   |                      |                    |             |   |   |
| e |   |                      |                    |             |   |   |
| l |   |                      |                    |             |   |   |
| t |   |                      |                    |             |   |   |
| a |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| D |   |                      |                    |             |   |   |
| e |   |                      |                    |             |   |   |
| n |   |                      |                    |             |   |   |
| t |   |                      |                    |             |   |   |
| a |   |                      |                    |             |   |   |
| l |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| a |   |                      |                    |             |   |   |
| d |   |                      |                    |             |   |   |
| m |   |                      |                    |             |   |   |
| i |   |                      |                    |             |   |   |
| n |   |                      |                    |             |   |   |
| i |   |                      |                    |             |   |   |
| s |   |                      |                    |             |   |   |
| t |   |                      |                    |             |   |   |
| e |   |                      |                    |             |   |   |
| r |   |                      |                    |             |   |   |
| s |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| a |   |                      |                    |             |   |   |
| l |   |                      |                    |             |   |   |
| l |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| o |   |                      |                    |             |   |   |
| f |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| o |   |                      |                    |             |   |   |
| u |   |                      |                    |             |   |   |
| r |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| D |   |                      |                    |             |   |   |
| e |   |                      |                    |             |   |   |
| n |   |                      |                    |             |   |   |
| t |   |                      |                    |             |   |   |
| a |   |                      |                    |             |   |   |
| l |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| b |   |                      |                    |             |   |   |
| e |   |                      |                    |             |   |   |
| n |   |                      |                    |             |   |   |
| e |   |                      |                    |             |   |   |
| f |   |                      |                    |             |   |   |
| i |   |                      |                    |             |   |   |
| t |   |                      |                    |             |   |   |
| s |   |                      |                    |             |   |   |
| . |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| F |   |                      |                    |             |   |   |
| o |   |                      |                    |             |   |   |
| r |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| i |   |                      |                    |             |   |   |
| n |   |                      |                    |             |   |   |
| f |   |                      |                    |             |   |   |
| o |   |                      |                    |             |   |   |
| r |   |                      |                    |             |   |   |
| m |   |                      |                    |             |   |   |
| a |   |                      |                    |             |   |   |
| t |   |                      |                    |             |   |   |
| i |   |                      |                    |             |   |   |
| o |   |                      |                    |             |   |   |
| n |   |                      |                    |             |   |   |
| , |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| c |   |                      |                    |             |   |   |
| a |   |                      |                    |             |   |   |
| l |   |                      |                    |             |   |   |
| l |   |                      |                    |             |   |   |
| > |   |                      |                    |             |   |   |
|   |   |                      |                    |             |   |   |
| 1 |   |                      |                    |             |   |   |
| - |   |                      |                    |             |   |   |
| 8 |   |                      |                    |             |   |   |
| 0 |   |                      |                    |             |   |   |
| 0 |   |                      |                    |             |   |   |
| - |   |                      |                    |             |   |   |
| 3 |   |                      |                    |             |   |   |
| 5 |   |                      |                    |             |   |   |
| 2 |   |                      |                    |             |   |   |
| - |   |                      |                    |             |   |   |
| 1 |   |                      |                    |             |   |   |
| 9 |   |                      |                    |             |   |   |
| 7 |   |                      |                    |             |   |   |
| 4 |   |                      |                    |             |   |   |
| . |   |                      |                    |             |   |   |
+---+---+----------------------+--------------------+-------------+---+---+

+--------------------------------+-----------+-----------+-----------+
| > **Dental benefits**          | **We pay  |           | **You     |
|                                | (         |           | pay**     |
|                                | scheduled |           |           |
|                                | all       |           |           |
|                                | owance)** |           |           |
+--------------------------------+-----------+-----------+-----------+
| > **Service**                  | *         | ##### Hi  |           |
|                                | *Standard | gh Option |           |
|                                | Option**  |           |           |
+--------------------------------+-----------+-----------+-----------+
| **Basic services**             |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > **Diagnostic**               |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Periodic oral evaluation     | > \$6.50  | > \$6.50  | \* All    |
| > (routine exams limited to    |           |           | charges   |
| > two per year)                |           |           | in excess |
|                                |           |           | of the    |
|                                |           |           | scheduled |
|                                |           |           | amounts   |
|                                |           |           | listed to |
|                                |           |           | the left  |
+--------------------------------+-----------+-----------+-----------+
| > Limited oral evaluation --   | > \$6.50  | > \$6.50  | > \*      |
| > problem focused              |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Comprehensive oral           | > \$9.00  | > \$9.00  | > \*      |
| > evaluation                   |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Detailed and extensive oral  | > N/A     | > \$11.00 | > \*      |
| > evaluation- problem focused, |           |           |           |
| > by report                    |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Intraoral, complete series   | > \$15.00 | > \$23.00 | > \*      |
| > including bite wings         |           |           |           |
| > (limited to one every three  |           |           |           |
| > years)                       |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Intraoral periapical first   | > \$1.00  | > \$3.50  | > \*      |
| > film                         |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Intraoral, periapical each   | > \$1.00  | > \$1.00  | > \*      |
| > additional film              |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Intraoral, occlusal film     | > \$7.50  | > \$7.50  | > \*      |
+--------------------------------+-----------+-----------+-----------+
| > Extraoral, first film        | > N/A     | > \$7.00  | > \*      |
+--------------------------------+-----------+-----------+-----------+
| > Extraoral, each additional   | > N/A     | > \$7.00  | > \*      |
| > film                         |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Bitewing, single film        | > \$3.00  | > \$3.50  | > \*      |
+--------------------------------+-----------+-----------+-----------+
| > Bitewings, two films         | > \$4.00  | > \$6.50  | > \*      |
+--------------------------------+-----------+-----------+-----------+
| > Bitewings, four films (      | > \$6.50  | > \$9.50  | > \*      |
| > bitewings limited to two     |           |           |           |
| > series per year)             |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Panoramic film (considered a | > \$15.00 | > \$19.00 | > \*      |
| > complete series)             |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Pulp vitality                | > N/A     | > \$7.00  | > \*      |
+--------------------------------+-----------+-----------+-----------+
| > Diagnostic casts             | > N/A     | > \$15.50 | > \*      |
+--------------------------------+-----------+-----------+-----------+
| **Preventive**                 |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Prophylaxis, adult (age 14   | > \$10.50 | > \$14.50 | > \*      |
| > or over)                     |           |           |           |
| >                              |           |           |           |
| > (prophylaxes or cleanings    |           |           |           |
| > are limited to two per year) |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Prophylaxis, child (under    | > \$10.50 | > \$10.50 | > \*      |
| > age 14) (prophylaxes or      |           |           |           |
| > cleanings are limited to two |           |           |           |
| > per year)                    |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Topical application of       | > \$16.00 | > \$17.00 | > \*      |
| > fluoride, including          |           |           |           |
| > prophylaxis                  |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Topical application of       | > \$5.50  | > \$6.50  | > \*      |
| > fluoride, prophylaxis not    |           |           |           |
| > included (application of     |           |           |           |
| > fluoride, limited to one per |           |           |           |
| > year and to children under   |           |           |           |
| > age 14)                      |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Space maintainer, fixed,     | > N/A     | > \$77.50 | > \*      |
| > unilateral                   |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Space maintainer, fixed,     | > N/A     | > \$77.50 | > \*      |
| > bilateral                    |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Space maintainer, removable, | > N/A     | \$113.50  | > \*      |
| > unilateral                   |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Space maintainer, removable, | > N/A     | >         | > \*      |
| > bilateral                    |           |  \$113.50 |           |
+--------------------------------+-----------+-----------+-----------+
| > Recementation of space       | > N/A     | > \$10.00 | > \*      |
| > maintainer (space maintainer |           |           |           |
| > are passive appliance,       |           |           |           |
| > schedule limit includes all  |           |           |           |
| > adjustments)                 |           |           |           |
+--------------------------------+-----------+-----------+-----------+

+--------------------------------+-----------+-----------+-----------+
| **Restorative**                | *         | > **High  | **You     |
|                                | *Standard | >         | pay**     |
| > Note: Multiple restorations  | Option**  |  Option** |           |
| > on one surface will be       |           |           |           |
| > considered as a single       |           |           |           |
| > restoration**.**             |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Amalgam, one surface,        | > \$11.50 | > \$13.50 | > \*      |
| > primary                      |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Amalgam, two surfaces,       | > \$16.50 | > \$19.50 | > \*      |
| > primary                      |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Amalgam, three surfaces,     | > \$22.00 | > \$25.00 | > \*      |
| > primary                      |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Amalgam, one surface,        | > \$11.50 | > \$14.50 | > \*      |
| > permanent                    |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Amalgam, two surfaces,       | > \$18.00 | > \$22.00 | > \*      |
| > permanent                    |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Amalgam, three surfaces,     | > \$22.00 | > \$29.50 | > \*      |
| > permanent                    |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Silicate cement              | > \$16.50 | > \$18.00 | > \*      |
+--------------------------------+-----------+-----------+-----------+
| > Resin, one surface           | > \$11.50 | > \$17.00 | > \*      |
+--------------------------------+-----------+-----------+-----------+
| > Resin, two surfaces          | > \$18.00 | > \$24.00 | > \*      |
+--------------------------------+-----------+-----------+-----------+
| > Resin, three surfaces        | > \$22.00 | > \$29.50 | > \*      |
+--------------------------------+-----------+-----------+-----------+
| > Pin retention, per tooth in  | > N/A     | > \$10.50 | > \*      |
| > addition to restoration      |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| **Endodontics**                |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Pulp cap, direct             | > N/A     | > \$9.50  | > \*      |
+--------------------------------+-----------+-----------+-----------+
| > Pulp cap, indirect           | > N/A     | > \$9.50  | > \*      |
+--------------------------------+-----------+-----------+-----------+
| > Therapeutic pulpotomy        | > N/A     | > \$17.50 | > \*      |
+--------------------------------+-----------+-----------+-----------+
| > Root canal, one              | > N/A     | >         | > \*      |
|                                |           |  \$108.00 |           |
+--------------------------------+-----------+-----------+-----------+
| > Root canal, two              | > N/A     | >         | > \*      |
|                                |           |  \$131.00 |           |
+--------------------------------+-----------+-----------+-----------+
| > Root canal, three or more    | > N/A     | >         | > \*      |
|                                |           |  \$178.50 |           |
+--------------------------------+-----------+-----------+-----------+
| > Apexifi                      | > N/A     | > \$7.00  | > \*      |
| cation/recalcification-initial |           |           |           |
| > visit                        |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Apicoectomy/periradicular    | > N/A     | >         | > \*      |
| > surgery-anterior             |           |  \$113.00 |           |
+--------------------------------+-----------+-----------+-----------+
| **Periodontics**               |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Gingivectomy or              | > N/A     | > \$86.00 | > \*      |
| > gingivosplasty, per quadrant |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Gingivectomy or              | > N/A     | > \$22.00 | > \*      |
| > gingivosplasty, per tooth    |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Gingival curettage,          | > N/A     | > \$12.00 | > \*      |
| > surgical, per quadrant, by   |           |           |           |
| > report                       |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Gingival flap procedure      | > N/A     | > \$33.50 | > \*      |
| > including root planning, per |           |           |           |
| > quadrant                     |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Clinical crown               | > N/A     | > \$90.00 | > \*      |
| > lengthening-hard tissue      |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Osseous surgery (including   | > N/A     | >         | > \*      |
| > flap entry and closure) per  |           |  \$194.00 |           |
| > quadrant                     |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Bone replacement graft-first | > N/A     | > \$84.00 | > \*      |
| > site in quadrant             |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Free soft tissue procedure   | > N/A     | >         | > \*      |
| > (including donor site        |           |  \$142.00 |           |
| > surgery)                     |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Provisional splinting,       | > N/A     | > \$33.50 | > \*      |
| > intracoronal                 |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Provisional splinting,       | > N/A     | > \$35.50 | > \*      |
| > extracoronal                 |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Periodontal scaling and root | > N/A     | > \$15.00 | > \*      |
| > planing, per quadrant        |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Periondontal maintenance     | > N/A     | > \$19.50 | > \*      |
| > procedure (following active  |           |           |           |
| > therapy)                     |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| ##### Pros                     |           |           |           |
| thodontics (removable) repairs |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Repair broken complete       | > N/A     | > \$26.00 | > \*      |
| > denture base                 |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Replace missing or broken    | > N/A     | > \$5.00  | > \*      |
| > teeth, complete denture      |           |           |           |
| > (each tooth)                 |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Repair resin denture base    | > N/A     | > \$25.00 | > \*      |
+--------------------------------+-----------+-----------+-----------+
| > Repair cast framework        | > N/A     | > \$34.00 | > \*      |
+--------------------------------+-----------+-----------+-----------+
| > Repair or replace broken     | > N/A     | > \$20.00 | > \*      |
| > clasp                        |           |           |           |
+--------------------------------+-----------+-----------+-----------+

*Prosthodontics (removable) -- Continued on next page*

+--------------------------------+-----------+-----------+-----------+
| > **Prosthodontics (removable) | > *       | > **High  | **You     |
| > repairs -**c*ontinued*       | *Standard | >         | Pay**     |
|                                | >         |  Option** |           |
|                                |  Option** |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Replace broken teeth, per    | > N/A     | > \$5.00  | > \*      |
| > tooth                        |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Add tooth to existing        | > N/A     | > \$11.00 | > \*      |
| > partial denture              |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Add clasp to existing        | > N/A     | > \$24.00 | > \*      |
| > partial denture              |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > **Oral surgery (includes     |           |           |           |
| > local anesthesia and routine |           |           |           |
| > postoperative care)**        |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Extraction, single teeth     | > \$12.50 | > \$17.00 | > \*      |
+--------------------------------+-----------+-----------+-----------+
| > Extraction, each additional  | > \$7.50  | > \$14.50 | > \*      |
| > tooth                        |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Root removal, exposed roots  | > N/A     | > \$18.00 | > \*      |
+--------------------------------+-----------+-----------+-----------+
| > Surgical removal of erupted  | > \$19.00 | > \$24.00 | > \*      |
| > tooth requiring elevation of |           |           |           |
| > mucoperiostael flap and      |           |           |           |
| > removal of bone and/or       |           |           |           |
| > section of tooth             |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Surgical removal of residual | > N/A     | > \$28.50 | > \*      |
| > tooth roots (cutting         |           |           |           |
| > procedure                    |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Surgical exposure of         | > N/A     | > \$46.50 | > \*      |
| > impacted or unerupted tooth  |           |           |           |
| > to aid eruption              |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Alveoloplasty in conjunction | > N/A     | > \$30.50 | > \*      |
| > with extractions per         |           |           |           |
| > quadrant                     |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Alveoloplasty not in         | > N/A     | > \$49.50 | > \*      |
| > conjunction with extractions |           |           |           |
| > per quadrant                 |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Removal of odontogenic cyst  | > N/A     | > \$42.00 | > \*      |
| > or tumor, lesion diameter up |           |           |           |
| > 1.25 cm                      |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Removal of odontogenic cyst  | > N/A     | > \$94.50 | > \*      |
| > or tumor, lesion diameter    |           |           |           |
| > over 1.25 cm                 |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Incision and drainage of     | > N/A     | > \$24.50 | > \*      |
| > abscess, intraoral soft      |           |           |           |
| > tissue                       |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Incision and drainage of     | > N/A     | > \$24.50 | > \*      |
| > abscess, extraoral soft      |           |           |           |
| > tissue                       |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Excision of hyperplastic     | > N/A     | > \$67.00 | > \*      |
| > tissue, per arch             |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Excision of pericoronal      | > N/A     | > \$28.50 | > \*      |
| > gingiva                      |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| ###                            |           |           |           |
| ## Adjunctive general services |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > General anesthesia           | > N/A     | > \$45.00 | > \*      |
+--------------------------------+-----------+-----------+-----------+
| > Analgesia                    | > N/A     | > \$9.00  | > \*      |
+--------------------------------+-----------+-----------+-----------+
| > Intravenous sedation         | > N/A     | > \$43.00 | > \*      |
+--------------------------------+-----------+-----------+-----------+
| > Consultation (diagnostic     | > N/A     | > \$18.00 | > \*      |
| > service provided by dentist  |           |           |           |
| > or physician other than      |           |           |           |
| > practitioner providing       |           |           |           |
| > treatment)                   |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Office visit for observation | > N/A     | > \$6.50  | > \*      |
| > (during regularly scheduled  |           |           |           |
| > hours)                       |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Office visit, after          | > N/A     | > \$8.00  | > \*      |
| > regularly scheduled hours    |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Occlusion analysis, mounted  | > N/A     | > \$17.50 | > \*      |
| > case                         |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Occlusal adjustment, limited | > N/A     | > \$25.00 | > \*      |
+--------------------------------+-----------+-----------+-----------+
| > Occlusal adjustment,         | > N/A     | >         | > \*      |
| > complete                     |           |  \$110.00 |           |
+--------------------------------+-----------+-----------+-----------+
| ##### Major services           |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > **Restorative**              |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Gold foil, one surface       | > N/A     | > \$24.50 | > \*      |
+--------------------------------+-----------+-----------+-----------+
| > Gold foil, two surfaces      | > N/A     | > \$53.50 | > \*      |
+--------------------------------+-----------+-----------+-----------+
| > Gold foil, three surfaces    | > N/A     | > \$74.50 | > \*      |
+--------------------------------+-----------+-----------+-----------+

*Restorative -- Continued on next page*

+--------------------------------+-----------+-----------+-----------+
| > **Restorative** --           | > *       | > **High  | **You     |
| > c*ontinued*                  | *Standard | >         | Pay**     |
|                                | >         |  Option** |           |
|                                |  Option** |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Inlay, metallic, one surface | > N/A     | > \$40.00 | > \*      |
+--------------------------------+-----------+-----------+-----------+
| > Inlay, metallic, two         | > N/A     | > \$92.50 | > \*      |
| > surfaces                     |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Inlay, metallic, three or    | > N/A     | >         | > \*      |
| > more surfaces                |           |  \$117.50 |           |
+--------------------------------+-----------+-----------+-----------+
| > Inlay, porcelain/ceramic,    | > N/A     | > \$24.50 | > \*      |
| > one surface                  |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Inlay, porcelain/ceramic,    | > N/A     | > \$45.00 | > \*      |
| > two surfaces                 |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Inlay, porcelain/ceramic,    | > N/A     | > \$69.00 | > \*      |
| > three or more surfaces       |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Crown, resin (laboratory)    | > N/A     | > \$73.50 | > \*      |
+--------------------------------+-----------+-----------+-----------+
| > Crown, resin with high noble | > N/A     | >         | > \*      |
| > metal                        |           |  \$198.50 |           |
+--------------------------------+-----------+-----------+-----------+
| > Crown, resin with            | > N/A     | >         | > \*      |
| > predominantly base metal     |           |  \$167.00 |           |
+--------------------------------+-----------+-----------+-----------+
| > Crown, resin with noble      | > N/A     | >         | > \*      |
| > metal                        |           |  \$182.50 |           |
+--------------------------------+-----------+-----------+-----------+
| > Crown, porcelain/ceramic     | > N/A     | >         | > \*      |
| > substrate                    |           |  \$184.00 |           |
+--------------------------------+-----------+-----------+-----------+
| > Crown, porcelain fused to    | > N/A     | >         | > \*      |
| > high noble metal             |           |  \$215.50 |           |
+--------------------------------+-----------+-----------+-----------+
| > Crown, porcelain fused to    | > N/A     | >         | > \*      |
| > predominantly base metal     |           |  \$184.00 |           |
+--------------------------------+-----------+-----------+-----------+
| > Crown, porcelain fused to    | > N/A     | >         | > \*      |
| > noble metal                  |           |  \$199.50 |           |
+--------------------------------+-----------+-----------+-----------+
| > Crown, full cast high noble  | > N/A     | >         | > \*      |
| > metal                        |           |  \$203.50 |           |
+--------------------------------+-----------+-----------+-----------+
| > Crown, full cast             | > N/A     | >         | > \*      |
| > predominantly base metal     |           |  \$172.00 |           |
+--------------------------------+-----------+-----------+-----------+
| > Crown, full cast noble metal | > N/A     | >         | > \*      |
|                                |           |  \$188.00 |           |
+--------------------------------+-----------+-----------+-----------+
| > Crown, ¾ cast metallic       | > N/A     | >         | > \*      |
|                                |           |  \$198.50 |           |
+--------------------------------+-----------+-----------+-----------+
| > Recement inlay               | > N/A     | > \$11.50 | > \*      |
+--------------------------------+-----------+-----------+-----------+
| > Recement crown               | > N/A     | > \$11.50 | > \*      |
+--------------------------------+-----------+-----------+-----------+
| > Prefabricated stainless      | > N/A     | > \$40.00 | > \*      |
| > steel crown primary or       |           |           |           |
| > permanent tooth              |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Prefabricated resin crown    | > N/A     | > \$40.00 | > \*      |
+--------------------------------+-----------+-----------+-----------+
| > Sedative filling             | > N/A     | > \$8.00  | > \*      |
+--------------------------------+-----------+-----------+-----------+
| > Core buildup including any   | > N/A     | > \$2.00  | > \*      |
| > pins                         |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Cast post and core in        | > N/A     | > \$56.50 | > \*      |
| > addition to crown            |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Prefabricated post and core  | > N/A     | > \$32.00 | > \*      |
| > in addition to crown         |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Temporary crown (fractured   | > N/A     | > \$40.00 | > \*      |
| > tooth)                       |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > **Prosthodontics             |           |           |           |
| > (removable)**                |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Complete upper or lower      | > N/A     | >         | > \*      |
| > denture                      |           |  \$242.50 |           |
+--------------------------------+-----------+-----------+-----------+
| > Immediate upper or lower     | > N/A     | >         | > \*      |
| > denture                      |           |  \$275.00 |           |
+--------------------------------+-----------+-----------+-----------+
| > Maxillary partial            | > N/A     | >         | > \*      |
| > denture-resin (including any |           |  \$237.50 |           |
| > conventional clasps, rest    |           |           |           |
| > and teeth)                   |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Mandibles partial            | > N/A     | >         | > \*      |
| > denture-resin base           |           |  \$237.50 |           |
| > (including any conventional  |           |           |           |
| > clasps, rest and teeth)      |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Maxillary partial            | > N/A     | >         | > \*      |
| > denture-cast metal framework |           |  \$271.00 |           |
| > with resindenture bases      |           |           |           |
| > (including any conventional  |           |           |           |
| > clasps and teeth)            |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Mandibular partial           | > N/A     | >         | > \*      |
| > denture-cast metal framework |           |  \$271.00 |           |
| > with resin denture bases     |           |           |           |
| > (including any conventional  |           |           |           |
| > clasps, rest and teeth)      |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Removable unilateral partial | > N/A     | >         | > \*      |
| > denture-one piece cast metal |           |  \$157.50 |           |
| > (including clasps and teeth) |           |           |           |
+--------------------------------+-----------+-----------+-----------+

*Prosthodontics (removable) -- Continued on next page*

+--------------------------------+-----------+-----------+-----------+
| > **Prosthodontics (removable) | *         | **High    | **You     |
| > --** *continued*             | *Standard | Option**  | pay**     |
|                                | Option**  |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Adjust complete upper or     | > N/A     | > \$17.00 | > \*      |
| > lower denture                |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Adjust partial upper or      | > N/A     | > \$17.00 | > \*      |
| > lower denture                |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Rebase complete denture      | > N/A     | > \$94.50 | > \*      |
+--------------------------------+-----------+-----------+-----------+
| > Rebase partial denture       | > N/A     | > \$71.00 | > \*      |
+--------------------------------+-----------+-----------+-----------+
| > Reline complete denture (    | > N/A     | > \$56.50 | > \*      |
| > chairside)                   |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Reline partial denture       | > N/A     | > \$43.00 | > \*      |
| > (chairside)                  |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Reline complete denture      | > N/A     | > \$76.00 | > \*      |
| > (laboratory)                 |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Reline partial denture       | > N/A     | > \$65.00 | > \*      |
| > (laboratory                  |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Interim complete denture     | > N/A     | >         | > \*      |
|                                |           |  \$115.50 |           |
+--------------------------------+-----------+-----------+-----------+
| > Interim partial denture      | > N/A     | > \$65.00 | > \*      |
+--------------------------------+-----------+-----------+-----------+
| > Tissue conditioning per      | > N/A     | > \$20.00 | > \*      |
| > denture unit                 |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Overdenture, complete, by    | > N/A     | >         | > \*      |
| > report                       |           |  \$350.00 |           |
+--------------------------------+-----------+-----------+-----------+
| > Overdenture, partial, by     | > N/A     | >         | > \*      |
| > report                       |           |  \$280.00 |           |
+--------------------------------+-----------+-----------+-----------+
| > Precision attachment, by     | > N/A     | > \$98.00 | > \*      |
| > report                       |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > **Prosthodontics (fixed)**   |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Pontic, cast high noble      | > N/A     | >         | > \*      |
| > metal                        |           |  \$204.00 |           |
+--------------------------------+-----------+-----------+-----------+
| > Pontic, cast predominantly   | > N/A     | >         | > \*      |
| > base metal                   |           |  \$172.00 |           |
+--------------------------------+-----------+-----------+-----------+
| > Pontic, cast noble metal     | > N/A     | >         | > \*      |
|                                |           |  \$188.00 |           |
+--------------------------------+-----------+-----------+-----------+
| > Pontic, porcelain fused to   | > N/A     | >         | > \*      |
| > high noble metal             |           |  \$215.50 |           |
+--------------------------------+-----------+-----------+-----------+
| > Pontic, porcelain fused to   | > N/A     | >         | > \*      |
| > predominantly base metal     |           |  \$184.00 |           |
+--------------------------------+-----------+-----------+-----------+
| > Pontic, porcelain fused to   | > N/A     | >         | > \*      |
| > noble metal                  |           |  \$199.50 |           |
+--------------------------------+-----------+-----------+-----------+
| > Pontic, resin with high      | > N/A     | >         | > \*      |
| > noble metal                  |           |  \$222.00 |           |
+--------------------------------+-----------+-----------+-----------+
| > Pontic, resin with           | > N/A     | >         | > \*      |
| > predominantly base metal     |           |  \$175.00 |           |
+--------------------------------+-----------+-----------+-----------+
| > Pontic, resin with noble     | > N/A     | >         | > \*      |
| > metal                        |           |  \$197.00 |           |
+--------------------------------+-----------+-----------+-----------+
| > Inlay, metallic two surfaces | > N/A     | > \$92.50 | > \*      |
+--------------------------------+-----------+-----------+-----------+
| > Inlay, metallic three or     | > N/A     | >         | > \*      |
| > more surfaces                |           |  \$117.50 |           |
+--------------------------------+-----------+-----------+-----------+
| > Retainer-Cast metal for      | > N/A     | > \$34.00 | > \*      |
| > resin bonded fixed           |           |           |           |
| > prosthetics                  |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Crown, resin with high noble | > N/A     | >         | > \*      |
| > metal                        |           |  \$215.50 |           |
+--------------------------------+-----------+-----------+-----------+
| > Crown, resin with            | > N/A     | >         | > \*      |
| > predominantly base metal     |           |  \$184.00 |           |
+--------------------------------+-----------+-----------+-----------+
| > Crown, resin with noble      | > N/A     | >         | > \*      |
| > metal                        |           |  \$199.50 |           |
+--------------------------------+-----------+-----------+-----------+
| > Crown, porcelain fused to    | > N/A     | >         | > \*      |
| > high noble metal             |           |  \$234.00 |           |
+--------------------------------+-----------+-----------+-----------+
| > Crown, porcelain fused to    | > N/A     | >         | > \*      |
| > predominantly to base metal  |           |  \$185.00 |           |
+--------------------------------+-----------+-----------+-----------+
| > Crown, porcelain fused to    | > N/A     | >         | > \*      |
| > noble metal                  |           |  \$205.00 |           |
+--------------------------------+-----------+-----------+-----------+
| > Crown, ¾ cast high noble     | > N/A     | >         | > \*      |
| > metal                        |           |  \$198.50 |           |
+--------------------------------+-----------+-----------+-----------+
| > Crown, full cast high noble  | > N/A     | >         | > \*      |
| > metal                        |           |  \$209.00 |           |
+--------------------------------+-----------+-----------+-----------+
| > Crown, full cast             | > N/A     | >         | > \*      |
| > predominantly base metal     |           |  \$187.00 |           |
+--------------------------------+-----------+-----------+-----------+
| > Crown, full cast noble metal | > N/A     | >         | > \*      |
|                                |           |  \$185.00 |           |
+--------------------------------+-----------+-----------+-----------+
| > Recement fixed partial       | > N/A     | > \$21.00 | > \*      |
| > denture                      |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Stress breaker               | > N/A     | > \$56.50 | > \*      |
+--------------------------------+-----------+-----------+-----------+
| > Precision attachment         | > N/A     | > \$92.50 | > \*      |
+--------------------------------+-----------+-----------+-----------+
| > Cast post and core in        | > N/A     | > \$66.00 | > \*      |
| > addition to fixed partial    |           |           |           |
| > denture retainer             |           |           |           |
+--------------------------------+-----------+-----------+-----------+

*Prosthodontics (fixed) -- Continued on next page*

+--------------------------------+-----------+-----------+-----------+
| > **Prosthodontics (fixed)** - | > *       | > **High  | **You     |
| > *continued*                  | *Standard | >         | pay**     |
|                                | >         |  Option** |           |
|                                |  Option** |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Cast post as part of fixed   | > N/A     | > \$51.00 | > \*      |
| > partial denture retainer     |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Prefabricated post and core  | > N/A     | > \$37.00 | > \*      |
| > in addition to fixed partial |           |           |           |
| > denture retainer             |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > *Not covered:*               | > N/A     | > N/A     | ###### Al |
|                                |           |           | l charges |
| -   *Services and supplies     |           |           |           |
|     furnished by other than a  |           |           |           |
|     licensed dentist, except   |           |           |           |
|     for a prophylaxis          |           |           |           |
|     (cleaning) which may be    |           |           |           |
|     performed by a licensed    |           |           |           |
|     dental hygienist working   |           |           |           |
|     under the supervision of a |           |           |           |
|     dentist or an accredited   |           |           |           |
|     school of dentistry*       |           |           |           |
|                                |           |           |           |
| -   *Dental services and       |           |           |           |
|     supplies for which other   |           |           |           |
|     benefits are payable*      |           |           |           |
|                                |           |           |           |
| -   *Replacement of bridges,   |           |           |           |
|     dentures or appliances     |           |           |           |
|     within five years of       |           |           |           |
|     coverage of previous       |           |           |           |
|     placement by this Plan*    |           |           |           |
|                                |           |           |           |
| -   *Fluorides for home use*   |           |           |           |
|                                |           |           |           |
| -   *Dental implants*          |           |           |           |
|                                |           |           |           |
| -   *Any dental service or     |           |           |           |
|     supply for cosmetic        |           |           |           |
|     purposes*                  |           |           |           |
|                                |           |           |           |
| -   *Training in preventive    |           |           |           |
|     care, oral hygiene or      |           |           |           |
|     dietary practices*         |           |           |           |
|                                |           |           |           |
| -   *Orthodontic treatment*    |           |           |           |
+--------------------------------+-----------+-----------+-----------+

Note: For questions related to Dental benefits, call Delta Dental Plan
of Virginia at **1-800-352-1974**.

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

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

## 

> **\$12,000 NO COST AD&D life insurance & Up to \$500,000 Group Term
> Life**
>
> There is NO COST to you for the \$12,000 in Accidental Death Life
> Insurance for yourself, if you join the PBP Health Plan. Acceptance is
> guaranteed. You get this \$12,000 Accidental Death Coverage just for
> being a PBP Health Plan member.
>
> **[TERM TO -- 100]{.underline}** (Senior Life Plan)

-   Secure between \$5,000 - \$25,000 of Term Life Protection

-   Level Term insurance to age 100

-   Guaranteed payout at age 100

-   Rates locked in at time of application and do not increase with age

> **ACCIDENT INSURANCE**

-   Provides \$10,000 of workplace accidental death insurance and
    \$2,000 worldwide 24 hour coverage at no-cost to the member,
    acceptance is guaranteed

-   Family Plan includes additional coverage for common carrier,
    workplace, and motor vehicle accidental deaths

> This insurance is underwritten by the Union Labor Life Insurance
> Company (ULLICO). For additional information regarding this life
> insurance, you may write to: ULLICO, Administrative Offices, Fort
> Worth, Texas, 76185, or call **1-800-542-5155**.

+-----------------------------------------------------------------------+
| > **\$1,400 Annual Maximum Dental Benefit -- Administered by Delta    |
| > Dental**                                                            |
| >                                                                     |
| > The **PBP Health Plan (PBP**) and its sponsor, the National         |
| > **League** of Postmasters offer two (2) new dental plans, which are |
| > administered by Delta Dental. The first dental plan is called       |
| > **"PBP's USA First"** and is for persons who are current PBP        |
| > members or who are joining PBP this year. PBP's Plan offers one of  |
| > the widest, most comprehensive set of dental benefits because it    |
| > offers our current PBP fixed schedule of benefits (shown in this    |
| > booklet) with this option to purchase a higher level of coverage.   |
| > **The second plan is called the "League Only"** program for persons |
| > who belong to the LEAGUE, but not the PBP Health plan.              |
| >                                                                     |
| > Both plans are voluntary, supplemental and offer \$1,400            |
| > **maximum** in covered dental services on a per person per calendar |
| > year basis. A separate \$850 **lifetime** orthodontic maximum on a  |
| > per person basis is also provided.                                  |
| >                                                                     |
| > For more information about these dental plans or to request an      |
| > application, call or write to ASI, P.O. Box 2510, Rockville, MD     |
| > 20847 or **1-877-598-7089**. DeltaPreferred Option USA® is          |
| > underwritten by Delta Dental Plan of Virginia, 4818 Starkey Road    |
| > SW, Roanoke, Virginia 24014 or **1-800-352-1974**.                  |
+-----------------------------------------------------------------------+

> **MilenniumScan** is the first non-invasive Full Body Multislice CT
> Screening Center in **Washington, DC Metro** area. In less then 3
> minutes, your brain, chest, abdomen and pelvis is completely scanned.
> The digital data obtained will allow our board certified fellowship
> trained radiologists to view your inner body in 3-dimensional detail
> and to search for pathology while it is most amenable to medical
> treatment.
>
> How is **MilleniumScan** different from a conventional CT scan? Our
> scanner is a state of the art unit which employs new multislice
> technology up to eight times faster than helical scanners, acquiring 4
> simultaneous images in one-half second.

***Non-FEHBP Benefits are not part of the FEHB contract***

+-----------------------------------------------------------------------+
| # 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 we
determine it is medically necessary to prevent, diagnose, or treat your
illness, disease, injury, or condition.**

We do not cover the following:

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

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

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

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

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

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

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

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

-   Charges that would not be made if covered individual had no health
    insurance coverage;

-   Services furnished by immediate relatives or household members, such
    as a spouse, parent, child, brother, or sister, by blood, marriage
    or adoption;

-   Services furnished or billed by a non-covered facility, except that
    medically necessary prescription drugs are covered;

-   Services not specifically listed as covered;

-   Services provided in connection with a non-covered service;

-   Any portion of a provider's fee or charge ordinarily due from the
    enrollee but that has been waived. If a provider routinely waives
    (does not require the enrollee to pay) a deductible, copay or
    coinsurance, we will calculate the actual provider fee or charge by
    reducing the fee or charge by the amount waived;

-   Charges neither you nor we have a legal obligation to pay, such as
    excess charges for annuitant age 65 or older who is not covered by
    Medicare Parts A and/or B ( see page 18), doctor charges exceeding
    the amount specified by the Department of Health and Human Services
    when benefits are payable under Medicare (limiting charge see page
    18), or State premium taxes however applied;

-   Routine preventive care, immunizations and all related expenses
    except as provided on pages 22, 23 and 24;

-   Treatment for weight control or reduction (except morbid obesity);

-   Social, recreational and educational services or training not
    specifically listed as covered;

-   Therapy, other than speech therapy, for developmental delays,
    learning disabilities, stuttering, tongue thrusting or deviate
    swallowing;

-   Treatment of temporomandibular joint disorder;

-   Services rendered by Christian Scientist providers (including
    sanitariums);

```{=html}
<!-- -->
```
-   Services rendered by massage therapists, rolfers, myotherapists, and
    trager clinics;

```{=html}
<!-- -->
```
-   Services rendered by hypnotherapists, neuromuscular therapists and
    naturopaths;

-   Hospital benefits for admissions required for surgical procedures
    excluded by us;

-   Interest, completion of claim forms, or similar administrative
    charges made by providers;

-   Travel, transportation, convalescent care or rest cures;

```{=html}
<!-- -->
```
-   Services and supplies for cosmetic purposes such as Rogaine or wigs;

-   Electronic bone-growth stimulators or similar devices;

-   Ventilation and respiratory therapy that is not billed as a part of
    skilled nursing; or

-   Leg presses or similar devices.

+-----------------------------------------------------------------------+
| # Section 7. Filing a claim for covered services                      |
+-----------------------------------------------------------------------+

**How to claim benefits** To obtain claim forms or other claims filing
advice or answers about our benefits, contact us at **800-544-7111**, or
at our website at [www.pbp.org](http://www.pbphealthplan.org/)

In most cases, providers and facilities file claims for you. Your
physician must file on the form HCFA-1500, Health Insurance Claim Form.
Your facility will file on the UB-92 form. For claims questions and
assistance, call us at **800-544-7111**

When you must file a claim \-- such as for services you receive overseas
or when another group health plan is primary \-- submit it on the
HCFA-1500 or a claim form that includes the information shown below. See
*Section 5 (f), Prescription drug benefits* for information about
special claim filing instructions.

> Bills and receipts should be itemized and show:

-   Name of patient and relationship to enrollee;

-   Plan identification number of the enrollee;

-   Name and address of person or firm providing the service or supply;

-   Provider tax identification number (needed for assigned claims and
    PPO providers);

-   Dates that services or supplies were furnished;

-   Diagnosis;

-   Type of each service or supply; and

-   The charge for each service or supply.

> Note: Canceled checks, cash register receipts, or balance due
> statements are not acceptable substitutes for itemized bills.

In addition:

-   You must send a copy of the explanation of benefits (EOB) from any
    primary payer (such as the Medicare Summary Notice (MSN)) with your
    claim.

-   Bills for home nursing care must show that the nurse is a registered
    or licensed practical nurse and should include nursing notes.

-   Claims for rental or purchase of durable medical equipment in excess
    of \$600; private duty nursing; and physical, occupational, and
    speech therapy require a written statement from the physician
    specifying the medical necessity for the service or supply and the
    length of time needed.

-   Claims for prescription drugs and supplies that are not ordered
    through the Mail Service Prescription Drug Program must include
    receipts with the prescription number, name of drug or supply,
    prescribing physician's name, date, and charge.

-   You must include an English translation and currency conversion to
    U.S. dollars with claims for overseas (foreign) services.

-   For dental claims, complete the member's section of the claim form
    and give it to the dentist to complete the remainder.

+-------------------------------------+--------------------------------+
| [Submit Medical Claims              | [Submit Dental Claims          |
| To:]{.underline}                    | To:]{.underline}               |
|                                     |                                |
| PBP Health Plan                     | Delta Dental Plan of Virginia  |
|                                     |                                |
| PO Box 782369                       | 4818 Starkey Road SW           |
|                                     |                                |
| San Antonio, TX 78278-2369          | Roanoke, VA 24014-4010         |
+-------------------------------------+--------------------------------+
| [Submit Mental and Substance Abuse  | [Submit non-network Pharmacy   |
| Claims To:]{.underline}             | Claims To:]{.underline}        |
|                                     |                                |
| PBP Health Plan                     | BeneCard                       |
|                                     |                                |
| PO Box 782369                       | 168 Franklin Corner Road       |
|                                     |                                |
| San Antonio, TX 78278-2369          | Building 2, Suite 201          |
|                                     |                                |
|                                     | Lawrenceville, NJ 08648        |
+-------------------------------------+--------------------------------+

**Error: Reference source not found**

**Records** Keep a separate record of the medical expenses of each
covered family member as deductibles and maximum allowances apply
separately to each person. Save copies of all medical bills, including
those you accumulate to satisfy a deductible. In most instances they
will serve as evidence of your claim. We will not provide duplicate or
year-end statements.

**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. Once we pay benefits, there is a three-year limitation on the
reissuance of uncashed checks.

**Overseas claims** For covered services you receive in hospitals
outside the United States and Puerto Rico and performed by physicians
outside the United States, send a completed claim form and the itemized
bills to:

PBP Health Plan

1019 N. Royal Street

Alexandria, VA 22314-1596.

Send any written inquiries concerning the processing of overseas claims
to this address.

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/prior approval:

+----+---+------------------------------------------------------------+
|    | * | **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;                                              |
|    |   |                                                            |
|    |   | (b) Send your request to us at: PBP Health Plan            |
|    |   |                                                            |
|    |   | 1019 N. Royal Street                                       |
|    |   |                                                            |
|    |   | Alexandria, Virginia 22314-1596                            |
|    |   |                                                            |
|    |   | (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     |
| *3 |   | decide within 30 more days.                                |
| ** |   |                                                            |
|    |   | If we do not receive the information within 60 days, we    |
|    |   | will decide within 30 days of the date the information was |
|    |   | due. We will base our decision on the information we       |
|    |   | already have.                                              |
|    |   |                                                            |
|    |   | We will write to you with our decision.                    |
+----+---+------------------------------------------------------------+
| >  |   | If you do not agree with our decision, you may ask OPM to  |
|  * |   | 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: United States Office of Personnel         |
|    |   | Management, Insurance Services Programs, Health Insurance  |
|    |   | Group II, 1900 "E" Street, NW, Washington, DC 20415-3620.  |
+----+---+------------------------------------------------------------+
|    |   | **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      |
| *5 |   | whether our decision is correct. OPM will send you a final |
| ** |   | decision within 60 days. There are no other administrative |
|    |   | appeals.                                                   |
+----+---+------------------------------------------------------------+
|    |   | If you do not agree with OPM's decision, your only         |
|    |   | recourse is to sue. If you decide to sue, you must file    |
|    |   | the suit against OPM in Federal court by December 31 of    |
|    |   | the third year after the year in which you received the    |
|    |   | disputed services, drugs, or supplies or from the year in  |
|    |   | which you were denied precertification or prior approval.  |
|    |   | This is the only deadline that may not be extended.        |
|    |   |                                                            |
|    |   | OPM may disclose the information it collects during the    |
|    |   | review process to support their disputed claim decision.   |
|    |   | This information will become part of the court record.     |
+----+---+------------------------------------------------------------+
|    |   | You may not sue until you have completed the disputed      |
|    |   | claims process. Further, Federal law governs your lawsuit, |
|    |   | benefits, and payment of benefits. The Federal court will  |
|    |   | base its review on the record that was before OPM when OPM |
|    |   | decided to uphold or overturn our decision. You may        |
|    |   | recover only the amount of benefits in dispute.            |
+----+---+------------------------------------------------------------+

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

(a) We haven\'t responded yet to your initial request for care or
    preauthorization/prior approval, then call us at **800-544-7111**
    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}
<!-- -->
```
-   You may call OPM\'s Health Insurance Group II at 202-606-3818
    between 8 a.m. and 5 p.m. Eastern time.

+-----------------------------------------------------------------------+
| # Section 9. Coordinating benefits with other coverage                |
+-----------------------------------------------------------------------+

## 

## **When you have other health 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. If our
benefits are subject to visit limits, we may apply those visit limits to
our secondary payments.

## What is Medicare?

+-------------------------+--------------------------------------------+
|                         | -   People 65 years of age and older.      |
|                         |                                            |
|                         | ```{=html}                                 |
|                         | <!-- -->                                   |
|                         | ```                                        |
|                         | -   Some people with disabilities, under   |
|                         |     65 years of age.                       |
|                         |                                            |
|                         | -   People with End-Stage Renal Disease    |
|                         |     (permanent kidney failure requiring    |
|                         |     dialysis or a transplant).             |
+-------------------------+--------------------------------------------+
|                         | Medicare has two parts:                    |
|                         |                                            |
|                         | -   Part A (Hospital Insurance). Most      |
|                         |     people do not have to pay for Part A.  |
|                         |     If you or your spouse worked 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 65 or older, you may be     |
|                         |     able to buy it. Contact                |
|                         |     **1-800-MEDICARE** for more            |
|                         |     information.                           |
|                         |                                            |
|                         | ```{=html}                                 |
|                         | <!-- -->                                   |
|                         | ```                                        |
|                         | -   Part B (Medical Insurance). Most       |
|                         |     people pay monthly for Part B.         |
|                         |     Generally, Part B premiums are         |
|                         |     withheld from your monthly Social      |
|                         |     Security check or your retirement      |
|                         |     check.                                 |
+-------------------------+--------------------------------------------+

If you are eligible for Medicare, you may have choices in how you get
your health care. Medicare + 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+Choice plan you have.

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

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

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

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

-   When Original Medicare is the primary payer, Medicare processes your
    claim first. In some cases, your claims will be coordinated
    automatically and we will then provide secondary benefits for
    covered charges. You will not need to do anything. To find out if
    you need to do something to file your claims, call us at
    **800-544-7111** or visit our website at
    [www.pbp.org](http://www.pbphealthplan.org/).

**We waive some costs if the Original Medicare Plan is your primary
payer \--** We will waive some out-of-pocket costs, as follows:

-   Medical services and supplies provided by physicians and other
    health care professionals. If you are enrolled in Medicare Part B,
    we will waive the calendar year deductible and coinsurance.

-   Surgical and anesthesia services provided by physicians and other
    health care professionals. If you are enrolled in Medicare Part B,
    we waive the calendar year deductible and the coinsurance.

-   Services provided by a hospital or other facility, and ambulance
    services. If you are enrolled in Medicare Part A, we waive the per
    admission copayment and the coinsurance. If you are enrolled in
    Medicare Part B, we waive the calendar year deductible and the
    coinsurance for covered ambulance services.

-   Emergency services/Accidents. If you are enrolled in Medicare Part
    B, we waive the coinsurance and copayment for covered emergency room
    charges. If you are enrolled in Medicare Part B, we waive the
    calendar year deductible and the coinsurance for covered ambulance
    services.

-   Mental health and substance abuse. If you are enrolled in Medicare
    Part A, we waive the per admission copayment and the mental health
    and substance abuse coinsurance. If you are enrolled in Medicare
    Part B, we waive the mental health and substance abuse deductible
    and coinsurance.

> In cases where we cover a service that is not covered by Medicare, we
> are the primary payer. In these cases, we do not waive any
> catastrophic protection out-of-pocket costs.

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

+-----------------------------------------------------+-----+---+---------+
| > **Primary Payer Chart**                           |     |   |         |
+-----------------------------------------------------+-----+---+---------+
| **A. When you - or your covered spouse - are age 65 | **  |   |         |
| or over and have Medicare and you...**              | The |   |         |
|                                                     | p   |   |         |
|                                                     | rim |   |         |
|                                                     | ary |   |         |
|                                                     | pa  |   |         |
|                                                     | yer |   |         |
|                                                     | for |   |         |
|                                                     | the |   |         |
|                                                     | i   |   |         |
|                                                     | ndi |   |         |
|                                                     | vid |   |         |
|                                                     | ual |   |         |
|                                                     | w   |   |         |
|                                                     | ith |   |         |
|                                                     | Me  |   |         |
|                                                     | dic |   |         |
|                                                     | are |   |         |
|                                                     | i   |   |         |
|                                                     | s.. |   |         |
|                                                     | .** |   |         |
+-----------------------------------------------------+-----+---+---------+
|                                                     | **M |   | **This  |
|                                                     | edi |   | Plan**  |
|                                                     | car |   |         |
|                                                     | e** |   |         |
+-----------------------------------------------------+-----+---+---------+
| 1)  Are an active employee with the Federal         |     |   |        |
|     government and**...**                           |     |   |         |
|                                                     |     |   |         |
|     -   You have FEHB coverage on your own or       |     |   |         |
|         through your spouse who is also an active   |     |   |         |
|         employee                                    |     |   |         |
+-----------------------------------------------------+-----+---+---------+
| -   You have FEHB coverage through your spouse who  |    |   |         |
|     is an annuitant                                 |     |   |         |
+-----------------------------------------------------+-----+---+---------+
| 2)  Are an annuitant and**...**                     |    |   |         |
|                                                     |     |   |         |
|     -   You have FEHB coverage on your own or       |     |   |         |
|         through your spouse who is also an          |     |   |         |
|         annuitant                                   |     |   |         |
+-----------------------------------------------------+-----+---+---------+
| -   You have FEHB coverage through your spouse who  |     |   | >      |
|     is an active employee                           |     |   |         |
+-----------------------------------------------------+-----+---+---------+
| 3)  Are a reemployed annuitant with the Federal     | \* |   |         |
|     government and your position is excluded from   |     |   |         |
|     the FEHB (your employing office will know if    |     |   |         |
|     this is the case)                               |     |   |         |
+-----------------------------------------------------+-----+---+---------+
| 4)  Are a reemployed annuitant with the Federal     |     |   |        |
|     government and your position is not excluded    |     |   |         |
|     from the FEHB (your employing office will know  |     |   |         |
|     if this is the case) and**...**                 |     |   |         |
|                                                     |     |   |         |
|     -   You have FEHB coverage on your own or       |     |   |         |
|         through your spouse who is also an active   |     |   |         |
|         employee                                    |     |   |         |
+-----------------------------------------------------+-----+---+---------+
| -   You have FEHB coverage through your spouse who  |    |   |         |
|     is an annuitant                                 |     |   |         |
+-----------------------------------------------------+-----+---+---------+
| 5)  Are a Federal judge who retired under title 28, | #   |   |         |
|     U.S.C., or a Tax Court judge who retired under  | ### |   |         |
|     Section 7447 of title 26, U.S.C. (or if your    | ##  |   |         |
|     covered spouse is this type of judge)           | \* |   |         |
+-----------------------------------------------------+-----+---+---------+
| 6)  Are enrolled in Part B only, regardless of your |    |   |  for   |
|     employment status                               | for |   | other   |
|                                                     | P   |   | s       |
|                                                     | art |   | ervices |
|                                                     | B   |   |         |
|                                                     | se  |   |         |
|                                                     | rvi |   |         |
|                                                     | 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 solely                         |     |  |         |
|  based 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 family 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 the primary payer before          |     | r |         |
|     eligibility 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 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                                   |     | m |         |
|                                                     |     | a |         |
|                                                     |     | r |         |
|                                                     |     | k |         |
|                                                     |     | } |         |
+-----------------------------------------------------+-----+---+---------+
| -   You have FEHB coverage through your 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 managed care plan**

If you enroll in a Medicare managed care plan, the following options are
available to you:

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

**Suspended FEHB coverage to enroll in a Medicare managed care plan:**
If you are an annuitant or former spouse, you can suspend your FEHB
coverage to enroll in a Medicare managed care plan, eliminating your
FEHB premium. (OPM does not contribute to your Medicare managed care
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
managed care plan\'s service area.

•Private Contract with your physician A physician may ask you to sign a
private contract agreeing that you can be billed directly for services
ordinarily covered by Original Medicare. Should you sign an agreement,
Medicare will not pay any portion of the charges, and we will not
increase our payment. We will still limit our payment to the amount we
would have paid after Original Medicare\'s payment.

+-------------------------+--------------------------------------------+
| **•If you do not enroll | If you do not have both Parts of Medicare, |
| in**                    | you can still be covered under the FEHB    |
|                         | Program. We will not require you to enroll |
| **Medicare Part A or    | in Medicare Part B and, if you can't get   |
| Part B**                | premium-free Part A, we will not ask you   |
|                         | to enroll in it.                           |
+-------------------------+--------------------------------------------+

**TRICARE and CHAMPVA**

## 

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

## **Workers' Compensation** 

-   you need because of a workplace-related illness or injury that the
    Office of Workers' Compensation Programs (OWCP) or a similar Federal
    or State agency determines they must provide; or

```{=html}
<!-- -->
```
-   OWCP or a similar agency pays for through a third party injury
    settlement or other similar proceeding that is based on a claim you
    filed under OWCP or similar laws.

> Once OWCP or similar agency pays its maximum benefits for your
> treatment, we will cover your care.

## **Medicaid** 

> **Suspending 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 are responsible for your care

+--------------------------+-------------------------------------------+
| ## **When others are re  | If you or any covered member of your      |
| sponsible for injuries** | family suffer injuries in an accident, or |
|                          | become ill because of the actions of      |
|                          | another person, and you thereafter        |
|                          | receive compensation, either from that    |
|                          | person or from your own or other          |
|                          | insurance for the injuries or illness,    |
|                          | you will be required to reimburse the     |
|                          | Plan for any services and supplies paid   |
|                          | by the Plan from the compensation you     |
|                          | receive.                                  |
|                          |                                           |
|                          | **This is known as the Plan's right of    |
|                          | reimbursement, and is also sometimes      |
|                          | referred to as subrogation.**             |
|                          |                                           |
|                          | You will have this obligation to          |
|                          | reimburse the Plan even if the            |
|                          | compensation you receive is not           |
|                          | sufficient to compensate you fully for    |
|                          | all of the damages which resulted from    |
|                          | the accident or illness. In other words,  |
|                          | the Plan is entitled to be reimbursed for |
|                          | all the expenditures it has made on your  |
|                          | behalf even if you are not "made whole"   |
|                          | for all of your damages by the            |
|                          | compensation you receive.                 |
|                          |                                           |
|                          | The Plan's right to reimbursement is also |
|                          | not subject to reduction for attorney's   |
|                          | fees under the "common fund" doctrine     |
|                          | without the Plan's written consent. The   |
|                          | Plan enforces this right of reimbursement |
|                          | by asserting a lien against any and all   |
|                          | compensation you receive, whether by      |
|                          | court order or out-of-court settlement.   |
|                          |                                           |
|                          | You must cooperate with the Plan in its   |
|                          | enforcement of this right of              |
|                          | reimbursement by telling the Plan whether |
|                          | you or a covered member of your family    |
|                          | has filed a claim for compensation        |
|                          | resulting from an accident or illness.    |
|                          |                                           |
|                          | You must also accept the Plan's lien for  |
|                          | the full amount of the benefits it has    |
|                          | paid. You must agree to assign any        |
|                          | proceeds from the third party claims or   |
|                          | your own insurance to the Plan when asked |
|                          | to do so.                                 |
|                          |                                           |
|                          | **We will not pay any benefits until this |
|                          | agreement is signed.**                    |
|                          |                                           |
|                          | The Plan's right to full reimbursement    |
|                          | applies even if the Plan has paid         |
|                          | benefits before we have known of the      |
|                          | accident or illness, and before we have   |
|                          | asked you to sign a Subrogation           |
|                          | Agreement. Unless the Plan agrees in      |
|                          | writing to accept less than 100% of the   |
|                          | Plan's lien amount, the Plan is entitled  |
|                          | to be reimbursed for all the benefits it  |
|                          | has paid on account of the accident or    |
|                          | illness.                                  |
|                          |                                           |
|                          | If you would like more information about  |
|                          | the subrogation process and how it works, |
|                          | please call the Plan's Third Party        |
|                          | Recovery Services unit at **(703)         |
|                          | 544-7111**, ext. 212.                     |
+--------------------------+-------------------------------------------+

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

**Assignment** An authorization by you or your spouse for us to issue
payment or benefits directly to the provider. We reserve the right to
pay the member directly for all covered services.

**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.

**Copayment** A copayment is a fixed amount of money you pay when you
receive covered services. See page 14.

**Coinsurance** Coinsurance is the percentage of our allowance that you
must pay for your care. You may also be responsible for additional
amounts. See page 14-15

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

**Congenital anomaly** A condition existing at or from birth which is a
significant deviation from the common form or norm. For purposes of this
Plan, congenital anomalies include protruding ear deformities, cleft
lips, cleft palates, birthmarks, webbed fingers or toes and other
conditions that we may determine to be congenital anomalies. In no event
will the term congenital anomaly include conditions relating to teeth or
intraoral structures supporting the teeth.

**Cosmetic surgery** Any operative procedure or any portion of a
procedure performed primarily to improve physical appearance and/or
treat a mental condition through change in bodily form.

**Custodial care** Treatment or services, regardless of who recommends
them or where they are provided, that could be rendered safely and
reasonably by a person not medically skilled, or that are designed
mainly to help the patient with daily living activities. These
activities include but are not limited to:

(1) personal care such as help in: walking; getting in and out of bed;
    bathing; eating by spoon, tube or gastrostomy; exercising; dressing;

(2) homemaking, such as preparing meals or special diets;

(3) moving the patient;

(4) acting as companion or sitter;

(5) supervising medication that can usually be self administered; or

(6) treatment or services that any person may be able to perform with
    minimal instruction, including but not limited to recording
    temperature, pulse, and respiration, or administration and
    monitoring of feeding systems.

> We determine which services are custodial. Custodial care that lasts
> 90 or more days may be considered 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 14.

**Durable medical equipment** Equipment that:

(1) is prescribed by your attending doctor;

(2) is medically necessary;

(3) is primarily and customarily used only for a medical purpose;

(4) is generally useful only to a person with illness or injury;

(5) is designed for prolonged use; and

(6) serve a specific therapeutic purpose in treatment of an illness or
    injury.

  -------------------------- --------------------------------------------
  **Experimental or          A drug, device or biological product is
  investigational services** experimental or investigational if the drug,
                             device, or biological product cannot be
                             lawfully marketed without approval of the
                             U.S. Food and Drug Administration (FDA) and
                             approval for marketing has not been given at
                             the time it is furnished. Approval means all
                             forms of acceptance by the FDA

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

A medical treatment or procedure, or a drug , device, or biological
product is experimental or investigational if 1) reliable evidence shows
that it is the subject of ongoing phase I, II, or III clinical trials or
under study to determine its maximum tolerated dose, its toxicity, its
safety, its efficacy, or its efficacy as compared with the standard
means of treatment or diagnosis; or 2) reliable evidence shows that the
consensus of opinion among experts regarding the drug, device, or
biological product or medical treatment or procedure is that further
studies or clinical trials are necessary to determine its maximum
tolerated dose, its toxicity, its safety, its efficacy, or its efficacy
as compared with the standard means of treatment or diagnosis.

Reliable evidence means only published reports and articles in the
authoritative medical and scientific literature; the written protocol or
protocols used by the treating facility or the protocol(s) of another
facility studying substantially the same drug, device, or medical
treatment or procedure; or the written informed consent used by the
treating facility or by another facility studying substantially the same
drug, device, or medical treatment or procedure.

Note: We use a formal procedure to determine if a service is
experimental or investigational. We review claims with no procedure
codes or experimental procedure codes. Physicians and medical
specialists review complex claims and recommend whether we should
consider the procedure to be experimental or investigational. We make
the final decision.

> A service or supply may be experimental or investigational if a:

-   Product is not FDA approved,

-   Service or treatment is still in some stage of trials,

-   Service or treatment is not normally used to treat your condition,
    or

-   Provider requires that you sign a special release prior to receiving
    the care.

> Enrollees who have a question about a specific service or supply may
> call us at **800-544-7111**

**Group health coverage** Health care coverage that a member is eligible
for because of employment by, membership in, or connection with, a
particular organization or group that provides payment for hospital,
medical, or other health care services or supplies, or that pays a
specific amount for each day or period of hospitalization if the
specified amount exceeds \$200 per day, including extension of any of
these benefits through COBRA.

**Home health care agency** An agency or organization that provides a
program of home health care that meets all the following requirements:
(1) it is certified by the patient's doctor as an appropriate provider
of home health services; (2) it has a full-time administrator; (3) it
maintains written records of services provided to the patient; and (4)
its staff includes at least one registered nurse(R.N.).

**Incurred date** The date services and supplies are received. The
applicable benefits are those in effect on this date. The incurred date
for major dental care expenses that involve preparatory services is the
date the inlay, crown, bridge or denture is seated, placed or installed
in the patient's mouth.

**Medical necessity** Services, drugs, supplies or equipment provided by
a hospital or covered provider of the health care services that we
determine;

(1) are appropriate to diagnose or treat the patient's condition,
    illness or injury;

(2) are consistent with standards of good medical practice in the United
    States;

(3) are not primarily for the personal comfort or convenience of the
    patient, the family, or the provider;

(4) are not a part of or associated with the scholastic education or
    vocational training of the patient; and

(5) in the case of inpatient care, cannot be provided safely on an
    outpatient basis.

> The fact that a covered provider has prescribed, recommended, or
> approved a service, supply, drug or equipment does not, in itself,
> make it medically or dentally necessary.

**Mental conditions/**

**substance abuse**

+-------------------------+--------------------------------------------+
| **Plan Allowance**      | Our "Plan Allowance" is the amount we use  |
|                         | to determine our payment and your          |
|                         | coinsurance for covered services.          |
|                         | Fee-for-service plans determine their      |
|                         | allowances in different ways. We determine |
|                         | our allowance as follows:                  |
|                         |                                            |
|                         | We refer to national databases such as     |
|                         | those provided by Ingenix, Interqual and   |
|                         | Milliman & Robertson to determine the      |
|                         | prevailing health care charges in a given  |
|                         | geographic area. We use the 70^th^         |
|                         | percentile of those charges as the Plan    |
|                         | allowance for a given covered service in a |
|                         | geographic area. In some cases such as     |
|                         | Dental benefits, the Plan Allowance is     |
|                         | printed in this brochure. Charges subject  |
|                         | to the Plan Allowance include, but are not |
|                         | limited to, charges for all surgery,       |
|                         | anesthesia, medical care and mental health |
|                         | care.                                      |
|                         |                                            |
|                         | We also use special industry or federal    |
|                         | guidelines or consult with medical         |
|                         | specialists to establish an allowance      |
|                         | based on unusual cases or complex care.    |
|                         | When we negotiate a discounted fee on an   |
|                         | individual claim, that fee is the Plan     |
|                         | Allowance. The fees that are negotiated    |
|                         | with network providers as part of their    |
|                         | network contract are considered the Plan   |
|                         | Allowances. If you use a network provider, |
|                         | your cost is limited to the cost sharing   |
|                         | provisions listed in this brochure's       |
|                         | benefit charts. If you use a non-network   |
|                         | provider, you are also responsible for     |
|                         | charges in excess of the Plan allowance.   |
+-------------------------+--------------------------------------------+

> For more information, see *Differences between our allowance and the
> bill* in Section 4.

+-------------------------+--------------------------------------------+
| **Remission**           | A remission is the halt or actual          |
|                         | reduction in the progression of illness    |
| **(hospice care)**      | resulting in discharge from a hospice care |
|                         | program with no further expenses incurred. |
|                         | A readmission within three months of a     |
|                         | prior discharge is considered as part of   |
|                         | the same period of care. A new period      |
|                         | begins three months after a prior          |
|                         | discharge with maximum benefits available. |
+-------------------------+--------------------------------------------+

**Sound natural tooth** A natural tooth that is whole or properly
restored, without impairing periodontal or other conditions and not in
need of the treatment rendered or proposed for any reason other than
accidental injury.

**Surgery** A " surgical procedure" means cutting, suturing, treating
burns, correcting a fracture, reducing a dislocation, manipulating a
joint under anesthesia, electrocauterizing, tapping (paracentesis),
applying plaster casts, administering pneumothorax, endoscopy or
injecting sclerosing solution.

**Us/We** Us and we refer to PBP Health Plan

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

+-----------------------------------------------------------------------+
| # Section 11. FEHB facts                                              |
+-----------------------------------------------------------------------+

## **No pre-existing condition limitation** 

## **Where you get information about enrolling in the FEHB Program**

> • 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** 

## **for you and your family**

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. Notify us when: 1)
your child turns 22 years of age; b) when your child (younger than 22)
actually marries or c) when your child is declared by a competent court
to be legally no longer your dependent.

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.

+-------------------------+--------------------------------------------+
| ## **                   | OPM has implemented the Federal Employees  |
| Children's Equity Act** | Health Benefits Children's Equity Act of   |
|                         | 2000. This law mandates that you be        |
|                         | enrolled in 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        |
|                         | coverage for your children. If you do not  |
|                         | do so, your employing office will enroll   |
|                         | you involuntarily as follows:              |
|                         |                                            |
|                         | -   If you have no FEHB coverage, your     |
|                         |     employing office will enroll you for   |
|                         |     Self and Family coverage in the Blue   |
|                         |     Cross and Blue Shield Service Benefit  |
|                         |     Plan's Basic Option;                   |
|                         |                                            |
|                         | -   if you have 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 your     |
|                         |     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 does   |
|                         | not serve the area in which your children  |
|                         | live, unless you provide documentation     |
|                         | that you have other coverage for the       |
|                         | children. If your court 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 benefi        | The benefits in this brochure are          |
| ts and premiums start** | effective on January 1. If you joined this |
|                         | Plan during Open Season, your coverage     |
|                         | begins on the first day of your first pay  |
|                         | period that starts on or after January 1.  |
|                         | 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 lose benefits**

### When FEHB coverage ends

-   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.

### Spouse equity coverage

## 

##  

### Temporary Continuation of Coverage (TCC)

+---+----------------------+--------------------------------------------+---+
|   |                      | 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)[.]{.underline} |   |
|   |                      | It explains what you have to do to enroll. |   |
+---+----------------------+--------------------------------------------+---+
| # |                      | You may convert to a non-FEHB individual   |   |
| # |                      | policy if:                                 |   |
| # |                      |                                            |   |
|   |                      | -   Your coverage under TCC or the spouse  |   |
| C |                      |     equity law ends (If you canceled your  |   |
| o |                      |     coverage or did not pay your premium,  |   |
| n |                      |     you cannot convert);                   |   |
| v |                      |                                            |   |
| e |                      | ```{=html}                                 |   |
| r |                      | <!-- -->                                   |   |
| t |                      | ```                                        |   |
| i |                      | -   You decided not to receive coverage    |   |
| n |                      |     under TCC or the spouse equity law; or |   |
| g |                      |                                            |   |
|   |                      | ```{=html}                                 |   |
| t |                      | <!-- -->                                   |   |
| o |                      | ```                                        |   |
|   |                      | -   You are not eligible for coverage      |   |
| i |                      |     under TCC or the spouse equity law.    |   |
| n |                      |                                            |   |
| d |                      |                                            |   |
| i |                      |                                            |   |
| v |                      |                                            |   |
| i |                      |                                            |   |
| d |                      |                                            |   |
| u |                      |                                            |   |
| a |                      |                                            |   |
| l |                      |                                            |   |
|   |                      |                                            |   |
| c |                      |                                            |   |
| o |                      |                                            |   |
| v |                      |                                            |   |
| e |                      |                                            |   |
| r |                      |                                            |   |
| a |                      |                                            |   |
| g |                      |                                            |   |
| e |                      |                                            |   |
+---+----------------------+--------------------------------------------+---+

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.

+-------------------------+--------------------------------------------+
| ### Getti               | The Health Insurance Portability and       |
| ng a Certificate of Gro | Accountability Act of 1966 (HIPPA) is a    |
| up Health Plan Coverage | Federal 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/h                     |
|                         | ealth](http://www.opm.gov/insure/health)); |
|                         | refer to the "TCC and HIPPA" frequently    |
|                         | asked questions. These highlight HIPPA     |
|                         | rules, such as the requirement that        |
|                         | Federal employees must exhaust any TCC     |
|                         | eligibility as one condition for           |
|                         | guaranteed access to individual health     |
|                         | coverage under HIPPA, and have information |
|                         | about Federal and State agencies you can   |
|                         | contact for more information.              |
+-------------------------+--------------------------------------------+

+-----------------------------------------------------------------------+
| # Two new Federal Programs complement FEHB benefits                   |
+-----------------------------------------------------------------------+

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

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

-   **What is an FSA?** It is a tax-favored benefit that allows you to
    set aside pre-tax money from your paychecks to pay for a variety of
    eligible expenses. *By using an FSA,* *you can reduce your taxes
    while paying for services you would have to pay for anyway,
    producing a discount that can be over 40%!!*

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

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

```{=html}
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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}
<!-- -->
```
-   **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!

```{=html}
<!-- -->
```
-   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.
>
> Plan carefully when deciding how much to contribute to an FSA. Because
> of the tax 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.
>
> Every FEHB health plan includes cost sharing features, such as
> deductibles you must meet before the Plan provides benefits,
> coinsurance or copayments that you pay when you and the Plan share
> costs, and medical services and supplies that are not covered by the
> Plan and for which you must pay. These out-of-pocket costs are
> summarized on page 16 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 the High Option of this Plan, typical out-of-pocket expenses
> include: 1) Member share of premium; 2) Rx copayments; 3) Dental
> deductibles.
>
> Under the Standard Option of this Plan, typical out-of-pocket expenses
> include: 1) Member share of premium; 2) Rx copayments; 3) Dental
> deductibles.
>
> 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.
>
> You *cannot* claim expenses on your Federal income tax return if you
> receive reimbursement for them from your HCFSA or DCFSA. Below are
> some guidelines that may help you decide whether to participate in
> FSAFEDS.

**Health care 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 \$3,700 (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.
>
> Probably not. While there is an administrative fee of \$4.00 per month
> for an HCFSA **to** 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.
>
> 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 the pages where the terms appear.

**A**bortion 65

Accidental injury 19, 29, 38, 47, 48, 57

Allergy care 19, 27

Alternative treatment 19, 28, 32, 33

Allogeneic (donor) bone marrow transplant 39-41

Ambulance 19, 42, 46, 48, 72

Assignment 17, 18, 77

Assisted reproductive technology 27

**B**iopsy 34

Blood and blood plasma 21, 22, 43, 44

Bone marrow transplant 28, 39-41

**C**alendar year deductible 8, 20, 34, 42, 44, 46, 49, 50, 71

Catastrophic protection out-of-pocket expenses 14-16, 18, 50, 51, 53,
64, 72, 91, 92

Chemotherapy 28, 41

Chiropractic 19, 32, 33

Coinsurance 14-17, 44, 50, 65, 72, 74, 77, 79, 86

Colorectal cancer screening 22

Congenital anomalies 34, 37, 38, 77

Contact lenses 29

Contraceptive drugs 26, 53, 54

Coordination of benefits 18, 71-76

Cosmetic surgery 37, 77

Covered charges 14, 18

Covered facility 9

Covered providers 9

Custodial care 77

**D**ays certified 11, 12

Deductible 14-17, 20, 23-25, 34, 42-44, 45-53, 56-57, 63-64, 77

Definitions 77

Dental care 57-64

Diabetes 56

Diagnostic services 20-21, 58

Disputed claims review 69-70

Donor expenses (transplants) 39-41

Durable medical equipment 31-32, 78

**E**ducational classes and programs 33

Effective date of enrollment 9, 11, 81

Embryo transfer 27

Emergency care 47-48

Experimental or investigational 78

Explanation of benefits 19, 49-51, 52-54, 57-63, 64, 91-92

Eyeglasses 29

**F**amily planning 26

Flexible benefits option 55, 85-87

Foot care 30

Freestanding ambulatory facilities 44

General Exclusions 65

**H**ealthier Feds Hotlines 56

Hearing services 29

Home health services 32, 79

Home nursing care 32

Home visits 20

Hospice care 45, 80

Hospital admission 11, 42

**I**mmunizations 23, 65

Independent laboratory 21

Infertility 27

Inhospital physician care 34-46

Inpatient Hospital Benefits, 42-43

Insulin 53, 54

In vitro fertilization 27

**L**aboratory and pathological services 10, 21, 40, 43, 44

**M**achine diagnostic tests 21, 50

Mail Order Drugs 52-54

Mammograms 21, 23

Maternity Benefits 25-26

Medicaid 75

Medical emergency 47-48

Medically necessary 65, 79

Medically underserved areas 9

Medicare 17, 18, 71-74

Mental Conditions/Substance Abuse Benefits 49-51, 79

Multislice CT scan 64

**N**ewborn care 24-26

Non-FEHB Benefits 64

Nurse 9, 10, 32, 36, 66, 77

Nursery charges 25

Nursing School Administered Clinic 9

**O**ccupational therapy 28

Office visits 14, 20, 23, 51, 60, 71

Oral and maxillofacial surgery 38

Orthopedic devices 19, 30, 35

Outpatient services 50, 51

Overseas claims 68

**P**ap test 21, 23

Physical examination 22, 23

Physical therapy 8, 10, 19, 33

Physician 7, 11, 12, 14, 15, 17, 18, 19, 20, 21, 28, 31, 32, 34, 36, 42,
47, 48, 52-54, 60, 67-70, 72, 74, 78

Precertification 11-13, 42, 70

Preferred Provider Organization (PPO) 7-9, 10, 15, 20-26, 30-33, 40, 42,
47, 48, 67, 91-92

Prescription drugs 43, 49, 65, 67, 71, 74

Preventive care, adult 19, 22-23

Preventive care, children 19, 24

Prostate specific antigen 22

Prosthetic devices 19, 30, 35, 37, 43, 44

**R**adiation therapy 28, 41

Room and board 16, 42, 43, 51

**S**econd surgical opinion 21

Skilled nursing facility care 10, 21, 41, 44, 66

Smoking cessation 33, 54

Speech therapy 19, 28, 33, 65, 67

Subrogation 75, 76

Surgery 12, 26, 29, 30, 34-38, 40, 42, 43, 45, 55, 59, 77, 78, 79, 80

-   Anesthesia 33, 34, 41, 60, 72, 79, 80

```{=html}
<!-- -->
```
-   Assistant surgeon 35

```{=html}
<!-- -->
```
-   Multiple procedures 35, 38

-   Oral 60

```{=html}
<!-- -->
```
-   Outpatient 12, 18, 30, 41-51, 79

-   Reconstructive 34, 37, 38

    **T**emporary continuation of coverage 82, 83, 84

Treatment therapies 28

**V**ision services 29

**W**ell-child care 24

Wheelchairs 31

Workers' compensation 73, 75

**X**-rays 20, 21, 43, 44

+-----------------------------------------------------------------------+
| #                                                                     |
|  Summary of benefits for the PBP Health Plan - Standard Option - 2004 |
+-----------------------------------------------------------------------+

-   **Do not rely on this chart alone.** All benefits 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}
<!-- -->
```
-   Below, an asterisk (\*) means the item is subject to the \$250
    (\$600 non-PPO) calendar year deductible. And, after we pay, you
    generally pay any difference between our allowance and the billed
    amount if you use a non-PPO physician or other health care
    professional.

+------------------------------------------+----------------------+---+
| **Benefits**                             | **You Pay**          | * |
|                                          |                      | * |
|                                          |                      | P |
|                                          |                      | a |
|                                          |                      | g |
|                                          |                      | e |
|                                          |                      | * |
|                                          |                      | * |
+------------------------------------------+----------------------+---+
| Medical services provided by physicians: | > PPO: 9%\*          | > |
|                                          | >                    |   |
| -   Diagnostic and treatment services    | > Non-PPO: 30%\*     | 2 |
|     provided in the office               |                      | 0 |
+------------------------------------------+----------------------+---+
| Services provided by a hospital:         | > PPO: 10%, non-PPO: | > |
|                                          | > 30%                |   |
| -   Inpatient                            | >                    | 4 |
|                                          | > PPO: 9%\*,         | 1 |
| -   Outpatient                           | > non-PPO: 30%\*     | > |
|                                          |                      | > |
|                                          |                      |   |
|                                          |                      | 4 |
|                                          |                      | 3 |
+------------------------------------------+----------------------+---+
| Emergency benefits:                      | > PPO: \$0, non-PPO: | > |
|                                          | > charges over our   |   |
| -   Accidental injury                    | > allowance          | 4 |
|                                          | >                    | 6 |
| -   Medical emergency                    | > PPO: \$50 then 9%, | > |
|                                          | > non-PPO: \$50 then | > |
|                                          | > 30%                |   |
|                                          |                      | 4 |
|                                          |                      | 7 |
+------------------------------------------+----------------------+---+
| > Mental health and substance abuse      | > PPO: Same as       | > |
| > treatment                              | > medical            |   |
|                                          | >                    | 4 |
|                                          | > Non-PPO: Reduced   | 8 |
|                                          | > benefits           |   |
+------------------------------------------+----------------------+---+
| Prescription drugs:                      | > \$4 generic, 20%   | > |
|                                          | > Plan allowance or  |   |
| -   Network retail                       | > \$30 formulary, or | 5 |
|                                          | > 20% Plan allowance | 2 |
|                                          | > or \$40            |   |
|                                          | > non-formulary      |   |
+------------------------------------------+----------------------+---+
| -   Non-network retail                   | > 30% of Plan        | > |
|                                          | > allowance and      |   |
|                                          | > amounts over our   | 5 |
|                                          | > allowance          | 2 |
+------------------------------------------+----------------------+---+
| -   Mail order                           | > \$8 generic, 20%   | > |
|                                          | > Plan allowance or  |   |
| -   Mail order with Medicare             | > \$30 formulary, or | 5 |
|                                          | > 20% Plan allowance | 3 |
|                                          | > or \$40            | > |
|                                          | > non-formulary.     | > |
|                                          | >                    |   |
|                                          | > \$7 generic, 20%   | 5 |
|                                          | > Plan allowance or  | 3 |
|                                          | > \$15 formulary, or |   |
|                                          | > 20% Plan allowance |   |
|                                          | > or \$25            |   |
|                                          | > non-formulary.     |   |
+------------------------------------------+----------------------+---+
| Dental Care                              | > Charges over our   | > |
|                                          | > fee schedule       |   |
|                                          |                      | 5 |
|                                          |                      | 6 |
+------------------------------------------+----------------------+---+
| Special features: Flexible benefits      | > Nothing            | > |
| option, 24-hour nurse line, Tobacco quit |                      |   |
| phone line, Complex surgery, Centers of  |                      | 5 |
| excellence, Dialysis services            |                      | 4 |
+------------------------------------------+----------------------+---+
| Protection against catastrophic costs    | > Nothing after      | > |
|                                          | > \$3,500 (\$5,000   |   |
| (your catastrophic protection            | > non-PPO) per       | 1 |
| out-of-pocket maximum)                   | > person or \$4,000  | 6 |
|                                          | > (\$5,500 non-PPO)  |   |
|                                          | > per family per     |   |
|                                          | > year               |   |
|                                          | >                    |   |
|                                          | > Some costs do not  |   |
|                                          | > count toward this  |   |
|                                          | > protection         |   |
+------------------------------------------+----------------------+---+

+-----------------------------------------------------------------------+
| # Summary of benefits for the PBP Health Plan - High Option -- 2004   |
+-----------------------------------------------------------------------+

-   **Do not rely on this chart alone.** All benefits 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}
<!-- -->
```
-   Below, an asterisk (\*) means the item is subject to the \$200
    (\$500 non-PPO) calendar year deductible. And, after we pay, you
    generally pay any difference between our allowance and the billed
    amount if you use a non-PPO physician or other health care
    professional.

+------------------------------------------+----------------------+---+
| Benefits                                 | **You Pay**          | * |
|                                          |                      | * |
|                                          |                      | P |
|                                          |                      | a |
|                                          |                      | g |
|                                          |                      | e |
|                                          |                      | * |
|                                          |                      | * |
+------------------------------------------+----------------------+---+
| Medical services provided by physicians: | PPO: 10%\*           | > |
|                                          |                      |   |
| -   Diagnostic and treatment services    | Non-PPO: 25%\*       | 2 |
|     provided in the office               |                      | 0 |
+------------------------------------------+----------------------+---+
| Services provided by a hospital:         | > PPO: 10%, non-PPO  | > |
|                                          | > 25%                |   |
| -   Inpatient                            | >                    | 4 |
|                                          | > PPO: 10%\*,        | 1 |
| -   Outpatient                           | > non-PPO: 25%\*     | > |
|                                          |                      | > |
|                                          |                      |   |
|                                          |                      | 4 |
|                                          |                      | 3 |
+------------------------------------------+----------------------+---+
| Emergency benefits:                      | > PPO: \$0, PPO:     | > |
|                                          | > charges over our   |   |
| -   Accidental injury                    | > allowance          | 4 |
|                                          | >                    | 6 |
| -   Medical emergency                    | > PPO: \$50 then     | > |
|                                          | > 10%, non-PPO: \$50 | > |
|                                          | > then 25%           |   |
|                                          |                      | 4 |
|                                          |                      | 7 |
+------------------------------------------+----------------------+---+
| > Mental health and substance abuse      | > PPO: Same as       | > |
| > treatment                              | > medical            |   |
|                                          | >                    | 4 |
|                                          | > Non-PPO: Reduced   | 8 |
|                                          | > benefits           |   |
+------------------------------------------+----------------------+---+
| Prescription drugs:                      | > \$3 generic, 20%   | > |
|                                          | > Plan allowance or  |   |
| -   Network retail                       | > \$25 formulary, or | 5 |
|                                          | > 20% Plan allowance | 2 |
|                                          | > or \$40            |   |
|                                          | > non-formulary      |   |
+------------------------------------------+----------------------+---+
| -   Non-network retail                   | > 20% of Plan        | > |
|                                          | > allowance and      |   |
|                                          | > amounts over our   | 5 |
|                                          | > allowance          | 2 |
+------------------------------------------+----------------------+---+
| -   Mail order                           | > \$6 generic, 20%   | > |
|                                          | > Plan allowance or  |   |
| -   Mail order with Medicare             | > \$25 formulary, or | 5 |
|                                          | > 20% Plan allowance | 3 |
|                                          | > or \$40            | > |
|                                          | > non-formulary.     | > |
|                                          | >                    |   |
|                                          | > \$5 generic, 20%   | 5 |
|                                          | > Plan allowance or  | 3 |
|                                          | > \$12 formulary, or |   |
|                                          | > 20% Plan allowance |   |
|                                          | > or \$25            |   |
|                                          | > non-formulary.     |   |
+------------------------------------------+----------------------+---+
| Dental Care                              | > Charges over our   | > |
|                                          | > fee schedule       |   |
|                                          |                      | 5 |
|                                          |                      | 6 |
+------------------------------------------+----------------------+---+
| > Special features: Flexible benefits    | > Nothing            | > |
| > option, 24-hour nurse line, Tobacco    |                      |   |
| > quit phone line, Complex surgery,      |                      | 5 |
| > Centers of excellence, Dialysis        |                      | 4 |
| > services                               |                      |   |
+------------------------------------------+----------------------+---+
| Protection against catastrophic costs    | Nothing after        | > |
|                                          | \$3,000 (\$3,500     |   |
| (your catastrophic protection            | non-PPO) per person  | 1 |
| out-of-pocket maximum)                   | or \$3,500 (\$4,000  | 6 |
|                                          | non-PPO) per family  |   |
|                                          | per year             |   |
|                                          |                      |   |
|                                          | Some costs do not    |   |
|                                          | count toward this    |   |
|                                          | protection           |   |
+------------------------------------------+----------------------+---+

# 2004 Rate Information

**for PBP Health Plan**

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

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

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

+--------------+-----+-------+-------+-------+-------+-------+-------+
| **High       | *   | **    | **    | **    | **    | **    | **    |
| Option**     | *36 | \$121 | \$183 | \$263 | \$396 | \$143 | \$161 |
|              | 1** | .40** | .06** | .03** | .63** | .32** | .14** |
| **Self       |     |       |       |       |       |       |       |
| Only**       |     |       |       |       |       |       |       |
+--------------+-----+-------+-------+-------+-------+-------+-------+
| **High       | *   | **    | **    | **    | **    | **    | **    |
| Option**     | *36 | \$277 | \$379 | \$600 | \$822 | \$327 | \$329 |
|              | 2** | .09** | .78** | .36** | .86** | .12** | .75** |
| **Self and   |     |       |       |       |       |       |       |
| Family**     |     |       |       |       |       |       |       |
+--------------+-----+-------+-------+-------+-------+-------+-------+

+--------------+-----+-------+-------+-------+-------+-------+-------+
| **Standard   | *   | **    | *     | **    | **    | **    | *     |
| Option**     | *36 | \$121 | *\$67 | \$263 | \$147 | \$143 | *\$45 |
|              | 4** | .40** | .90** | .03** | .12** | .32** | .98** |
| **Self       |     |       |       |       |       |       |       |
| Only**       |     |       |       |       |       |       |       |
+--------------+-----+-------+-------+-------+-------+-------+-------+
| **Standard   | *   | **    | **    | **    | **    | **    | **    |
| Option**     | *36 | \$277 | \$151 | \$600 | \$328 | \$327 | \$101 |
|              | 5** | .09** | .70** | .36** | .69** | .12** | .67** |
| **Self and   |     |       |       |       |       |       |       |
| Family**     |     |       |       |       |       |       |       |
+--------------+-----+-------+-------+-------+-------+-------+-------+